Advantages to using capillary blood beta-hydroxybutyrate determination for the detection and treatment of diabetic ketosis

Ketone body determination is indicated in all diabetic patients when the risk of ketotic decompensation exists. New methods of screening for ketosis, in particular capillary blood ketone body determination, provide analytical, technical and clinical advantages compared to the conventional ketonuria. It is proposed that a diabetic patient with hyperglycaemia (capillary blood glucose > 2.50 g.l(-1)) and capillary blood ketone bodies exceeding 0.5 mmol.l(-1) requires therapeutic management. For values greater than 3 mmol.l(-1) or in case of more serious clinical symptoms, hospitalisation is indicated, considering the high probability of ketoacidotic decompensation. The advantages of capillary blood ketone body determination including easy use, and rapid and objective results may improve management of the diabetic patient, especially in emergency situations. However, prescription by a physician of capillary blood ketone body determination should be offered to targeted populations that have a high risk of ketoacidotic decompensation, after providing education to patients that is above all aimed at preventing this metabolic complication. In this context of determining ketone bodies in capillary blood, the term "capillary blood ketone bodies" is therefore preferable to the term "capillary blood beta-hydroxybutyrate determination". Indeed, it appears more appropriate, simple, descriptive and significant both for health-care staff and for patients.

Sensitivity of the ultrasonic interferometry method (Echo-Cell) to changes of red cell aggregation: application to diabetes

The sensitivity of the ultrasonic interferometry method (Echo-Cell) to changes in red blood cell (RBC) aggregation was investigated in comparison to the Regulest erythroaggregometry known as a reference method. In experiments where different concentrations of dextrans of 40 or 70 kD molecular weights were added to normal RBCs, the Echo-Cell was proved as sensitive as erythroaggregometry. A comparative study using RBC samples from normal and diabetic subjects showed that the Echo-Cell was much more sensitive when aggregation was measured in diluted than undiluted plasma. The sensitivity of Echo-Cell measurements in diluted plasma was similar to that of erythroaggregometry. Further analysis revealed that RBC aggregation was underestimated by Echo-Cell when measurements were made in undiluted plasma containing high fibrinogen levels, implying that in that case an elevated plasma viscosity might indirectly affect the sensitivity of the Echo-Cell. The low sensitivity of the Echo-Cell to detect an abnormal RBC aggregation when suspensions were prepared in undiluted plasma, is likely related to a relatively high shear stress exerted on RBC aggregates by the suspending medium. In conclusion, the sensitivity of the Echo-Cell to detect abnormal changes in RBC aggregation can be optimized by diluting the plasma.

Impaired hemorheological properties in diabetic patients with lower limb arterial ischaemia

The rheological properties of blood play an important role in the regulation of blood flow resistance in vessels. Numerous data show evidence for an impaired hemorheological characteristic in diabetes mellitus. The aim of this study was to investigate whether chronic severe leg ischaemia in diabetes may be associated with further hemorheologic impairment. To do this, whole blood viscosity, erythrocyte aggregation/disaggregation, plasma viscosity and proteins were measured in 32 healthy control subjects, in 32 diabetic patients without micro- and macroangiopathy, in 21 diabetic patients with chronic tissue hypoxia of lower limbs and in 23 diabetic patients with severe leg ischaemia. The diabetic patients with leg hypoxia and leg ischaemia were selected according to their value of transcutaneous oxygen pressure (TcPO2) measured on dorsal side of the foot in supine position. The TcPO2 value was within 10-30 mmHg or less than 10 mmHg in patients with chronic hypoxia and severe ischaemia, respectively. Results in diabetic patients without micro- and macroangiopathy showed an increased erythrocyte aggregation associated with an increased fibrinogen level while albumin levels were decreased. Both diabetic patients with chronic hypoxia and those with severe ischaemia exhibited similarly more aggravated hemorheological disturbances including an increased whole blood viscosity at low shear rate, an increased erythrocyte hyperaggregation, increased plasma viscosity, increased fibrinogen level, decreased albumin level and decreased hematocrit. In conclusion, the hemorheological disturbances are present even in diabetic patients without clinically detectable micro- and/or macroangiopathy. The fact that the extent of disturbances was similar in the two later diabetic groups, emphasizes that the hemorheological disturbances are not the consequences of chronic hypoxia and/or severe ischaemia but are likely among factors promoting the maldistribution of blood flow in nutritive capillaries as evidenced by decreased TcPO2 in patients with chronic leg hypoxia or severe leg ischaemia.

