Antidiabetic activity of Gladiolus psittascinus in alloxan induced diabetic rats

The methanol extract of Gladiolus psittascinus bulb was evaluated for its antidiabetic activities in alloxan-induced diabetic rats. Blood glucose levels of the glucose loaded and alloxan-induced diabetic rats were estimated over 180 minutes using the O-toluidine and glucose-oxidase methods. The methanol extract at 1 g/kg dose exhibited 16.2% decrease in blood glucose level in the glucose loaded rats and a peak effect of 78.9% in the alloxan-induced diabetic rats. The extract exhibited significant blood glucose lowering effects in the oral glucose tolerance test and type 2 diabetic rats. This study shows a possible beneficial effect of Gladiolus psittascinus in the management of non-insulin dependent diabetes (NIDDM).

Environmental arsenic as a disruptor of insulin signaling

Previous laboratory studies have shown that exposures to inorganic As (iAs) disrupt insulin production or glucose metabolism in cellular and animal models. Epidemiological evidence has also linked chronic human exposures to iAs to an increased risk of diabetes mellitus, a metabolic disease characterized by impaired glucose tolerance and insulin resistance. We have recently shown that arsenite and its methylated metabolites inhibit insulin-stimulated glucose uptake in cultured adipocytes by disrupting insulin-activated signal transduction pathway and preventing insulin-dependent translocation of GLUT4 transporters to the plasma membrane. Here, we present results of follow-up studies using male C57BL/6 mice chronically exposed to arsenite (1 to 50 ppm As) or to its metabolite methylarsonite (0.1 to 5 ppm As) in drinking water for 8 weeks. Results of these studies show that only the exposure to arsenite at the highest level of 50 ppm As produces symptoms attributable to impaired glucose tolerance. Notably, tissue concentrations of iAs and its methylated metabolites in pancreas and in major glucose metabolizing tissues in mice in this exposure group were comparable to the concentrations of total As reported in livers of Bangladeshi residents exposed to much lower concentrations of iAs in drinking water. These results suggest that because mice clear iAs and its metabolites more rapidly than humans, much higher exposure levels may be needed in mouse studies to produce the diabetogenic effects of iAs commonly found in human populations exposed to iAs from environmental sources.

Prolonged cerebellar ataxia: an unusual complication of hypoglycemia

A 51-year-old male with a history of insulin-dependent diabetes and polysubstance abuse presented after overdose on insulin. Soon after resuscitation, he displayed a severe ataxia in all 4 limbs and was unable to walk; all of which persisted for at least 5 days. Laboratory testing was unrevealing, including relatively normal brain magnetic resonance imaging. He had recovered full neurologic function 3 months after the event. This report describes a case of reversible cerebellar ataxia as a rare complication of severe hypoglycemia that may occur in patients with abnormal cerebellar glucose metabolism. Thus, this phenomenon should be included in the differential diagnosis of patients with a history of hypoglycemia who present with ataxia. In this context, the differential diagnosis of cerebellar ataxia is discussed, as is the proposed mechanism for hypoglycemia-induced cerebellar dysfunction.

Pathogenesis, risk assessment and prevention of type 2 diabetes mellitus

Type 2 diabetes mellitus is a complex, polygenic disease with a heterogeneous pathophysiology, mainly characterised by obesity-associated insulin resistance and a progressive failure of pancreatic beta-cells. Predominant risk factors for its development are abdominal obesity and age; other factors that augment the individual disease risk independent of obesity are the nutritional pattern (low consumption of fibres, high consumption of red meat, saturated and trans fat), lifestyle (smoking, low physical activity), and biomarkers such as blood pressure, HbA1c, serum adiponectin and inflammatory cytokines. These variables can provide the basis for a precise risk assessment and a personalised prevention. Genotyping for the presently known gene variants conferring an increased disease risk adds relatively little to the information provided by the phenotypic risk factors and biomarkers. However, genetic information is necessary for a personalised risk assessment and intervention that begins before phenotypic risk factors are detectable. The incidence of type 2 diabetes can significantly be lowered by reduction of the intraabdominal fat mass (by nutritional intervention and exercise), and by pharmacological control of post-prandial blood glucose excursions. Because of the high portion of non-responders to a preventive intervention, current efforts aim at the identification of phenotypic and genetic variables predicting the success of the intervention.

Spinal epidural abscess associated with moxibustion-related infection of the finger

OBJECTIVE

To describe a spinal epidural abscess that originated from cellulitis after moxibustion.

METHODS

Case report.

FINDINGS

A 78-year-old woman with diabetes mellitus was diagnosed with tetraplegia due to a cervical spinal epidural abscess extending to the thoracic spinal epidural space. The abscess was caused by osteomyelitis and cellulitis of the right third finger, which had been cauterized repeatedly with moxa. After surgical decompression and drainage of the spinal epidural abscess and comprehensive rehabilitation, motor strength and functional level improved.

CONCLUSIONS

This case illustrates the risk of spinal epidural abscess in persons with diabetes mellitus who present with focal cellulitis and osteomyelitis.

Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician's assistants

PURPOSE

The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician's assistants (PAs), or neither, and which practice attributes contribute to any differences in care.

METHODS

This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs.

RESULTS

Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A(1c) levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P <or= .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A(1c) levels (66% vs 49%) and lipid levels (80% vs 68%) (P<or=.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices.

CONCLUSIONS

Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.

Self-reported diabetes mellitus and risk of mortality from all causes, cardiovascular disease, and cancer in Takayama: a population-based prospective cohort study in Japan

BACKGROUND

Diabetes mellitus has been reported to be a major risk factor for cardiovascular disease (CVD), and higher risk of CVD among women than that among men has been observed in many studies. Further, the association of diabetes with increasing risk of cancer has also been reported. Well-designed studies conducted among men and women in the general Japanese population remain scarce.

METHODS

Our cohort consisted of 13355 men and 15724 women residing in Takayama, Japan, in 1992. At the baseline, the subjects reported diabetes in a questionnaire. Any deaths occurring in the cohort until 1999 were noted by using data from the Office of the National Vital Statistics. The risk of mortality was separately assessed for men and women by using a Cox proportional hazard model after adjusting for age; smoking status; body mass index (BMI); physical activity; years of education; history of hypertension; and intake of total energy, vegetables, fat, and alcohol.

RESULTS

Diabetes significantly increased the risk of mortality from all causes [hazard ratio (HR): 1.35, 95% confidence interval (CI): 1.11-1.64] and from coronary heart disease (CHD) (HR: 2.96, 95% CI: 1.59-5.50) among men, and that from all causes (HR: 1.74, 95% CI: 1.34-2.26) and cancer (HR: 1.88, 95% CI: 1.16-3.05) among women. Diabetes was not significantly associated with mortality from CHD among women.

CONCLUSION

The findings suggest that diabetes increases the risk of mortality from CVD among men and that from cancer among women. The absence of increased risk of mortality from CHD among women may suggest a particular pattern in the Japanese population.

Diabetes management in urban African Americans: review of a public hospital experience

OBJECTIVE

To review characteristics of an urban (primarily African American) diabetes patient population and discuss experience with treatment strategies, we summarize key retrospective and prospective analyses conducted during 15 years.

RESULTS

Severe socioeconomic and personal barriers to diabetes care were often seen in the population. An atypical presentation of diabetic ketoacidosis was observed and extensively studied. A structured diabetes care delivery program was implemented more than three decades ago. A better understanding of how to provide simpler but effective dietary education and factors that affect lipid levels were elucidated. The phenomenon of clinical inertia was described, and methods were developed to facilitate the intensification of diabetes therapy and improve glycemic control.

CONCLUSIONS

Structured diabetes care can be successfully introduced into a public health system and effective diabetes management can be provided to an under-served population that can result in improved metabolic outcomes. Lessons learned on diabetes management in this population can be extended to similar clinical settings.

