The effect of strict control with the artificial beta-cell on plasma lipid levels in insulin-dependent diabetes.

The artificial beta-cell can establish normoglycemia within 2 h in an indifferently controlled diabetic patient. In the present study, the temporal relationship between the achievement of normoglycemia and its effect on plasma lipid concentrations has been examined in 12 insulin-dependent diabetic patients regulated by the artificial beta-cell for 7 days. The fasting values (mean +/- SEM) of blood glucose (BG), triglycerides (TG), total cholesterol (T-chol), HDL-cholesterol (HDL), and the calculated LDL/HDL ratio (obtained while participants were on single or split insulin regimens) were 385 +/- 42 mg/dl, 148 +/- 24 mg/dl, 219 +/- 22 mg/dl, 39 +/- 3.6 mg/dl, and 3.8 +/- 1.04, respectively. Within 12 h of establishing normoglycemia TG levels fell to 87 +/- 10 mg/dl (P less than 0.001), T-chol to 196 +/- 15 mg/dl (P less than 0.005), and HDL to 37 +/- 3 mg/dl (P = NS). The LDL/HDL ratio remained unchanged. After 7 days on the artificial beta-cell, the corresponding values were: 73 +/- 5 mg/dl (P less than 0.001), 169 +/- 9 mg/dl (P less than 0.001), 41 +/- 2.6 mg/dl (P = NS), and 2.6 +/- 0.56 (P less than 0.05). Twenty-four hours after discontinuation of artificial beta-cell therapy, the TG and T-chol concentrations reverted to baseline. These findings underscore the rapidity and effectiveness with which strict control can improve plasma lipid profiles.

Senile cataract and glucose intolerance: the Israel Study of glucose Intolerance Obesity and Hypertension (The Israel GOH Study).

Association of "senile" cataract (SC) with glucose intolerance (impaired tolerance and diabetes) was assessed by sex and age in a random population sample comprising 930 individuals aged 40-70 yr, who underwent concurrent oral glucose tolerance test and ophthalmoscopy. The eye examination was performed without knowledge of the glucose tolerance status. SC was defined as lens opacification preventing visualization of the eyeground or as surgical aphakia due to SC. To assess the independent effect of hyperglycemia, glycosylated hemoglobin (HbA1) was determined in 769 participants. In men, no association was found between SC, glucose intolerance, and HbA1. In women of all ages, glucose intolerance was associated with an SC risk ratio of 6.1 (95% confidence limits 3.3-11.1; P less than 0.001). Furthermore, SC was associated in women with increased HbA1 independently of the effect of glucose intolerance (P less than 0.01). These findings confirm the reported association of SC with diabetes (although unlike the Framingham and HANES population studies, the association was confined in women), indicate its presence at all degrees of glucose intolerance, and suggest a possible independent role of nonenzymatic glycosylation in its pathogenesis.

Adherence to IDDM regimens: relationship to psychosocial variables and metabolic control.

Thirty-four adolescents (ages 12-14 yr) with IDDM completed a questionnaire assessing regimen adherence over the previous week and psychosocial measures potentially related to adherence. Four aspects of the IDDM regimen were studied: insulin injections, dietary patterns, glucose testing, and exercise. Psychosocial variables included (1) Social Learning Theory measures of diabetes-specific family behaviors and barriers to adherence and (2) more general measures of family interaction. Glycosylated hemoglobin levels were predicted accurately (R = 0.68) from a combination of three adherence measures. The psychosocial measures were not directly related to metabolic control, but they were associated with adherence. Degree of adherence to one aspect of the IDDM regimen was not related to adherence to other aspects of the regimen and different psychosocial variables predicted adherence to different regimen components. The diabetes-specific measures were generally more predictive of adherence than were the more global measures. Implications and limitations of this cross-sectional, correlational study were discussed.

Diabetes mellitus in elderly nursing home patients. A survey of clinical characteristics and management.

The clinical features of 47 frail nursing home diabetic patients with a mean age of 81 +/- 1.6 years were compared to those of 61 nondiabetic nursing home residents with a mean age of 80.2 +/- 1.2 years. Diabetic patients had a higher prevalence of renal failure, proteinuria, retinopathy, neuropathy, and infections than did other nursing home residents. Macroangiopathic disease tended to be equally common in both age groups. Diabetic nursing home residents had higher body weights compared to nondiabetic nursing home residents. Surprisingly, however, 21% of nursing home diabetics were greater than 20% below average body weight (compared to 24.5% of other nursing home residents), suggesting that undernutrition is a major problem in diabetic patients in a nursing home setting. Overall, the diabetic nursing home patients had better blood glucose control than younger ambulatory diabetic patients (mean age 66.2 +/- 4.7 years). The glycosylated hemoglobin (HbA1) level in those on oral agents was 8.9% +/- 0.7% for nursing home patients compared to 11.8% +/- 0.7% in ambulatory patients (P less than 0.01). The HbA1 in insulin-treated patients was similarly lower in nursing home diabetics (9.6% +/- 0.4% vs 11.8% +/- 0.7, P less than 0.05). There were only two mild hypoglycemic episodes in nursing home patients over 6-month observation period, whereas 12 ambulatory patients reported hypoglycemic episodes during the same period of time. We conclude that although the diabetic nursing home patients are sicker than the ambulatory diabetics, it is possible to achieve a fair blood glucose control in nursing home patients without a significant risk of recurrent hypoglycemia.

