A clinical algorithm to determine the etiology of brittle diabetes

Brittle diabetes is a subset of insulin-dependent diabetes mellitus for which multiple causes have been suggested. In its most severe form, brittle diabetes is incapacitating, preventing gainful employment and a normal lifestyle. Although some brittle diabetic individuals will significantly improve by intensive insulin therapy and education, many others remain unable to function normally because of recurrent episodes of hyperglycemia and hypoglycemia. We studied 30 incapacitated brittle diabetic subjects and developed an efficient algorithmic approach to determine the etiology of brittleness. Central to our diagnostic algorithm was the glucose response to 0.1 U/kg insulin administered subcutaneously and intravenously. If this response was normal, then psychosocial evaluations were completed, including psycholinguistic and health psychological testing. Other parameters affecting blood glucose concentration were also assessed, such as gastric motility, counterregulatory hormones, and, most important, patient compliance with prescribed regimens. However, if an "abnormal" glucose response to the insulin challenge tests was observed, the location of the insulin resistance was identified as being subcutaneous, intravascular, or at the peripheral tissue. Using our diagnostic algorithm, the identification of the etiology of brittleness in 29 of the 30 referred patients was possible. Thus, the purpose of an algorithmic approach to diagnosis is not only to avoid unnecessary testing, but also to determine the correct etiology of the brittle diabetes to determine appropriate therapy.     

Prevalence of diabetes in care home residents

OBJECTIVE--To determine the prevalence of known and undetected diabetes diagnosed either by an elevated fasting baseline sample or by a 2-h post-glucose load sample in a group of residents of care homes in an urban-district setting. RESEARCH DESIGN AND METHODS--We completed individual interviews with patients and caregivers in 30 care homes (both residential and nursing homes) in two metropolitan districts of Birmingham, West Midlands, U.K. All care homes were under the supervision of primary care physicians (general practitioners). We carried out 75-g oral glucose tolerance tests (OGTTs) in consenting residents without previous known diabetes. Criteria for diagnosis of diabetes were obtained from the World Health Organization (1998) and the American Diabetes Association (1997). RESULTS--Of 636 residents available for study, 76 residents (12.0%) were known to have diabetes; of the 560 remaining residents, 286 either refused to participate or were deemed too ill or unavailable to undergo testing. Complete data on 274 OGTTs were obtained (median age 83 years, range 45-101). A total of 46 subjects were diagnosed as having diabetes and 94 as having impaired glucose tolerance. Allowing for subjects who refused or were unable to participate, the calculated total prevalence (which includes known and newly detected diabetes) was 26.7% (95% CI 21.9-32.0). The calculated overall prevalence of impaired glucose tolerance was 30.2% (25.2-35.6). CONCLUSIONS--In a group of care home residents not known to have diabetes and able to undergo testing, a substantial proportion have undetected diabetes based on a 2-h postglucose load. These residents warrant further study as they may be at higher cardiovascular risk and require an intervention.     

川东北地区体检人群糖尿病和糖尿病前期的流行率分析

目的调查川东北地区健康体检人群中糖尿病和糖尿病前期(PDM)的流行情况。方法选取2013年于该院进行健康体检的8 053例18岁以上体检者,检测其空腹血糖、糖化血红蛋白(HbA1C)和血脂等项目。糖尿病和PDM诊断采用2013年美国糖尿病协会(ADA)诊断标准。结果川东北地区18岁以上健康体检人群的空腹血糖和HbA1C水平随年龄的增加而升高,糖尿病患病率为8.5%,PDM的患病率为39.6%。男性人群糖尿病和PDM患病率分别为10.7%、41.5%,均明显高于女性(分别为5.7%、37.2%),差异有统计学意义(P0.05)。糖尿病患病率随年龄的增加而逐渐增加,而PDM患病率呈先升后降趋势。结论川东北地区糖尿和PDM病流行程度较高。     