Becaplermin gel in the treatment of diabetic neuropathic foot ulcers

Diabetic foot ulcers remain a major cause of morbidity. Significant progress has been accomplished in ulcer healing by improved management of both ischemia and neuropathy in the diabetic foot. Nevertheless, there is a vital need for further improvement. Becaplermin gel represents an important therapeutic advance for diabetic neuropathic foot ulcers with adequate blood supply. Randomized controlled trials have shown that it is effective in increasing healing rates. However, this efficacy has not translated to positive clinical experience, and the drug is not widely used. Moreover, becaplermin is an expensive medication. Even though it has repeatedly been estimated as cost-effective, its high cost may be prohibitive for some clinicians, especially in developing countries. Clearly, further work is needed to clarify whether use of becaplermin is justified in everyday clinical practice. Future research also needs to assess the potential room for improvement with becaplermin, for instance by combination with other growth factors or by exploring alternative modes of drug delivery.

Computerized learning technologies for diabetes: a systematic review

BACKGROUND

The objective of this study was to evaluate computerized learning technology interventions that can empower patients in the self-management of diabetes and support diabetes education over a distance.

METHODS

We searched Medline (1966-2006), CINAHL (1982-2006), and the Cochrane Central Register of Controlled Trials (first quarter 2007) databases. We also reviewed reference lists from included studies to identify additional studies. We included 25 articles representing 21 randomized controlled trials that evaluated a computerized learning technology and measured the outcome of patient care. We extracted patient sample, intervention, educational content topics, outcome measures, and statistical significance.

RESULTS

Of 21 eligible trials, 18 trials (85.7%) reported significant positive outcomes. Almost 44% (43.8%) of the outcomes demonstrated significant improvements (49 of 112 outcomes).

CONCLUSIONS

Patient self-management behaviors are important in chronic disease management, and initial evidence suggests that computerized learning technology interventions can play a significant role in the future.

Hypoglycemic and hypolipidemic activity of ethanolic extract of Salvadora oleoides in normal and alloxan-induced diabetic rats

OBJECTIVE

To find out the hypoglycemic and hypolipidemic activity of an ethanolic extract of the aerial part of Salvadora oleoides Decne in euglycemic and alloxan-induced diabetic albino rats.

MATERIALS AND METHODS

Diabetes was induced in albino rats by administration of alloxan monohydrate (120 mg/kg, i.p.). Normal as well as diabetic albino rats were divided into groups (n = 6) receiving different treatments: vehicle (control), ethanolic extract (1 g and 2 g/kg b.w), and standard antidiabetic drug tolbutamide (0.5 g/kg b.w.). Blood samples were collected by cardiac puncture and were analyzed for blood glucose and lipid profile on days 0, 7, 14, and 21.

RESULTS

The ethanolic extract of S oleoides produced significant reduction (P < 0.001) in blood glucose and also had beneficial effects (P < 0.001) on the lipid profile in euglycemic as well as alloxan-induced diabetic rats at the end of the treatment period (21(st) day). However, the reduction in the blood glucose and improvement in lipid profile was less than that achieved with the standard drug tolbutamide.

CONCLUSION

We concluded that an ethanolic extract of S oleoides is effective in controlling blood glucose levels and improves lipid profile in euglycemic as well as diabetic rats.

Building a diabetes registry from the Veterans Health Administration's computerized patient record system

BACKGROUND

Little information is available describing how to implement a disease registry from an electronic patient record system. The aim of this report is to describe the technology, methods, and utility of a diabetes registry populated by the Veterans Health Information Systems Architecture (VistA), which underlies the computerized patient record system of the Veterans Health Administration (VHA) in Veteran Affairs Integrated Service Network 10 (VISN 10).

METHODS

VISN 10 data from VistA were mapped to a relational SQL-based data system using KB_SQL software. Operational definitions for diabetes, active clinical management, and responsible providers were used to create views of patient-level data in the diabetes registry. Query Analyzer was used to access the data views directly. Semicustomizable reports were created by linking the diabetes registry to a Web page using Microsoft asp.net2. A retrospective observational study design was used to analyze trends in the process of care and outcomes.

RESULTS

Since October 2001, 81,227 patients with diabetes have enrolled in VISN 10: approximately 42,000 are currently under active management by VISN 10 providers. By tracking primary care visits, we assigned 91% to a clinic group responsible for diabetes care. In the Cleveland Veterans Affairs Medical Center (VAMC), the frequency of mean annual hemoglobin A1c levels > or =9% has declined significantly over 5 years. Almost 4000 patients have been seen in diabetes intervention programs in the Cleveland VAMC over the past 4 years.

CONCLUSIONS

A diabetes registry can be populated from the database underlying the VHA electronic patient record database system and linked to Web-based and ad hoc queries useful for quality improvement.

β-cell regeneration to treat Type 1 diabetes mellitus

Type 1 diabetes mellitus (T1DM) results from the autoimmune destruction of the insulin-producing pancreatic β-cells. The autoimmune response begins years before the presentation of hyperglycemic symptoms. At the time of clinical diagnosis, less than 30% of β-cell mass still remains. The conventional therapeutic option to T1DM is daily insulin injections, which is shown to promote tight glucose control and reduce the majority of chronic diabetic complications. Subgroup analysis of the Diabetes Control and Complication Trial showed another important aspect related to long-term complications of diabetes, that is, patients with initially higher serum levels of C-peptide with sustained levels over the subsequent years suffered less microvascular complications and less hypoglycemic events than those patients with low or undetected C-peptide levels. In face of this, β-cell preservation is another important target in the management of T1DM and its related complications. Along the years, many efforts toward the identification of precursors of β-cells have been made, not only with the aim of understanding the physiology of β-cell preservation, but also as a potential source of β-cell replacement. In this review, we summarize the most important studies related to probable precursor cells implied in the process of regeneration, and the results of various immunomodulatory regimens aiming at blocking autoimmunity against pancreatic β-cells and at promoting β-cell preservation. Finally, we comment on the future perspective related to stem cell therapy in T1DM.

Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?

BACKGROUND

The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.

OBJECTIVE

We sought to understand how the number, type, and severity of comorbidities influence diabetes patients' self-management and treatment priorities.

DESIGN

Cross-sectional observation study.

PATIENTS

A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.

MEASUREMENTS

We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).

RESULTS

40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.

CONCLUSIONS

The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients' self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.

Use of a registry-generated audit, feedback, and patient reminder intervention in an internal medicine resident clinic--a randomized trial

BACKGROUND

Disease registries, audit and feedback, and clinical reminders have been reported to improve care processes.

OBJECTIVE

To assess the effects of a registry-generated audit, feedback, and patient reminder intervention on diabetes care.

DESIGN

Randomized controlled trial conducted in a resident continuity clinic during the 2003-2004 academic year.

PARTICIPANTS

Seventy-eight categorical Internal Medicine residents caring for 483 diabetic patients participated. Residents randomized to the intervention (n = 39) received instruction on diabetes registry use; quarterly performance audit, feedback, and written reports identifying patients needing care; and had letters sent quarterly to patients needing hemoglobin A1c or cholesterol testing. Residents randomized to the control group (n = 39) received usual clinic education.

MEASUREMENTS

Hemoglobin A1c and lipid monitoring, and the achievement of intermediate clinical outcomes (hemoglobin A1c <7.0%, LDL cholesterol <100 mg/dL, and blood pressure <130/85 mmHg) were assessed.

RESULTS

Patients cared for by residents in the intervention group had higher adherence to guideline recommendations for hemoglobin A1c testing (61.5% vs 48.1%, p = .01) and LDL testing (75.8% vs 64.1%, p = .02). Intermediate clinical outcomes were not different between groups.

CONCLUSIONS

Use of a registry-generated audit, feedback, and patient reminder intervention in a resident continuity clinic modestly improved diabetes care processes, but did not influence intermediate clinical outcomes.

The dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians and nurses

OBJECTIVE

To explore physicians' and nurses' views on patient and professional roles in the management of lifestyle-related diseases and their risk factors.

DESIGN

A questionnaire study with a focus on adult obesity, dyslipidemia, high blood pressure, type 2 diabetes, and smoking.

SETTING

Healthcare centres in Päijät-Häme hospital district, Finland.

SUBJECTS

Physicians and nurses working in primary healthcare (n =220).

MAIN OUTCOME MEASURES

Perceptions of barriers to treatment of lifestyle-related conditions, perceptions of patients' responsibilities in self-care, experiences of awkwardness in intervening in obesity and smoking, perceptions of rushed schedules, and perceptions of health professionals' roles and own competence in lifestyle counselling.

