Prevalence of diabetes mellitus and impaired glucose tolerance among second-generation Japanese-American men.

We describe the initial findings from a multidisciplinary, epidemiologic study of diabetes mellitus conducted in a population of second-generation Japanese-American (Nisei) men born between 1910 and 1939 who reside in King County, Washington (n = 1746). From this study population, 487 volunteered, and 229 were enrolled to comprise the study sample. A random sample of Nisei men was also drawn from the population to develop a reference sample of 189 men. All subjects participated in a 75-g oral glucose tolerance test; the National Diabetes Data Group (NDDG) and World Health Organization (WHO) diagnostic criteria as well as a modification of the WHO criteria were used to classify individuals with normal glucose tolerance, impaired glucose tolerance (IGT), or diabetes. Within the study sample, 79 men were found to have normal glucose tolerance, 72 had IGT, and 78 had type II diabetes. The mean age of the study sample was 61.4 yr. Based on comparison of the study sample to the reference sample, the study sample was ascertained to be representative of Nisei men in King County. Extrapolating from our observations in the reference sample and in the study sample, we have estimated that approximately 56% of Nisei men in the study population have abnormal glucose tolerance. Much of this is undiagnosed because only approximately 13% of the reference sample of Nisei men reported a prior diagnosis of diabetes. Of the men who enrolled in the study as nondiabetic subjects, 11.1% had diabetes and 39.2% had IGT; i.e., 50.3% had previously unknown abnormalities in glucose tolerance. We estimate that approximately 20% of Nisei men have diabetes (both previously diagnosed and undiagnosed) and approximately 36% have IGT.

Prevalence of complications among second-generation Japanese-American men with diabetes, impaired glucose tolerance, or normal glucose tolerance.

In a study sample of 229 second-generation Japanese-American (Nisei) men, 79 with normal glucose tolerance, 72 with impaired glucose tolerance (IGT), and 78 with non-insulin-dependent diabetes, we have determined prevalence rates for certain conditions (ischemic heart disease, peripheral vascular disease, hypertension, retinopathy, neuropathy, and nephropathy) associated with diabetes. All subjects participated in a 75-g oral glucose tolerance test. World Health Organization (WHO) diagnostic criteria and information from the subject's medical history and personal physician were used to classify the subjects. Retinopathy was observed only in diabetic men in the study sample (11.5% of diabetic men). Furthermore, it was observed only in men who were receiving drug treatment for diabetes--40.0% of insulin-treated and 17.2% of sulfonylurea-treated men. Electrophysiologic evidence of peripheral neuropathy was observed in 46.2% of diabetic men and in 4.0% of nondiabetic (normal and IGT) men. For diabetic men with fasting serum glucose greater than or equal to 140 mg/dl, 63.8% had peripheral neuropathy and 19.1% had retinopathy, whereas for diabetic men with fasting serum glucose less than 140 mg/dl, 19.4% had neuropathy and none had retinopathy. For diabetic men with a diabetes duration of greater than or equal to 10 yr, 72.7% had neuropathy and 31.8% had retinopathy; with a diabetes duration of 5-9 yr, 70.6% had neuropathy and 11.8% had retinopathy; and with a diabetes duration of less than 5 yr, 20.5% had neuropathy and none had retinopathy. Nephropathy was distinctly uncommon, and among the measurements of kidney function, only proteinuria was clearly abnormal with diabetes. Prevalence rates of hypertension, peripheral vascular disease, and ischemic heart disease were highest in Nisei men with diabetes, lowest in men with normal glucose tolerance, and intermediate in men with IGT.(ABSTRACT TRUNCATED AT 250 WORDS)

Glucose intolerance and diabetic complications among Japanese-American women.

The prevalence of glucose intolerance and diabetic complications was determined in second-generation Japanese-American (Nisei) women and compared to previously obtained results in Nisei men. A volunteer study sample of 191 Nisei women 45-74 years old was enrolled from a study population of 1489 Nisei women born 1913-1942, raised and educated in the U.S., and residing in King County, Washington. The enrolled sample included 72 with normal glucose tolerance, 67 with impaired glucose tolerance (IGT), and 52 with non-insulin-dependent diabetes. A random sample was also drawn from the study population to form a reference sample of 157 women. Based upon observations in the reference and enrolled samples, an estimated 16% of Nisei women in the study population have diabetes and 40% IGT. These rates compare to 20% diabetes and 36% IGT previously estimated for Nisei men 45-74 years old. The prevalence of cardiovascular disease (hypertension, peripheral vascular disease, and/or coronary heart disease) was highest among diabetic women, lowest in those with normal glucose tolerance, and intermediate in women with IGT. In comparison to diabetic men, there was a significantly lower frequency of neuropathy, peripheral vascular disease, and coronary heart disease in diabetic women. However, hypertension occurred equally often in both. Thus Japanese-American men and women 45-74 yr old have a similar prevalence of glucose intolerance, although less severe in women, and complications, except for hypertension, are reduced in women.

