Osteopenia and circulating levels of vitamin D metabolites in diabetes mellitus

The degree of diabetic osteopenia and serum vitamin D metabolite levels were measured in 14 type 1 (insulin-dependent) and 168 type 2 (non-insulin-dependent) diabetic patients. Based on six indices obtained by microdensitometry, we found the bone mass in 28.6% of type 1 and 26.2% of type 2 diabetic patients to be decreased and in 14.3% and 11.9%, respectively, the decrease was severe. Our method of analysis of bone mass has shown that diabetic osteopenia differs from typical osteoporosis in character. In addition, serum 24,25-dihydroxyvitamin D was significantly decreased both in type 1 and in type 2 diabetes (p less than 0.01), but 1,25-dihydroxyvitamin D was significantly decreased only in type 1 diabetes (p less than 0.01) compared to the controls, being lower than that in type 2 diabetes (p less than 0.05). On the other hand, 25-hydroxyvitamin D was similar to that of the controls, in both types of diabetes.

Complications of diabetes. Prevalence, detection, current treatment, and prognosis

The late complications associated with diabetes mellitus affect the eye (retinopathy and cataract), the kidney (diabetic glomerulosclerosis), the nerves (mononeuropathies, distal symmetric polyneuropathy, and autonomic neuropathy), and the large blood vessels (coronary artery, cerebrovascular, and peripheral vascular disease). With the exception of large blood vessel disease, evidence in animals and humans has suggested that the development of diabetes-associated complications is related to metabolic abnormalities associated with hyperglycemia. Although the exact mechanism by which hyperglycemia causes damage in individual tissues is unknown, a number of potentially pathogenic mechanisms have been proposed. These include increased activity of the polyol pathway, disturbance in the metabolism of myo-inositol and its phospholipid derivatives, abnormal permeability of the small blood vessels, and excessive glycosylation of various proteins. With the introduction of potent aldose reductase inhibitors, the role of increased activity of the polyol pathway (and related abnormalities in myo-inositol metabolism) in the pathogenesis of diabetes-associated complications can be clarified.

United Kingdom Prospective Diabetes Study. III. Prevalence of hypertension and hypotensive therapy in patients with newly diagnosed diabetes. A multicenter study

We measured the blood pressure of 1226 patients with newly diagnosed maturity-onset diabetes, age 25 to 65 years (mean 52 years), mean fasting plasma glucose 11.4 mmol/L. Forty percent of males and 53% of females had hypertension by the World Health Organization criteria of either having blood pressure more than 160/95 mm Hg or receiving hypotensive therapy. Male patients were less obese than female patients (21% and 40% over ideal weight respectively) and a mean 1.3 years younger. Blood pressure was higher in women than men, but it was not significantly greater if age and obesity were taken into account. Twenty-three percent of men and 42% of women had already been informed they were hypertensive, and 12% of men and 26% of women were already receiving hypotensive therapy. The prevalence of hypertension in diabetic white patients was greater than that reported in a sex- and age-matched healthy population. The blood pressure of those taking diuretics was not significantly greater than that of untreated patients, but the 8% of men and 13% of women receiving other hypotensive drugs still had significantly higher blood pressure than the untreated patients. Both patients treated by diuretics and those treated by other hypotensive agents had significantly higher mean plasma urea and creatinine concentrations than untreated patients. This may have been induced by therapy, but one cannot exclude the possibility that treated patients already had renal impairment from diabetic, hypertensive, or other pathology.

Early vitrectomy for severe vitreous hemorrhage in diabetic retinopathy. Two-year results of a randomized trial. Diabetic Retinopathy Vitrectomy Study report 2. The Diabetic Retinopathy Vitrectomy Study Research Group

Six hundred sixteen eyes with recent severe diabetic vitreous hemorrhage reducing visual acuity to 5/200 or less for at least one month were randomly assigned to either early vitrectomy or deferral of vitrectomy for one year. After two years of follow-up, 25% of the early vitrectomy group had visual acuity of 10/20 or better compared with 15% in the deferral group (P = .01). In patients with Type I diabetes, who were on the average younger and had more-severe proliferative retinopathy, there was a clear-cut advantage for early vitrectomy, as reflected in the percentage of eyes recovering visual acuity of 10/20 or better (36% vs 12% in the deferral group, P = .0001). No such advantage was found in the Type II diabetes group (16% in the early group vs 18% in the deferral group), but evidence that this advantage differed by diabetes type was of borderline significance.

