Influence of gestational diabetes mellitus on neonatal weight outcome in twin pregnancies

AIMS

To evaluate the influence of gestational diabetes mellitus on neonatal birthweight, macrosomia and weight discrepancy in twin neonates.

METHODS

An observational retrospective study was performed. One hundred and six women with gestational diabetes and twin pregnancy and 166 twin controls who delivered viable fetuses > 24 weeks were included. Impact of maternal pre-pregnancy BMI, smoking habit, method of conception, chorionicity, gestational age at delivery, mode of delivery and hypertensive complications were also analysed. The effect of maternal hyperglycaemia and metabolic control in gestational diabetes pregnancies was assessed.

RESULTS

Gestational hypertension and pre-eclampsia were significantly higher in the group with gestational diabetes (21.5% vs. 6.3%, P = 0.007 and 6.2% vs. 0%, P = 0.025). There were no differences in the incidence of macrosomia (5.7% vs. 7.2%, P = 0.803), large for gestational age (10.3% vs. 13.2%, P = 0.570), small for gestational age (10.3% vs. 12.0%, P = 0.701), severely small for gestational age (6.6% vs. 7.8%, P = 0.814) or weight discrepancy (20.6% vs. 15.2%, P = 0.320) in the group with gestational diabetes compared with twin pregnancies without diabetes. There were no differences when comparing insulin-requiring gestational diabetes pregnancies and twins without diabetes for any of the neonatal weight outcomes. There was no relationship between third trimester HbA1c and neonatal birthweight or infant birthweight ratio.

CONCLUSION

Gestational diabetes did not increase the risk of macrosomia or weight discrepancy of twin newborns. Furthermore, glycaemic control did not influence the rate of any of the weight outcomes in our study population. In twin pregnancies, gestational diabetes was associated with a higher risk of gestational hypertension and pre-eclampsia.

Prepregnancy body mass index and prenatal fasting glucose are effective predictors of early postpartum metabolic syndrome in Spanish mothers with gestational diabetes

BACKGROUND

Gestational diabetes mellitus (GDM) may be an expression of early metabolic syndrome. It is unknown whether weight and/or glucose parameters assessed at GDM pregnancies predict the risk of metabolic syndrome at the early postpartum period.

METHODS

A group of women with GDM (N=1512) was evaluated at 3-11 months postpartum. Incident cases of diabetes were excluded. Antenatal measurements of GDM severity, third-trimester average glycated hemoglobin levels, prepregnancy body mass index (BMI), and increased gestational weight gain were considered. The predictive capability of these factors for postpartum metabolic syndrome was estimated.

RESULTS

The prevalence of postpartum metabolic syndrome was 10.9%. The three most common features of metabolic syndrome were low levels of high-density lipoprotein cholesterol (31.2%), high fasting glucose values (23.5%), and a high waist circumference (22.8%). The main predictors of metabolic syndrome were overweight or obesity prepregnancy and high antenatal fasting glycemia. This analysis was adjusted for family history of diabetes, prior GDM, dyslipidemia before pregnancy, chronic arterial hypertension, age, and smoking. The model area 95% confidence interval under the receiver operating characteristic curve was 0.87 (0.84-0.90) for metabolic syndrome presence. The risk for metabolic syndrome was progressively increased as risk factors were added (P<0.001 for trend). When obesity and high fasting glycemia were combined, a multiplied effect ensued.

CONCLUSIONS

Women having GDM are at threat of early postpartum metabolic syndrome. This risk can be easily identified by assessing prepregnancy BMI and antenatal fasting glycemia in the first pregnancy visit.

Body weight, weight gain and hyperglycaemia are associated with hypertensive disorders of pregnancy in women with gestational diabetes

AIM

The aim of this study was to measure the capacity of glucose- and weight-related parameters to predict pregnancy-induced hypertensive disorders in women with gestational diabetes.

METHODS

An observational study was conducted involving 2037 women with gestational diabetes. The associations of glycaemic and weight-related parameters with pregnancy-induced hypertensive disorders were obtained by univariate and adjusted multivariate analyses. Also, model predictability and attributable predictor risk percentages were calculated, and collinearity and factor interactions examined.

RESULTS

Multivariate analyses revealed that hypertensive disorders were mainly predicted by average third-trimester glycated haemoglobin (HbA(1c)) levels ≥ 5.9%, by being overweight or obese before pregnancy and by excess gestational weight gain after adjusting for age, tobacco use, chronic hypertension, parity, urinary tract infections and gestational age at delivery. Prepregnancy body weight (overweight and obesity) had the strongest impact on pregnancy-related hypertensive disorders (attributable risk percentages were 51.5% and 88.8%, respectively). The effect of being overweight or obese on hypertensive disorders was enhanced by HbA(1c) levels and gestational weight gain, with elevated HbA(1c) levels multiplying the effect of being overweight before pregnancy.

CONCLUSION

The average third-trimester HbA1c level is a novel risk factor for pregnancy-induced hypertensive disorders in women with gestational diabetes. HbA(1c) levels ≥ 5.9%, prepregnancy overweight or obesity and excess gestational weight gain are all independent risk factors of pregnancy-related hypertensive disorders in such women. In treated gestational diabetes patients, the strongest influence on hypertensive disorders is prepregnancy obesity.

Coexistence of two different pseudohypoparathyroidism subtypes (Ia and Ib) in the same kindred with independent Gs{alpha} coding mutations and GNAS imprinting defects

BACKGROUND

Pseudohypoparathyroidism (PHP) defines a rare group of disorders whose common feature is resistance to the parathyroid hormone. Patients with PHP-Ia display additional hormone resistance, Albright hereditary osteodystrophy (AHO) and reduced Gsalpha activity in easily accessible cells. This form of PHP is associated with heterozygous inactivating mutations in Gsalpha-coding exons of GNAS, an imprinted gene locus on chromosome 20q13.3. Patients with PHP-Ib typically have isolated parathyroid hormone resistance, lack AHO features and demonstrate normal erythrocyte Gsalpha activity. Instead of coding Gsalpha mutations, patients with PHP-Ib display imprinting defects of GNAS, caused, at least in some cases, by genetic mutations within or nearby this gene.