RESULTS

A majority agreed that a major barrier to the treatment of lifestyle-related conditions is patients' unwillingness to change their habits. Patients' insufficient knowledge was considered as such a barrier less often. Self-care was actively encouraged. Although a majority of both physicians and nurses agreed that providing information, and motivating and supporting patients in lifestyle change are part of their tasks, only slightly more than one half estimated that they have sufficient skills in lifestyle counselling. Among nurses, those with less professional experience more often reported having sufficient skills than those with more experience. Two-thirds of the respondents reported that they had been able to help many patients to change their lifestyles into healthier ones.

CONCLUSIONS

The primary care professionals experienced a dilemma in patients' role in the treatment of lifestyle-related diseases: the patient was recognized as central in disease management but also, if reluctant to change, a major potential barrier to treatment.

Differences in insulin sensitivity and secretory capacity based on OGTT in subjects with impaired glucose regulation

BACKGROUND

This study examined whether defects in insulin secretion contribute to the development and progression of type 2 diabetes mellitus (T2DM).

METHODS

Plasma insulin and glucose were measured after a glucose tolerance test to calculate the insulinogenic index (IGI) and the HOMA-IR Homeostasis model assessment of insulin resistance in subjects with normal glucose tolerance (NGT), prediabetes (preDM, n = 49), and T2DM patients with disease duration < 1 year (n = 84), 1 approximately 5 years (n = 45), or > 5 years (n = 37). Plasma proinsulin and adiponectin levels were also measured as a parameter of insulin secretion and resistance.

RESULTS

The mean HOMA-IR increased and the adiponectin levels decreased relative to the deterioration of glucose tolerance in NGT and preDM subjects. However, differences in the HOMA-IR were not related to disease duration in T2DM subjects. The mean IGI was similar in NGT and preDM subjects, but there were significant deteriorations in IGI relative to the duration of diabetes.

CONCLUSIONS

Defects in both insulin sensitivity and insulin secretion contribute to T2DM, but decreased insulin secretion may be more important in the development and progression of T2DM.

Mechanisms of impaired calcium handling underlying subclinical diastolic dysfunction in diabetes

Isolated diastolic dysfunction is found in almost half of asymptomatic patients with well-controlled diabetes and may precede diastolic heart failure. However, mechanisms that underlie diastolic dysfunction during diabetes are not well understood. We tested the hypothesis that isolated diastolic dysfunction is associated with impaired myocardial Ca(2+) handling during type 1 diabetes. Streptozotocin-induced diabetic rats were compared with age-matched placebo-treated rats. Global left ventricular myocardial performance and systolic function were preserved in diabetic animals. Diabetes-induced diastolic dysfunction was evident on Doppler flow imaging, based on the altered patterns of mitral inflow and pulmonary venous flows. In isolated ventricular myocytes, diabetes resulted in significant prolongation of action potential duration compared with controls, with afterdepolarizations occurring in diabetic myocytes (P < 0.05). Sustained outward K(+) current and peak outward component of the inward rectifier were reduced in diabetic myocytes, while transient outward current was increased. There was no significant change in L-type Ca(2+) current; however, Ca(2+) transient amplitude was reduced and transient decay was prolonged by 38% in diabetic compared with control myocytes (P < 0.05). Sarcoplasmic reticulum Ca(2+) load (estimated by measuring the integral of caffeine-evoked Na(+)-Ca(2+) exchanger current and Ca(2+) transient amplitudes) was reduced by approximately 50% in diabetic myocytes (P < 0.05). In permeabilized myocytes, Ca(2+) spark amplitude and frequency were reduced by 34 and 20%, respectively, in diabetic compared with control myocytes (P < 0.05). Sarco(endo)plasmic reticulum Ca(2+)-ATPase-2a protein levels were decreased during diabetes. These data suggest that in vitro impairment of Ca(2+) reuptake during myocyte relaxation contributes to in vivo diastolic dysfunction, with preserved global systolic function, during diabetes.

[Prevalence of diabetic polyneuropathy in a rural population. Application of the Toronto Clinical Scoring System (TCSS)]

Objetivo

Determinar la prevalencia de polineuropatía periférica diabética (PNPDM) en nuestro medio.

Diseño

Estudio observacional, descriptivo, transversal.

Emplazamiento

Zona básica de salud (ZBS) de Porzuna, Ciudad Real.

Participantes

Todos los pacientes de la ZBS diagnosticados de diabetes mellitus en cualquiera de sus modalidades clínicas e independientemente del tiempo de evolución o edad del paciente, exceptuando los transeúntes o adscritos sólo de manera temporal a alguno de los cupos. Se excluyó del estudio a los pacientes con deterioro cognitivo lo suficientemente importante a juicio del investigador como para hacer inviable la anamnesis o la exploración necesaria.

Mediciones principales

Se registraron datos sobre antecedentes personales y familiares, comorbilidad, evolución de la diabetes (antigüedad, tratamiento, complicaciones), datos clínico-exploratorios (peso, talla, presión arterial, frecuencia cardíaca) y datos de laboratorio referentes a la diabetes. Para determinar la presencia de polineuropatía diabética (PNP-DM) se ha utilizado el Toronto Clinical Scoring System (Escala de Toronto [ET])1.

Resultados

Se identificó a 297 pacientes diabéticos (prevalencia del 5,51%), de los cuales 26 presentaban criterios de exclusión. El 96,7% eran diabéticos tipo 2, con una edad media de 68,6 ± 11,1 años y 9,7 ± 6,5 años de evolución. El 60,5% eran mujeres. Sus características se resumen en la tabla 1.

Tabla 1 Características generales de los pacientes diabéticos de la ZBS incluidos en el estudioParámetro n % Sexo  Varones 107 39,5%  Mujeres 164 60,5%  Edad (media ± DE) 68,6 ± 11,10 −  Tipo de DM  DM tipo 1 4 1,5%  DM tipo 2 262 96,7%  Otros 5 1,9% Años de evolución (media ± DE) 9,7 ± 6,5 (1-37) Edad de inicio (media ± DE) 58,9 ± 12,3 − Comorbilidad  HTA 194 71,6%  Obesidad 153 57,5%  Dislipemia 172 63,5%  Tabaquismo 21 7,7%  Patología tiroidea 20 7,4%  Cardiopatía isquémica 63 23,2%  ACV 19 7,0%  Arteriopatía periférica 17 6,3 Amputaciones 8 2,9% Presencia de complicaciones  Retinopatía DMa 61 22,5%  Nefropatía DMb 72 26,6%  Neuropatía DMc 6 2,2% Tratamiento de la DM  Dieta solo 46 17,0%  ADO 142 52,6%  ADO + insulina 48 17,8%  Insulina solo 34 12,6%  Peso (media ± DE) 78,2 ± 15,8 −  IMC (media ± DE) 31,4 ± 5,7 − Perímetro abdominal  Varones 105,1 ± 14 −  Mujeres 105,0 ± 13,9 − PAS (media ± DE) 152,4 ± 18,7 − PAD (media ± DE) 79,3 ± 10,2 − Glucemia basal (media ± DE) 158,6 ± 54,4 − HbA1c (media ± DE) 7,1 ± 1,6 − Creatinina (media ± DE) 0,9 ± 0,3 − TSH (media ± DE) 2,7 ± 5,4 − Rango de puntuación  < 6 (normal) 184 67,9%  6-8 (PNP-DM leve) 51 18,8%  9-11 (PNP-DM moderada) 30 11,1%  > 11 (PNP-DM grave) 6 2,2% ADO: antidiabéticos orales. aNo proliferativas, 72,1%; proliferativas 26,2%. bUsando la fórmula de Cockroft y Gault, de las cuales son leve el 58,3%, moderada el 34,7% y grave el 1,4%. cSegún informe de la historia clínica.

Los valores obtenidos en la ET muestran que un 32,1% de los pacientes presentaba algún grado de PNP-DM: leve (ET = 6-8) en el 18,8%, moderada (ET = 9-11) en el 11,1% y grave (ET > 11) en el 2,2%. La puntuación media del conjunto de diabéticos para dicha escala era de 3,9 ± 3,5. El grado de gravedad de la PNP-DM se acentúa con la edad (p = 0,0003) y las puntuaciones de PNP-DM grave no aparecen antes de los 60 años de edad; los pacientes con algún grado de polineuropatía llevan más años de evolución de su diabetes (10,7) que los pacientes sin polineuropatía (9,12), aunque sin alcanzar la significación estadística (p = 0,07); sin embargo, sí se encuentra significación estadística respecto a la edad de inicio clínico de la diabetes (según fecha registrada en la historia clínica: 62,2 frente a 57,4 años; p = 0,0028), el índice de masa corporal (IMC) (p = 0,0056), perímetro abdominal (p = 0,0008), la cifra de la velocidad de sedimentación globular (p = 0,002) y los diagnósticos de retinopatía diabética (p < 0,0001) o cardiopatía isquémica (p = 0,0003), rozando la significación estadística con la hipertensión arterial (p = 0,052) y la arteriopatía periférica (p = 0,0573).

