Skeletal and joint manifestations of childhood diabetes

Inflammatory conditions of the pediatric hand and non-inflammatory mimics

Hand involvement can assume an outsized role in the perception and presentation of disease as a result of functional impairment, visual conspicuity and susceptibility to early structural damage. Rheumatologic referral for inflammatory conditions can be delayed because of assumptions of a traumatic, infectious or neoplastic etiology; conversely, initial rheumatologic evaluation might be pursued for many of the same non-inflammatory causes. This pictorial essay highlights inflammatory conditions affecting the pediatric hand, including juvenile idiopathic arthritis, infectious arthritis, systemic connective tissue disorders, and a variety of less common inflammatory diseases, as well as non-inflammatory congenital, vascular, neoplastic and metabolic differential considerations.

Impact of diabetes mellitus on surgical outcomes in sports medicine

Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.

The effects of diabetes mellitus and diabetic nephropathy on bone and mineral metabolism in T2DM patients

AIM

To assess the effects of both diabetes mellitus and diabetic nephropathy on bone mineral metabolism in patients with type 2 diabetes mellitus (T2DM).

METHODS

Serum osteocalcin (BGP), serum alkaline phosphatase (ALP), bone-specific alkaline phosphatase (BAP), 24-h urinary hydroxyproline (HOP), blood and urine calcium (Ca), phosphate (P) levels and bone mineral density (BMD) were assessed and compared in 30 patients with T2DM (group D), 25 T2DM patients with nephropathy (group DN) and 27 nondiabetic control subjects (group C).

RESULTS

Compared with the nondiabetic controls, patients in both groups D and DN had decreased serum osteocalcin (BGP) and bone mineral density (BMD) while serum alkaline phosphatase (ALP) and urinary hydroxyproline (HOP) were increased. Decrease in BGP was not correlated with ALP (r = -0.1, P<0.37). Within both diabetes groups (group D and group DN), no significant change in BAP is observed, however group DN showed higher level of BGP, higher level of HOP and lower BMD than group D. Urine calcium was increased in both group D and DN with group D having higher levels than group DN. In DN patients had increased circulating phosphate and decreased urinary excretion of phosphate, while decreased circulating phosphate and increased urinary excretion phosphate are seen in group D patients.

CONCLUSION

Patients with T2DM show an imbalance of bone mineral metabolism, and co-existence of nephropathy tends to aggravate this. Serum osteocalcin and 24-h hydroxyproline may be considered useful biochemical markers for monitoring possible bone mineral metabolism disorder in T2DM patients.

Deterioration of bone quality by streptozotocin (STZ)-induced type 2 diabetes mellitus in rats

Patients with diabetes mellitus (DM) have various skeletal disorders and bone quality can be impaired in DM leading to fractures. Wistar albino male rats (270-300 g; n = 16) were assigned randomly to nondiabetic and diabetic rats (single dose intravenous injection of 45 mg/kg streptozotocin). All rats in each group were perpetuated for 8 weeks, and blood glucose levels as well as body weights were measured once weekly. Biomechanical measurements were performed at the mid-diaphysis of the left femur with tensile test. Extrinsic and intrinsic properties were measured or calculated. Bone mineral density (BMD) was also evaluated and measured by dual-energy X-ray absorptiometry. Cross-sectional area of the femoral shaft was evaluated by computerized tomography. Blood glucose levels in diabetic rats were significantly increased compared to that of the nondiabetic rats, while the body and femur weights were decreased (P < 0.05). In respect to the BMD, cross-sectional area and femur length, there were no statistically significant differences between the nondiabetic and diabetic rats (P > 0.05). The maximum load, ultimate stress, and toughness endpoints in diabetic rats were significantly decreased compared to that of the nondiabetics (P < 0.05). There were no statistically significant differences between the nondiabetic and diabetic rats with regard to the displacement and stiffness (P > 0.05). Femurs of diabetic rats had less absorbed energy than that in nondiabetics (P < 0.05). Ultimate strain was lower in diabetic rats than that in nondiabetics, while the elastic modulus was higher (P > 0.05). The bone quality of rats is decreased by streptozotocin-induced type 2 diabetes mellitus.