Tissular oxygenation and venoarteriolar reflex disturbances in diabetes mellitus: vasoregulator effect of Buflomedil

The present study was designed to investigate whether the Veno-Arteriolar Reflex (VAR) mediated via a local nervous reflex mechanism may be used as a microvascular approach to predict the effect of vasoactive drugs in diabetic patients. The vasoactive drug we studied here was Buflomedil. The effect of a single infusion of 400 mg of Buflomedil was examined on VAR and on transcutaneous oxygen pressure (TcPO2). Investigations were performed in 42 diabetic patients. The VAR was assessed on dorsal foot and dorsal big toe by measuring changes in skin blood flux induced by lowering the leg. TcPO2 was measured on dorsal foot. Before Buflomedil infusion, patients were characterized by a loss of the VAR in comparison to healthy volunteers. The loss of the VAR was associated to significant decreases in TcPO2 values. Buflomedil infusion led to significant increases in VAR at the two sites of measurement and also in TcPO2 values. These findings indicate that the VAR can be used as a sensitive microvascular test, as it allows to detect the effect of Buflomedil. Furthermore, our findings demonstrate that the Buflomedil-induced improvement in VAR is identical in the two diabetic groups with or without complications. This result emphasizes the benefit of Buflomedil not only in diabetics with microangiopathy or those suffering from a peripheral vascular disease for reducing pain or healing trophic lesions, but also in those patients without any clinically detectable macro- or microangiopathy in order to prevent or to reduce as long as possible the risk of developing diabetes related complications by the normalization of functional microangiopathy.

Haemorheological consequences of hyperglycaemic spike in healthy volunteers and insulin-dependent diabetics

The present study has been designed to examine the role of a hyperglycaemic spike of short duration as a factor possibly involved in haemorheological microcirculatory and (or) haemostatic dysfunctions in ten insulin-dependent diabetes mellitus patients (IDDM) and five healthy volunteers. The hyperglycaemic spike was induced by glucose infusion via GCIIS Biostator. Blood viscosity, erythrocyte aggregation, erythrocyte deformability, plasma viscosity and proteins' levels, cell counts, and transcutaneous oxygen pressure were investigated during normoglycaemic period and at the end of a 1 h hyperglycaemic spike. Hyperglycaemia induced in IDDM patients significant decreases in erythrocyte aggregation, in blood and plasma viscosities and in both fibrinogen and albumin levels. The number of platelets was significantly decreased as a result of the hyperglycaemic spike. There was no significant change induced by the hyperglycaemic spike in healthy volunteers. These findings show that a hyperglycaemic spike of 280 mg/dl (15.6 mmol/l) of short duration in IDDM patients causes numerous significant changes in both blood components and rheological behaviour. These changes were accompanied by a significant decrease in transcutaneous oxygen tension indicating an impaired tissue oxygenation during the hyperglycaemia.

Relationship between hemorheological and microcirculatory abnormalities in diabetes mellitus

From numerous studies, it is now well known that diabetes mellitus is usually accompanied by miscellaneous hemorheological disturbances. These may alter the microcirculatory flow and lead ultimately to tissue chronic hypoxia. In this report, red blood cell aggregation characteristics and transcutaneous oxygen pressure (TcPO2) have been evaluated in diabetic patients without any sign of angiopathy. Results showed a tendency towards erythrocyte hyperaggregation in diabetic patients, even when under good glycaemic control. TcPO2 measurements, were found to be significantly lower in diabetic patients than in control subjects. Furthermore, the TcPO2 values were related with the aggregation parameters, confirming thereby the existence of an inter-relationship and thus the possible role played by hemorheological parameters in oxygen transport to tissues and hence in the pathogenesis of microangiopathy at the functional level.