Study of the effect of metformin on platelet aggregation in insulin-dependent diabetics.

The role of metformin on platelet aggregation was studied in subjects affected by relatively well controlled type 1 diabetes. 1700 mg of metformin were added to their usual daily treatment; nothing else was changed. Patients were trained to monitor their own glycaemia and presence of degenerative retinopathy was proved. Before the administration of metformin and on day 21, the platelet induced by 1.25, 2.5 and 5 mumol of ADP and by collagen was studied. Fibrinogen, cholesterol, triglycerides, glycosylated haemoglobin and mean blood glucose levels did not show any significant modification after treatment but the maximum aggregation induced by ADP was significantly decreased; the inhibition of aggregation was particularly sensitive for low doses of ADP. No significant correlation was found between the variations in metabolism data and the reduction of the amplitude of platelet aggregation. Metformin, added to the usual treatment undergone by a diabetic treated with insulin, seems to affect platelet aggregation independently of other metabolic factors.

Long-term performance of the fructosamine assay.

We have investigated the long-term performance of the fructosamine assay based on secondary glycated protein standards and attempted to define the interpretation of varying degrees of increase in fructosamine concentration in comparison to haemoglobin A1 (HbA1) values both in insulin dependent (IDDM) and non-insulin dependent (NIDDM) diabetic patients. Between-batch imprecision of fructosamine over 5 months was (CV) 2.5% at 2.09 mmol/L, 2.8% at 3.52 mmol/L and 3.6% at 4.14 mmol/L. Variation of fructosamine concentration in vivo in stable diabetic patients monitored over 8-18 weeks was 2.3% to 7.1%. Fructosamine correlated with HbA1 both in IDDM (n = 110, r = 0.701, P less than 0.001) and NIDDM (n = 71, r = 0.764, P less than 0.001). Specificity and sensitivity of fructosamine for the prediction of degree of control assessed on the basis of HbA1 level (cut-off point for good vs. poor control, HbA1 = 10%) was determined. In NIDDM, specificity above 90% was achieved at a fructosamine concentration of 3.4 mmol/L with a corresponding sensitivity of 64.1%. 22.5% of patients were classified differently on the basis of fructosamine as compared to HbA1. In IDDM, specificity over 90% was achieved at 3.8% mmol/L fructosamine with a sensitivity of 35%. Discordancy rate between HbA1 and fructosamine based assessment of control was 31.8%. The assessment of diabetic control based on fructosamine may be different from that based on HbA1, particularly in IDDM. Fructosamine and HbA1 should be used as complementary rather than alternative tests.

Glycosylated haemoglobin: comparison of five different methods, including measurement on capillary blood samples.

Glycosylated haemoglobin was measured in venous blood samples and in blood collected in 'Unistep' bottles by isoelectric focusing (IEF), as the reference method, and by electroendosmosis (EEO), the thiobarbituric acid method (TBA), ion-exchange chromatography (IEC) and affinity chromatography (AC). Isoelectric focusing, electroendosmosis and thiobarbituric acid gave similar results. Affinity chromatography gave lower results than isoelectric focusing for normal values but similar results for diabetics. Ion-exchange chromatography gave 24% lower results than isoelectric focusing across the range. Using Unistep collected blood samples and comparing multiple samples from the same patient, electroendosmosis gave the best results (coefficient of variation 4%) and thiobarbituric acid gave slightly less good precision that other methods. Re-use of affinity chromatography columns gave less good precision. Collection of blood samples into a Unistep bottle gave similar results to venous sample results. Storage of venous capillary blood samples in Unistep bottles over 1 week at 21 degrees C gave similar results to immediate assay. Electroendosmosis of blood samples in Unistep bottles gave stable results over 2 weeks. Home collection by a patient of a capillary blood sample into a Unistep bottle allows glycosylated haemoglobin results to be available when seen in the clinic.

Maternal diabetes and neonatal macrosomia. II. Neonatal anthropometric measurements.

Anthropometric measurements were obtained within 12 h of birth in 52 infants of non-diabetic mothers and 61 infants of diabetic mothers. Most of the diabetic patients were under good control, only ten of 61 having postpartum hemoglobin A1c levels in excess of normal. Neonates were grouped as normally-grown or macrosomic. Birthweight, crown-heel length, head circumference and skinfold thickness were measured. In each diabetes class, macrosomic neonates had larger mean length, head circumference and skinfold thickness than their normally-grown peers. At equal birthweight, neonates of gestational diabetic mothers and of non-diabetic mothers were similar in length, head circumference and skinfold thickness. Neonates of permanently insulin-requiring diabetics were similar to their non-diabetic peers in length and head circumference but had thicker skinfold thicknesses. Anthropometric measurements do not permit differentiation of the origin of neonatal macrosomia.