Limited joint mobility (LJM) in elderly subjects with type II diabetes mellitus

LJM is frequently observed in young subjects with insulin-dependent diabetes mellitus (IDDM). Aim of this study was to evaluate whether non-insulin-dependent diabetes mellitus (NIDDM) increases the risk of LJM in elderly subjects. Thirty patients (15 males, 15 females, mean age 73.93 ± 12.72 years) with NIDDM in good glycemic control were compared with thirty non-diabetic elderly, well matched for sex and age (15 males, 15 females, mean age 74.3 ± 4.24 years), and with ten young normal subjects (5 males, 5 females, mean age 26.3 ± 1.56 years). In these subjects, the range of motion (ROM) of ankle, knee, hip, elbow and shoulder were measured with a double-armed goniometer. Moreover, abnormalities of supraspinatus, patellar and Achilles tendons were evaluated with a standardized ultrasound (US) procedure. A significant reduction in the mobility of all joints was found in elderly subjects, compared to younger ones, with exception for the knee and elbow flexion. Elderly patients with diabetes, compared with their age-matched counterpart, showed LJM for ankle dorso- and plantar flexion, hip flexion and adduction, shoulder abduction and flexion. Moreover, tendons sonographic abnormalities were more frequently observed in diabetics. Our data confirm that diabetes worsens the LJM in the elderly, increasing the cross-linking of collagen by the non-enzymatic advanced glycation end products formation.

The diabetic hand: a forgotten complication?

The manifestations of diabetes in the hand were much discussed in the 1970s and 1980s. The present review aims to revisit the diabetic hand and to discuss the pathology of the hand that may be clinically important in diabetic patients. In the strict sense of the term, the "diabetic hand" encompasses the three most widely studied conditions which have traditionally been associated with diabetes, namely limited joint mobility, Dupuytren's contracture and trigger finger. There is evidence that these entities are significantly more frequent in patients with diabetes and also that they may be associated with diabetes duration, poor metabolic control and presence of microvascular complications. In a more general sense, though, there are other conditions affecting the hands, which also occur more frequently in diabetes. From a practical point of view, increased alertness both for neuropathic hand ulcers in patients with profound neuropathy and for diabetic hand infections is absolutely necessary. Recently, reduced hand strength is beginning to be recognized as a further complication of diabetes. Thus, the hand may reveal substantial pathology in diabetes, and ideally, clinical examination should not ignore it.

Bone Turnover Markers in Patients with Type 2 Diabetes and Their Correlation with Glycosylated Haemoglobin Levels

The aim of this prospective, longitudinal study was to investigate, over a period of 12 months, the effects of metabolic control on bone turnover markers in patients with type 2 diabetes mellitus. The study included 17 male and 18 female patients with type 2 diabetes, aged 37 − 66 years. Mean follow-up period was 12 ± 1.2 months. Mean glycosylated haemoglobin (HbA1C) levels were 10.6% ± 1.6% at the start of the study and decreased to 7.7% ± 1.0% by the end of the study. Levels of the bone resorption markers, urinary deoxypyridinoline and N-telopeptide, were 28.6 ± 11.6 nmol/mmol creatinine and 93.6 ± 13.7 nmol bone collagen equivalents [BCE]/mmol creatinine, respectively, at the start of the study, and decreased significantly to 17.9 ± 7.1 nmol/mmol creatinine and 67.8 ± 12.8 nmol BCE/mmol creatinine, respectively, by the end of the study. Bone formation parameters also significantly decreased in parallel with HbA1c levels over the study period. It is concluded that effective management of metabolic disorder in patients with type 2 diabetes plays an important contribution to bone turnover improvement.

The epidemiology of major joint contractures: a systematic review of the literature

Current knowledge on the epidemiology of major joint contractures is limited. We systematically reviewed the literature to identify studies examining the epidemiology of joint contracture regardless of clinical condition. Epidemiologic measures of interest were prevalence, incidence, and prognostic risk factors. We used Medline to identify all epidemiologic studies of major joint contractures published from 1966 to March 2005. There was a high prevalence of major joint contractures. Most studies focused on one joint rather than including all relevant major contractures. However, most studies did provide a definition of a contracture or the measures used to assess contractures. Immobility is a highly prevalent disability in at-risk populations, and constitutes a tremendous burden to patients in nursing homes, hospitals, and the outpatient community. The lack of epidemiologic data is a major impediment to providing appropriate treatment.