Height is an independent risk factor for neuropathy in diabetic men.

Height may increase the risk of diabetic polyneuropathy, but previous studies are inconclusive. Our purposes were to further examine the hypothesis that height (HT) is an independent risk factor for diabetic polyneuropathy and to determine which electrophysiologic measures are influenced by HT in diabetic subjects. We studied 170 Japanese American men (ages 43-73 years, mean 61) including: 69 diabetic men (mean HT 166 cm), 54 normal men (mean HT 167 cm), and 47 men with impaired glucose tolerance (IGT) (mean HT 164 cm), measuring 28 nerve conduction study (NCS) parameters. We used data from normal men in developing regression models to adjust NCS parameters for HT, age, and temperature. Factor analysis was employed to reduce the 28 NCS parameters to five physiologically meaningful factors, one of which, a factor representing median and peroneal sensory amplitudes, was significantly correlated with HT (r = -0.38, P = 0.0011) in diabetic men; taller subjects having smaller sensory nerve amplitudes. No significant correlation was found between this factor and body mass index. This factor had no correlation with HT in normal or IGT men. Our data do not confirm previous reports of associations between HT and slowed motor conduction velocities in diabetic subjects. This study does, however, support the hypothesis that HT is an independent risk factor for sensory polyneuropathy in diabetic subjects.

Diabetes and diabetes risk factors in second- and third-generation Japanese Americans in Seattle, Washington.

In Seattle, Washington, the prevalence of diabetes was 20% in second-generation (Nisei) Japanese-American men and 16% in Nisei women 45-74 years old, while the prevalence of impaired glucose tolerance (IGT) was 36% in Nisei men and 40% in Nisei women. Hyperglycemia was less and duration of diabetes shorter in women. Related to diabetes and IGT in Nisei were higher fasting plasma insulin levels and central (visceral) adiposity. Prevalence of diabetes was low among the younger (34-53 years old) third-generation (Sansei) men and women. Among self-reported non-diabetic Sansei, however, prevalence of IGT was 19% in men and 29% in women, and IGT was associated with both increased fasting plasma insulin levels and more visceral fat, suggesting that many Sansei are at risk of future diabetes. An important lifestyle factor in the development of NIDD in Japanese Americans appeared to be dietary saturated (animal) fat. Another factor may be physical inactivity. In Japanese-American women, menopause also appeared to be an important risk factor. These risk factors may be related to fostering the accumulation of visceral fat and the development of insulin resistance. Five-year follow-up examinations performed in non-diabetic Nisei men and women have yielded additional information concerning the prognosis of IGT. Of those women who were IGT at baseline, 34% were diabetic at follow-up while 17% returned to normal. In men who had been IGT at baseline, 18% were diabetic at follow-up while 36% returned to normal. Over the 5-yr follow-up interval, proportionally more women progressed from normal to IGT (54%) then went from IGT to normal (17%). For men, roughly equal proportions went from normal to IGT (37%) as from IGT to normal (36%). It would therefore appear that greater proportions of Nisei women are progressing to IGT and to NIDD than are Nisei men. This observation may be related to the increased risk of developing central obesity and insulin resistance following menopause. Prevalence of cardiovascular disease (hypertension, peripheral vascular disease, and/or coronary heart disease) was increased in Japanese Americans with IGT and NIDD. Neuropathy and retinopathy were associated only with NIDD.

Spine and scalp recordings as a function of intensity. A model for changes during spinal cord monitoring.