Discusión y conclusiones

La prevalencia de la PNP-DM es mal conocida debido a la diversidad de métodos empleados en la captación de las muestras de pacientes y los criterios diagnósticos utilizados, con una oscilación en la literatura científica entre el 23 y el 49,5%2. En nuestro país no hemos encontrado ningún trabajo que aborde el problema con una base poblacional bien definida, no expuesta a sesgos de selección en función de la edad de los pacientes, el ámbito asistencial u otros. La prevalencia encontrada en nuestro estudio (32,1%) está alejada de la obtenida en otros estudios realizados en el ámbito de la atención primaria de nuestro país2-5 y más cercana a la de los estudios publicados del Reino Unido y Estados Unidos6 efectuados en un ámbito hospitalario.

Por otro lado, la ET para PNP-DM ha resultado ser rápida y fácil de aplicar, y en general muy bien tolerada por el paciente, requiriendo un instrumental fácilmente asequible para el médico de atención primaria (monofilamento, diapasón de 126 Hz y martillo de exploración), útil tanto para la exploración sistemática del paciente diabético con intención diagnóstica como para el seguimiento de la evolución de la posible sintomatología de su polineuropatía. Puede constituir, en nuestra opinión, una excelente herramienta para facilitar la aproximación diagnóstica a la PNP-DM.

Lacunar infarction in type 2 diabetes is associated with an elevated intracranial arterial pulsatility index

PURPOSE

The arterial pulsatility index (PI) is measured by transcranial Doppler ultrasonography (TCD) and is postulated to reflect the vascular resistance distal to the artery being examined. An increased PI of the intracranial artery is often reported with diabetes mellitus (DM), old age, hypertension, intracranial hypertension, vascular dementia, and small artery disease. Microvascular complication of DM, which may contribute to cerebral infarction, involves the small perforating artery and may influence the PI of the proximal artery.

MATERIALS AND METHODS

We performed a TCD examination in patients with type 2 DM with acute lacunar infarction (DML, n=35), type 2 DM without cerebral infarction (DMO, n=69), and in control cases with no DM or cerebral infarction (control group, n=41). We then compared the TCD findings among these groups.

RESULTS

The PI was significantly higher in the DML and DMO groups than in the control group (1.05, 0.93, 0.73. respectively, for the right middle cerebral artery; 1.04, 0.90, 0.73, respectively, for the left middle cerebral artery; 0.97, 0.89, 0.70, respectively, for the basilar artery). The PI was also significantly higher in the DML group than in the DMO group for both middle cerebral arteries. The flow velocity was comparable among the three groups.

CONCLUSION

The elevated PI of the intracranial arteries may reflect diabetic cerebral microvascular complications. The PI measurement using TCD may be a useful predictor of lacunar infarction in type 2 DM patients.

Prevalence of musculoskeletal disorders in patients with type 2 diabetes mellitus: a pilot study

BACKGROUND

Diabetes mellitus is associated with a variety of musculoskeletal disorders. The prevalence of connective tissue disorders in these patients has increased in the recent years affecting significantly their quality of life.

METHODS-RESULTS

We conducted a pilot study including 208 sequentially selected patients with type 2 diabetes mellitus regularly followed-up at the Diabetes Center of the Hippokration University Hospital. Among the diabetic patients who were screened according to the Short Musculoskeletal Function Assessment Questionnaire for musculoskeletal symptoms and findings, 82.6% were found to exhibit musculoskeletal abnormalities, mainly of the degenerative, noninflammatory type.

CONCLUSIONS

Musculoskeletal disorders are a common finding among patients with type 2 diabetes. Obesity and accumulation of abnormally glycosylated byproducts have been proposed as potential pathogenetic mediators of these connective tissue abnormalities. Of particular interest is, however, the common association of osteoarthritis, involving even non-weight bearing joints in patients with type 2 diabetes, indicating a common pathophysiologic mechanism connecting these two clinical conditions.

[Evaluation of a protocol to monitor cardiovascular risk factors in diabetic patients attended in primary care]

OBJECTIVE

To evaluate a primary care protocol for intensive monitoring of cardiovascular risk (CVR) factors in type-2 diabetes patients versus usual care.

DESIGN

Randomised trial with clusters.

SETTING

Primary care clinics.

PARTICIPANTS

Sixty family physicians.

INTERVENTIONS

Participants were randomised between following a protocol of intensive monitoring of CVR factors and maintaining their habitual practice with DM2 patients. Follow-up lasted 12 months. Data on HbA1C, CVR factors and CVR were collected at the start of the study and at 12 months.

RESULTS

In all, 188 patients (94 intervention group and 94 control group) were included. At baseline measurement, CVR in control group (CG) was 36.3% (95% CI, 33.9%-38.6%); and in intervention group (IG), 35.9% (95% CI, 33.5%-38.4%), with no significant differences between groups. At one year, CVR in CG was 33.1% (95% CI, 30%-36.1%) and in IG 30.5% (95% CI, 27.8%-33.2%). The CVR difference between baseline and 1-year measurements was 2.9% (95% CI, 0.2%-5.7%) in CG and 5.4% (95% CI, 2.8%-7.1%) in IG.

CONCLUSIONS

Although improvement of CVR is greater in the IG, the difference between the two groups is not significant. The characteristics of the doctors chosen may have meant that the patients of the two groups received similar treatment.

Colesevelam hydrochloride: reducing atherosclerotic coronary heart disease risk factors

Colesevelam HCl is a bile acid sequestrant (BAS) which has been specifically designed with a unique structure for the purpose of improving tolerability and reducing potential drug interactions compared to older BAS, such as cholestyramine and colestipol. As a class, BAS are known to reduce cholesterol and glucose levels, and to reduce atherosclerotic coronary heart disease (CHD) risk as monotherapy, and in combination with other lipid-altering drug therapies. Colesevelam HCl has specifically been shown to reduce total and low-density lipoprotein (LDL) cholesterol levels, and has been approved as a cholesterol-lowering drug since year 2000. It has also been shown to reduce glucose levels. This discussion reviews mechanisms by which BAS lower cholesterol, and potential mechanisms by which BAS lower glucose levels in patients with type 2 diabetes mellitus. Finally this paper specifically reviews colesevelam HCl's pharmacology, lipid and glucose efficacy, safety/tolerability, and clinical use.

A critical review of anti-adrenergic therapy in patients with heart failure and diabetes mellitus

Anti-adrenergic therapy has been widely accepted as an important therapeutic intervention in patients with chronic heart failure. However, there has been continuing controversy regarding the risks and clinical significance of metabolic effects of different anti-adrenergic drugs. This review summarizes what has been learned from clinical trial evidence regarding the benefits of anti-adrenergic drugs in diabetic patients with chronic heart failure.

Inhibitory activity of Euonymus alatus against alpha-glucosidase in vitro and in vivo

The major goal in the treatment of diabetes mellitus is to achieve near-normal glycemic control. To optimize both fasting blood glucose and postprandial glucose levels is important in keeping blood glucose levels as close to normal as possible. α-Glucosidase is the enzyme that digests dietary carbohydrate, and inhibition of this enzyme could suppress postprandial hyperglycemia. The purpose of this study was to test the inhibitory activity of methanol extract of Euonymus alatus on α-glucosidase in vitro and in vivo to evaluate its possible use as an anti-diabetic agent. Yeast α-glucosidase inhibitory activities of methanol extract of E. alatus were measured at concentrations of 0.50, 0.25, 0.10, and 0.05 mg/ml. The ability of E. alatus to lower postprandial glucose was studied in streptozotocin-induced diabetic rats. A starch solution (1 g/kg) with and without E. alatus extract (500 mg/kg) was administered to diabetic rats by gastric intubation after an overnight fast. Plasma glucose levels were measured at 30, 60, 90, 120, 180, and 240 min. Plasma glucose levels were expressed in increments from baseline, and incremental areas under the response curve were calculated. Extract of E. alatus,which had an IC₅₀ value of 0.272 mg/ml, inhibited yeast α-glucosidase activity in a concentration-dependent manner. A single oral dose of E. alatus extract significantly inhibited increases in blood glucose levels at 60 and 90 min (p<0.05) and significantly decreased incremental response areas under the glycemic response curve (p<0.05). These results suggest that E. alatus has an antihyperglycemic effect by inhibiting α-glucosidase activity in this animal model of diabetes mellitus.