Risk assessment of the diabetic foot and wound

Diabetic foot ulcers are among the most common severe complications of diabetes, affecting up to 68 per 1,000 persons with diabetes per year in the United States. Over half of these patients develop an infection and 20% require some form of amputation during the course of their malady. The key risk factors of diabetic foot ulceration include neuropathy, deformity and repetitive stress (trauma). The key factors associated with non healing of diabetic foot wounds (and therefore amputation) include wound depth, presence of infection and presence of ischaemia. This manuscript will discuss these key risk factors and briefly outline steps for simple, evidence-based assessment of risk in this population.

Lifetime risk of symptomatic carpal tunnel syndrome in Type 1 diabetes

AIMS

To determine the lifetime risk of developing symptomatic carpal tunnel syndrome (CTS) in subjects with Type 1 diabetes and to investigate the effect of glycaemic control, body mass index (BMI), gender and age of onset of diabetes.

METHODS

One hundred and twenty-two consecutive subjects with Type 1 diabetes seen by a single investigator, over 1-year, were questioned about previous surgery for, or current symptoms of CTS. Those with current symptoms were referred for nerve conduction studies (NCS). Those with previous surgery and/or diagnostic NCS were classified as having CTS. Lifetime risk was calculated by the Kaplan-Meier method.

RESULTS

Twenty six out of 122 patients had CTS, 18 of whom (69%) had undergone median nerve decompression surgery. The predicted lifetime risk of CTS reached 85% after 54 years of Type 1 diabetes (95% confidence interval: 72-97%). The duration of diabetes was greater in those who had developed CTS than in those who had not (29 vs. 19 years, P=0.0001). In those diagnosed with diabetes before the age of 20 there was a lag time of at least 19 years before the development of CTS, whereas patients with later onset of diabetes, began to develop CTS from as early as 5 years diabetes duration. There was no demonstrable effect of glycaemic control, obesity, gender or retinopathy on the appearance of CTS.

CONCLUSION

The lifetime risk of developing symptomatic CTS with Type 1 diabetes is high, and is related to age and duration of diabetes, but not to the development of microvascular complications.

Ultrasonography of plantar soft tissues thickness in young people with diabetes

AIMS

The aims of this study were to examine soft tissue changes in the skin and plantar aponeurosis of young people with Type 1 diabetes mellitus (T1DM) and to evaluate any relationship between any soft tissue changes, arch length, limited joint mobility (LJM) and plantar pressure.

METHODS

The thickness of the skin on the plantar surface of the foot and plantar aponeurosis were examined using ultrasound in 216 young people with diabetes and 57 controls. Foot length, arch length, joint mobility, peak pressure and pressure time integrals were evaluated.

RESULTS

Skin was not significantly thicker in the diabetic subjects. The plantar aponeurosis was significantly thicker in the diabetic subjects and was associated with foot size, male gender and subtalar joint (ST) LJM (P < 0.01). Males were nearly three times more likely to have thickened plantar aponeurosis.

CONCLUSION

Soft tissue thickening in young people with T1DM affects the deeper structures on the plantar surface of the foot rather than the skin. Thickening of the plantar aponeurosis was associated with LJM at the ST joint and male gender, but was not associated with plantar pressure or arch height changes. Plantar aponeurosis thickening does not appear to alter foot mechanics in young people with T1DM.

Complications of pediatric and adolescent type 1 diabetes mellitus

Type 1 diabetes mellitus is potentially associated with serious microvascular and macrovascular complications, although these are usually subclinical during the pediatric and adolescent years. There is no "grace" period for the beginnings of such complications. Duration of diabetes, glycemic control, age, and pubertal stage are critical factors contributing toward development of such problems. Other risk factors include family history (genetic predisposition), hyperlipidemia, hypertension, and smoking. The Diabetes Control and Complications Trial (DCCT) proved the importance of glycemic control and emphasized the ability of improved glucose control to prevent or decrease retinopathy, nephropathy, and neuropathy using a multidisciplinary same-philosophy-of-care approach plus targeted glucose and hemoglobin A(1c) values. Other natural history and intervention studies support the findings of the DCCT. Although our current tools are not perfect, they allow us to decrease microangiopathic complications very significantly if we educate our patients and their family members. Metabolic control counts.

Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot

BACKGROUND

The purpose of this study was to determine the degree to which pressure on the plantar aspect of the forefoot is reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot.

METHODS

Ten diabetic patients who had a history of neuropathic plantar ulceration of the forefoot were enrolled in a laboratory gait trial. A repeated-measures design and a computer analysis of force-plate data were used to examine dynamic pressures on the forefoot, with the patient walking barefoot, immediately before percutaneous lengthening of the Achilles tendon and at eight weeks afterward. Although the wound in each patient had healed at least one month before the operation, we considered the patients to be at high risk for ulceration because they had had an ulcer previously.