PATIENTS

Two unrelated PHP families, each of which includes at least one patient with a Gsalpha coding mutation and another with GNAS loss of imprinting, are reported here.

RESULTS

One of the patients with GNAS imprinting defects has paternal uniparental isodisomy of chromosome 20q, explaining the observed imprinting abnormalities. The identified Gsalpha coding mutations include a tetranucleotide deletion in exon 7, which is frequently found in PHP-Ia, and a novel single nucleotide change at the acceptor splice junction of intron 11.

CONCLUSIONS

These molecular data reveal an interesting mixture, in the same family, of both genetic and epigenetic mutations of the same gene.

Metabolic syndrome: prevalence, associated factors, and C-reactive protein: the MADRIC (MADrid RIesgo Cardiovascular) Study

The metabolic syndrome (MS) is defined by the clustering of a number of cardiovascular risk factors. The aims of the present study were to estimate the prevalence of MS in Madrid (Spain) by 2 definitions and to investigate its relationship with several sociodemographic factors and C-reactive protein (CRP) levels. This was a cross-sectional population study, and participants were 1344 subjects aged 31 to 70 years. Clinical evaluation included data on sociodemographic and cardiovascular background, physical examination, fasting glucose, triglycerides, and high-density lipoprotein cholesterol. The CRP levels were determined in a subgroup of 843 subjects. The diagnosis of MS was made according to the 2005 Adult Treatment Panel III (ATP III) and International Diabetes Federation (IDF) definitions. The age- and sex-adjusted prevalence of MS was 24.6% (95% confidence interval [CI], 22.3%-26.9%) using the ATP III definition and 30.9% (95% CI, 28.4%-33.3%) using the International Diabetes Federation definition. The overall agreement rate was 91.5% (kappa = 0.80; 95% CI, 0.76-0.83). Prevalence figures by both definitions were higher in men than in women and increased with age. Male sex, older age, low educational level, and physical inactivity were all determinants of ATP III-defined MS. The presence of MS or any of its components was associated with high CRP levels. In a logistic regression analysis, low educational level and waist circumference were the best predictors for high CRP level. The prevalence of MS in the Madrid region is one of the highest in Europe and confirms the strong Spanish regional variability in this syndrome frequency. Some sociodemographic and lifestyle factors, particularly educational level, are predictors for MS and high CRP levels.

Maternal glucose tolerance status influences the risk of macrosomia in male but not in female fetuses

OBJECTIVE

To elucidate whether the risk of macrosomia, large for gestational age (LGA) and small for gestational age (SGA) is influenced by maternal body mass index and glucose tolerance differently in male and female fetuses.

METHODS

A population study was conducted in 16 general hospitals from the Spanish National Health Service that included 9270 consecutive women with singleton pregnancies and without a former diagnosis of diabetes mellitus who delivered 4793 male and 4477 female newborns. Logistic regression analyses were performed to predict the effect of body mass index (BMI) category and glucose tolerance on macrosomia, large for gestational age newborns (LGA) and small for gestational age newborns (SGA) Separate analyses according to foetal sex were carried out for each outcome. The results were adjusted for maternal age, gestational age and pregnancy-induced hypertension.

RESULTS

There were significant differences between males and females in the percentage of infants who had macrosomia, LGA or SGA. Maternal BMI category was positively associated with the risk of macrosomia and LGA in both male and female newborns. In addition, there was a negative association between maternal BMI and SGA that only reached significance in males. In contrast, gestational diabetes was only a predictor of macrosomia exclusively in male fetuses (OR 1.67, 95% CI 1.12 to 2.49)

CONCLUSIONS

There is sexual dimorphism in the risk of abnormal birth weight attributed to maternal glucose tolerance status. A closer surveillance of foetal growth might be warranted in pregnant women with abnormal glucose tolerance carrying a male fetus.

Reproducibilidad de la prueba de sobrecarga oral de glucosa en pacientes con glucosa alterada en ayunas

BACKGROUND AND OBJECTIVES

Impaired fasting glucose (IFG) is defined by a fasting glucose between 5.6 and 6.9 mmol/l in subjects with no known diabetes. The present study objectives were: a) to analyze the glucose tolerance test (GTT) reproducibility and b) to assess this test's diagnostic classification agreement.

PATIENTS AND METHOD

Cross-sectional study in adult patients diagnosed with IFG. Study subjects underwent a 75 g GTT in two occasions.

RESULTS

Fifty-nine patients were studied. The interval between GTT tests was 37 +/- 26 days. Fasting and post-GTT plasma glucose intra-individual variation coefficients were 6.9 and 31.0%, respectively. Diagnostic agreement between the two tests (normal tolerance vs. abnormal tolerance) was measured using the kappa index: 0.62 (95% CI 0.42-0.82). Agreement ranged from 80% (95% CI, 70-90%) to 83% (95% CI, 73-93%) depending on whether the first GGT results were abnormal or normal, respectively.

CONCLUSIONS

GTT reproducibility is moderate in patients diagnosed with IFG. Considering this fact, perhaps this test should be repeated before therapeutic decisions are made.

Maternal third trimester hyperglycaemic excursions predict large-for-gestational-age infants in type 1 diabetic pregnancy

OBJECTIVE

To determine which maternal glycaemic parameters in type 1 diabetes better predict large-for-gestational-age (LGA) infants.