Survival of diabetic hypertensive patients

Seventy-nine of 673 patients attending a hypertensive outpatient clinic were classified as diabetics at the first examination. These patients were age- and sex-matched to two control groups: nondiabetic hypertensives and the background population. Nondiabetic hypertensive patients had a significantly poorer survival than expected during a 10-year observation period; the survival of diabetic hypertensives was even poorer, although not significantly. No sex difference was observed in the survival rates of hypertensive diabetics, neither was a difference seen between insulin-dependent and non-insulin-dependent patients. Acute myocardial infarction was the most frequent cause of death in both diabetic (40%) and nondiabetic (42%) hypertensive persons.

Vitiligo and polyglandular autoimmune endocrinopathy

Vitiligo is probably an autoimmune disorder of the skin and is commonly associated with a number of known autoimmune endocrinopathies. We present a patient with vitiligo associated with diabetes mellitus and autoimmune thyroid disease. Further, we present evidence that vitiligo and autoimmune disorders coexist and discuss the interrelationship between vitiligo and autoimmune endocrine disorders.

Association of low HDL and HDL2 cholesterol with coronary heart disease in noninsulin-dependent diabetics

Lipids and lipoproteins were measured in 139 men and 145 women who were noninsulin-dependent diabetics (NIDDs) aged 45 to 64 years. Of these, 27 men and 16 women had had a previous definite myocardial infarction (MI). The NIDDs with MI (MI+) showed lower values of HDL and HDL2 cholesterol concentrations than NIDDs without previous MI (MI-) or NIDDS without any symptoms or electrocardiographic signs of coronary heart disease (CHD-). The inverse relationship between HDL, HDL2, and CHD was evident in both sexes, but it was particularly strong among male NIDDs. The difference in HDL and HDL2 cholesterol concentrations between the MI+ and MI- groups or between the MI+ and CHD- groups persisted after adjustment by analysis of covariance for the effect of physical activity, alcohol intake, obesity, duration of diabetes, and glycemic control. It is concluded that in a cross-sectional study, even among NIDDs with generally low HDL and HDL2 cholesterol concentrations, the presence of CHD is associated with a further depression of HDL and HDL2 cholesterol levels. Prospective studies are needed, however, to confirm that the association is predictive and not a consequence of CHD.

Indapamide in the treatment of hypertension in non-insulin-dependent diabetes

The antihypertensive effect of indapamide, a new thiazide derivative, has a low diuretic effect and a primary action on vascular smooth muscle. It was evaluated in a series of 20 patients with non-insulin-dependent diabetes (age range 47-75 years) who had arterial hypertension of mild to moderate degree treated with hypoglycemic agents and/or diet. Indapamide, 2.5 mg, was given as a single daily dose for 6 months. A statistically significant reduction of systolic and diastolic pressures was observed in both supine and upright positions. This decrease was significant beginning in the first month of therapy (p less than 0.001). No significant modifications of fasting glycemia, postprandial glycemia, and glycosylated hemoglobin were noted. No significant changes were observed in serum sodium, potassium, chloride, calcium, and uric acid. Indapamide is an effective and practical treatment of hypertension of mild to moderate degree in patients with diabetes. The absence of effect on glucose metabolism makes it an especially interesting drug.

Influence of bisoprolol on blood glucose, glucosuria, and haemoglobin A1 in noninsulin-dependent diabetics

In a double-blind crossover study, the influence of bisoprolol and placebo was tested in 20 noninsulin-dependent diabetics with concomitant essential hypertension. A 2-week washout placebo period was followed by two treatment periods of 2 weeks each with 10 mg bisoprolol or placebo. Compared with placebo, bisoprolol did not change blood glucose, haemoglobin A1 (HbA1), and glucosuria. No hypoglycaemia was observed. Serum cholesterol and triglyceride levels remained constant. Systolic (SBP) and diastolic (DBP) blood pressure, and heart rate (HR) were significantly (p less than 0.01) reduced after 2 weeks of bisoprolol therapy, compared with placebo. It was concluded that bisoprolol, in a dose therapeutically effective in essential hypertension, has no influence on carbohydrate and lipid metabolism in noninsulin-dependent patients with diabetes mellitus; and 10 mg bisoprolol is effective for the normalisation of SBP and DBP in mildly hypertensive diabetics. Since bisoprolol was well tolerated in the dosage studied, it can be recommended for noninsulin-dependent diabetics with hypertension.