RESULTS

The mean peak pressure (and standard deviation) on the plantar aspect of the forefoot decreased significantly from 86+/-9.4 newtons per square centimeter preoperatively to 63+/-13.2 newtons per square centimeter at eight weeks postoperatively (p<0.001). Commensurately, the mean dorsiflexion of the ankle joint increased significantly from 0+/-3.1 degrees preoperatively to 9+/-2.3 degrees at eight weeks post-operatively (p<0.001).

CONCLUSIONS

The results of this study suggest that peak pressures on the plantar aspect of the forefoot are significantly reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. We are unaware of any other reports in the medical literature that describe such findings. These data may lend support to studies that have indicated that this procedure should be used as an adjunctive therapeutic or prophylactic measure to reduce the risk of neuropathic ulceration.

Limited joint mobility in the hands and feet of adolescents with Type 1 diabetes mellitus

AIMS

Limited joint mobility (LJM) in the foot has not been assessed in adolescents with Type 1 diabetes mellitus (DM) but is associated with neuropathic ulceration in adults. This study was designed to determine the presence of LJM in adolescents with Type 1 DM and its association with microvascular disease.

METHODS

The hands, feet and hips were examined in 302 diabetic adolescents and 51 nondiabetic controls (aged 11.5-20 years). LJM was defined as less than the fifth percent reference for controls.

RESULTS

Reduced motion was found in 35% of diabetic adolescents at the subtalar (ST) joint, 18% at the first metatarsophalangeal (MTP) joint, 26% at the fifth metacarpophalangeal (MCP) joint and 13% had limited passive extension of the interphalangeal (IP) joints of the hands. Limited passive IP joint extension of the hands was not present in the controls. Limited active IP joint extension, a positive 'prayer sign', occurred in 35% of diabetic adolescents and 14% of controls. Diabetic adolescents showing LJM in any of these areas, except the prayer sign, were more likely to have retinopathy (odds ratio 2.53, CI: 1.53-4.18). Those with LJM in the foot were more likely to have albumin excretion rates >7.5 microg/min (OR 2.06, CI: 1.16-3.68).

CONCLUSION

LJM in the feet of adolescents with Type 1 DM is associated with microvascular disease and is a useful routine clinical measure.

Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients

Limited mobility of the cervical spine or temperomandibular joint may contribute to increased difficulty of laryngoscopy in patients who have severe diabetes mellitus. The frequency of difficult laryngoscopy in diabetics undergoing renal and/or pancreatic transplants has been reported to be as high as 32%. We retrospectively reviewed the anesthetic records of all adult patients who underwent renal and/or pancreatic transplant and endotracheal intubation from January 1, 1985 to October 31, 1995. Characteristics specifically reviewed included the presence of diabetes mellitus, type of organ donor, age, gender, body mass index, previous difficult laryngoscopy, known characteristics potentially related to difficult laryngoscopy, and degree of difficulty with laryngoscopy. Laryngoscopy was graded as easy, minimally to moderately difficult, and moderately to extremely difficult to perform. Factors associated with any degree of difficult intubation were univariately assessed by using Fisher's exact test. Of 725 patients, 15 (2.1%) were identified as having difficult laryngoscopies, although all underwent successful endotracheal intubations. Factors associated with difficult laryngoscopy were diabetes mellitus (P = 0.002) and characteristics known to be related to difficult laryngoscopy (P = 0.02). These findings confirm an increase in the frequency of difficult laryngoscopy in diabetic patients undergoing renal and/or pancreatic transplant, although no laryngoscopies were rated as moderately to extremely difficult. We conclude that the frequency of difficult laryngoscopy in these diabetic patients is much lower than previous reports have suggested.

IMPLICATIONS

Previous studies have suggested that airway management of many diabetic patients may be difficult. Our medical record review of patients with severe diabetes undergoing organ transplants showed that extraordinary techniques were not required to successfully manage their airways.