[Hemorheological parameters in isolated obesity]

Obesity in adults is evoked by several authors as a risk factor for thrombosis and vascular diseases. There are also some reports in the literature describing hemorheological disturbances associated with obesity. However, the majority of these studies have been performed on obese populations with another concomitant pathology which can interfere on the measured rheological parameters. The present study was therefore devoted to the effect of obesity on the rheological properties of blood in the absence of any associated pathology. Results showed a significant increase in erythrocyte aggregation in obese population when compared to the controls while the red blood cell deformability was significantly decreased. The increase of aggregation was accompanied by significant increases in plasma viscosity and fibrinogen level. By contrast, albumin level was found to be decreased. The red cell aggregation differences between normal and obese subjects can be explained mainly in terms of the effects of altered fibrinogen concentration and albumin level. These results lead one to conclude that the plasma proteins metabolism and consequently erythrocyte aggregation could be altered only because of weight excess. These disturbances may also be considered as a risk factor promoting vascular diseases in obese patients.

Transcutaneous oxygen pressure and hemorheology in diabetes mellitus

Diabetes is associated with altered blood viscosity and abnormal tissue oxygenation. Transcutaneous oxygen tension is measured in 119 diabetic and 20 normal subjects. Measurements of transcutaneous oxygen pressure (TcPO2) are made by Oxymonitor SM 361 at 45 degrees C at the dorsum of the foot. At the same time, the main microrheological parameters (plasma viscosity, albumin, fibrinogen, red cell aggregation times, disaggregation threshold and red cell aggregate structure index) are measured in diabetic patients with good and poor glycemic control, with and without angiopathy. All the diabetics have a significant reduction of TcPO2 and have rheological disturbances. TcPO2 values are related significantly with plasma viscosity and with several parameters of aggregation-disaggregation phenomenon. As for microrheological parameter abnormalities, it seems that tissue hypoxia precedes clinical signs of angiopathy and depends on the metabolic state as rheological abnormalities. TcPO2 values are the result of numerous parameters as rheological parameters. It seems that TcPO2 measurement is able to provide useful informations about microcirculation in diabetes mellitus without clinical signs of tissue hypoxia.

Red blood cell aggregation in diabetes mellitus

The aim of this work is to study the red blood cell aggregation in diabetic patients. Investigations have been performed via rheometric technics on four various types of diabetics (diabetics with good metabolic control, diabetics with poor metabolic control, diabetics with a distal angiopathy, without clinical signs, diabetics with a distal angiopathy characterized by cutaneous trophic disorders). Results, compared with those of healthy subjects, show that the reversible phenomenon of erythrocyte aggregation is significantly modified in diabetic. Indeed, the red cell aggregation tendency is found to be increased in diabetics. This hyperaggregation becomes more important when the diabetes is characterized by a poor metabolic control or a distal angiopathy with or without cutaneous trophic disorders. Disturbances of red cell aggregation observed in this report are discussed as a result of plasma protein changes and may confirm the role of hemorheological properties in the pathogenesis of diabetic angiopathy.

Pharmacoclinical study of the action of vinburnin versus placebo: study of the hemodynamic, microcirculatory and rheological effects in angiopathy of the lower limbs in diabetes mellitus