Captopril in the treatment of hypertension in type I and type II diabetic patients

Ten type I and 10 type II hypertensive diabetic patients were treated for 12 weeks with captopril (50 mg twice daily). Good control of blood pressure was achieved without any significant adverse effect on carbohydrate metabolism or renal haemodynamics and without evidence of glomerular or tubular damage.

Painless myocardial infarction in diabetes mellitus--a myth?

One hundred and ten consecutive diabetic patients with acute myocardial infarction (AMI) were compared to a matched group of non-diabetics with AMI, and the pain experienced during the acute episode by each patient was estimated by counting the number of morphine injections given. No significant difference was found regarding the frequency of painless infarctions, the distribution of injections given during the first three days in the coronary unit, or the need for injections after that time. We conclude that contrary to the common supposition, painless AMI in hospitalised patients is almost as frequent among nondiabetics as among diabetics.

Asymptomatic transient ST changes during ambulatory ECG monitoring in diabetic patients

The reported higher incidence of painless myocardial infarction in diabetic patients suggests that asymptomatic transient myocardial ischemia may also be frequent in diabetes. To explore this possibility 51 subjects with type II diabetes, aged 43 to 71 years (mean +/- SEM 56 +/- 8), 70 nondiabetic patients with coronary artery disease (mean age 55 +/- 5), and 40 nondiabetic patients without overt coronary disease (age 54 +/- 9) were studied. Thirty-eight of the 51 diabetic patients (74%) had evidence of associated coronary disease and 19 (37%) had evidence of previous myocardial infarction. All subjects underwent continuous 24-hour ambulatory ECG monitoring. In 18 of 51 diabetic patients 93 episodes (73% of the total number) of asymptomatic ST segment changes were recorded; the total number of symptomatic episodes was 36, and they were observed in seven patients (27%). Forty-eight (60%) asymptomatic and 32 symptomatic episodes of significant ST changes were found in nondiabetic patients with coronary artery disease. When patients with previous myocardial infarction were examined separately, asymptomatic episodes of significant ST changes were observed in 10 of 19 diabetic patients and in 5 of 25 nondiabetic patients with coronary artery disease (p less than 0.05). In an additional 28 diabetic patients who underwent exercise stress test, 15 exhibited an abnormal ECG response; however, only five of them (33%) were symptomatic. This study suggests that the incidence of transitory myocardial ischemia, as assessed by ambulatory ECG monitoring and exercise stress test, is higher in type II diabetic patients than in nondiabetic control subjects with coronary artery disease.

Insulin and new bone formation in diffuse idiopathic skeletal hyperostosis

The tendency of patients with DISH towards obesity or an adult onset of diabetes has been reflected in marked hyperinsulinaemia following glucose challenge. It is hypothesized that insulin at prolonged and high physiologic levels promotes new bone growth, particularly in the entheseal regions. These areas are also subject to various mechanical forces. The resulting new bone produces the radiological changes which characterise DISH.

Limited finger joint mobility in insulin-dependent and non-insulin-dependent Ethiopian diabetics

The prevalence of limited joint mobility (LJM) was studied in 110 insulin-dependent (IDDM) and 190 non-insulin-dependent (NIDDM) consecutive Ethiopian African diabetics and 300 age- and sex-matched controls at the Tikur Anbassa Teaching Hospital in Addis Ababa over a period of 18 months. Mean ages +/- S.D. of the IDDM, NIDDM, and controls were 35 +/- 9.9, 49.4 +/- 12.0, and 43.3 +/- 14.0 years, respectively. LJM was found in 44.5% of IDDM, 25.3% of NIDDM, and 6.7% of controls, being significantly commoner in IDDM than NIDDM (p less than 0.001) and in the diabetics than in controls (p less than 0.001). In IDDM those with LJM were significantly younger (p less than 0.05), had a higher prevalence of median fasting blood glucose (FBG) levels of 15 mmol/l and above (p less than 0.01), and retinopathy (p less than 0.05), but did not differ from those without LJM in duration of diabetes, or prevalence of neuropathy and nephropathy. In NIDDM those with LJM had a significantly longer duration of diabetes (p less than 0.005) and a higher prevalence of nephropathy (p less than 0.005), but did not differ from those without LJM in age at onset of diabetes, prevalence of neuropathy, and retinopathy or median FBG level.