Treatment of osteopenia in children with insulin-dependent diabetes mellitus: the effect of 1 alpha-hydroxyvitamin D3

Twelve children (8 boys and 4 girls) with insulin-dependent diabetes mellitus (IDDM), aged 9-15 years, received 1 alpha-hydroxyvitamin D3 (1 alpha-OHD3) in a dose of 0.05 microgram/kg per day for 1 year. Duration of disease varied between 2.8 and 9 years. Bone density was determined in the distal third of forearm using single photon absorptiometry, and was expressed as standard scores (+/- SD) with respect to sex- and age-matched controls. Bone density measurements and ultrasound studies of the kidneys were performed at 0, 6 and 12 months. Serum calcium, ionized calcium, phosphorus, magnesium, creatinine, alkaline phosphatase, glycosylated haemoglobin in morning blood samples and urinary Ca, P, Mg, and hydroxyproline were regularly determined. One patient was excluded from the study because of hypercalciuria and one because of lack of compliance. Bone density increased significantly after 6 and 12 months of 1 alpha-OHD3 administration (P = 0.015, P < 0.001 respectively). None of the biochemical parameters changed significantly.

CONCLUSION

Osteopenia is not uncommon in children and adolescents with IDDM. In 10 children with IDDM and osteopenia the administration of 1 alpha-OHD3 for 1 year corrected bone loss.

Calcitonin secretion in children with insulin-dependent diabetes mellitus

To test the hypothesis that calcitonin (CT) deficiency may contribute to bone mineral loss in insulin-dependent diabetes mellitus (IDDM), we studied basal and calcium stimulated (2 mg/kg body wt. in 5 min) CT levels in 15 children with IDDM and osteopenia. Ten age-sex matched healthy children were studied as controls. Since extractable CT (exCT) allows more sensitive and specific measurement of CT monomer, we measured both total serum CT (tCT) and exCT. Diabetic children had slightly but significantly (P less than 0.05) higher basal levels of both tCT (24.5 +/- 7.1 ng/l) and exCT (5.6 +/- 1.6 ng/l) than controls (tCT: 18.7 +/- 5.4 ng/l; exCT: 4.3 +/- 1.2 ng/l). Calcium stimulation test pointed out significant increase (P less than 0.001) of tCT and exCT in both groups with peak values not significantly different in IDDM in respect to controls. However, diabetic children showed a reduced CT reserve evidenced by a lower peak/basal ratio (diabetics: tCT 1.68, exCT 1.84; controls: tCT 2.49, exCT 2.88) and by a more rapid decrease in CT levels. We conclude that CT deficiency is not a causative factor of diabetic osteopenia. The slightly higher basal CT values suggest that an increased bone reabsorption may be operative in IDDM and it stimulates CT secretion. This chronic "C" cell stimulation may induce the reduction in CT reserve observed employing the calcium infusion test.

Hypomagnesemia and the parathyroid hormone-vitamin D endocrine system in children with insulin-dependent diabetes mellitus: effects of magnesium administration

Because insulin-dependent diabetes mellitus is associated with altered electrolyte metabolism and a derangement of the parathyroid hormone (PTH)-vitamin D endocrine system, we studied 23 children with diabetes (age 9.4 +/- 2.5 years) and found lower serum values for total and ionized calcium, magnesium, intact PTH, calcitriol, and osteocalcin than in age- and sex-matched control subjects. All patients were given magnesium orally (6 mg/kg daily of elemental magnesium) for up to 60 days. During treatment, serum magnesium, total and ionized calcium, intact PTH, calcitriol, and osteocalcin concentrations significantly increased, reaching control values. After a 3-day low-calcium diet, the patients had a significantly reduced delta-increment of PTH and calcitriol in comparison with values obtained during hypomagnesemia. After magnesium repletion, the delta-increments of both PTH and calcitriol, in response to the low-calcium diet, were not significantly different from control values. These data suggest that magnesium deficiency plays a pivotal role in altering mineral homeostasis in insulin-dependent diabetes mellitus.

Predictability of difficult laryngoscopy in patients with long-term diabetes mellitus

The laryngoscopic conditions of 62 diabetic patients who underwent renal transplantation or vitrectomy were studied. Anaesthesia was induced with fentanyl and a sleep dose of thiopentone. Conditions for direct laryngoscopy after 0.1 mg/kg vecuronium were scored from 0 to 3 (easy-very difficult). All patients gave their palm prints after operation which were scored: 0, phalangeal areas completely visible; 1, phalangeal areas partly visible; 2, phalangeal areas hardly visible; 3, only fingertips printed. The incidence of difficult laryngoscopy was 31%. The higher the scores in the palm test, the more difficult was the laryngoscopy. The correlation coefficient between these two factors was r = 0.6 (p less than 0.001). Our study shows that joint rigidity possibly caused by tissue glycosylation may also involve laryngeal and cervical areas resulting in a strenuous laryngoscopy. A defective palm print is a warning sign for difficult laryngoscopy.