Diabetic retinopathy

The prognosis of some of the most prevalent conditions seems to be intricately related to myriad risk factors, largely modifiable, but often leading to irreversible complications when left unmanaged. This study exemplifies the multidisciplinary approach necessary, to successfully control diabetic retinopathy, one of the leading complications of diabetes, and to discuss promising therapies. Based on a Medline Ovid database search, we present a clinical and economic review of the evidence on the epidemiology and risk factors of diabetic retinopathy, its prognosis and economic implications. Among adults aged 20-74, diabetic retinopathy (DR) is the most frequent cause of blindness. However, in both types 1 and 2 DM, improved glycemic control reduces the development and progression of DR. Risk factors of DR include duration of diabetes, pregnancy, renal disease, age, smoking, alcohol, hyperlipidemia and antioxidants. A number of drugs may play a role in DR therapy in the coming few years; eg, somatostatin agonists (sandostatin), corticosteroids (triamcinolone, dexamethasone, fluocinolone), vascular endothelial growth factor inhibitors (pegaptanib, ranibizumab), hyaluronidase and plasmin enzyme. Whether these therapies have a clinically significant impact on DR progression however, remains to be seen.

The efficacy of somatostatin analogues in the treatment of diabetic retinopathy and thyroid eye disease

Somatostatin, a polypeptide hormone of 14 or 28 aminoacids, is produced by neuroendocrine, inflammatory and immune cells. It has multiple inhibitory functions on the secretion of various hormones and growth factors and modulates several cellular functions. Somatostatin analogues provide an elegant pharmacological principal to modify the high-risk form of proliferative diabetic retinopathy. Pilot investigations have provided evidence that octreotide can very effectively suppress new bleeding and stop visual loss in patients who have failed conventional photocoagulation therapy. In this cohort, octreotide was found to be a safe treatment modality. The same applies also for thyroid eye disease, in which some non-randomized, as well as randomized studies have shown a beneficial effect. More potent analogues, like SOM230, which are not yet in the market, can be proved to have a better therapeutic outcome in such patients and may be considered a safe treatment modality to stop the progression from pre-proliferative to proliferative diabetic retinopathy. This is also true for adolescent patients with thyroid eye disease, as well as for adults who also suffer from diabetes mellitus.

Insulin aspart: rapid control for postmeal glucose excursions

Insulin aspart is a rapid-acting insulin analog that can be used to control prandial glucose levels as part of basal-bolus therapy, in continuous subcutaneous insulin infusion or in combination with oral antidiabetic drugs. Compared with exogenous human soluble insulin, insulin aspart has a faster onset of action, a higher peak concentration and a shorter duration of action, and is therefore more comparable to the physiological prandial insulin response. Randomized clinical trials have shown efficacy and safety advantages with insulin aspart over human soluble insulin, in particular, improved postprandial glucose control and lower rates of hypoglycemia. Currently, insulin aspart has been approved for use not only in adults and children with diabetes mellitus, but also for pregnant women with diabetes, including those with gestational diabetes.

IGF-1 is an independent risk factor for anemia in diabetic pre-dialysis patients

BACKGROUND

We investigated whether the presence of diabetes mellitus (DM) was related to the degree of the anemia in predialytic patients with renal failure and what was the most relevant factor for anemia in patients with chronic kidney disease (CKD) from DM (DM-CKD).

METHODS

Seventy seven patients (47 predialytic patients with long-term type 2 DM (DM-CKD) and 30 predialytic patients whose disease was due to other causes (non DM-CKD)) were enrolled in this study. The blood hemoglobin (Hb) and hematocrit, and the creatinine, ferritin, vitamin B12, folate, iron, LDH, albumin, hs-CRP, intact-PTH, erythropoietin, leptin and Insulin-like growth factor I (IGF-1) levels were measured using standard methods. The estimated GFR was calculated using the abbreviated MDRD equation.

RESULTS

The two groups did not significantly differ as to age, gender, the serum creatinine level and the inflammatory status. The Hb level was significantly lower in the DM-CKD patients than that in the non DM-CKD patients (8.5+/-1.7 g/dL vs 9.6+/-1.6 g/dL, respectively, p=0.01). The Hb level was significantly lower in the DM-CKD patients who were being treated with ACE inhibitors (the DM-ACE patients) than that in the non DM-CKD patients who were being treated with ACE inhibitors (the non DM-ACE patients) (8.5+/-1.5 g/dL vs 10.8+/-1.6 g/dL, respectively, p=0.001). Multiple regression analysis indicated that serum IGF-1 concentration was independently associated with the Hb level (beta=0.425, p=0.02) in the DM-CKD patients.

CONCLUSIONS

The Hb concentration was significantly lower in the DM-CKD patients than that in the non DM-CKD patients. It was independently associated with the serum IGF-1 concentration in the DM-CKD patients.

Effect of duration of disease on ventilatory function in an ethnic Saudi group of diabetic patients

BACKGROUND

Diabetes mellitus is a leading cause of illness and death across the world and is responsible for a growing proportion of global health care expenditures. The present study was designed to observe the effect of diabetes mellitus on lung function in patients with diabetes belonging to a specific ethnic group, namely Saudis.

METHOD

In this study, a group of 47 apparently healthy volunteer male Saudi patients with diabetes was randomly selected. Their ages ranged from 20 to 70 years. The patients were matched with another group of 50 healthy male control subjects in terms of age, height, weight, ethnicity, and socioeconomic status. Both groups met exclusion criteria as per standard. Spirometry was performed with an electronic spirometer (Schiller AT-2 Plus, Switzerland), and results were compared by a Student's t test.

RESULTS

Subjects with diabetes showed a significant reduction in forced vital capacity (FVC) and forced expiratory volume in the first second (FEV(1)) relative to their matched controls. However, there were no significant differences in the forced expiratory ratio (FEV(1)/FVC%) and the middle half of the FVC (FEF(25-75%)) between the groups. We observed a significantly negative correlation between duration of disease and pulmonary function, as measured by FEV(1) (r = 0.258, p = 0.04), FVC (r = 0.282, p = 0.28), and the middle half of the FVC (FEF(25-75%)) (r = 0.321, p = 0.014).

CONCLUSIONS

Pulmonary function in a specific ethnic group of patients with diabetes was impaired as evidenced by a decrease in FVC and FEV(1) compared to pulmonary function in matched controls. Stratification of results by years of disease revealed a significant correlation between duration of disease and a decline in pulmonary function.

Crystal structure of the incretin-bound extracellular domain of a G protein-coupled receptor

Incretins, endogenous polypeptide hormones released in response to food intake, potentiate insulin secretion from pancreatic beta cells after oral glucose ingestion (the incretin effect). This response is signaled by the two peptide hormones glucose-dependent insulinotropic polypeptide (GIP) (also known as gastric inhibitory polypeptide) and glucagon-like peptide 1 through binding and activation of their cognate class 2 G protein-coupled receptors (GPCRs). Because the incretin effect is lost or significantly reduced in patients with type 2 diabetes mellitus, glucagon-like peptide 1 and GIP have attracted considerable attention for their potential in antidiabetic therapy. A paucity of structural information precludes a detailed understanding of the processes of hormone binding and receptor activation, hampering efforts to develop novel pharmaceuticals. Here we report the crystal structure of the complex of human GIP receptor extracellular domain (ECD) with its agonist, the incretin GIP(1-42). The hormone binds in an alpha-helical conformation in a surface groove of the ECD largely through hydrophobic interactions. The N-terminal ligand residues would remain free to interact with other parts of the receptor. Thermodynamic data suggest that binding is concomitant with structural organization of the hormone, resulting in a complex mode of receptor-ligand recognition. The presentation of a well structured, alpha-helical ligand by the ECD is expected to be conserved among other hormone receptors of this class.

