BACKGROUND: A high prevalence of impaired glucose tolerance and unknown type 2-diabetes in patients with coronary heart disease and no previous diagnosis of diabetes have been reported. The aims of the present study were to investigate the prevalence of abnormal glucose regulation (AGR) 3 months after an acute ST-elevation myocardial infarction (STEMI) in patients without known glucometabolic disturbance, to evaluate the reliability of a 75-g oral glucose tolerance test (OGTT) performed very early after an acute STEMI to predict the presence of AGR at 3 months, and to study other potential predictors measured in-hospital for AGR at 3 months. METHODS: This was an observational cohort study prospectively enrolling 224 STEMI patients treated with primary PCI. An OGTT was performed very early after an acute STEMI and was repeated in 200 patients after 3 months. We summarised the exact agreement observed, and assessed the observed reproducibility of the OGTTs performed in-hospital and at follow up. The patients were classified into glucometabolic categories defined according to the World Health Organisation criteria. AGR was defined as the sum of impaired fasting glucose, impaired glucose tolerance and type 2-diabetes. RESULTS: The prevalence of AGR at three months was 24.9% (95% CI 19.1, 31.4%), reduced from 46.9% (95% CI 40.2, 53.6) when measured in-hospital. Only, 108 of 201 (54%) patients remained in the same glucometabolic category after a repeated OGTT. High levels of HbA1c and admission plasma glucose in-hospital significantly predicted AGR at 3 months (p
The treatment of Type II diabetes (NIDDM) includes an appropriate diet and prudent exercise program. If these measures are insufficient to control the blood sugar, oral agents (sulphonylureas or biguanides) or insulin are added to the therapeutic regimen. Although the diet prescription has undergone some changes and refinements, this approach has been the traditional treatment for NIDDM for nearly 40 years. Recently a new class of oral agents, the alpha-glucosidase inhibitors, has become available. These drugs are competitive inhibitors of the alpha-glucosidase enzymes in the brush border of the bowel wall. They act to slow and delay the rate of carbohydrate absorption, thereby decreasing postprandial hyperglycemia. A recent study was designed to evaluate the long-term efficacy of acarbose, an alpha-glucosidase inhibitor, in improving the glycemic control of patients with NIDDM who were sub-optimally controlled on either diet alone, or diet plus sulphonylurea, metformin or insulin. A total of 354 patients with NIDDM were studied, 77 on diet alone, 83 on metformin, 103 and sulphonylurea and 91 on insulin. Subjects in each treatment stratum were randomized, double-blind to either acarbose or placebo, for 1 year. At baseline and every 3 months thereafter, fasting and postprandial glucose and C-peptide, HbA1c and fasting lipids were measured. Compared to placebo, acarbose treatment resulted in a decrease in mean postprandial glucose in all four strata (19 +/- 0.8 to 15.3 +/- 0.7 mmol/l: P
Erratum In: Diabetes Res Clin Pract 1995 Sep;29(3):215
PURPOSE: Patients with insulin-dependent diabetes mellitus (IDDM) are especially susceptible to microangiopathic complications such as nephropathy, retinopathy, and neuropathy. Microangiopathic changes are also the most important findings in histopathologic studies of the inner ear and central nervous systems in diabetic subjects. No previous studies have measured acoustic-reflex latencies (ARL) or amplitudes (ARA) in patients with IDDM. ARL and ARA reflect the function of the acoustic-reflex arch. Furthermore, possible changes in the tympanic membrane, ossicular chain, and stapedius muscle may affect the shape of acoustic-reflex. SUBJECTS AND METHODS: Acoustic-reflex thresholds, latencies, and amplitudes were studied in 53 patients with IDDM and 42 randomly selected nondiabetic control subjects, aged between 20 and 40 years, using the Madsen Model ZO 73 Impedance Bridge (Madsen Electronics, Copenhagen, Denmark). Subjects with an abnormal tympanic membrane, conductive hearing loss, and known cause for hearing impairment eg, noise damage, were excluded from the study. RESULTS: There were no differences between control and diabetic subjects in the contralateral acoustic-reflex thresholds. In contrast, patients with IDDM had longer ARLs and decreased ARAs compared with those of control subjects. ARA amplitude had linear correlation with the amplitude of tympanogram, whereas ARL had no linear correlation with auditory brainstem latencies in the same study subjects. Acoustic-reflex responses in insulin-dependent diabetic patients were not associated with the duration of diabetes, metabolic control, microangiopathy, or neuropathy. CONCLUSIONS: Prolonged ARLs and decreased ARAs in patients with insulin-dependent diabetes are probably caused more by the stiff middle ear system than disturbances in the brainstem.