Necrotizing fasciitis: a potentially fatal complication of diabetes mellitus

We describe a fatal case of necrotizing fasciitis in a newly diagnosed 73-year-old diabetic patient. This rare condition which has been described previously in diabetic patients, is characterized by widespread necrosis of underlying fascial tissue associated with severe systemic upset, despite few overt cutaneous manifestations. Without prompt recognition and extensive debridement it may be fatal.

Diabetic osteopenia and circulating levels of vitamin D metabolites in type 2 (noninsulin-dependent) diabetes

The degree of diabetic osteopenia and serum vitamin D metabolite levels were measured in 168 type 2 (noninsulin-dependent) diabetic patients. Based on six indices obtained by microdensitometry, we found the bone mass in 26.2% of diabetic patients to be clearly decreased and in 11.9% to be severely decreased. Our direct method of analysis of bone mass shows that diabetic osteopenia differs from typical osteoporosis in character. In addition, serum 24,25-dihydroxyvitamin D was significantly decreased (P less than 0.01), but 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D were similar to those of controls.

Mucormycosis and ameloblastoma of the upper jaw

We report a case of mucormycotic infection complicating a clinically silent ameloblastoma in an aged diabetic woman. Diagnosis was made by culture and biopsy of the affected tissue, where foreign-body granulomas were seen, an unusual inflammatory response for mucormycosis. A good outcome was achieved on the basis of radical surgery and amphotericin B infusion.

Insulin resistance: receptor and post-binding defects in human obesity and non-insulin-dependent diabetes mellitus

Insulin resistance is a prominent feature of three clinical conditions: obesity, impaired glucose tolerance, and non-insulin-dependent (type II) diabetes mellitus. Numerous studies over the past 15 years have provided a better understanding, from both a clinical and cellular standpoint, of the pathophysiology of these insulin-resistant states as well as of insulin action. In addition, it has recently been recognized that correction of glucose intolerance leads to an improvement in insulin secretion and a reduction in insulin resistance. Examination of the most recent data suggests that the basis for insulin resistance in these common clinical disorders is often multifactorial. In uncomplicated obesity, the cellular alterations responsible for insulin resistance appear to be at the level of the hepatic insulin receptor and in post-binding processes in peripheral target tissues. In type II diabetes, a post-binding defect(s) in peripheral tissues appears to be the primary lesion. In humans, many of the factors that mediate the changes leading to insulin resistance are still unknown and are the object of current investigations.

Macro creatine kinase type 1 with electrophoretic mobility identical to that of the MB isoenzyme

We describe the case of an elderly woman whose symptoms and electrocardiographic pattern initially suggested acute myocardial infarction. The value for total serum creatine kinase (EC 2.7.3.2; CK) was 737 U/L (reference interval: 22-269 U/L), and electrophoresis for CK isoenzymes demonstrated two bands, the more anodal migrating to the CK-MB region and the second migrating between the CK-MB and CK-MM regions. The above-normal total CK and electrophoretic pattern persisted during her 11-day hospital course. The QuiCK-MB (International Immunoassay Labs.) and Tandem-E CK-MB (Hybritech) immunoassays, however, showed CK-MB mass measurements within the normal range. In further investigation with a mixture of patient's serum and human-serum-based control containing all CK isoenzymes, the electrophoretic mobility of only CK-BB was altered, proving that the patient had antibody to the B unit of CK in her serum. Immunofixation revealed the more anodal band to be a CK-IgA lambda complex, and the more cathodal band, a CK-IgG kappa complex. Mixing the patient's serum with polyclonal antibody specific for CK-B slowed the electrophoretic mobility of only the more anodal band. Polyclonal antibody specific for CK-M had no effect on either band. Evidently, this patient had two different types of macro CK type 1, both containing CK-BB. We conclude that macro CK type 1 can mimic CK-MB and be a source of confusion.

Diabetic osteopenia in central Japan

A large scale study of diabetic osteopenia was conducted in central Japan. The degree of bone mass loss was measured in 1267 diabetic patients and 646 control subjects. Based on six indices obtained by microdensitometry, the bone mass of 21.1% of the diabetic patients was found to be markedly decreased and that of 8.2% was found to be severely decreased, while only 7.9% of the control group showed bone mass loss. The prevalence of diabetic osteopenia in female patients was significantly higher than in males, but a positive correlation between the degree of bone mass loss and age was observed in both the male and female patients. Patients requiring oral agents or insulin had significantly more bone mass loss than those on dietary therapy alone.