STUDY DESIGN: Spinal cord monitoring has used both spine and scalp recordings as indicators of spinal cord integrity. The relative merits of spine or scalp recordings to predict the quality of the afferent volley in the somatosensory pathway were addressed in this study by using various stimulus intensities as a way to model alterations of the size of the afferent volley. OBJECTIVES: The results were analyzed to determine the correlation of central recordings taken at the spine or scalp with peripheral recordings. SUMMARY OF BACKGROUND DATA: Spinal cord monitoring with somatosensory evoked potentials has been achieved with recordings of signals generated by either the spinal cord or the somatosensory cortex. Spine recordings are thought to be more stable, yet little evidence exists to document this statement. METHODS: Seven patients were studied in the course of standard intraoperative spinal cord monitoring. Responses were recorded at the popliteal fossa, thoracic epidural, cervical spine, and scalp to tibial nerve stimulation at intensities varying from 0.5 to 2.0 times muscle twitch threshold. RESULTS: Normalized amplitudes of the response at the popliteal fossa were used to reflect the magnitude of the afferent volley. The amplitudes of the popliteal fossa response showed a high correlation (r = 0.90) with normalized amplitudes of epidural and cervical spine responses and moderate correlation (r = 0.49) with normalized amplitudes of scalp responses. The width of the 95% confidence limits for the inverse prediction of the afferent volley from epidural and cervical responses was nearly a third narrower than that from scalp responses. At low stimulus intensities, scalp responses were consistently observed when spine responses were absent, and scalp responses had lower response thresholds than did spine responses. The latencies of the popliteal fossa responses were not well correlated with latencies of either the epidural or cervical responses. CONCLUSIONS: These correlation and inverse prediction data suggest that the size of an afferent volley may be predicted more accurately by spine responses than by scalp responses. The presence of scalp responses at intensities too low to elicit detectable spinal-level responses suggests that scalp responses may be considered a sensitive indicator of a minimal afferent volley.

The efficacy of femoral nerve intraoperative somatosensory evoked potentials during surgical treatment of thoracolumbar fractures.

Somatosensory evoked potential (SEP) monitoring of thoracolumbar procedures typically includes posterior tibial and peroneal nerve recordings. The addition of femoral nerve SEP monitoring, however, should better predict the evolution of postoperative neurologic deficits affecting the midlumbar roots. To assess the value of intraoperative femoral SEPs, 26 cases of traumatic injury to the thoracolumbar spine between T12 and L4 were prospectively assessed. Twenty-four had clear femoral nerve responses bilaterally recorded from an epidural electrode. Five had significant intraoperative SEP changes: one had isolated femoral nerve changes, two had only peroneal or tibial nerve changes, and two had concomitant changes in both femoral and peroneal or tibial nerves. Loss of the femoral nerve response in one patient was correlated with marked postoperative knee extensor weakness, in spite of immediate action taken by the surgeon. The authors conclude that femoral nerve SEPs provide an effective tool to monitor the midlumbar roots intraoperatively.

Sympathetic skin response in fifth lumbar and first sacral radiculopathies.

Skin temperature changes and sympathetic skin response (SSR) changes have previously been reported in lumbosacral radiculopathy patients (6). The SSR was studied in 14 normals and in 8 radiculopathy subjects with unilateral, EMG documented active radiculopathies to assess if the SSR becomes asymmetric when measured across appropriate dermatomes. The SSR was recorded in dermatomal patterns in both feet simultaneously with active electrodes on the plantar surface and reference electrodes on the dorsum. Four wave types were identified and normal values for latency of onset, latency of peak, and amplitude are presented with the normal left/right ratios presented. In all individual subjects the amplitudes of the SSR were extremely variable and asymmetric while latencies were less variable and more symmetric. There were no significant differences in symmetry between radiculopathy and normal subjects. When using this technique the SSR is not significantly altered in L5 and S1 radiculopathies.

Rehabilitation research: habit analysis and recommendations.

Respondents to a survey by the Association of Academic Physiatrists (AAP) on the research grant application behavior of its members indicated that 41% (45) made no applications during the 6-year period ending December 1980. Of the remainder, 12% (13) were aggressive achievers (eg, earned 54% of the awards), 33% were mild achievers and 14% were unsuccessful applicants. The successful applicants submitted 1 1/2 times more applications than did the unsuccessful ones. Of the awards made, 42% were federally funded. Of articles published in the Archives of Physical Medicine and Rehabilitation by physicians in the years 1978-1980, 76% were federally funded. Study of these data suggest that upgrading of knowledge and skills in the grant application process plus an exposure to new funding sources could increase rehabilitation research productivity. This paper discusses factors influencing success, research initiation and methods of accessing funds available from corporations and foundations.

Rehabilitation research training.

The need for increased productivity in rehabilitation research by a larger number of physicians is discussed. The ingredients of appropriate research training are described, and include recruitment, education, skill attainment and an apprenticeship. An estimate is made that the desired increase in research productivity could be achieved if each year for the next five to ten years just 20 physiatrists could be trained in rehabilitation research. Suggestions are made as to how the training of that number of physiatrists annually can be brought about.

Physical medicine and rehabilitation: somatosensory evoked potentials in monitoring spinal operations.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in physical medicine and rehabilitation. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in physical medicine and rehabilitation that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Physical Medicine and Rehabilitation of the California Medical Association and the summaries were prepared under its direction.