Combined use of brain natriuretic peptide and C-reactive protein for predicting cardiovascular risk in outpatients with type 2 diabetes mellitus

Appropriate tools are necessary for predicting cardiovascular events in patients with diabetes mellitus because of their high incidence. In this study, we assessed whether a combination of brain natriuretic peptide (BNP) and C-reactive protein (CRP) measurement were useful prognosticators in patients with type 2 diabetes mellitus. One hundred and nine patients with type 2 diabetes mellitus, aged 52 to 93 years, were examined at outpatient clinics for blood, urinary samples, and echocardiography. They were then followed prospectively. During the average follow-up period of 30 months (range, 3 to 37), 15 patients (14%) had cardiovascular events: This was the first event in 5 patients and a recurrence in 10. Cox regression analysis showed that the past event (hazard ratio [HR] 4.819 [95% confidence interval (CI): 1.299-17.881]; p = 0.019) and plasma BNP level (HR 1.007 [95% CI: 1.002-1.012]; p = 0.010] were independently significant factors for the cardiovascular events during the follow-up period. Patients with plasma BNP > or =53 pg/mL and CRP > or =0.95 mg/dL demonstrated the highest incidence in cardiovascular event, compared to those categorized into either or both low levels of BNP and CRP. This study suggests that combination of plasma BNP and CRP measurement provides the additive prognostic information of cardiovascular events in patients with type 2 diabetes mellitus.

Diabetes Research in Children Network (DirecNet) Study Group. Impaired overnight counterregulatory hormone responses to spontaneous hypoglycemia in children with type 1 diabetes

To assess the changes in counterregulatory hormones overnight after an afternoon of structured exercise or sedentary activity in children with type 1 diabetes mellitus (T1DM), the Diabetes Research in Children Network (DirecNet) studied 50 children (10 to <18 yr) with T1DM in five clinical research centers on two separate days (with and without an afternoon exercise session) using a crossover design. Glucose, epinephrine, norepinephrine, cortisol, growth hormone (GH), and glucagon concentrations were measured hourly overnight. Nocturnal hypoglycemia [plasma glucose concentrations < or =70 mg/dL (3.9 mmol/L)] occurred more frequently on the nights following exercise (56 vs. 36%; p = 0.008). Mean hourly concentrations of most hormones did not differ between sedentary or exercise nights or between nights with or without hypoglycemia. Spontaneous nocturnal hypoglycemia only stimulated small increases in plasma epinephrine and GH concentrations and failed to cause a rise in norepinephrine, cortisol, or glucagon levels in comparison with values during the hour before or after hypoglycemia or other times during those same nights. Counterregulatory hormone responses to spontaneous nocturnal hypoglycemia were markedly decreased regardless of whether there was antecedent afternoon exercise in children with T1DM. Sleep-induced impairments in counterregulatory hormone responses likely contribute to the increased risk of hypoglycemia during the entire overnight period in youth with T1DM.

Randomized studies are needed to assess the true role of self-monitoring of blood glucose in noninsulin-treated type 2 diabetes

Numerous trials have been conducted to assess the utility of self-monitoring of blood glucose (SMBG) in noninsulin-treated type 2 diabetic (T2DM) patients. Although recent meta-analyses support the benefits of SMBG, the clinical utility of SMBG in this population remains controversial due to a lack of large, randomized controlled trials. Much of the skepticism regarding SMBG in noninsulin-treated T2DM may stem from a misapplication or misunderstanding of the true role of SMBG. The benefits of SMBG are realized only when both the patient and the health care provider (HCP) know how and are willing to monitor, interpret, and respond appropriately to acute glucose excursions and patterns of glycemia identified through SMBG. Optimal utilization of SMBG requires that patients be trained and motivated to accurately perform SMBG at the time and frequency prescribed, accurately interpret the data they obtain, act upon the information when appropriate, and consistently document results for later review with their HCP. HCPS must be willing and able to routinely monitor SMBG data and make appropriate adjustments in therapy. Numerous studies are needed to evaluate the true value and utility of SMBG within the diverse T2DM population to ensure that resources for diabetes management can be used efficiently. This article identifies and discusses key factors to consider for the design of randomized studies that can provide a foundation upon which HCPs and health care systems may reevaluate their current strategies/protocols and incorporate the learnings into more effective approaches to patient care.

Comparing knowledge of diabetes mellitus among rural and urban diabetics

A questionnaire-based cross-sectional study was carried out to assess the awareness of diabetes mellitus among rural and urban diabetics. After analyzing the awareness level of both populations, the urban diabetics were found to be more educated about diabetes. A 25-question survey was used to judge the awareness level of diabetes mellitus. A total of 240 diabetics were surveyed, 120 each from rural and urban areas. The mean awareness among the rural population was 13 (SD+/-2) correct answers out of a possible 25. Similarly, in the case of the urban diabetics the mean awareness was 18 (SD+/-2) correct answers. The survey was conducted on randomly chosen diabetics belonging to Lahore and Faisalabad, (urban areas), as well as Habibabad, Haveli Koranga and Baba Kanwal (rural areas). The results emphasize the interrelation between demography and awareness of diabetes mellitus. The rural diabetics are far less knowledgeable about diabetes mellitus, its management and its complications. Thus, there is an urgent need to improve the awareness level of diabetes mellitus in rural areas. Doing so will give rise to a healthier workforce and a lessened economic burden on Pakistan.

[Medical treatment for diabetic nephropathy and the nephropathic form of the diabetic foot]

To date, we have a huge data on problems of prevention and treatment of late complications of diabetes, which largely determine the duration and quality of life of patients. One of the most serious complications is diabetic foot syndrome - a complex of pathological changes in the peripheral nervous system, arterial and microvasculature, which pose a direct threat to the development of ulcerative necrotic processes and gangrene of the foot.

Glycated Collagen I (GC) impairs angiogenesis in vitro: a study using an innovative chamber for cell research

Studies of cell-matrix, cell-cell interaction or angiogenesis on different matrices require simultaneous comparison of read-out parameters from differently treated companion cells. The culture conditions (cell number, temperature and volume of culture medium) in different chambers are not completely equalized using conventional methods. It has been reported that cells growing in different environmental conditions may exhibit different proliferation patterns [P. Tracqui, J.W. Liu, O. Collin, J. Clement-Lacroix, E. Planus, Global analysis of endothelial cell line proliferation patterns based on nutrient-depletion models: implications for a standardization of cell proliferation assays, Cell Proliferat. 38(June (3)) (2005) 119-135]. Herein we describe an innovative chamber, which could resolve this problem by significantly improving the standardization of experimental conditions. The chamber was manufactured from a standard cell culture well by its division with a septum into two sections. We utilized the chamber and recently developed topological analysis to examine the effects of glycated matrices on the capillary-like network formation by endothelial cells. Glycated Collagen I resulted in dose-dependent changes to all measured topological characteristics of the capillary-like network, such as the number of branching points, number of meshes and total capillary length. These differences were observed only in neighbored compartments coated with different matrices, but not in the compartments coated with the same matrix. The novel chamber brings an opportunity for better standardization of experimental conditions and simultaneous observation of different experimental groups, reducing the possible effect of any systematic error.

Microarray for genes associated with signal transduction in diabetic OLETF keratocytes

PURPOSE

The purpose of this study was to identify differences in signal transduction gene expression between normal and diabetic keratocytes stimulated with interleukin-1alpha (IL-1alpha) and tumor necrosis factor-alpha (TNF-alpha).

METHODS

Normal and diabetic keratocytes were primarily cultured and treated with 20 ng/ml IL-1alpha and TNF-alpha for 6 h. cDNA was hybridized to an oligonucleotide microarray. Genes identified by the microarray were further evaluated by real-time PCR.

RESULTS

Diabetic keratocytes over-expressed components of the MAPK and Notch pathways, and under-expressed components of the insulin, calcium, and TGF-beta pathways. Cytokine treated diabetic keratocytes differentially expressed components of the TGF-beta and MAPK pathways. After IL-1alpha and TNF-alpha treatment, nine genes were under-expressed, falling in the insulin, TGF-beta, and Toll-like receptor pathways. Real-time PCR showed a significant decrease in the IL-6 and TGF-beta2 genes and a significant increase in the Ppm1a gene.