METHODS

Maternal glycaemic parameters (mean overall, preprandial, and postprandial glucose; the percentage of glucose readings above and below target and HbA1c levels) of LGA (n=37) and appropriate-for-gestational-age (n=36) infants were compared during preconception and each trimester of pregnancy. Logistic regression was used to select predictive variables.

RESULTS

Preconception glycaemic parameters were not different. Mean glucose and the percentage of glucose readings above target were higher in mothers of LGA infants in every trimester of pregnancy. Second and third trimesters mean postprandial glucose, third trimester mean preprandial glucose and third trimester HbA1c were also higher. Only third trimester glycaemic variables were risk indicators of LGA infants: mean glucose (OR: 3.45; 95% CI: 1.52-7.80), mean preprandial glucose (OR: 2.97; 95% CI: 1.34-6.60), mean postprandial glucose (OR: 2.09; 95% CI: 1.19-3.67) and the percentage of glucose readings above target (OR: 1.08; 95% CI: 1.03-1.14). The percentage of glucose readings above target was the best risk indicator.

CONCLUSIONS

Third trimester glycaemic parameters are more powerful predictors of foetal growth than glycaemic parameters earlier in pregnancy or during preconception. Hyperglycaemic excursions are the strongest predictor of LGA infants.

Body mass index has a greater impact on pregnancy outcomes than gestational hyperglycaemia

AIMS/HYPOTHESIS

We evaluated diabetes-related pregnancy outcomes in a cohort of Spanish women in relation to their glucose tolerance status, prepregnancy BMI and other predictive variables.

METHODS

The present paper is part of a prospective study to evaluate the impact of American Diabetes Association (2000) criteria in the Spanish population. A total of 9,270 pregnant women were studied and categorised as follows according to prepregnancy BMI quartiles and glucose tolerance status: (1) negative screenees; (2) false-positive screenees; (3) gestational diabetes mellitus (GDM) according to American Diabetes Association criteria only; and (4) GDM according to National Diabetes Data Group criteria (NDDG). We evaluated fetal macrosomia, Caesarean section and seven secondary outcomes as diabetes-related pregnancy outcomes. The population-attributable and population-prevented fractions of predictor variables were calculated after binary logistic regression analysis with multiple predictors.

RESULTS

Both prepregnancy BMI and abnormal glucose tolerance categories were independent predictors of pregnancy outcomes. The upper quartile of BMI accounted for 23% of macrosomia, 9.4% of Caesarean section, 50% of pregnancy-induced hypertension and 17.6% of large-for-gestational-age newborns. In contrast, NDDG GDM accounted for 3.8% of macrosomia, 9.1% of pregnancy-induced hypertension and 3.4% of preterm births.

CONCLUSIONS/INTERPRETATION

In terms of population impact, prepregnancy maternal BMI exhibits a much stronger influence than abnormal blood glucose tolerance on macrosomia, Caesarean section, pregnancy-induced hypertension and large-for-gestational-age newborns.

Potential impact of American Diabetes Association (2000) criteria for diagnosis of gestational diabetes mellitus in Spain

AIMS/HYPOTHESIS

This study was carried out to determine the impact of American Diabetes Association (ADA) 2000 criteria for the diagnosis of gestational diabetes mellitus (GDM) in the Spanish population.

METHODS

Pregnant women were assigned to one of four categories: negative screenees, false-positive screenees, ADA-only-GDM (untreated) and GDM according to National Diabetes Data Group (NDDG) criteria (treated). Fetal macrosomia and Caesarean section were defined as primary outcomes, with seven additional secondary outcomes.

RESULTS

Of 9,270 pregnant women screened for GDM, 819 (8.8%) met NDDG criteria. If the threshold for defining GDM had been lowered to ADA criteria, an additional 2.8% of women would have been defined as having the condition (relative increase of 31.8%). Maternal characteristics of women with ADA-only-GDM were between those of false-positive screenees and women with NDDG-GDM. The risk of diabetes-associated complications was slightly elevated in the individuals who would have been classified as abnormal only after the adoption of ADA criteria. In addition, the ADA-only-GDM contribution to morbidity was lower than that of other variables, especially BMI.

CONCLUSIONS/INTERPRETATION

Use of the ADA criteria to identify GDM would result in a 31.8% increase in prevalence compared with NDDG criteria. However, as the contribution of these additionally diagnosed cases to adverse GDM outcomes is not substantial, a change in diagnostic criteria is not warranted in our setting.

What is the relative contribution of blood glucose levels at different time points of the day to HbA1c in Type 1 diabetes?

AIMS

To evaluate the relative contribution of blood glucose levels at different time points of the day to HbA(1c) in Type 1 diabetes.

METHODS

Consecutive home blood glucose records (n = 146) from 71 Type 1 diabetic patients who were on an intensive diabetes therapy programme were examined. Each home blood glucose record included six daily blood glucose profiles over 2 months. The relationship between glycaemic values at each time point and HbA(1c) measured at the end of each record period was analysed.

RESULTS

Significant linear correlations were found between HbA(1c) and glycaemia at each time point of the day (ranged from 0.413 to 0.593), the strongest being with predinner glycaemia (r = 0.593; P = 0.000). Total daily glycaemia, mean preprandial and mean postprandial glycaemia were also significant and linearly correlated with HbA(1c) (r = 0.701; r = 0.686; r = 0.620, respectively; P < 0.0001). Multiple linear regression analysis showed that predinner, prebreakfast and post-breakfast glycaemia correlated significantly and independently with HbA(1c). The model accounted for 47.8% of the variance in HbA(1c).

CONCLUSIONS

Our study shows that among individual time points, prebreakfast and predinner are those with more influence on HbA(1c) in Type 1 diabetes and, to a lesser extent, post breakfast. It also confirms that preprandial glycaemia better predicts overall glycaemic control in Type 1 diabetes than postprandial glycaemia.