Vitiligo in diabetes mellitus

We studied the association between vitiligo and diabetes mellitus, and found that vitiligo is associated with insulin-dependent diabetes but not with non-insulin-dependent diabetes. This gives further weight to the theory that vitiligo is an autoimmune disease.

[Use of divascan in the treatment of diabetic retinopathy]

Divascan (iprasochrome), a drug designed by GDR pharmacologists, brings about a positive effect in the management of diabetic microangiopathies, particularly at early stages. Altogether 22 patients with diabetes mellitus, types I and II, were on divascan therapy. Before and after treatment the patients were subjected to clinical and ophthalmoscopic studies including the determination of microcirculation in the conjunctiva, renal function, the level of serotonin, its precursors and the main metabolite. The optimal dose of divascan is 7.5-10 mg/day, the period of therapy not less than 3 months followed by the use of maintenance doses. The drug produces no side effects.

Incidence of diabetic retinopathy and blindness: a population-based study in Rochester, Minnesota

Among the 1135 Rochester residents discovered to have diabetes in the period 1945-69, the prevalence of retinopathy was 2.6% at the time of initial diagnosis. Among those free of retinopathy at diagnosis of diabetes, the subsequent incidence of any retinopathy was 17.4 per 1000 person-years and for proliferative retinopathy alone was 1.6 per 1000 person-years, based on 12,000 person-years of follow-up. The incidence rate of retinopathy was almost three times greater among residents with insulin-dependent (IDDM) than with non-insulin-dependent diabetes (NIDDM); however, the actual number of retinopathy cases was over four times greater among the more numerous residents with NIDDM. By 20 yr after diagnosis of diabetes, the cumulative incidence of retinopathy approached 70% among IDDM subjects and was 30% and 36%, respectively, among the obese and nonobese NIDDM residents. The epidemiologic patterns for proliferative retinopathy were qualitatively similar to those for nonproliferative retinopathy. The risk of blindness was greater among those with proliferative than with nonproliferative retinopathy but was substantial even for those without retinopathy. Most blindness was caused by factors other than isolated diabetic retinopathy.

Serum and erythrocyte magnesium levels in type I and type II diabetics

Serum and red blood cell magnesium (RBC-Mg) concentrations of 195 type I and 111 type II diabetic outpatients with different degree of control and 40 control subjects have been evaluated using atomic absorption spectrophotometry. In the total group, no significant difference in serum and RBC-Mg levels in type I and II diabetic outpatients could be found. However, poor control was often associated with lower serum magnesium levels. A negative correlation was found between serum magnesium levels and HbA1. A particular group of male patients with severe macroangiopathy showed high RBC-Mg levels; this finding was probably due to atherosclerotic and hypertensive renal involvement.

Prevalence of sexual dysfunctions in non-insulin dependent (type II) diabetic males

Since previous papers about the frequency of sexual dysfunctions (SD) in diabetic males did not consider the genetical and clinical heterogeneity of diabetes mellitus, we studied the prevalence and the pathogenesis of SD in 77 non insulin dependent diabetics (NIDD). The diagnostic procedures consisted of physical and psychological examinations, compilation of a questionnaire, evaluation of autonomic and peripheral nervous systems, measurement of penile arterious flow, dosage of hormonal and metabolic parameters. SD were present in 52% of patients: 24% of them had organic impotence, 28% psychological sexual impairment. Age, duration of diabetes and metabolic control were superimposable in the patients with and without SD. Most patients with organic impotence had an alteration of parasympathetic nervous system; less frequently a reduced penile arterious flow was observed. The relief of such a high prevalence of SD in NIDD males suggests that future studies should consider the various groups of diabetics separately.

Serum cholesterol binding reserve percentage in diabetes mellitus

Serum cholesterol binding reserve percentage (SCBR%) in patients with diabetes mellitus (22.17 +/- 13.40%) was significantly lower than in controls (40.93 +/- 8.69%) (p less than 0.001). SCBR% of controls did not vary with age (age range 20-80 years). SCBR% declined significantly with increasing duration of diabetes. It also decreased with macrovascular complications and was lowest in multiple/fatal complications further corroborating the value of SCBR% as a risk indicator of atherogenesis. The relationship of SCBR% with treatment was very striking. All adequately controlled patients had a significantly higher SCBR% than those who were poorly controlled regardless of treatment modality and those adequately controlled on insulin had the highest SCBR%, which was close to that of normal controls.