Analytical performance specifications can be based on three different models: the effect of analytical performance on clinical outcome, based on components of biological variation of the measurand or based on state-of-the-art. Models 1 and 3 may to some degree be combined by using case histories presented to a large number of clinicians. The Norwegian Quality Improvement of Primary Care Laboratories (Noklus) has integrated vignettes in its external quality assessment programme since 1991, focusing on typical clinical situations in primary care. Haemoglobin, erythrocyte sedimentation rate (ESR), HbA1c, glucose, u-albumin, creatinine/estimated glomerular filtration rate (eGFR), and Internationl Normalised Ratio (INR) have been evaluated focusing on critical differences in test results, i.e., a change from a previous result that will generate an "action" such as a change in treatment or follow-up of the patient. These critical differences, stated by physicians, can translate into reference change values (RCVs) and assumed analytical performance can be calculated. In general, assessments of RCVs and therefore performance specifications vary both within and between groups of doctors, but with no or minor differences regarding specialisation, age or sex of the general practitioner. In some instances state-of-the-art analytical performance could not meet clinical demands using 95% confidence, whereas clinical demands were met using 80% confidence in nearly all instances. RCVs from vignettes should probably not be used on their own as a basis for setting analytical performance specifications, since clinicians seem "uninformed" regarding important principles. They could rather be used as a background for focus groups of "informed" physicians in discussions of performance specifications tailored to "typical" clinical situations.
To describe clinical characteristics and antihyperglycemic treatment patterns in patients with varying duration of diabetes.
We performed a cross-sectional survey of 61890 type 2 diabetic (DM2) patients from the Swedish National Diabetes Register (NDR) in 2004. We also analysed the effect of types of treatment and risk factors on glycaemic control in a longitudinal cohort study from 1996 to 2004. HbA(1c), risk factors and treatments were determined locally in primary care as well as hospital outpatient clinics.
Insulin was frequently used in DM2 patients with long duration of diabetes, although the mean HbA(1c) increased and only a few in this group reached HbA(1c) 1%) from 1996 to 2004 were more often treated with insulin than with oral hypoglycaemic agents (OHA). During this period, the HbA(1c) levels leading to additional treatment decreased. A low BMI, decreasing BMI and not smoking were predictors of good long-term metabolic control. Hypertension and hyperlipidaemia were frequent in both newly diagnosed DM2 patients and in patients with a long duration of diabetes.
Insulin treatment was frequently used, particularly in patients with a long duration of DM2. The glycaemic control, which usually deteriorates over time, did not reach the recommended goal, despite the fact that complementary treatment was added at lower HbA(1c) levels in 2003 than in 1996. High frequencies of hypertension, hyperlipidaemia and high 10-year risks of coronary heart disease necessitate intensified risk factor control in the future.
Diabetes and alcohol abuse may cause severe metabolic disturbances that can be fatal. These may be difficult to diagnose in autopsies based solely on macroscopical and histological findings. In such cases, metabolic markers, such as postmortem glucose and ketone levels, can provide supporting information. Glucose or combined glucose and lactate, the Traub value, is often used to indicate hyperglycemia. The use of the Traub value, however, has been questioned by some, because the lactate levels are known to elevate in postmortem samples also due to other reasons than glycolysis of glucose molecules. Ketoacidosis can be detected by analyzing ketone body levels, especially beta-hydroxybutyric acid (BHB). Acetone is also elevated in severe cases of ketoacidosis. Here, we have evaluated the value of these biomarkers for postmortem determination of the metabolic disturbances. Retrospective data of 980 medico-legal autopsies performed in Finland, where glucose, lactate and ketone bodies were analyzed, was collected. Our findings show that the Traub value indicates hyperglycemia, even when glucose levels are low. For diagnosis, evaluation of complementing markers, e.g. ketone bodies and glycated hemoglobin is needed. Our results show that BHB can be used for screening and diagnosis of ketoacidosis. Acetone alone is not sufficient, since it is elevated only in the most severe cases. We also found that alcohol abuse rarely causes severe ketoacidosis. However, sporadic cases do exist where ketone body levels are extremely high. Despite this, alcoholic ketoacidosis is very rarely diagnosed as the cause of death.