Molecular scanning for mutations in the insulin receptor substrate-1 (IRS-1) gene in Mexican Americans with Type 2 diabetes mellitus

BACKGROUND

Insulin receptor substrate-1 (IRS-1) is an endogenous substrate for the insulin receptor tyrosine kinase, which plays an important role in insulin signaling. Mutations in the IRS-1 gene are associated in some populations with obesity and Type 2 diabetes.

METHODS

To determine whether variation in the IRS-1 gene contributes to genetic susceptibility to insulin resistance and Type 2 diabetes in Mexican Americans, the entire coding region of the IRS-1 gene was screened for variation in 31 unrelated subjects with Type 2 diabetes using single-stranded conformational polymorphism analysis (SSCP) and dideoxy sequence analysis. Variants encoding amino acid substitutions were genotyped in 27 unrelated nondiabetic Mexican Americans and in all family members of subjects containing these variants, and association analyses were performed. To trace the ancestral origins of the variants, Iberian Caucasians and Pima Indians were also genotyped.

RESULTS

Eight single base changes were found: four silent polymorphisms and four missense mutations (Ala94Thr, Ala512Pro, Ser892Gly and Gly971Arg). Allele frequencies were 0.009, 0.017, 0.017 and 0.043, respectively. There were no significant associations of any of these variants with diabetes, glucose or insulin levels during an oral glucose tolerance test, or with body mass index (BMI) in Mexican American families except for a modest association between the Ala94Thr variant and decreased BMI (30.4 kg/m(2) vs 24.0 kg/m(2); p=0.035). None of these four missense mutations were detected in Pima Indians. In Iberian Caucasians, neither Ala94Thr nor Ser892Gly were detected, and Ala512Pro was detected in only 0/60 diabetic patients and 1/60 nondiabetic controls. Gly971Arg was relatively more common in Iberian Caucasians with 12/58 diabetic patients and 7/60 nondiabetic controls being heterozygous for this variant (p=0.21 for comparison between diabetic and nondiabetic subjects).

CONCLUSIONS

Ala94Thr, Ala512Pro and Ser892Gly mutation are rare in the populations studied. Gly971Arg, is more common in Mexican Americans and Caucasians, but is not a major contributor to genetic susceptibility to Type 2 diabetes.

Hürthle cell tumors

OBJECTIVES

a) To provide a clinicopathological profile of Hürthle cell neoplasms (HCT) in our experience. b) To evaluate if there are any differences in the clinical or morphological features between three HCT categories: benign, malignant and indeterminate. c) To examine the role of the clinical and morphological features in predicting the behavior of these neoplasms.

METHODS

We reviewed the clinical reports of all patients with a histological diagnosis of HCT at our Hospital between 1981 and 1996. The final study group consisted of 25 cases. The neoplasms were divided into three categories on the basis of presence and degree of capsular and vascular invasion, marked nuclear atypia, tumour necrosis and pattern of growth. A series of clinical parameters were evaluated.

RESULTS

Of the 25 tumors, 52% were morphologically classified as benign, 8% as indeterminate and 40% as malignant. Follow-up ranged from 10 months to 14.8 years or until death (average 3.8 years). There were four local recurrences (20%), three in the malignant group (30%) and one in the benign group (7.6%) (p = 0.15). One patient presented metastases and died because of tumor during the follow-up. Apart from capsular and vascular invasion and some aspects of therapy, no significant differences were found in the clinical and histological parameters analyzed between the three histological groups or between the groups with or without recurrence.

CONCLUSION

We did not find any clinical or morphological parameter which can predict recurrence among these tumors. Our study further establishes the controversial issues surrounding the biological behavior of Hürthle cell neoplasms.

Body fat distribution, insulin mediated suppression of non-esterified fatty acids and plasma triglycerides in obese subjects

Triglyceride levels and free fatty acid metabolism are influenced by body fat distribution. To test whether the pattern of fat distribution in obese subjects results in distinct insulin mediated suppression of non-esterified fatty acids which could account for differences in plasma triglycerides, we studied 59 obese subjects who were classified according to waist-to-hip ratio. Non-esterified fatty acids and insulin response to a 75 g oral glucose tolerance test were higher in abdominal obesity. Total non-esterified fatty acids response, after adjustment for sex, showed a positive association with waist-to hip ratio (r = 0.292; p < 0.05). The abdominal obese group had higher fasting triglycerides (1.74+/-0.83 versus 1.11+/-0.71 mmol/L; p = 0.003) and lower glucose/insulin ratio (5.2+/-2.3 versus 7.1+/-2.4; p = 0.003). Stepwise multiple regression analysis showed that triglyceride levels are explained by fasting and 120 min non-esterified fatty acids and by glucose/insulin ratio. We conclude that abdominal obesity is associated with a higher resistance to insulin mediated suppression of non-esterified fatty acids in obese subjects. Variation of triglyceride concentrations in obesity is dependent on both fasting and 120 min non-esterified fatty acids as well as on insulin sensitivity to glucose utilization.