Pregnancy complicated by non-insulin dependent diabetes mellitus and type V hyperlipoproteinaemia: case report

Type V hyperlipoproteinaemia complicated a pregnancy in a 38 year old Samoan multigravida with previous noninsulin dependent diabetes. The hypertriglyceridaemia was associated with severe insulin resistance, nonacidotic ketosis and poor control of the diabetes. Continuous subcutaneous insulin infusion resulted in excellent diabetic control and plasma triglyceride levels fell to normal without specific dietary fat restriction. The pregnancy resulted in the live birth of a normal healthy infant at 38 weeks' gestation.

Glucose metabolism in noninsulin-dependent diabetic patients with experimental hyperthyroidism

Hyperthyroidism is known to further impair carbohydrate metabolism in diabetic patients. In the present study we examined in noninsulin-dependent (type 2) diabetic patients the effect of T3-induced hyperthyroidism on glucose utilization and endogenous glucose production by means of the hyperinsulinemic and hyperglycemic clamp technique in combination with [3H]3-glucose kinetic analysis. Administration of T3 for 1 week increased the mean serum T3 concentration from 1.0 +/- 0.1 (SEM) to 4.1 +/- 0.2 ng/ml, and the mean fasting plasma glucose from 8.7 +/- 0.7 to 9.9 +/- 0.9 mmol/liter. Basal hepatic glucose production (HGP) rose from 3.23 +/- 0.23 to 3.98 +/- 0.25 mg/kg X min, whereas basal MCR of glucose (MCRG) increased only slightly from 2.12 +/- 0.24 to 2.30 +/- 0.14 ml/kg X min. When the plasma insulin concentration was acutely raised and maintained at 82 +/- 8 microU/ml (hyperinsulinemic clamp study), HGP decreased to 0.71 +/- 0.29 mg/kg X min and MCRG increased to 3.16 +/- 0.47 ml/kg X min. After T3 administration suppression of HGP by insulin was reduced (1.55 +/- 0.37 mg/kg X min), but at the same time MCRG was only slightly affected (3.64 +/- 0.54 ml/kg X min). In the hyperglycemic clamp study the plasma glucose concentration was maintained 7 mmol/liter above the individual fasting level. MCRG was again slightly higher after T3 administration (1.98 +/- 0.18 vs. 1.66 +/- 0.15 ml/kg X min), but insufficient to completely compensate for the higher residual HGP at the hyperthyroid as compared to the euthyroid state (2.42 +/- 0.24 vs. 1.45 +/- 0.36 mg/kg X min). Thus, deterioration of metabolic control in noninsulin-dependent diabetic patients by hyperthyroidism is due primarily to enhancement of basal HGP and its reduced suppressibility by insulin and glucose.

The possibility of an early growth delay in White's class A diabetic pregnancy

Ultrasound scanning has revealed that some fetuses of women with insulin-dependent diabetes are smaller than normal in early pregnancy as judged by the crown-rump length. This early growth delay is negatively correlated to the quality of diabetes regulation. Nine White's Class A diabetic women had fetuses that were on average 4.5 days (range, 0-11 days) smaller than expected from the menstrual history. Apparently, the expectedly modest metabolic disturbances in early pregnancy of Class A diabetic women are able to interfere with normal embryonic growth.

Effect of clonidine on glucose, insulin and glucagon responses to a protein meal in type 2 diabetics

The authors investigated the effects of clonidine (alpha-2 stimulating agent) on blood glucose, insulin and glucagon levels in order to assess the alpha-adrenergic regulation of endocrine pancreatic secretion. Ten hypertensive female subjects affected with type 2 diabetes were studied; each subject was given a protein meal (boiled beef 200 g); blood samples were taken at -30, 0, 30, 60, 90 and 120 min; after this test each subject was treated for 4 days with clonidine (0.150 mg, 3 times/day per os); at the 5th day the protein meal was repeated under the same conditions except for the added administration of clonidine. Plasma glucose, insulin and glucagon were estimated. The administration of a protein meal caused a significant increase of blood glucose (peak at 60 min), insulin (peak at 90 min) and glucagon (peak at 90 min) levels; the association of clonidine caused an increase of blood glucose (single values and total areas) without changes of insulin and glucagon levels, when compared to those obtained before clonidine treatment. In conclusion, the association of clonidine to a protein meal caused impaired glucose tolerance presumably due to a direct glycogenolytic effect, occurring in the liver on account of an alpha-2 receptor stimulation, insulin and glucagon not being involved in this phenomenon.