Effect of low-protein diet on alveolar bone loss in streptozotocin-induced diabetic rats

The present study demonstrated that hyperglycemic diabetic rats fed a low-protein (8%) diet maintained an alveolar bone height similar to controls; in contrast, those fed a standard protein diet (24%) had reduced alveolar bone height (P less than 0.05). Euglycemic diabetic and untreated control rats fed low-protein diets did not have significant differences in alveolar bone height compared to those fed standard protein diets. There was no evidence of gingival or periodontal inflammation or osteoclastic bone resorption at the alveolar crest in any animal studied. Thus, (1) hyperglycemic diabetic rats have significant alveolar bone loss in the absence of periodontal inflammation (P less than 0.001) and (2) this bone loss can be alleviated by diet (P less than 0.05). This data, taken together with previous studies on the effects of low-protein diet on the kidney, suggest that relieving the protein load on the diabetic kidney in poorly controlled diabetics is beneficial to the longevity of that organ, as well as the preservation of alveolar bone surrounding the teeth.

[Tunnel syndromes and blood glucose anomalies]

The fasting blood glucose was studied in 406 patients with carpal tunnel syndrome. We found 3.3% patients with diabetes mellitus and 15% with abnormal blood glucose levels. A prospective study was performed in 36 patients (oral glucose tolerance test, and blood lipid parameters). 45% of the patients in this group had an abnormal OGTT and 52% presented with hyperlipoproteinemia.

Childhood diabetes

The child with diabetes mellitus has special problems that require skilled attention best achieved by a team of professionals. The goals of managing a child with diabetes are summarized in Table 7. The features that distinguish the child from an adult with diabetes are inability to communicate or verbalize symptoms, unpredictable eating and exercise patterns, special nutritional requirements of growth, and the emotional and psychological upheavals experienced during adolescence.

Calcium homeostasis in prepubertal diabetic children

Many authors have described abnormalities of calcium homeostasis in type I diabetes mellitus, but data in the literature are conflicting. Consequently we studied calcium, phosphorus and magnesium (in serum and urine), parathyroid hormone, calcitonin and 25-hydroxyvitamin D (25-OHD) levels in 21 prepubertal diabetic patients and in 21 sex- and age-matched controls. We did not find any significant difference of all the aforementioned parameters between diabetics and controls. Also the value of 25-OHD was similar in diabetic and healthy subjects (24.33 +/- 6.04 vs 22.09 +/- 5.01 ng/ml). The results suggest that the principal parameters of calcium metabolism are normal in prepubertal diabetic children.

Outpatient management of diabetes mellitus

Outpatient encounters form the mainstay of managing type I diabetes mellitus in children and adolescents. Management philosophy rests on the premise that normal physical and emotional growth is attainable and long-term complications minimized by maintenance of metabolic (glycemic) control. Management principles involve a coordinated team approach of physician, nurse-educator, and dietitian interacting with the family unit to educate them in the appropriate use and adjustment of insulin regimens, to recognize and treat the Somogyi and dawn phenomena, adjustment of nutritional needs, short- and long-term monitoring via home blood glucose and glycosylated hemoglobin measurements, and clues from the history and physical examination that permit anticipatory or reactive steps to achieve the treatment goals.

Histological and histochemical skin changes in insulin-dependent diabetic patients with and without limited joint mobility

We studied 24 skin biopsies of the hand in 24 IDDM patients followed at the National Institute of Endocrinology (NIE). Biopsies of 7 healthy individuals were used as controls. The diabetics were divided into two groups, with limited joint mobility (LJM) and without LJM. We compared the different structural components of the skin, and their changes; we used quantitative, semi-quantitative and qualitative methods. We found that patients with LJM had a greater levelling, less rete pegs and dermal papillae (p less than 0.05), increased alteration of the mucopolysaccharides distribution (p less than 0.005), higher frequency of alterations of the elastic fibers (p less than 0.05) and collagen (p less than 0.005), vessel enlargement (p less than 0.025) acquiring cord shape, and reduction of the vessel lumen (p less than 0.005) in comparison with patients without LJM and controls. This could be a consequence of the chronic hyperglycemia from childhood that affects the structure, architecture and function of collagen fibers. Genetic and immunologic studies could help to elucidate the mechanisms of this alteration.