[The metabolic control of insulin-dependent diabetes mellitus and diabetic nephropathy]

Long-term complications of Insulin Dependent Diabetes Mellitus (IDDM) have been associated with several risk factors, particularly the degree of metabolic control and evolution time of the disease. A study was conducted with 219 randomly selected patients with IDDM at our clinic; evolutive, clinical and analytical parameters were assessed and conventional or multiple insulin therapy was evaluated. The classification of glycated hemoglobin (Hb A1c) in quartiles demonstrated a relatively higher incidence of diabetic retinopathy and nephropathy in the upper quartiles versus the lower quartile (p < 0.05). Likewise, patients with multiple insulin therapy had lower retinopathy (24.5% vs. 50.6, p < 0.001) and nephropathy rates (12.9% vs. 26.6%, p < 0.05) compared with those following a conventional insulin therapy. The multivariate analysis showed a statistically significant regression model (p < 0.001) for microalbuminuria level in patients with no established nephropathy; in these patients, the evolution time of IDDM and their Hb A1c level showed a positive independent association, and the use of multiple insulin therapy was a protective factor. The regression analysis of microalbuminuria levels compared with glycated hemoglobin in patients with no established nephropathy showed a value for Hb A1c of 9% as a break-point; from this point upwards microalbuminuria levels increased more markedly. The multivariate analysis here presented can help identify the presence of microalbuminuria in the pathological range in patients with IDDM followed at a hospital clinic from feasible clinical variables (evolution time, glycated hemoglobin level, program of insulin therapy used) establishing a metabolic objective which helps prevent the development of this complication.

[Magnesium. New perspectives]

We reviewed the literature on the Mg++ cation with special attention on the clinico-therapeutical, physiopathogenic, and biochemical aspects. We extended the survey to some pathologies such as cardiovascular diseases and diabetes mellitus, given our understanding that a deficiency of this ion may constitute a primary cardiovascular risk factor. The dissociation present between the levels of intracellular and serum Mg++ is shown, since it may invalidate results that follow. We place special emphasis on the necessity to treat certain pathologies with magnesium salts and to quantify, with successive studies, the amount to administer.

Plasma molecular forms of gastrin, neurotensin and somatostatin in pregnancy and gestational diabetes after an oral glucose load or a mixed meal

At present the physiological role of gastrin, neurotensin and somatostatin in pregnancy and gestational diabetes is scarcely known. We have measured their different molecular forms in plasma of six female controls, six normal pregnant (NP) women and six gestational diabetic (GD) women under basal conditions and 30 min after an oral glucose load (100 g) and a liquid mixed meal in order to study if their alteration could contribute to the impaired glucose tolerance in GD. Total basal concentrations of neurotensin and somatostatin were higher in GD than in controls and NP, and no change was found after the glucose load or mixed meal in GD. Neurotensin-1-13 was the main molecular form of all neurotensins at basal time in the three groups studied, being higher in GD in comparison with controls and NP. Somatostatin-1-14 was the predominant molecular form in controls and GD under basal conditions and did not show any change any change after stimuli. In NP, somatostatin-1-14 showed a significant increase following both kinds of stimuli. Total gastrin concentrations in NP and GD showed a significant increase after the glucose load, which was not observed in controls. Gastrin-17 was the main molecular form at basal time and 30 min post-stimuli in GD but not in NP and controls. We suggest that the basal elevation of neurotensin and somatostatin levels could contribute to the impaired glucose tolerance observed in gestational diabetes, as well as to the lack of post-stimuli responses for neurotensin and somatostatin in GD.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical effectiveness and tolerance of acarbose in the treatment of insulin-dependent diabetic patients (type I)]

BACKGROUND

Acarbose is a reversible inhibitor of the intestinal alpha-glucosidases, the oral administration of which delays or diminishes the postprandial increase of glucose and insulin.

METHODS

A multicentric double-blind clinical trial (11 centers), controlled versus placebo, crossed and randomized, was carried out with 137 insulin-dependent diabetic type I patients treated with diet and insulin. During the first 3 months of the trial the patients received placebo or acarbose randomly. Following one month of wash out with placebo the patients received the inverse medication for 3 more months. During the first month of each phase the patients were given 50 mg three times per day of acarbose or placebo and the two following moths received 100 mg x 3/day.

RESULTS

Upon comparison of the two treatments significant statistical differences were found in HbA1 (p = 0.0005) and in postprandial glycemia (p = 0.007). There were differences, although not statistically significant, in the amounts of triglycerides, cholesterol and fasting glycemia. One hundred and two patients referred adverse events, most being gastrointestinal (flatulence, meteorism).

CONCLUSIONS

Acarbose may be useful in the treatment of insulin-dependent diabetic type I patients treated with insulin and diet since it reduces the levels significantly of HbA1 and postprandial glucose.

[Clinical efficacy and tolerance to acarbose in the treatment of non-insulin-dependent diabetic patients]

BACKGROUND

Acarbose is a pseudotetrasacaride which reversibly and competitively inhibits the intestinal alpha-glycosidases leading to a decrease in the increase of postprandial glycemia.

METHODS

A multicentric double-blind clinical trial (8 centers), controlled versus placebo, crossover and randomized was carried out in 90 non insulin dependent diabetic patients under treatment with diet or with diet and sulphonilureas. During the first three months of the trial the patients received placebo or acarbose randomly. Following one months of wash-out with placebo the patients received the inverse medication for 3 more months. During the first month of each phase the patients received 3 x 50 mg/day of acarbose or placebo and the following 2 months 3 x 100 mg/day.

RESULTS

Upon comparison of the two treatments significant statistical differences were observed in HbA1 (p = 0.0115) and in postprandial glycemia (p = 0.0001). There were differences, although not significant, in the levels of triglycerides, cholesterol, fasting glycemia, and postprandial insulinemia. Episodes of hypoglycemia appeared in 12 patients and 57 patients referred undesirable gastrointestinal effects.

CONCLUSIONS

The results of this trial indicate that acarbose may be useful in the treatment of non insulindependent diabetic patients since it significantly reduces the amount of postprandial glycemia and HbA1.