Prevalence of hypertension and diabetes in the population of Kosovo

Objectives: To observe the prevalence of arterial pressure and glycemia in Kosovo and to provide free screening service through health promotion.Methods: This prospective study was conducted over a 3-year period, during 2017–2019. All data were collected by AAB College staff in 11 Kosovo cities prior to a random sample with 7254 observations. Data included demographic information as well as blood pressure and glycemic level measurements. Results: The overall prevalence of arterial pressure was registered at 27.6％ and diabetes mellitus at 9.2％. Arterial pressure in females had a tendency to increase with age (r = 0.3552, P < 0.001), as well as the glycemic index (r = 0.1997, P < 0.001). Never theless, age had a stronger impact on males than in females, with regard to higher ar terial pressure in the year 2017 (P < 0.001). In the following years, 2018 and 2019, the ratio had reversed. Glycemia had strong correlation with systolic arterial pressure value (P < 0.001). For a 1 mmol/L increase in glycemia, the diastolic value increased by 0.19 mmHg on average. Conclusions: This study concluded that at younger ages the values of ar terial pressure and glycemia remain within the commonly observed range, but over the years the probability for higher blood pressure or glicemia increases. Through continuous control of arterial pressure and glycemia at an early age, it is possible to identify abnormal diagnostics, in order to address them in time. Educational initiatives and screenings should take place in order to increase awareness of the citizens for checking themselves regularly.     

Prevalence of diabetes mellitus in rural Saudi Arabia

Several studies have clearly shown the impact of modernization on the prevalence of diabetes mellitus in susceptible communities. Saudi Arabia has faced a rapid development program over the last two decades. In a recent study, we found a high prevalence of diabetes mellitus in urban Saudi Arabia. A total of 5222 rural subjects of both sexes were involved in a study of the prevalence of diabetes mellitus in the western region of Saudi Arabia. Random capillary blood glucose, body weight and height, and income were recorded. The results showed an overall prevalence of 4.3%. There was a rise of prevalence with age and higher-income groups. Prevalence also differed with sex. The overall prevalence in women (5.9%) was twice that for men (2.9%; P less than .001). Obesity occurred in 41.2% of our diabetic subjects compared to 29.3% in nondiabetic subjects (P less than .001). Multiple logistic regression analysis with body mass index (BMI) as the dependent variable showed that sex and income status were significant factors (P less than .0001 and P less than .04, respectively). When blood glucose was fixed as the dependent variable, the analysis showed that age, income, and BMI were significant factors (P less than .004, P less than .0001, and P less than .045, respectively).     

Continuous intravenous insulin infusion in the management of brittle diabetes: etiologic and therapeutic implications

Continuous intravenous insulin infusion (CIVII) was used to treat five brittle insulin-dependent diabetic women (aged 16-29 yr) who had failed to achieve satisfactory glycemic control during intensified subcutaneous insulin treatment including continuous subcutaneous insulin infusion (CSII). Insulin was infused through an indwelling central venous catheter by a portable pump for 3-16 mo. During CIVII, only three subjects obtained satisfactory glycemic control and only for short periods. Generally, as with CSII, control was erratic and unpredictable and three subjects intermittently had high insulin requirements (200 U/day). By contrast, three stable insulin-dependent diabetic subjects achieved near-normoglycemia within 1-3 days of starting CIVII with daily insulin dosages of 30-90 U. The lives of all five brittle subjects continued to be disrupted by frequent hospital admissions during CIVII treatment. Deliberate interference with their own treatment (including tampering with pumps and central venous catheters) was thought to be a major contribution to instability in two of the brittle subjects. In the others, the ineffectiveness of CIVII suggests that brittleness was not due solely to defective subcutaneous insulin absorption, as had previously been suggested in other CSII-unresponsive brittle subjects. Although CIVII has reportedly been successful in managing brittle diabetes, the technique may not be useful in all brittle individuals, as illustrated by the poor glycemic responses of these subjects and the serious complications (including local infection, septicemia, and thrombosis) they suffered.     

Pathomorphological characteristics of unstable bronchial asthma (brittle phenotype)