AAEM minimonograph #16: instrumentation and measurement in electrodiagnostic medicine--Part I.

Technical and instrumentation factors play an important role in obtaining reliable information during electrodiagnostic studies. With contemporary electrodiagnostic equipment, neurophysiologic potentials are detected using a variety of electrodes and undergo differential amplification, filtering, conversion to digital form, and finally, analysis and display. Understanding the signal processing principles, limitations, and sources of errors that can occur during this multistep process can improve the technical quality of studies, minimize preventable errors, and improve clinical interpretation. Part I of this minimonograph reviews the basic principles of action potential generation and overviews electrodiagnostic instrumentation. The concept of waveform frequency content is related to the role of filters in suppressing noise while preserving waveform latency, amplitude, and morphology. The electrical characteristics of various surface and needle electrodes influence instrument design and the nature of the potentials recorded. This is especially important in understanding the differences in motor unit characteristics obtained from monopolar and concentric needle electrodes.

AAEM minimonograph #16: instrumentation and measurement in electrodiagnostic medicine--Part II.

A review of instrumentation and measurement in electrodiagnostic medicine is continued in this Part II which focuses on digital instrumentation principles, gain and sweep effects, noise, nerve stimulation, and conduction measurement limitations. With the adoption of microprocessor-based equipment, the neurophysiologic signal must undergo analog-to-digital conversion (ADC) before analysis and display on a video monitor. ADC resolution and sampling rates affect accuracy and measurement precision. Following waveform display, the visual assessment of latency and duration may be influenced by sweep and gain settings, often overlooked sources of error. Undesired signal or noise typically originates from power-line interference, electronic amplifier noise, background muscle activity, or nerve stimulation artifact. Noise often interferes with clinical studies but techniques exist to reduce noise to acceptable levels in virtually all situations. An awareness and understanding of these technical issues will lead to an appreciation of the limitations of electrodiagnostic testing and improve interpretation and clinical decision-making.

Microscopic features and transient contraction of palpable bands in canine muscle.

Ten pairs of biopsies were excised from gracilis and semitendinosus muscles of 4 mongrel dogs. These were compared with the histological findings reported in painful spots and muscle hardenings of human muscles. Test biopsies sampled a palpable band. Paired control biopsies sampled a portion of the same muscle where it showed no palpable hardening. Processed sections were randomized and read blind. Sections stained with aqueous toluidine blue showed no convincing metachromasia. Sections stained with trichrome showed no proliferation of endomysial connective tissue. Test sections stained with hematoxylin and eosin showed no proliferation of nuclei and no increase in the number of central nuclei in muscle fibers compared to control sections. No convincing histological difference was found. During surgery under Nembutal anesthesia, rubbing palpation of the exposed muscle elicited a transient contraction of a bundle of muscle fibers several milli-meters in diameter. This corresponded in time and position to the palpable band in the dog muscle. The band-like hardness palpated in these canine muscles appears to be caused by a circumscribed transient muscular contraction rather than histologically demonstrable structural changes.

Muscle fiber number in immobilization atrophy.

Eight Sprague-Dawley rats 10 to 12 weeks of age had one limb immobilized by plaster in knee flexion and ankle plantar flexion for four weeks. The soleus muscles from the control and immobilized limbs were excised and frozen. The technique used insured that cross sections subsequently cut and stained would contain all the fibers extending from the origin to the insertion aponeuroses. The total number of muscle fibers per muscle was counted from 25 to 50 photomicrographs made for each muscle cross section. Paired comparisons of total muscle fibers in control and immobilized muscles revealed no significant differences. The total number of fibers in control and immobilized soleus muscles was 2812 +/- 521 and 2930 +/- 403, respectively. Therefore, muscle fiber loss does not occur in disuse atrophy produced by external immobilization as has been reported.

Action myoclonus following acute cerebral anoxia.

Action myoclonus secondary to posthypoxic encephalopathy is being seen increasingly with improved resuscitation techniques. A case report describes 5 specific physical and occupational therapeutic techniques for achieving independence in ambulation, transfers and self-care: (1) analysis and segmentation of complex motions into small steps; (2) controlled progression of training; (3) voluntary cessation of abnormal activity (pacing); (4) progressive densensitization to external stimuli; and (5) quantification of progress. Literature review suggests that posthypoxic action myoclonus is secondary to a loss of inhibitory synapses in the brainstem reticular formation due to low serotonin levels. The proposed therapeutic effect of clonazepam, the drug used in this patient, is decreased serotinin degredation. L-5-hydroxytryptamine, an investigative drug, is also therapeutic, for it stimulates increased serotonin production.