Longitudinal study of plasma lipoproteins and hormones during pregnancy in normal and diabetic women

Plasma lipoproteins were studied longitudinally at the 1st, 2nd, and 3rd trimester of gestation and at postpartum and postlactation in 12 age-matched PGDM women, 9 GDM women, and 12 healthy control subjects. FPG and HbA1c were higher in every case in PGDM women than in control subjects, whereas in GDM patients, glucose was augmented only after parturition. FFA and beta-hydroxybutyrate levels were higher in both PGDM and GDM patients than in control subjects during gestation but not after parturition. Total TGs and VLDL, LDL, and HDL TGs increased with gestational time in the three groups and declined at postpartum, and although total cholesterol and VLDL, LDL, and HDL cholesterol followed a similar trend, their rise was less pronounced, and the decline after parturition was slower than that of the TGs in the three groups, with no difference among them. The VLDL TG/cholesterol ratio declined in the three groups at the 3rd gestational trimester, whereas in both LDL and HDL, the TG/cholesterol ratio, but not the cholesterol/phospholipid ratio, increased during gestation in the three groups, indicating a specific enrichment of TGs in these particles. The increase in apoA-I and apoB with gestation was parallel to the respective changes in HDL and LDL cholesterol and, again, no difference was observed between the three groups. Plasma levels of beta-estradiol, progesterone, and prolactin increased sharply with gestation and declined at postpartum in the three groups, but absolute values of beta-estradiol and prolactin, at the three trimesters of gestation, were lower in PGDM patients, but progesterone levels were lower than controls in GDM women only at the 3rd trimester. (ABSTRACT TRUNCATED AT 250 WORDS)

Autoimmune insulin syndrome in a patient with progressive systemic sclerosis receiving penicillamine

The case of a patient with progressive systemic sclerosis, who developed hypoglycaemia and insulin autoantibodies, is described. Repeated blood glucose measurements showed levels less than 2.8 mmol/l. High immunoreactive insulin levels, with undetectable free insulin, led to the discovery of anti-insulin antibodies in the patient's serum. He had no history of exogenous insulin use and was receiving penicillamine treatment. A double mechanism for the autoimmune insulin syndrome in this case is proposed: acting in a patient with increased humoral immunoresponsiveness, penicillamine might have induced the development of insulin autoantibodies.

25(OH)D levels in diabetic pregnancies relation with neonatal hypocalcemia

The levels of 25(OH)D have been quantified in 42 insulin diabetic pregnancies (DP) through the three trimesters of pregnancy with a total of 177 determinations. In parallel we quantified this metabolite in 114 normal pregnant women (NP) and also in 116 normal controls (NC). In addition 25(OH)D was quantified in 18 (DP) and 19 (NP) at delivery in the 35-37th week of pregnancy, and ionic calcium was measured in their newborns at 24 h of life. Grouping by trimesters of gestation, the (NP) group had 25(OH)D levels similar to those of (NC) and none showed significant differences between trimesters of pregnancy. (DP) showed in all seasons lower (25(OH)D levels than (NC) but did not have differences in these levels between trimesters of pregnancy. The newborns of (DP) had lower ionic calcium levels than newborns of (NP). Eight newborns of (DP) had hypocalcemia and seven of their mothers showed 25(OH)D levels lower than 10 ng/ml. These findings suggest that lower 25(OH)D levels in (DP) can influence the neonatal hypocalcemia in their newborns.

[Diabetes and pregnancy. Our experience in pregnancy diabetes (1977-1988)]

The records of 303 females with gestational diabetes (GD) seen from 1977 to 1988 in the Hospital La Paz in Madrid were reviewed. In some respects, two periods were separately considered, period A from 1977 to 1983 and period B from 1983 to 1988, the latter corresponding to the activity of the Diabetes and Pregnancy Unit. Significant differences in fetal mortality (0.65%) with nondiabetic pregnant women or between periods A and B were not found. Macrosomic fetuses (the most common abnormality, 18.5%) were related with maternal age, a macrosomic fetus in previous pregnancies, degree of carbohydrate intolerance at the time of diagnosis of the diabetes and need for insulin therapy. This latter feature indicates a more severe degree of metabolic involvement. Regarding risk factors, the most common were older maternal age, family history of diabetes and obesity. The pancreatic reserve in nonobese women with GD (2.1 +/- 0.8 ng/ml) was lower than in obese women with GD (3.3 +/- 0.9 ng/l) (p less than 0.001), higher than in progestational diabetic women type II (1.1 +/- 0.7 ng/ml) and type I (0.15 +/- 0.1 ng/ml) (p less than 0.001), and it was not different from that in normal pregnant women (2.15 +/- 0.6 ng/ml). Insulin therapy for the control of diabetes was required in 24.5% of pregnant women. During the period B, termination of pregnancy by means of cesarean section (25.3%) was higher than in normal pregnant women (11.2%) (p less than 0.001). After pregnancy, 13.2% of patients in period A and 39.1% in period B (p less than 0.01) complied with the evaluation of carbohydrate metabolism. Overall, 26.2% had carbohydrate intolerance and 5.9% diabetes mellitus. Although the creation of the Diabetes and Pregnancy Unit has provided a better care and follow-up of the diabetic pregnant women, has not resulted in significant differences in fetal mortality.

[Bilateral nodular hyperplasia of the adrenal glands; diagnostic problems]

Bilateral adrenal nodular hyperplasia (BAND) is rarely presented as a cause of Cushing Syndrome. The pathogenicity of the disease is unknown and it does not present either symptoms or specific signs, furthermore, its steroid dynamic is atypical and the morphologic tests are not conclusive. The clinical stories of six BAND-diagnosed patients in our Department have been reviewed with the aim of unifying the criteria of the preoperative diagnosis with regard to treatment, comparing our results with literature's wider series. The results from both studies demonstrate an hypophyseal dependence together with some others showing a adrenal autonomy. Thus, our conclusions perpetuate the pathogenic question about BAND (whether is an adrenal primary disfunction or a secondary effect caused by hypophyseal ACTH hypersecretion?) and we point out the usefulness of radioisotopic gammagraphy and abdominal-TAC, since usually they show the bilaterality of the injury at adrenal level.