The diabetic macroangiopathy of lower limbs in characterized by chronic hypoxia with several abnormalities of hemodynamic, microcirculatory, rheological and metabolic red cell parameters. This study, in a double blind test with placebo was carried out on 40 subjects: 20 normal subjects and 20 diabetic patients suffering from microangiopathy of lower limbs. Ten are treated by 45 mg iv per day of Vinburnin, the 10 others received a placebo. Before and after treatment, the following parameters were measured: arterial flow rate at rest and after hyperhemia, transcutaneous oxygen level (TCpO2), red cell deformability, plasma viscosity, fibrinogen, red cell 2,3-diphosphoglycerate (2,3-DPG) and adenosine triphosphate (ATP). In this study, we have proved several effects of Vinburnin on the microcirculatory and rheological parameters the most essential for the transport of oxygen. The significant improvement of TCpO2, of ATP and 2,3-DPG red cell levels, of plasma viscosity and red cell deformability, even though we have no haemodynamic changes, confirm the rheological effects of Vinburnin. These pharmacological properties prove the interest and the special position of Vinburnin in the treatment of vascular diseases with acute or chronic tissular hypoxia.

Dietary behavior of French men according to alcohol drinking pattern

Relationships of alcohol consumption with diet were studied in 216 French men aged 18-44. The sample was divided on the basis of alcohol intake in the preceding 7 days: controls (less than or equal to 43 g/day), moderate drinkers (44-87 g/day) and heavy drinkers (88-200 g/day). Moderate and heavy drinkers consumed more meat and meat products, bread and toast, dried vegetables and potatoes than controls but fewer nonalcoholic drinks and less milk, yogurt, cooked vegetables, raw and cooked fruits, pastries and confectioneries. Total energy intake was higher in drinkers than in controls but nonalcoholic energy intake was not significantly different; alcohol was simply added to food intake. Moderate and heavy drinkers consumed significantly less carbohydrates but more fat and protein than controls. Vitamins A and C intakes were lower in the moderate and heavy drinkers than in controls but folate and iron intakes were higher. The differences in dietary habits between controls and drinkers were not related to age nor to socioprofessional status since after adjustment for these two parameters the same relationships were still found.

[Plasma retinol, carotenoids and tocopherols: biological variations between 18 and 45 years of age]

Variation factors of plasma retinol, carotenoids and vitamin E, and particularly sex and alcohol consumption, were studied on a sample of 271 males and females aged between 18 and 45 years. For analysis needs two subsamples were constituted: I (males and females with alcohol consumption less than or equal to 43 g/day) and II (males only). Sex and level of alcohol intake were two independent variation factors of plasma retinol and carotenoids. Associated with triglyceride and cholesterol for I and with triglyceride and ponderal index for II, they explained 40% of the total variance of plasma retinol. For carotenoids, the other associated independent variables were cholesterol, vitamin A and energy intake (r2 = 23% of explained variance). And for plasma vitamin E, neither sex nor alcohol consumption was a significant predictor of the model, the only variation factors being plasma lipids and age for I (r2 = 37%) and the same parameters associated with ponderal index for II (r2 = 55%).

Reference intervals for vitamins B1, B2, E, D, retinol, beta-carotene, and folate in blood: usefulness of dietary selection criteria

Reference intervals for normal concentrations in blood of vitamins B1, B2, E, D, retinol, beta-carotene, and folic acid were determined from a selected sample of people attending a Health Examination Center or being examined in occupational health services in France. This reference sample consisted of 362 men and women, ages 18 to 44 years, selected according to the main variation factors known for the vitamins studied: consumption of tobacco and alcohol, ponderal index (relating height and weight), use of drugs and oral contraceptives, and past history of surgical or medical treatment. Reference intervals were determined for each sex. Vitamin B1 (erythrocyte transketolase activity), plasma retinol, and folic acid values in whole blood are significantly higher in men than in women (p less than 0.001), but vitamin B2 (activation of erythrocyte glutathione reductase) and plasma beta-carotene values are significantly higher in women (p less than 0.001 and less than 0.01 respectively). Dietary intake of vitamins produced no significant displacement of the reference values. For each vitamin we discuss the other major sources of variation factors and the usual values reported in the literature.

