Hypoglycemic symptoms and decreased beta-adrenergic sensitivity in insulin-dependent diabetic patients.

Thirty-seven insulin-dependent diabetic patients were tested for symptoms of hypoglycemia, cardiac autonomic neuropathy (i.e., heart rate variation during deep breathing, Valsalva maneuver, immediate heart rate response to standing), and isoproterenol sensitivity (defined as the dose of isoproterenol required to increase heart rate by 25 beats/min: I25). Tests of cardiac autonomic neuropathy showed no relation to hypoglycemic symptoms. On the contrary, a clear relationship could be established between isoproterenol sensitivity and adrenergic symptoms of hypoglycemia. Diabetic patients with decreased response to isoproterenol had fewer adrenergic symptoms, perceived hypoglycemia at a lower blood glucose level, and had more hypoglycemic accidents. Symptoms most related to isoproterenol sensitivity were tremor, sweaty palms, and hunger. With the isoproterenol-sensitivity test a distinction could be made between the groups at high (I25 greater than 3 micrograms) and low (I25 less than 3 micrograms) risk for hypoglycemic accidents. We suggest that the isoproterenol-sensitivity test could be used to identify diabetic patients at increased risk for hypoglycemia.

Lack of hypoglycemic symptoms and decreased beta-adrenergic sensitivity in insulin-dependent diabetic patients.

Plasma epinephrine, norepinephrine, and dopamine responses were studied in insulin-dependent diabetic patients at rest, on standing and during insulin-induced hypoglycemia. beta-Adrenergic sensitivity was evaluated by the isoproterenol sensitivity test. Five men who had adrenergic symptoms during hypoglycemia and no severe hypoglycemic accidents (coma, seizures) (group A) and five men who had repeated severe hypoglycemic accidents but lack of adrenergic symptoms of hypoglycemia (group B) were studied. The mean resting plasma epinephrine was lower in group B (147 +/- 22 pmol/L, SEM) than in group A (398 +/- 98 pmol/L, P less than 0.02). On standing plasma epinephrine increased significantly in both groups. During hypoglycemia blood glucose decreased identically in the two groups; plasma epinephrine and norepinephrine increased significantly and to the same extent in both groups; the mean maximal heart rate was significantly greater in group A than in group B. Isoproterenol sensitivity (defined as the dose of isoproterenol required to increase heart rate by 25 beats/min) was lower in group B (5.87 +/- 1.12 micrograms) than in group A (2.37 +/- 0.22 micrograms, P less than 0.01). The group B patients had significantly fewer hypoglycemic symptoms during insulin-induced hypoglycemia than did group A patients. We conclude that decreased beta-adrenergic sensitivity contributes to the lack of adrenergic symptoms of hypoglycemia in insulin-dependent diabetic patients.

Management of diabetic patients by general practitioners in France 1997: an epidemiological study.

To describe the characteristics of diabetic patients, the associated risk factors, the complications of the disease and its management by general practitioners (GPs) in France, a randomised sample of French GPs was asked to record data on all consecutive diabetic patients attending a regular visit within 3 months. Data were obtained by interview, clinical examination and usual follow-up complementary examinations of the patients. Patients were classified into 3 groups:, patients treated with insulin and considered to have type 1 diabetes, [2i], insulin-treated patients expected to have type 2 diabetes, [2d], patients with type 2 diabetes and not treated with insulin. Data from 7540 diabetic out-patients were recorded by 3084 GPs: 657 patients (8.7%) belonged to group 1, 1383 patients (18.3%) to group 2i and 5351 (71.0%) to group 2d. Patients, including 53.7%, [2i] 54.1%, and [2d] 56.5% of men, were (mean +/- SE) 58.8 +/- 0.7, [2i] 63.4 +/- 0.3, and [2d] 63.9 +/- 0.2 years old, respectively. Duration of diabetes was 15.9 +/- 0.4, [2i] 11.4 +/- 0.2, and [2d] 10.1 +/- 0.1 yr. The last fasting blood glucose level (laboratory assay) was 1.61 +/- 0.02, [2i] 1.68 +/- 0.01, and [2d] 1.61 +/- 0.01 g/L, and the last HbA1c 8.5 +/- 0.1, [2i] 8.1 +/- 0.1, and [2d] 7.8 +/- 0.1%, respectively. Tobacco smoking was observed in 19.2%, [2i] 13.1%, and [2d] 12.6% of the patients, hypertension in 39.6%, [2i] 55.9%, and [2d] 58.6%, micro- or macro-albuminuria in 18.6%, [2i] 11. 2%, and [2d] 9.5%, retinopathy in 31.1%, [2i] 12.9%, and [2d] 8.6%, and history of coronary artery disease in 16.3%, [2i] 15.0%, and [2d] 12.8%. Self-monitoring of blood glucose was performed by 93.2%, [2i] 37.9%, and [2d] 16.9% of the patients. During the previous 12 months, a visit had been performed with a diabetologist in 54.0%, [2i] 20.7%, and [2d] 12.9% of the patients, with an ophthalmologist in 62.9%, [2i] 51.5%, and [2d] 49.4%. These results underline the specific characteristics of French diabetic patients. A high prevalence of uncontrolled risk factors, mainly hypertension, contrasts with a relatively low frequency of micro- and macro-angiopathy, maybe underestimated by non-systematic routine follow-up. Closer collaboration between GPs and specialists should be developed to improve the management and care of diabetic patients in France.