OBJECTIVE: To assess age-related changes in stimulated plasma C-peptide in a population-based sample of adults. DESIGN: Cross-sectional study. SETTING: Wadena, Minnesota, a city of 4,699 residents (1980 census) in west central Minnesota, approximately 150 miles from Minneapolis/St. Paul. STUDY SUBJECTS: 344 non-diabetic subjects (NDDG standards) from a stratified random sample of the total adult population of Wadena, MN. The six-study strata were men and women from three age groups: young, 20-39 years of age; middle-aged, 40-59; and older, greater than 60 years of age. MEASUREMENTS: During a liquid meal of Ensure-Plus (Ensure-Plus challenge test; EPCT; Ross Laboratories), blood samples were taken for glucose, free fatty acids, creatinine, and C-peptide. Plasma C-peptide taken 90 minutes after the EPCT was used as a surrogate measure for insulin. Clinical tests included one-time samples for hemoglobin, glycosylated hemoglobin, plasma cholesterol, triglycerides, and lipoproteins. Physical measurements included height, weight, and blood pressure. Urine was assayed for C-peptide and creatinine. Assays of urine and plasma C-peptide used antibody M1221 (from Novo; Copenhagen, Denmark). MAIN RESULTS: No differences were observed for the relationship between age and C-peptide within each of the three age groups for men and the three age groups for women. However, the levels of plasma C-peptide for older men or women were statistically significantly higher than levels for the young age groups of the same sex; fasting plasma glucose also was higher for older groups of both sexes, and postmeal glucose was significantly higher for older women. There were decreases with age in urine C-peptide clearance for women and men; the decline for women was statistically significant. In multiple regression models for men alone and women alone, that controlled for age, post-meal plasma glucose best explained plasma C-peptide levels. For young men, plasma glucose alone provided the best prediction of plasma C-peptide levels; body mass index (BMI) and plasma glucose provided the best prediction for young women. For older men and both middle-aged and older women, a combination of urine C-peptide clearance and plasma glucose best predicted plasma C-peptide levels; for middle-aged men, BMI also contributed to the prediction. CONCLUSIONS: Secretion of insulin in response to an orally administered mixed meal is undiminished with age in non-diabetic adults.
Carbohydrate counting is an established approach used by patients with type 1 diabetes to improve their glycemic control. The aims of this study were to evaluate, in real life conditions, the accuracy of meal carbohydrate estimate and its impact on glycemic variability.
In this cross-sectional study, we observed the ability of 50 adults (48% women) with type 1 diabetes (age: 42.7±11.1 years); diabetes duration: 21.4±12.7 years; HbA1c: 7.2±1.2% (60±10 mmol/mol) to accurately estimate carbohydrates by analyzing 72-h food records and their corresponding 72-h blood glucose excursions using a continuous glucose monitor.
The mean meal carbohydrate difference, between the patients' estimates and those assessed by a dietitian using a computerized analysis program, was 15.4±7.8 g or 20.9±9.7% of the total CHO content per meal (72.4±34.7 g per meal). Sixty-three percent of the 448 meals analyzed were underestimated. Greater differences in CHO's estimates predicted higher glycemic variability, as measured by the MAGE index and glucose standard deviation, and decreased time with glucose values between 4 and 10 mmol/L (R²=0.110, 0.114 and 0.110, respectively; P
OBJECTIVE: To estimate the prevalence of and the cardiovascular risk associated with the metabolic syndrome using the new definition proposed by the World Health Organization RESEARCH DESIGN AND METHODS: A total of 4,483 subjects aged 35-70 years participating in a large family study of type 2 diabetes in Finland and Sweden (the Botnia study) were included in the analysis of cardiovascular risk associated with the metabolic syndrome. In subjects who had type 2 diabetes (n = 1,697), impaired fasting glucose (IFG)/impaired glucose tolerance (IGT) (n = 798) or insulin-resistance with normal glucose tolerance (NGT) (n = 1,988), the metabolic syndrome was defined as presence of at least two of the following risk factors: obesity, hypertension, dyslipidemia, or microalbuminuria. Cardiovascular mortality was assessed in 3,606 subjects with a median follow-up of 6.9 years. RESULTS: In women and men, respectively, the metabolic syndrome was seen in 10 and 15% of subjects with NGT, 42 and 64% of those with IFG/IGT, and 78 and 84% of those with type 2 diabetes. The risk for coronary heart disease and stroke was increased threefold in subjects with the syndrome (P
The aim of this study was to evaluate the salivary status, prevalence of caries and the status of primary dentition, when primary teeth were exfoliated, in 41 patients, 18-24 years of age, with type 1 diabetes since childhood in comparison with age- and sex-matched non-diabetic controls. The blood glucose and glycosylated haemoglobin concentration (HbA1c), dosage of daily insulin and retinal fundus photography was recorded for the diabetic group. According to the concentration of HbA1c, the diabetic patients were divided into well and poorly controlled groups. The study was based on three intra-oral photos, dental examination including intra-oral radiographs, flow rate and buffering capacity of the saliva and amount of Streptococcus mutans and Lactobacilli. Retrospective data regarding the primary dentition was found in the dental files of each patient, and are based on the last registration for respective tooth before exfoliation. The patients with type 1 diabetes, without any relationship to metabolic control, displayed more initial buccal caries compared to healthy controls (p