Management of type II diabetes mellitus. Achieving optimum metabolic control

Exciting information is rapidly accruing about diabetes and suggests that maintenance of good metabolic control may prevent onset or delay progression of diabetic complications. Patients, as well as their families and health care providers, should be encouraged by the knowledge that tools are available for successful management of type II diabetes. Treatment consists of a diet-exercise-sulfonylurea regimen and, in a substantial number of patients, administration of insulin. Proper assessment of these modalities is essential if optimum metabolic control is to be achieved.

Cutaneous reactions secondary to heparin injections

Ten to 20 days after starting prophylactic doses of heparin in six patients, large, indurated, erythematous plaques appeared at the sites of the subcutaneous injections. Pruritus, local tenderness, and burning sensation or pain were present. No skin necrosis developed. Heparin was discontinued and topical corticosteroids were applied to the involved areas. Five to 9 days later the lesions had resolved completely. The reaction seen in the six patients is similar to the early erythematous phase of the so-called heparin necrosis. There is a spectrum of cutaneous changes ranging from mild erythematous pruritic areas to large symptomatic plaques and to heparin necrosis, following subcutaneous injections of heparin.

The course of peripheral vascular disease in non-insulin-dependent diabetes

The present report is an analysis of the course of peripheral vascular disease (PVD) in 619 patients with non-insulin-dependent diabetes (NIDDM) recruited within 1 yr of diagnosis and followed quarterly for up to 14 yr (X = 10.5 yr). At 13 yr duration, the actuarially determined cumulative risks for intermittent claudication (IC), nonpalpable dorsalis pedis pulse (NPUL), and arterial calcification (CALC) were, respectively, 37.9%, 34.5%, and 60.9% for men and 24.3%, 37.6%, and 32.2% for women. Major amputations (AMP) occurred in only 1.3% of the patients, equivalent to approximately one case per 1000 patients per year. The corresponding incidences of IC, NPUL, and CALC were, respectively, 29, 27, and 47 per 1000 men and 19, 27, and 25 per 1000 women per year. CALC and NPUL were strongly related to mortality. Baseline risk factors with probability levels that suggest a relationship to PVD were, in women, age versus CALC (P less than 0.01), age versus NPUL (P less than 0.05), weight versus NPUL (P less than 0.05), systolic BP versus CALC (P less than 0.01), summed glucose tolerance test versus CALC (P less than 0.01), and triglyceride level versus CALC (P less than 0.05). In men, the only significant risk factors were diminished vibration perception, which was related to NPUL (P less than 0.05), and the serum triglyceride level, which was related to IC (P less than 0.05). In patients who are carefully followed prospectively, IC is far more common, but AMP is far less common than has been generally appreciated. Further studies are needed to clarify the roles of the diverse risk factors that are possibly related.

Alterations in plasma lipids in the presence of mild glucose intolerance in the offspring of two type II diabetic parents

Plasma lipids and oral glucose tolerance were determined in 67 normal control subjects (age range 19-67 yr) and 150 individuals (17-69 yr) who were offspring of two type II diabetic parents. Age- and weight-adjusted analyses of covariance were performed for lipids and for glucose and insulin responses. For both men and women, the mean concentrations of total, low-density-, and high-density-lipoprotein-cholesterol and of triglycerides in the offspring with normal glucose tolerance (N = 109) were similar to respective controls. For offspring with abnormal glucose tolerance (N = 41), the mean levels of total cholesterol, LDL-cholesterol, and triglycerides were significantly elevated (P = 0.02 or less) in women but not in men. The mean HDL-cholesterol levels were 20% lower and LDL/HDL-cholesterol ratios 60% greater in women with abnormal glucose tolerance, whereas no significant differences existed for any of the lipid fractions in men, compared with respective controls. Both men and women with abnormal glucose tolerance had a comparable magnitude of hyperglycemia as well as hyperinsulinemia. These observations indicate that significant alterations in plasma lipids exist in individuals with mild, asymptomatic glucose intolerance and there are important sex differences in lipid metabolism in the early stage of diabetes, despite comparable degrees of glucose intolerance and insulin responses.