[Influence of diabetes mellitus in hospital emergencies]

A study performed at the Internal Medicine Emergency Department of the General Hospital "La Paz" (Madrid) over a six month period is presented. Its goal was to check the problems of the diabetic patient at his entrance to the medical emergency. We review the emergency pathological causes and we established that vascular (32%) and acute metabolic (17%) alterations were the most common pathologies, both in insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetic patients. We analyzed the acute metabolic alterations considering that they can be foreseeable with an adequate knowledge of the disease. We point out an aspect that to our knowledge is basic: the diabetological information-education of diabetic patients (only 5% had a good knowledge of the disease and, furthermore, only 18% declared to have received some diabetological information). We also highlight the overuse that diabetic patients do of the hospital emergency departments, as a consequence of the previously mentioned poor information received which also reflects the insufficient or inadequate medical assistance in Primary Care Centers.

[Detection of gestational diabetes with the 50-gram glucose test: prevalence and relationship with to factors]

Prevalence of gestational diabetes was investigated in 222 pregnant women between the 24th and 28th weeks of gestation. A glucose screening test (GST) was performed with a 50 g glucose load, followed by a blood sample 1 hour later. Patients with glycemic levels greater than or equal to 140 mg/dl (7.8 mmol/l) 1 hour after the glucose administration were considered as having a positive GST and scheduled for a full oral glucose tolerance test (OGTT), which was interpreted according to O'Sullivan and Mahan criteria. Fifty-four patients had a positive GST, and 10 of them were diagnosed as having gestational diabetes mellitus. These figures indicate a gestational diabetes prevalence of 4.5% in general population and 18.5% in women selected by GST. The fetal weight index in patients with gestational diabetes was 1.13 +/- 0.10, whereas in normal women this index was significantly lower (p less than 0.01). Patients with positive GST and normal OGTT did not have an increased risk for fetal macrosomia. GST results were significantly higher in pregnant women with advanced age (greater than or equal to 35 years) and with late menarche (greater than or equal to 16 years), but did not vary according to maternal parity. Also, these results were significantly related with the number of risk factors for gestational diabetes encountered in a given patient, but not with any of them as examined alone, except for age. We conclude that GST performed in the 24th-28th weeks of gestation reveals 4.5% undetected gestational diabetes in our population. Certain maternal features (age, menarche, number of risk factors) influence on GST results.

Testicular biopsy and hormonal study in a male with Noonan's syndrome

The testicular biopsy study of a 17-year-old male with Noonan's syndrome revealed seminiferous tubules of reduced diameter with hypospermatogenesis. Many spermatocytes underwent degeneration and many spermatids developed abnormal. The Sertoli cells were similar to immature Sertoli cells. Fully differentiated Leydig cells were rare while precursor Leydig cells were numerous. Both gonadotropin and testosterone levels were low, and a lack of response to LH-RH as well as to clomiphene was found. The testicular biopsy performed at 20 years of age revealed a certain maturation of the seminiferous tubules which increased the germ cell number. The abnormalities in the spermatogenesis as well as the immature appearance of Sertoli cells continued. Leydig cells were more numerous and showed a certain development without reaching the normal pattern. Gonadotropin levels were normal while testosterone levels low. The response to LH-RH was increased and the absence of response to clomiphene persisted. These features suggest a delayed puberty.

Renal tubular function and urinary acidification capacity in early juvenile diabetes

Renal elimination of uric acid, calcium, phosphorus, sodium, potassium, chloride and magnesium and urinary acidification capacity were determined in ten insulin-dependent diabetics and in ten matched control subjects. The diabetics showed excessive excretion of uric acid, sodium, potassium, chloride and ammonia. Sodium, chloride and ammonia excretion fractions was also increased with respect to controls. The enhanced excretion of these substances in diabetics failed to relate to glomerular filtration rate, glycosuria or insulin requirements. These findings might be explained on the basis of glomerular filtration rate elevation, tubular response to this increment, and the underlying metabolic disturbances of diabetes.

Relation of kidney size to kidney function in early insulin-dependent diabetes

Renal function and renal size have been studied in ten early insulin-dependent diabetic patients and in ten matched control subjects. Glomerular filtration rate, renal plasma flow and radiological kidney size were determined in each subject. Glomerular filtration rate and renal plasma flow were increased in diabetics (mean +/- SD: 169.6 +/- 16.1 and 690.1 +/- 52.6 ml/min/1.73 m2, respectively) compared with controls (120.6 +/- 9.7 and 605.9 +/- 67.2 ml/min/1.73 m2; p less than 0.001 and p less than 0.01). Calculated kidney weight corrected to 1.73 m2 of body surface area was elevated in diabetics (385.2 +/- 29.0 g) with respect to controls (277.5 +/- 17.5 g; p less than 0.001). No significant differences were found between diabetics and control subjects when glomerular filtration rate was expressed per gram calculated kidney weight, while renal plasma flow was significantly lower in diabetics than control subjects when so expressed (p less than 0.01). A positive correlation was found between glomerular filtration rate, renal plasma flow and kidney size in both controls and diabetics (p less than 0.01 in all cases). These findings support the conclusion that in the early state of diabetes glomerular hyperfunction is related to enlargement of the kidneys and augmented renal plasma flow.

[Tubular function and renal acidifying in juvenile diabetes mellitus of short evolution]

The fractional excretion of uric acid, calcium, phosphorus, magnesium and other ions, and the urinary acidifying capacity were studied in then patients with juvenile diabetes of short evolution and in a control group matched for age, sex, and body surface. The diabetic patients showed a hyperexcretion of uric acid, sodium, potassium, chloride and ammonium which was unrelated to the increment of glomerular filtration rate or to glucosuria, and could not be ascribed to diet. The pathophysiologic interpretation of these findings is discussed, concluding that they might be the result of an increase in the filtered load and the behaviour of the tubules in front of the glomerular hyperfunction or metabolic disturbance inherent to the diabetic condition.