AIM: To ascertain morphological features of severe uncontrolled bronchial asthma (BA) of brittle phenotype. MATERIAL AND METHODS: Standard bronchofibroscopy was made in 10 patients with severe BA (brittle phenotype) and 9 patients with moderate BA. Cell composition of bronchial lavage and morphological indices of bronchial mucosa biopsies were studied. RESULTS: Patients with brittle BA had low total cytosis of lavage fluid compared to patients with moderate BA patients (1.73 +/- 0.10 and 2.84 +/- 0.21 x 10(6) in 1 ml, respectively, p = 0.001). Bronchobiopsy samples from patients with brittle BA were characterized by reduced cubic density of tegmental epithelium, ciliary and goblet epithelyocytes, height of epithelial layer and relative gland volume, increased thickness of basal membrane (18. 77 +/- 2.74 mcm), relative volume of connective tissue, hyperplasia of smooth muscle cells in the proper mucous plate. Infiltrate of bronchial mucosa in brittle BA contained a predominant amount of histiomacrophagal elements (65.80 +/- 3.83 in 1 mm2) and lymphocytes (52.94 +/- 4.38 in 1 mm2), moderate count of easinophils and neutrophils (15.35 +/- 2.13 and 19.04 +/- 2.23 in 1 mm2, respectively). CONCLUSION: Patients with severe brittle BA had atrophic alterations, inflammatory mucosal infiltration, marked bronchial remodeling in spite of therapy with high doses of inhalatory corticosteroids.     

Prevalence, characteristics, and prognostic significance of HFE gene mutations in type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE—To examine the relationship between iron status, hereditary hemochromatosis (HFE) gene mutations, and clinical features and outcomes of type 2 diabetes in a well-characterized representative sample of community-based patients.RESEARCH DESIGN AND METHODS—HFE genotype data were available for 1,245 type 2 diabetic patients from the longitudinal observational Fremantle Diabetes Study (FDS), representing 96.2% of the total FDS type 2 diabetes cohort. Data were collected at recruitment between 1993 and 1996 and annually until the end of June 2001. Hospitalization and mortality data were available until the end of June 2006. The presence of the C282Y HFE mutation was determined in all subjects and H63D in C282Y heterozygotes. Fasting serum iron, transferrin, and ferritin were measured in all C282Y homozygotes and C282Y/H63D heterozygotes and in 286 randomly selected wild-type subjects. Multiple logistic regression analysis was performed to determine independent baseline associates of prevalent complications (myocardial infarction, cerebrovascular disease, retinopathy, neuropathy, and nephropathy), as was Cox proportional hazards modeling to determine predictors of incident complications and mortality.RESULTS—Although there were expected positive associations between HFE gene mutations and serum iron and transferrin saturation, there were no independent positive associations between HFE gene status and either microvascular or macrovascular complications in cross-sectional and longitudinal analyses. HFE gene status did not independently predict cardiac or all-cause mortality. Measures of iron metabolism including serum ferritin were not associated with combined microvascular or macrovascular end points.CONCLUSIONS—Directed screening for iron overload and/or HFE mutations appears unwarranted in patients with type 2 diabetes.Although early reports suggested that hemochromatosis protects against the chronic complications of diabetes (1), recent studies have identified adverse metabolic and vascular effects that could be associated with iron overload (2–11). Serum ferritin correlates positively with insulin resistance and glycated hemoglobin (2) and has been suggested to be an additional component of the metabolic syndrome (3). Hyperglycemia, and other effects of excess tissue iron including oxidant stress, angiogenesis, and fibrosis (4–6), could promote the development of complications such as nephropathy (7,8). The C282Y and H63D variants of the hemochromatosis (HFE) gene product are important determinants of iron storage. HFE-related hemochromatosis is considered to include C282Y homozygous and compound C282Y/H63D heterozygous genotypes (9). H63D and C282Y have been reported to be independent risk factors for diabetic nephropathy (10) and proliferative retinopathy (11), respectively.Because most published studies have been small-scale and cross-sectional, with a restricted number of potentially explanatory variables, there is a need for detailed large-scale longitudinal studies examining the relationship between iron metabolism, HFE mutations, and the clinical features and complications of diabetes (4). Such studies are essential before directed screening for iron overload can be recommended in diabetic patients (12). We have, therefore, analyzed data from the observational Fremantle Diabetes Study (FDS) to assess the effects of iron status and HFE mutations on the characteristics and outcome of type 2 diabetes.     

Prevalence and characteristics of headache in Dutch schoolchildren.

The aim of this study was to determine whether there has been an increase in headache prevalence in Dutch children and to compare headache characteristics of children with low, medium and high headache severity.A sample of 2358 schoolchildren between the ages of 10 and 17 years filled out Waters' Headache Questionnaire and the Paediatric Pain Assessment Tool. Results showed that 21% of the boys and 26% of the girls at elementary school, and 14% of the boys and 28% of the girls at high school reported weekly headaches. When compared to figures from a previous study in the Netherlands published in 1985, the prevalence of weekly headaches in 10-17-year-olds has increased by 6%. In boys at elementary school, the prevalence of headaches with a frequency of a few times a week has doubled.Children with low, medium and high headache severity differed with respect to all headache characteristics, i.e. pain quality, accompanying symptoms, warning signals, location, onset, impact of headache, family occurrence, perceived cause, medical consultation, and school absence.     

