Relationship of glycation, antioxidant status and oxidative stress to vascular endothelial damage in diabetes

AIMS

To examine the inter-relationships of various microvascular pathogenic mechanisms in diabetic patients.

METHODS

Patients with diabetes (n = 18) and non-diabetic subjects (n = 18) were studied.

RESULTS

Blood markers of glycaemic control and glycation differed between the two groups (glucose 10.9 +/- 7.6 vs. 4.7 +/- 0.63 mmol/l, p < 0.01; HbA1c 7.0 +/- 1.3 vs. 4.5 +/- 0.3%, p < 0.001; glycated LDL 8.8 +/- 2.5 vs. 6.1 +/- 1.2%, p < 0.001) but plasma antioxidant status did not. LDL oxidation resistance, measured as lag time to maximum oxidation initiated by copper ions, was decreased in diabetes (58. +/- 14.3 vs. 76.3 +/- 21.5 min, p < 0.01). Both soluble intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1), markers of endothelial dysfunction, were significantly higher in diabetes (ICAM 491 +/- 128 vs. 403 +/- 131 micro g/l, p < 0.05; VCAM 546 +/- 157 vs. 393 +/- 106 micro g/l, p < 0.01). Linear correlations were significant between HbA1c and lag time of LDL oxidation (r = -0.39, p < 0.05), ICAM (r = 0.40, p < 0.05) and VCAM (r = 0.38, p < 0.05). LDL oxidizability correlated with vitamin C (r = 0.51, p < 0.01) but not any adhesion molecule. In multivariate analysis, both ICAM and VCAM correlated with HbA1c only (r(2) = 0.16, F = 6.3, p < 0.01; r(2) = 0.14, F = 5.4, p < 0.01 respectively).

CONCLUSION

In diabetes, glycation, tissue oxidation and endothelial function are all abnormal and predisposing to microvascular complications but interrelationships are complex with glycation appearing most direct.

Combination of insulin and thiazolidinedione therapy in massively obese patients with Type 2 diabetes

AIMS

To evaluate the influence of addition of rosiglitazone to insulin therapy over a 24-week period in massively obese patients with poorly controlled Type 2 diabetes taking large doses of insulin.

METHODS

Eight massively obese patients (median body mass index (BMI) 42 kg/m2) with Type 2 diabetes who were on large doses of insulin (median daily dose of 204 U) and/or had poor glycaemic control (median HbA1c of 8.1% (upper limit for normal 5.5%)) were treated over a 24-week period with the combination of insulin and maximum doses of rosiglitazone. Outcomes monitored were changes in weight, BMI, HbA1c, dose of insulin and development of side-effects.

RESULTS

At the end of 24 weeks there was a median weight gain of 3 kg (P < 0.01), a fall in median HbA1c from 8.1% to 6.7% (16% reduction from baseline) (P < 0.01) and a reduction in median insulin dose from 204 U/day to 159 U/day (P < 0.01) (23% reduction from baseline). Peripheral oedema was the only significant side-effect and was seen in five patients.

CONCLUSIONS

Combination of insulin and rosiglitazone is effective in massively obese patients with Type 2 diabetes, though there is a high incidence of peripheral oedema.

LMNA, encoding lamin A/C, is mutated in partial lipodystrophy

The lipodystrophies are a group of disorders characterized by the absence or reduction of subcutaneous adipose tissue. Partial lipodystrophy (PLD; MIM 151660) is an inherited condition in which a regional (trunk and limbs) loss of fat occurs during the peri-pubertal phase. Additionally, variable degrees of resistance to insulin action, together with a hyperlipidaemic state, may occur and simulate the metabolic features commonly associated with predisposition to atherosclerotic disease. The PLD locus has been mapped to chromosome 1q with no evidence of genetic heterogeneity. We, and others, have refined the location to a 5.3-cM interval between markers D1S305 and D1S1600 (refs 5, 6). Through a positional cloning approach we have identified five different missense mutations in LMNA among ten kindreds and three individuals with PLD. The protein product of LMNA is lamin A/C, which is a component of the nuclear envelope. Heterozygous mutations in LMNA have recently been identified in kindreds with the variant form of muscular dystrophy (MD) known as autosomal dominant Emery-Dreifuss MD (EDMD-AD; ref. 7) and dilated cardiomyopathy and conduction-system disease (CMD1A). As LMNA is ubiquitously expressed, the finding of site-specific amino acid substitutions in PLD, EDMD-AD and CMD1A reveals distinct functional domains of the lamin A/C protein required for the maintenance and integrity of different cell types.