[Glycosylated plasma proteins in chronic renal failure]. / Protéines glyquées plasmatiques dans l'insuffisance rénale chronique.

In chronic renal failure HbA1c values and plasma fructosamine concentrations are difficult to interpret owing to anaemia (for HbA1c) and analytical interferences (for fructosamine test). Plasma proteins glycation was measured more specifically by affinity chromatography. Glycated albumin, glycated immunoglobulins G and glycated proteins were determined in 30 control patients, 30 diabetics and 28 patients with chronic renal failure divided into 17 non diabetics and 11 diabetics. Glycated albumin, glycated IgG and glycated total proteins were not modified by chronic renal failure in non diabetic patients on the contrary of HbA1c and fructosamine test.

[Adrenal histoplasmosis in a non-insulin-dependent diabetic patient]. / Histoplasmose surrénalienne chez un sujet idabétique non insulinodépendant.

Adrenal histoplasmosis is a rare infection that can be misdiagnosed as tuberculosis. We present here a case of adrenal histoplasmosis in a 65 year-old male diabetic with marked weight loss. Laboratory investigations noticed an inflammatory syndrome and the abdominal computed tomography scanner reported an heterogenous left adrenal mass of 6 cm in diameter. Hormonal as well as bacteriological studies were negative. The patient was operated and the histopathological examination proved that the mass was a tuberculoma and an anti-tuberculous treatment was started. Four months later, the patient suffered from recurrence of symptoms and laboratory investigations confirmed the inflammatory syndrome and the abdominal computed tomography scanner showed a right adrenal mass. A surgical biopsy was performed and specific fungal researches proved that the lesion was due to Histoplasma capsulatum. The patient experienced a remarkable improvement under anti-fungal treatment.

[Innocuousness of the limited reuse of injection materials by insulin-dependent diabetics]. / Innocuité de la réutilisation limitée du matériel d'injection chez les diabétiques insulino-traités.

A survey was conducted in 120 insulin-dependent diabetics to determine their routine daily procedure for insulin injection and the possible reuse of the material employed. Aseptic precautions were usually sufficient, half of the diabetic patients (51.6%) conforming with the overall rules for hygiene generally recommended. Spontaneous reuse of injection material was rare (10/120), and local incidents as a result of reuse infrequent: pain from the 3rd injection in 2 patients and an abdominal abscess in a third case due to total lack of asepsis rules. Insulin injections in 37 insulin-dependent diabetics admitted to hospital care were administered throughout their stay by means of plastic syringes and needles used 3 times consecutively. The mean number of needles-syringes used per diabetic was 7.3, representing a total of 813 injections. Infectious sequelae were not observed and minor local incidents (pain, pruritus) were rare and unrelated to the reuse of equipment. Limited reuse, under satisfactory conditions of asepsis, of material termed for "once only use" appears to be free from risk particularly with respect to infection. Generalization of this practice will provide substantial economy in the treatment of diabetes.

[Diabetic microangiopathy. Role of capillaroscopy]. / Microangiopathie diabétique. Place de la capillaroscopie.

In order to evaluate the significance of ungual and conjunctival microvascular abnormalities observed in diabetics prior to retinopathy, nailfold and conjunctival capillaroscopy was performed in 20 controls and 40 insulin-dependent diabetics of the same age. The diabetics were divided into 4 groups according to their state of retinopathy: absent, incipient, non-proliferative and proliferative. No difference was found between controls and diabetics and between groups of diabetics in the frequency of conjunctiva microaneurysms and specific nailfold microangiopathy, nor even in that of the so-called characteristic "fish shoal" image. The percentage of abnormalities detected was concordant with the results of previous studies in diabetics (12.5 per cent of non-specific organic microangiopathy), but it was 2 to 4 times higher than the frequency usually found in non-diabetic controls. This discrepancy could be due to the method used, since in contrast with earlier studies the operator did not know whether the subject was diabetic or not and was unaware of the patient's retina state. In the absence of other blind and prospective studies, capillaroscopic examination for diabetic microangiopathy should be reserved strictly to clinical research.

[Listeria monocytogenes liver abscess. In a diabetic patient]. / Abcès du foie à Listeria monocytogenes. Chez une malade diabétique.

Most liver abscesses are caused by Enterobacteriaceae, sometimes associated with anaerobes. Listeriosis is an exceptional cause of liver abscess, usually in a context of disseminated infections. We report the case of a diabetic woman who had liver abscess due to Listeria monocytogenes. The organism was isolated after guided needle aspiration, and there was no other site of infection. The course of the disease gradually moved towards recovery under an antibiotic therapy that was based on sensitivity tests. A search for immunodeficiency proved negative. A review of the literature showed that the rare cases of listerial liver abscess share a common factor, diabetes mellitus, the importance of which has not yet been noticed.