CONCLUSIONS

There were some differences in gene expression between normal and diabetic keratocytes related to signal transduction pathways, such as the insulin, MAPK, calcium, and TGF-beta pathways. In addition, IL-1alpha and TNF-alpha stimulating the insulin, TGF-beta, and Toll-like receptor signaling pathways may have different effects in diabetic keratocytes.

Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus

INTRODUCTION

Detection and response to medically urgent situations in patients with diabetes mellitus can improve the process and outcomes of care and potentially decrease morbidity and mortality. We examined the detection and remediation of medically urgent situations among older patients receiving telemedicine case management for diabetes.

METHODS

In the setting of a randomized trial, 338 patients in the intervention group and living in upstate New York received a home telemedicine unit to transmit blood glucose and blood pressure values to a nurse case manager, videoconference with a nurse or dietitian every 4-6 weeks and access educational websites. The educators met with a supervising endocrinologist 4-5 times weekly and clinical recommendations were proposed to the primary care providers via mail, fax, or phone.

RESULTS

Over a 36 month period, 67 medically urgent situations were identified and addressed (1.9 events/month). Some of these situations were potentially life-threatening, including major drug contraindications (N = 24), other medically urgent situations (N = 19), and medical urgent conditions (ie, unstable angina) (N = 24).

CONCLUSION

The interaction via telemedicine in rural upstate New York between patients with diabetes mellitus, a diabetes care team, and primary care providers can successfully identify and remediate medically urgent situations.

Circulating vascular endothelial growth factor (VEGF) levels in advanced stage cancer patients compared to normal controls and diabetes mellitus patients with critical ischemia

Anti-angiogenic therapy is emerging as a valuable tool in the treatment of patients with cancer. As VEGF is a central target in anti-angiogenic therapy, its levels in the circulation might be relevant in selecting tumor types or patients likely to respond to this treatment. Additional VEGF has been recognized as a key factor in the pathogenesis of diabetic retinopathy. Recently anti-angiogenic therapy has been advocated in this situation.We measured VEGF levels in whole blood in 42 patients with high grade (n = 26) and low grade (n = 16) end stage cancer, and in 28 healthy controls and 37 patients with diabetes related vascular disease. Only 2/26 patients in the group of high grade cancer had significantly elevated VEGF levels, 1/16 in the low grade group and 1/28 in the healthy control group. In contrast, in 10/37 diabetic patients the mean VEGF levels were significantly elevated compared to the other groups. The mean level in these diabetic patients was significantly elevated compared to the other groups.These data indicate the limitation of the use of circulating VEGF levels as a potential selection criterion for anti-angiogenic therapy in cancer patients and suggest further studies into its application in the management of diabetic complications.

Assessing quality of life for new diabetes treatments and technologies: a simple patient-centered score

BACKGROUND

A simple quality of life measure is needed for use in diabetes, particularly for the assessment of new treatments and technologies. We devised and validated a patient-centered quality of life (PCQoL) measure that should be applicable to routine clinical practice or trial of therapies.

METHODS

People with diabetes completed a two-part, PCQoL questionnaire where they nominated five aspects of general- and diabetes-related life judged most important for their overall quality of life and rated each for current level of satisfaction. Scores derived from the questionnaire were compared with a reference measure-the Diabetes Control and Complications Trial diabetes quality of life (DQoL) score. Both were repeated after 1 month. The participants were 72 diabetic patients (60% with type 1 diabetes); 29 people with type 1 diabetes were treated by continuous subcutaneous insulin infusion (CSII) and 14 were treated by multiple daily insulin injections (MDI).

RESULTS

Patients most often cited family and relationships or fear of complications and hypoglycemia as important facets of quality of life for them. The PCQoL measure was highly correlated with the reference DQoL measure (r = 0.73, p < 0.0001), had high repeatability (r = 91, p < 0.0001), and could be completed in less than 5 minutes. The test was sensitive enough to detect a better quality of life in CSII-treated patients vs MDI-treated patients.

CONCLUSION

The PCQoL measure is simple, quick, valid, and suitable for routine use in diabetes or trials of new treatments.

Acanthosis nigricans and diabetes risk factors: prevalence in young persons seen in southwestern US primary care practices

PURPOSE

Evidence shows acanthosis nigricans is often associated with hyperinsulinemia and may indicate increased risk of type 2 diabetes mellitus. The purpose of this study was to determine the association of acanthosis nigricans with type 2 diabetes risk factors and disease in young persons.

METHODS

We conducted a cross-sectional study in the Research in Outpatient Settings Network, a practice-based research network in southwestern US communities. Participating clinicians (N = 96) collected data on children and young adults aged 7 to 39 years seen during a 2-week sampling period. The main outcomes were the prevalence of acanthosis nigricans, type 2 diabetes risk factors (ethnicity, family history of type 2 diabetes, hypertension, overweight/obesity), type 2 diabetes, and the relationships among these.

RESULTS

Among 1,133 patients sampled, risk factors for type 2 diabetes were common: 69% had a family history of the disease; 3% of children (aged 7 to 19 years) and 12% of adults had hypertension; 43% of children and 73% of adults were overweight or obese; and 80% were members of ethnic minorities. Acanthosis nigricans was found in 17% of children and 21% of adults. Among children and adults alike, the more type 2 diabetes risk factors that were present, the higher the prevalence of acanthosis nigricans (P <.001). The prevalence ratio for type 2 diabetes in patients with acanthosis nigricans was 1.97 (95% confidence interval, 1.18-3.27; P = .01) after controlling for age, body mass index, and the number of type 2 diabetes risk factors. Clinicians reported that the identification of acanthosis nigricans frequently led to discussions about lifestyle modification for decreasing the risk of type 2 diabetes.

CONCLUSIONS

Patients with acanthosis nigricans are likely to have multiple risk factors for type 2 diabetes. Acanthosis nigricans may be an independent risk factor for this disease. Detection of acanthosis nigricans may help clinicians more rapidly identify high-risk individuals for diabetes counseling.

Electronic medical records and diabetes quality of care: results from a sample of family medicine practices

PURPOSE

Care of patients with diabetes requires management of complex clinical information, which may be improved by the use of an electronic medical record (EMR); however, the actual relationship between EMR usage and diabetes care quality in primary care settings is not well understood. We assessed the relationship between EMR usage and diabetes care quality in a sample of family medicine practices.

METHODS

We conducted cross-sectional analyses of baseline data from 50 practices participating in a practice improvement study. Between April 2003 and December 2004 chart auditors reviewed a random sample of medical records from patients with diabetes in each practice for adherence to guidelines for diabetes processes of care, treatment, and achievement of intermediate outcomes. Practice leaders provided medical record system information. We conducted multivariate analyses of the relationship between EMR usage and diabetes care adjusting for potential practice- and patient-level confounders and practice-level clustering.

RESULTS

Diabetes care quality in all practices showed room for improvement; however, after adjustment, patient care in the 37 practices not using an EMR was more likely to meet guidelines for process (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.42-3.57) treatment (OR, 1.67; 95% CI, 1.07-2.60), and intermediate outcomes (OR, 2.68; 95% CI, 1.49-4.82) than in the 13 practices using an EMR.

CONCLUSIONS

The use of an EMR in primary care practices is insufficient for insuring high-quality diabetes care. Efforts to expand EMR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality.

Management of hypertension in diabetes mellitus

Overall, approximately 40% of diabetic patients have hypertension at the time of diagnosis of diabetes and a similar percentage may develop hypertension during their follow-up. Factors contributing to this high prevalance of hypertension in diabetes include obesity, old age, insulin resistance, increased extracelluar volume, diabetic nephropathy and increased arterial stiffness. Well-conducted clinical trials that have been completed in the last decade demonstrated a major impact of hypertension on the micro- and macrovascular complications of diabetes and remarkable benefits of its control. Based on this large trial database, the currently accepted level of blood pressure used in diabetes for definition and target of therapy is 130/80 mmHg. Dietary and behavioral lifestyle modifications should be an intergral part of any management regimen. These include weight reduction, low sodium diet, exercise, moderate alcohol intake and smoking cessation. Effective control of blood pressure to target levels is more important than the drug(s) used. Combination drug therapy is needed frequently to achieve a target blood pressure. Although blockers of the renin-angiotensin-aldosterone system seem to have a favorable effect in diabetes, high-level evidence suggests that low-dose thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and calcium channel blockers are all good choices, both as initial and add-on therapy. Frequently, more than one drug is needed, and a low-dose thiazide diuretic combined with an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker is a commonly used effective combination. Other drugs that can be added include calcium channel blockers and β-blockers. In certain clinical situations, specific drug classes are indicated. These include angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in the case of diabetic nephropathy, β-blockers in the case of ischemic heart disease, and calcium channel blockers and loop diuretics in the case of advanced renal insufficiency, where the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers carries a significant risk of hyperkalemia.