47,XXY Klinefelter's syndrome with low FSH and LH levels and absence of Leydig cells

Examination of testicular biopsy from a patient with 47,XXY Klinefelter's syndrome revealed a diffuse hyalinization of seminiferous tubules as well as absence of mature Leydig cells. Ultrastructural findings showed some immature Leydig cells in the testicular interstitium. Hormone assays revealed low serum FSH and LH levels. The association of both, hormone assays and testicular morphologic pattern, suggests the presence of a Klinefelter's syndrome with hypogonadotropic hypogonadism.

Diurnal variations of fecal and urinary iodine excretion in rats

The present study was carried out to elucidate whether there are differences between the renal and fecal iodine patterns over 12-hour day and night intervals. Normal rats fed 125I-LID ad libitum and thyroidectomized animals maintained with 125I-labeled l-thyroxine showed diurnal changes in urinary and fecal iodine excretion, the highest values corresponding to the night period. The urinary volume and fecal weight were also increased during darkness hours. A positive correlation was found between the urinary loss of iodine and the quantitative iodine intake during any urine collection period. The changes of periodicity and timing of food intake alter the diurnal pattern of iodine metabolism. These observations suggest that the difference in food iodine intake between both periods constitutes the best explanation for the spontaneous cyclicity of urinary iodine excretion. However, as a significant difference in urinary iodine content exists between day and night periods in rats fed with the same amount of food within each period, and the morning corticosterone injection increases the renal loss of iodine in this period, it would indicate that other influences may be operative in regulating the diurnal variation of iodine excretion. In conclusion, the present results indicate that the high extrathyroidal metabolism of thyroid hormone and the high proportion of the hormone excreted into the feces during night hours may trigger off the TSH secretion in these situations, where an extrathyroidal pool of thyroid hormones were just adequate for normal peripheral requirements.

Diurnal variations of plasma and pituitary thyrotrophin in adult male and female rats

Male and female rats fed a low iodine diet for 20 days were used to study the diurnal variations in resting levels of plasma and pituitary TSH concentration using a highly sensitive radioimmunoassay. Sex differences in the fluctuations in plasma TSH levels and in amount of TSH in the pituitary gland were observed. The daily fluctuations of plasma TSH were characterized by two peaks that occurred in males at 6 a.m. and at 3 p.m. while in females the peaks were delayed until 9 a.m. and 7:30 p.m. Moreover, in the females the morning and the afternoon peaks were of the same intensity while in the males the afternoon peak that occurred just before the onset of darkness was much greater than the morning peak. There was a fall in TSH content of the pituitary in the male rats at 6 a.m. and also in the afternoon just before the onset of darkness. Thus, the diurnal variations in the plasma and pituitary TSH levels were related in male rats. In the females, however, the pituitary TSH concentration did not reflect the changes observed in the plasma TSH levels. The level of plasma PBI did not appear to be responsible for the fluctuations in plasma TSH concentration. It is suggested that the main mechanism for the control of the circadian rhythm of TSH might be related to a high activity at night.

Thyroid iodine uptake, thyroid iodine secretion and plasma TSH levels in male rats during the day and night

Experiments were performed to assess whether the diurnal changes in thyroid 131I metabolism are paralleled by variations in endogenous iodine. The uptake of iodide by the thyroid gland was determined by a double isotope technique. The T/S iodine ratio and the rate of 131I and 127I secretion from the thyroid gland were determined in rats fed LID during 20 days. The accumulation of iodine by the thyroid gland was prevented by CK1O4 and organic iodine formation was blocked by PTU. The absolute uptake of iodide by the thyroid gland was twice as high during the night than during the day. The thyroid/serum iodide ratios were highest during the night. The rate of release of 131I and 127I from the thyroid gland was augmented in the afternoon. The concentration of TSH in the plasma, measured by radioimmunoassay, was elevated in the afternoon as compared to other times during the day and night. The close association between the diurnal changes in thyroid iodine secretion and plasma TSH concentrations suggest that TSH may be responsible for the differences in iodine secretion observed during the day and night. On the other hand, the intake of iodine in the diet and the urinary clearance of iodine showed diurnal rhythms; the highest values occurred during the night. In addition, about twice as much iodine was available to the thyroid gland at night than during the day. These factors might also contribute to the diurnal variations observed in thyroid iodine metabolism.

Increased intrahematic glycolysis in vitro. A new abnormality in prediabetes and chemical diabetes

Glucose uptake by human blood cells was measured under appropriate conditions in blood samples during a standard oral glucose tolerance test in three groups: control, prediabetics (offspring of conjugal diabetics) and diabetic subjects. Glucose uptake was expressed as micromoles of glucose disappearance per gram of hemoglobin per hour of incubation. The significance of results, compared to fasting values, was studied for each group. Controls had lower values at every postchallenge point, but a significant difference occurred only at 120 mins. (p&lt;0.05). On the contrary, all postchallenge values in both experimental groups were higher than corresponding fasting levels. In prediabetics these differences were significant at 60 and 120 mins. (p&lt;0.025) and at 180 mins. (p&lt;0.01). In chemical diabetes these differences were significant at 30 mins. (p&lt;0.05) and at 60, 120 and 180 mins. (p&lt;0.005). The increments produced in prediabetes and chemical diabetes were also compared to the decrements produced in controls. Highly significant differences were found: for prediabetes, p&lt;0.005 at60 and 120 mins., and p&lt;0.025 at 180 mins.; for chemical diabetes, p&lt;0.05 at 30 mins. and p&lt;0.005 at 60, 120 and 180 mins.