Prevalence rates for diabetes mellitus in Puerto Rico

The aim of this study was to analyze prevalence data for diabetes mellitus obtained from a household interview of a random sample of the general population by the Department of Health of the Commonwealth of Puerto Rico for the years 1975-1986. Details of the prevalence rate by sex and age were analyzed for the years 1981, 1984, 1985, and 1986 and for the urban and rural population in 1985. The mean prevalence rate of known cases of diabetes showed a tendency to increase from 3.1% in 1975 to 5.1% in 1986. Prevalence rates adjusted for age and sex showed an increase in the mean prevalence for 1986 compared with that of 1981. The prevalence rate was significantly higher for the rural population for the age-group 45-64 yr old and for the urban population for the age-group greater than or equal to 65 yr. The prevalence rate compares with that of Mexican Americans and Puerto Ricans in the New York City area. On the basis of the prevalence data, approximately 90% of the diabetic population is non-insulin dependent and 10% are insulin dependent. Major risk factors thought to explain the increased prevalence of non-insulin-dependent diabetes are increasing longevity of the Puerto Rican population, genetic predisposition, obesity, and changes in life-styles. In conclusion, Puerto Ricans, as other Hispanic Americans, have a higher prevalence of diabetes than the white American population.     

威海地区居民糖尿病患病率调查

目的：了解威海地区15岁以上居民的糖尿病（DM）患病率及危险因素,为制定防治措施提供依据。方法：对2012年1月至2012年12月来我院健康查体的16854名居民血糖结果进行统计学分析。结果：威海地区居民血糖均值为（5．77±1．36）mm01／L,DM患病率为6．91％（FPG〉7．0mmol／L）,空腹血糖调节受损（IFG）患病率为12．89%（FPG〉6．1lmmol／L）,其中男性患病率分别为7．038％、14．06％,女性分别为6．789％、11．84％,差异无统计学意义（P〈0．05）。患病率随年龄增大而上升,30岁以下人群DM及IFG患病率分别为0．791％、1．58％,30～60岁年龄组患病率分别为5．27％、10．95％,60岁以上患病率分别为17．97％,29．93％,各组间比较差异有统计学意义（P〈0．05）。结论：DM是威海地区居民常见的慢性病,针对DM的主要危险因素,应当采取综合措施控制DM的发生发展。     

Prevalence of gestational diabetes and macrosomic newborns in a Mexican population

Prevalence of gestational diabetes was investigated in 693 pregnant patients between the 24th and 28th wk of gestation. A glucose screening test (GST) was performed with a 50-g glucose load, followed by a blood sample 1 h later. Patients with glucose levels greater than 140 mg/dl 1 h after the GST were scheduled for a full oral glucose tolerance test (OGTT). One hundred seven patients had an abnormal GST, and 30 patients (4.3%) were diagnosed as having gestational diabetes mellitus (GDM). The percentage of GDM increased significantly when glucose levels were greater than 180 mg/dl to a maximum of 84.61% when glucose levels were greater than 200 mg/dl. Also, patient age was directly related to GDM, which increased in incidence to 20% when patients greater than 26 yr had an abnormal GST. After delivery, newborn weights were compared between those born to mothers with GDM (n = 30) and those born to mothers with an abnormal GST (n = 77). Patients with an abnormal GST and normal OGTT had 12 (15.58%) macrosomic and 2 premature newborns. However, patients with GDM had 5 (16.66%) macrosomic and no premature newborns. Patients with a normal GST had 7.33% of the macrosomic newborns. There was no perinatal mortality in newborns of GDM mothers; only 1 of the 5 macrosomic newborns presented transient hypoglycemia. Evaluation of 26 GDM patients was possible after delivery, disclosing 3 (11.53%) with non-insulin-dependent diabetes mellitus and 5 (19.23%) with impaired glucose tolerance. These results showed 4.3% undetected GDM in our population and no differences in the proportion of macrosomic newborns between those born to mothers with GDM and those born to mothers with an abnormal GST.     

Prevalence and mortality of acute myocardial infarction in patients with diabetes

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