Advanced glycation end products cause increased CCN family and extracellular matrix gene expression in the diabetic rodent retina

AIMS/HYPOTHESIS

Referred to as CCN, the family of growth factors consisting of cystein-rich protein 61 (CYR61, also known as CCN1), connective tissue growth factor (CTGF, also known as CCN2), nephroblastoma overexpressed gene (NOV, also known as CCN3) and WNT1-inducible signalling pathway proteins 1, 2 and 3 (WISP1, -2 and -3; also known as CCN4, -5 and -6) affects cellular growth, differentiation, adhesion and locomotion in wound repair, fibrotic disorders, inflammation and angiogenesis. AGEs formed in the diabetic milieu affect the same processes, leading to diabetic complications including diabetic retinopathy. We hypothesised that pathological effects of AGEs in the diabetic retina are a consequence of AGE-induced alterations in CCN family expression.

MATERIALS AND METHODS

CCN gene expression levels were studied at the mRNA and protein level in retinas of control and diabetic rats using real-time quantitative PCR, western blotting and immunohistochemistry at 6 and 12 weeks of streptozotocin-induced diabetes in the presence or absence of aminoguanidine, an AGE inhibitor. In addition, C57BL/6 mice were repeatedly injected with exogenously formed AGE to establish whether AGE modulate retinal CCN growth factors in vivo.

RESULTS

After 6 weeks of diabetes, Cyr61 expression levels were increased more than threefold. At 12 weeks of diabetes, Ctgf expression levels were increased twofold. Treatment with aminoguanidine inhibited Cyr61 and Ctgf expression in diabetic rats, with reductions of 31 and 36%, respectively, compared with untreated animals. Western blotting showed a twofold increase in CTGF production, which was prevented by aminoguanidine treatment. In mice infused with exogenous AGE, Cyr61 expression increased fourfold and Ctgf expression increased twofold in the retina.

CONCLUSIONS/INTERPRETATION

CTGF and CYR61 are downstream effectors of AGE in the diabetic retina, implicating them as possible targets for future intervention strategies against the development of diabetic retinopathy.

Beneficial effects of thiazolidinediones on diabetic nephropathy in OLETF rats

PURPOSE

Diabetic nephropathy is the most serious of complications in diabetes mellitus. Thiazolidinedione (TZD) is thought to ameliorate diabetic nephropathy; however, the mechanism underlying this effect has not been elucidated. We hypothesized that the vascular endothelial growth factor (VEGF) participates in the pathogenesis of diabetic nephropathy and that TZD may be beneficial for the treatment of diabetic nephropathy because of the effect it has on VEGF.

MATERIALS AND METHODS

23 Otsuka- Long-Evans-Tokushima-Fatty (OLETF) rats and eight control Long-Evans-Tokushima-Otsuka (LETO) rats were divided into the following four groups: LETO group, control OLETF group, pioglitazone treated group (10mg/ kg/day), and rosiglitazone treated group (3mg/kg/day).

RESULTS

A progressive increase in urinary protein excretion was observed in the diabetic rats. Glomerular VEGF expression in the control OLETF rats was significantly higher than in the control LETO rats. However, there was a significant reduction in both the glomerular VEGF expression and the VEGF mRNA levels after treatment with pioglitazone and rosiglitazone. The twenty-four hour urine protein levels were significantly decreased in both groups of the treated OLETF rats.

CONCLUSION

These results suggest that TZD may have beneficial effects on diabetic nephropathy by reducing the VEGF expression.

Wnt signaling regulates pancreatic beta cell proliferation

There is widespread interest in defining factors and mechanisms that stimulate proliferation of pancreatic islet cells. Wnt signaling is an important regulator of organ growth and cell fates, and genes encoding Wnt-signaling factors are expressed in the pancreas. However, it is unclear whether Wnt signaling regulates pancreatic islet proliferation and differentiation. Here we provide evidence that Wnt signaling stimulates islet beta cell proliferation. The addition of purified Wnt3a protein to cultured beta cells or islets promoted expression of Pitx2, a direct target of Wnt signaling, and Cyclin D2, an essential regulator of beta cell cycle progression, and led to increased beta cell proliferation in vitro. Conditional pancreatic beta cell expression of activated beta-catenin, a crucial Wnt signal transduction protein, produced similar phenotypes in vivo, leading to beta cell expansion, increased insulin production and serum levels, and enhanced glucose handling. Conditional beta cell expression of Axin, a potent negative regulator of Wnt signaling, led to reduced Pitx2 and Cyclin D2 expression by beta cells, resulting in reduced neonatal beta cell expansion and mass and impaired glucose tolerance. Thus, Wnt signaling is both necessary and sufficient for islet beta cell proliferation, and our study provides previously unrecognized evidence of a mechanism governing endocrine pancreas growth and function.

Fusion of proinsulin-producing bone marrow-derived cells with hepatocytes in diabetes

We previously reported that diabetes in mice is associated with the appearance of proinsulin-producing (Proins-P) cells in the liver. It was unclear, however, whether these Proins-P bone marrow-derived cells (BMDC) merely transit through the liver or undergo fusion with hepatocytes, normally an extremely rare event. In this study, we found that, in diabetes, BMDC in the liver produce not only Proins but also TNF-alpha, suggesting that diabetes reprograms gene expression in BMDC, turning on "inappropriate" genes. Bone marrow transplantation using genetically marked donor and recipient mice showed that fusion occurs between Proins-P BMDC and hepatocytes. Cell fusion is further supported by the presence of the Y chromosome in Proins-P cells in female mice that received male bone marrow transplantation cells. Morphologically, Proins-P fusion cells are albumin-producing hepatocytes that constitute approximately 2.5% of the liver section area 5 months after diabetes induction. An extensive search failed to reveal any fusion cells in nondiabetic mice. Thus, diabetes causes fusion between Proins-P BMDC and hepatocytes in vivo, an observation that has implications for the pathophysiology of diabetes as well as the fundamental biology of heterotypic cell fusion.

Expression of motilin in the hypothalamus and the effect of central erythromycin on gastric motility in diabetic rats

OBJECTIVE

To investigate the expression of motilin-immunoreactive neurons in the hypothalamus and the effect of central administration of erythromycin (EM) on the regulation of gastric motility in diabetic rats.

METHODS

The motilin immunoreactive neurons in the hypothalamus and the hippocampus were detected by immunohistochemistry with rabbit anti-motilin polyclonal antibody. To measure the gastric motility, force transducers were surgically affixed to the gastric serosa. A microinjection syringe was connected via a plastic tube to an injection cannula, which was connected with a stainless steel guide cannula. The syringe was inserted into the right lateral cerebral ventricle for microinjecting the chemicals.

RESULTS

Diabetic mellitus was successfully induced in cohorts of rats. Motilin-immunoreactive neurons significantly increased in the paraventricular (PVN) and supraoptic nuclei (SON) of the hypothalamus in the diabetic rats. Intracerebroventricular (i.c.v.) administration of EM, a motilin receptor agonist, stimulated the gastric motility of diabetic rats. EM (91.56 nmol, i.c.v.) dose-dependently increased the amplitude by (174.82 +/- 48.62)% (P<0.05), and increased the frequency by (70.43 +/- 27.11)% (P < 0.05) in 5 min. The stimulatory effect lasted more than 15 min to the end of the measurement, and can be blocked partially by the prior treatment of motilin receptor antagonist GM-109.

CONCLUSION

Motilin-immunoreactive neurons are increased in the PVN and SON of the hypothalamus in diabetic rats. Centrally administered EM may regulate gastric motility by binding to the central motilin receptors, and central motilin might be involved in regulation of gastric motility in diabetic rats.