Type 1 diabetes mellitus in a routine diabetes clinic: the association of psycho-social factors, diabetes knowledge and glycaemic control to insulin regime

In controlled trials intensified diabetes therapy including multiple insulin injection regimes has been shown to improve glycaemic and microvascular disease outcomes in insulin dependent diabetes but this is not clear in routine outpatient practice. We undertook a pragmatic cross sectional study of 200 patients with Type 1 diabetes aged 18-50 years. There were 108 on two insulin injections/day (conventional) and 92 on four injections/day (multiple) with no significant difference for age, sex, social class, body mass index, diabetes duration, hypoglycaemia rate or complications prevalence. The relationship of insulin injection regime used with diabetes knowledge, psychological factors and glycaemic control outcomes was evaluated. Percent glycated HbA1c concentrations (normal range < 5.5%) were worse in the multiple injection group (7.5 +/- 1.7 vs. 6.8 +/- 1.4%, P < 0.001) (mean +/- SD). Their scores for diabetes knowledge (72.5 +/- 8.2 vs. 69.0 +/- 9.8, P < 0.01) were better but treatment satisfaction (29.9 +/- 5.1 vs. 28.5 +/- 6.1, ns) and well-being (49.1 +/- 10.7 vs. 46.5 +/- 12.7, ns) scores were not. Parameters of perceived locus of control were (multiple v conventional): personal (self), 24.5 +/- 5.0 vs. 22.3 +/- 5.9, P < 0.05; medical (doctor), 11.8 +/- 5.1 vs. 10.8 +/- 5.8, ns; situational (chance), 7.9 +/- 5.1 vs. 8.9 +/- 5.9, ns. In multiple regression of HbA1c versus multiple variables only insulin regime (P < 0.001) was significant. We conclude that in routine clinical practice the use of intensive insulin regimes are associated with worse glycaemic control despite patients being marginally more knowledgeable and self directed.

Prevalence of hypovitaminosis D in Indo-Asian patients attending a rheumatology clinic

This study was performed to determine the prevalence of hypovitaminosis D (HD) and hypovitaminosis D associated with secondary hyperparathyroidism (HD-SHPT) among Indo-Asians attending rheumatology clinics in Wolverhampton. A cross-sectional survey of 98 clinic attenders and 36 normal controls subjects was undertaken. The groups were matched for age, gender, and body mass index. There was a high prevalence of vegetarianism, and milk consumption was low in both groups. Clinical scores for musculoskeletal pain, gait, and muscle strength were all significantly worse in clinic attenders (p < 0.001). Comparing clinic attenders with controls, 25-OH-vitamin D levels were 6.6 +/- 3.9 vs. 8.2 +/- 4.8 microg/L (p < 0.01) and the prevalence of HD (<8 microg/L) was 78% vs. 58% (p < 0.05), but neither parathyroid hormone levels (53 +/- 60 vs. 50 +/- 18 ng/L, n.s.) nor HD-SHPT prevalence (22% vs. 33%, n.s.) were significantly different. Routine biochemical tests were not discriminant, but none of the controls and 10 of 98 (10%) clinic attenders had elevated alkaline phosphatase levels: 6 with HD and 3 with HD-SHPT. Vitamin D deficiency has an extremely high prevalence among Indo-Asians in the U.K., particularly in those attending rheumatology clinics. Detection of HD and HD-SHPT is only possible using measurements of 25-OH-vitamin D and PTH.

High-frequency in vitro multiplication of disease-free Zingiber officinale Rosc

High-frequency in vitro multiplication of disease-free clones of ginger (Zingiber officinale Rosc.) was obtained by culturing small and active buds of ginger on MS medium supplemented with 2 mg/l Kin and 20 g/l sucrose. An average of 7.7 shoots per bud was obtained on this medium after 4 weeks of culture. A high multiplication rate of well-developed plantlets (7.0 shoots per bud) with a 6.8-cm shoot length and a 7.0-cm root length was also obtained on MS medium containing 2.0 mg Kin, 2.0 mg NAA and 20 g sucrose per liter. The multiplication rate did not decrease even up to 28 months of subculture on the same medium. A simple method of successfully transferring more than 95% of tissue-cultured plants into pots was also standardized. In vitro-derived plants performed well under field conditions, were morphologically identical to the mother plants and were free from ginger yellows (Fusarium oxysporum f. sp. zingiberi). Well-developed rhizomes obtained from the tissue-cultured plants did not rot during storage of up to 6 months, thus indicating that the method is also effective in checking storage rot caused by F. oxysporum f. sp. zingiberi.

High variability of glycated hemoglobin concentrations in patients with IDDM followed over 9 years. What is the best index of long-term glycemic control?

OBJECTIVE

To determine variability of long-term glycemic control in patients with IDDM.

RESEARCH DESIGN AND METHODS

A retrospective analysis of HbA1 among 122 IDDM patients followed over 9 years.

RESULTS

Annual group mean HbA1 ranged from 8.4 to 9.3% with large standard deviations (1.7-2.0%), indicating marked variability among individuals. Fluctuations of more than +/- 1% HbA1 occurred in 50% of the patients year to year, and over 9 years the minimum-maximum range was > 3 and > 5% HbA1 in 55 and 11% of patients, respectively. In any one year, 22-43% of patients had HbA1 < 8%, but over 9 years only 3.3% were consistently < 8%. Groups divided according to baseline HbA1 of < 8, 8-10, and > 10% were significantly separated over 9 years by frequency distribution analysis of individual mean HbA1 but were indistinguishable when analyzed by individual HbA1 interquartile range (measure of variability).