Sensitivity of serum fructosamine in short term glycemic control.

The serum fructosamine concentrations measured in 64 diabetic patients correlated (r = 0.73) with glycated hemoglobins (HbA1c). However, 23 percent of the diabetic patients had normal fructosamine and abnormal HbA1c levels. In order to determine whether or not the discrepant values were the result of recent glycemic regulation by the diabetic patient, fructosamine levels of patients suffering from diabetic ketoacidosis (along with beta-hydroxybutyrate levels) were closely monitored. It was shown that short term alterations (one to three days) in serum glucose did not significantly affect fructosamine levels. Therefore, disagreements between fructosamine and HbA1c are most likely due to longer term improvement in glucose control by the diabetic or the result of the higher imprecision of the HbA1c assay.

[Homeostasis of blood glucose and abuse of exogenous opiates: evaluation of fructosamine and glycosylated hemoglobin]. / Omeostasi glicemica ed abuso di oppioidi esogeni: valutazione della fruttosamina e dell'emoglobina glicosilata.

The study was designed to assess glycaemic homeostasis in different situations of chronic stimulation of the opiate receptors by exogenous opiates. After an OGTT, levels of glycosylated haemoglobin (HbA1c) and serum fructosamine were measured in 3 groups of male drug addicts of comparable age. Group A consisted of 10 subjects undergoing substitution treatment with oral methadone. Group B consisted of 10 subjects addicted to intravenous injection of the syrup based methadone intended for oral administration. Group C consisted of 10 heroin addicts. Ten healthy subjects of the same age and sex were used as controls. Analysis of the results showed normal glucose tolerance in all groups with tendentially higher basal glycaemia levels in group B. HbA1c levels were significantly higher, though within normal limits, in group B than in either those receiving oral methadone (p less than 0.01) or the heroin addicts (p less than 0.01). The group B subjects also showed the highest fructosamine levels that were both well above normal limits and higher than those in the other groups in whom fructosamine levels were normal. The data therefore confirm normal glycaemia compensation in those taking oral methadone and in heroin addicts during the period considered. A new type of drug addiction involving the intravenous injection of methadone was also encountered. This produces an outstanding short-term change in glycaemic homeostasis and may well lead to future alterations in glucose tolerance.

[Programs of diabetological education: a basic tool in the treatment of diabetes mellitus]. / Programas de educación diabetológica: arma fundamental para el tratamiento de la diabetes mellitus.

To assess whether the programs of diabetologic education (PDE) are effective to improve metabolic control in diabetes mellitus, depending on their inclusion in an overall therapeutic program and on the setting where they are imparted (hospital versus primary care center, PCC), we evaluated the changes in the HbA1 values in 230 insulin-treated diabetic patients, after receiving a PDE in a PCC (group A; n = 88) or as hospital inpatients (group B; n = 72) or outpatients (group C; n = 50). The remaining 20 patients (group D) received the same PDE, but their treatment did not depend on our Unit. The initial mean HbA1 levels were significantly reduced 3, 6 and 9 months after the PDE in group A patients (10.6% vs 9.6%, p less than 0.05; vs 9.4%, p less than 0.02; vs 9.1%, p less than 0.01), in group B patients (10.0% vs 9.5%, p less than 0.05; vs 9.1%, p less than 0.05; vs 9.0%, p less than 0.05) and group C patients (10.1% vs 9.5%, p less than 0.05; vs 9.1%, p less than 0.02; vs 8.9, p less than 0.01); however, they did not significantly change in group D patients (10.3% vs 10.7%, vs 10.3%, and vs 10.0%). Mean HbA1 in months 3, 6 and 9 were not different between groups A, B and C, but they were lower (p less than 0.05) than in group D. Our results confirm that PDE and treatment are effective to improve metabolic control in diabetic patients, whereas diabetological education alone is not useful. The place where PDE is given is not determinant for its effectiveness.

[The level of glycohaemoglobin (Hb A1c) in connection with diabetes and pregnancy (author's transl)]. / Dosage de l'hémoglobine glycosylée (Hb A1c) dans l'association "diabète et grossesse".

The authors worked out a normal curve using 379 levels obtained over 9 months in 180 normal pregnancies. 6% (with a confidence level between 4.4% and 7.6%) was usual for haemoglobin A1c. Then they compared 42 levels of glycohaemoglobin obtained from 14 pregnant diabetic patients where the mean value was 8.34%. Glycohaemoglobin A1c therefore is a good indicator or the level of stabilisation in diabetic pregnancies in the two months before the estimation is taken. It is therefore possible to think that it does indicate chronic hyperglycaemia and does seem to have a future in screening diabetic pregnancies. On the other hand it does not seem to be of any supplementary value in monitoring the fetus of the diabetic mother in the third trimester of pregnancy because of the small variations in the levels that are obtained as compared with the suddenness of fetal complications.