Reference intervals for vitamins B1, B2, E, D, retinol, beta-carotene, and folate in blood: usefulness of dietary selection criteria

Reference intervals for normal concentrations in blood of vitamins B1, B2, E, D, retinol, beta-carotene, and folic acid were determined from a selected sample of people attending a Health Examination Center or being examined in occupational health services in France. This reference sample consisted of 362 men and women, ages 18 to 44 years, selected according to the main variation factors known for the vitamins studied: consumption of tobacco and alcohol, ponderal index (relating height and weight), use of drugs and oral contraceptives, and past history of surgical or medical treatment. Reference intervals were determined for each sex. Vitamin B1 (erythrocyte transketolase activity), plasma retinol, and folic acid values in whole blood are significantly higher in men than in women (p less than 0.001), but vitamin B2 (activation of erythrocyte glutathione reductase) and plasma beta-carotene values are significantly higher in women (p less than 0.001 and less than 0.01 respectively). Dietary intake of vitamins produced no significant displacement of the reference values. For each vitamin we discuss the other major sources of variation factors and the usual values reported in the literature.

Pharmacological influences of pentoxifylline on red cell filterability and 2-3 diphosphoglycerate

The diabetic's impairment of the red cell filterability is all the more important if the diabetic subject is suffering from an acute and progressive lower limb arteriopathy. Red cell 2-3 diphosphoglycerate (2-3 DPG) increases when red cell filterability decreases among these patients. Pentoxifylline (i.v. 600 mg per day) produces a rapid initial improvement of red cell filterability and then increases red cell 2-3 DPG level.

Red cell filterability and metabolic state in diabetic subjects with macro-angiopathy

In twenty control subjects, twenty diabetic patients without macro-angiopathy and forty diabetic patients with an acute and severe arteriopathy of lower limbs, we studied the red cell filterability (TFE) on total blood, the 2-3 diphosphoglycerate level (2-3 DPG) and the Adenosine Triphosphate level (ATP). The diabetic's impairement of the red cell filterability and ATP level are all the more important than the subject is suffering from an acute arteriopathy of lower limbs. For the same subjects, we notice that the 2-3 DPG level increases significantly. The filterability is related to the ATP red cell concentration. An ATP depletion produces an increase membrane rigidity and a minor filterability. These findings strongly suggest a relation that can exist between the red cell metabolic state and filterability in diabetic population with or without macroangiopathy.

Vitamin B1, B2, B6, and C status in hospital inpatients

The status of vitamin B1, B2, B6 and C was investigated in 656 hospital inpatients by means of a dietary interview, biochemical studies, and clinical investigation. The daily intake was lower than the Recommended Dietary Allowance for vitamin B1 in 57%, B2 in 47%, B6 in 53%, and C in 9% of the patients; it was less than half the Recommended Dietary Allowance in 19, 12, 15, and 3%, respectively. A biochemical deficiency was observed in 25% of the patients for vitamin B1, in 11% for B2, in 25% for B6, and in 14% for C. On the basis of the parameters selected for this study, the biochemical vitamin status, the dietary vitamin intake, and the clinical symptoms correlated significantly with each other except in the case of vitamin B6.

Impairment of memorization by high doses of pyridoxine in man

Two controlled trials were performed successively to evaluate the effect of high doses of oral pyridoxine on brain performance in man. In trial I, medical students volunteered to take 100 mg, 500 mg of pyridoxine a day or placebo for 10 days. A digit coding test was performed before, and at the end of the treatment period and a third 15 days later. The improvement of performance from the first to the third test (learning effect) was significantly better in the placebo group than in the B6 treated groups. This could be attributed to memorization of skills. Trial II was performed in obese patients starting a low calorie diet in whom vitamins are routinely prescribed. Performance in a work recognition test and in a visual retention test was lower for the group receiving 1 g of pyridoxine a day. Thus, high doses of oral pyridoxine are likely to impair memorization in man. Disturbances of neuro-transmitter metabolism such as increase of GABA production might explain the effect. As the benefit of high doses of pyridoxine has not been well-documented and as the study has suggested that undesired effects may indeed exist, the widespread use of such doses is questionable.