Prevalence and mortality of acute myocardial infarction in patients with diabetes

The purpose of this study was to investigate if insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) predispose to the development of acute myocardial infarction (AMI) and modify the prognosis. The study includes 832 AMI patients consecutively hospitalized over a 3-yr period. The prevalence of diabetes mellitus among the AMI patients was 9.7% and is significantly higher than in an age-matched population, where it is 6.1% (P less than 0.001). The prevalence of diabetes was higher for women than for men (14.9% versus 7.6%). The risk of AMI was found to be twice as high among IDDM than among nondiabetic patients (P less than 0.001). Men with NIDDM were not found to have a significantly higher risk of AMI (P greater than 0.1), but the risk of AMI in women with NIDDM was approximately doubled (P less than 0.01). During the first month following AMI the mortality rate for nondiabetic patients was 20.2% compared with 42.0% for diabetic patients (P less than 0.001). Insulin treatment in NIDDM was associated with a reduced mortality rate compared with treatment with oral agents (P less than 0.05). The mortality rate was significantly higher in patients with poor metabolic control compared with patients in good control, whether before AMI or at the time of hospitalization. Diabetic patients had a higher risk of developing cardiogenic shock and conduction disorders than nondiabetic patients. We conclude that diabetes mellitus disposes to AMI and that the mortality rate of AMI is significantly increased among diabetic patients. Poor metabolic regulation of the diabetes may aggravate the prognosis for AMI.

Rhino-orbital zygomycosis

A 63-year-old diabetic man presented with sinusitis with orbital and intracranial signs progressing over one week, due to zygomycosis. Despite control of the diabetes, surgical excision of infected tissue and antifungal therapy he died in the fifth week of illness. Pathological study showed extensive fungal infiltration of periorbital structures and mycotic thrombosis of many blood vessels with associated necrosis and infarction of fat and extraocular muscles.

Hepatitis B virus markers in diabetes mellitus

Serum markers for hepatitis B virus (HBV) were studied in 395 healthy control subjects and in 100 diabetic patients. Of the patients, 28 had type I diabetes, 31 had type II diabetes requiring insulin, and 41 had type II diabetes treated with oral agents or diet alone. None gave history of previous icterus or other signs of hepatitis, had received blood transfusions, or had been on hemodialysis. There was a significant difference in the prevalence of HBV markers (mainly HB surface antibody) between the diabetic group and the controls (51% versus 25%, P less than 0.001). The control subjects included hospital personnel and, hence, their risk of HBV exposure was already relatively high. The increased occurrence of HBV markers did not seem to be related to diabetes duration, patient age, intake of insulin injections, or presence of microvascular complications. This study reveals a high degree of exposure to HBV in a moderately controlled diabetic group and possibly a high degree of proneness to subclinical hepatitis B.

Hyperlipidemia: forestalling complications in older diabetics

Mild to moderate hypertriglyceridemia is not associated with specific signs or symptoms in either IDDM or NIDDM. However, symptoms of the "chylomicronemia syndrome," including abdominal pain and acute pancreatitis, can occur when poorly controlled diabetes is present in a patient with a familial form of hyperlipidemia. The low-carbohydrate, high-fat diet that was commonly recommended for diabetics during past years may have contributed to the elevated plasma LDL levels in some individuals. Such "diabetic diets" may also have played a role in the predisposition of diabetics toward atherosclerotic complications.

Effect of atenolol on serum beta 2-microglobulin level in hypertensive diabetic patients

The effects of atenolol (50 mg once daily) on serum beta 2-microglobulin levels in 11 hypertensive diabetic patients uncomplicated by renal dysfunction were studied. Atenolol significantly decreased serum beta 2-microglobulin levels (micrograms/mL) at four weeks (1.5 +/- 0.13) and at eight weeks (1.4 +/- 0.09) from pretreatment level (1.8 +/- 0.17) (P less than 0.05, respectively), along with statistically significant antihypertensive effects. Blood urea nitrogen, serum creatinine, fasting plasma glucose, HbA1C levels, and body weight remained unchanged. The results suggest that atenolol provides a favorable effect on renal function in hypertensive diabetic patients uncomplicated by renal dysfunction.