CONCLUSIONS

High variability of long-term glycemic control is a marked feature of IDDM, the extent of which may be relevant to microvascular risk.

In vitro microrhizome production in Zingiber officinale Rosc

Microrhizomes of Zingiber officinale were successfully produced from tissue culture derived shoots by transferring them to liquid MS medium supplemented with 1 mg/l BAP, 2 mg/l calcium pantothenate, 0.2 mg/l GA3 and 0.05 mg/l NAA for shoot proliferation. After 4 weeks of incubation, the medium was replaced with microrhizome induction medium, consisting of MS salts supplemented with 8 mg/l BAP and 75 g/l sucrose. Microrhizome formation started after 20 d of incubation in stationary cultures at 25+1 ° in the dark. Microrhizomes with 1-4 buds and weighing 73.8 to 459 mg each were harvested after 50-60 d. After storage for 2 months in moist sand at room temperature, 80% of the microrhizomes sprouted producing roots and shoots.

Effects of autonomic neuropathy on glucose, fatty acid, and ketone body metabolism following insulin withdrawal in patients with insulin-dependent diabetes

It has been postulated that sympathetic denervation due to autonomic neuropathy may protect against the development of diabetic ketoacidosis in patients with insulin-dependent diabetes. We tested this hypothesis by withdrawing exogenous insulin from five men with established insulin-dependent diabetes and severe symptomatic autonomic neuropathy. Six men also with insulin-dependent diabetes of more than 5-years duration but no clinical evidence of neuropathy served as controls. Normoglycemia was maintained during the night before the study using a variable intravenous insulin infusion that was terminated at 0800 h the following morning (time 0 min). During a 600-min observation period following termination of the insulin infusion the rise (mean +/- SEM) in blood glucose concentration between 0 min and 600 min was comparable between the autonomic neuropathy and control groups (8.2 +/- 1.3 versus 8.3 +/- 1.1 mmol/L; p > 0.1). The rise in plasma nonesterified fatty acids was significantly less for the autonomic neuropathy patients (0.96 +/- 0.06 versus 1.65 +/- 0.14 mmol/L; p < 0.01) with a similar trend for the rise in total ketone body concentration (2.74 +/- 0.85 versus 3.72 +/- 0.38 mmol/L). Capillary pH at 600 min, however, was not significantly different between the groups (23 +/- 2 versus 20 +/- 1 mmol/L). In conclusion, plasma fatty acids and ketone body concentrations rise less rapidly following withdrawal of insulin in patients with insulin-dependent diabetes and autonomic neuropathy suggesting that such patients may have a degree of protection against the development of diabetic ketoacidosis.

Diagnostic characteristics of child psychiatric service utilizers

Sex, age and diagnostic characteristics of a consecutive series of first contact children seen over a period of one year at a psychiatric center was analyzed Most of (he referrals were for male adolescents. "No diagnosis on Axis I" was quite common, especially in the younger age group; most of them had mental retardation. "Hysteria " was uncommon, and this was the only category which was slightly more common in girls. Manic depressive psychosis was the most common disorder among adolescents.

Effect of advertising on awareness of symptoms of diabetes among the general public: the British Diabetic Association Study

OBJECTIVE

To determine the impact of posters advertising symptoms of diabetes on public knowledge of these symptoms.

DESIGN

Structured street interviews of members of the general public before, at the end of, and 10 weeks after a campaign advertising the main symptoms of diabetes.

SETTING

Basingstoke and Wolverhampton.

SUBJECTS

Three samples of 1000 members of the general public were interviewed. Samples were selected randomly but stratified to match the local population's age (20-75), sex, social class, and racial characteristics.

MAIN OUTCOME MEASURES

Knowledge of symptoms of diabetes; perceived seriousness of diabetes; and induction of anxiety about symptoms in the target population.

RESULTS

Advertising significantly raised knowledge (without prompting) of symptoms: thirst, 245 before v 411 at end of campaign (P < 0.0001) v 341 after (P = 0.0012 v before); polyuria, 72 v 101 (P = 0.0211) v 92 (P = 0.5169); lethargy, 180 v 373 (P < 0.0001) v 298 (P < 0.0001); knowledge of weight loss and visual disturbance was unaffected. The number of subjects lacking knowledge of any symptoms was reduced from 550 to 388 (P < 0.0001). The perceived seriousness of diabetes was unaffected (mean 7.6 in each phase on a scale of 1 (not) to 10 (very). Before advertising, 449 (45%) claimed to have one or more symptoms of diabetes, but this number fell at the end of the campaign (403; P = 0.0419) and 10 weeks afterwards (278; P < 0.0001).

CONCLUSIONS

An advertising campaign raised public knowledge of diabetes symptoms without inducing fear of diabetes or anxiety about symptoms. Its potential for achieving earlier detection of non-insulin dependent diabetes should be evaluated.

Production of disease-free encapsulated buds of Zingiber officinale Rosc

Shoot buds of ginger were successfully encapsulated in 4% sodium alginate gel. Encapsulated buds were germinated in vitro to form roots and shoots. In vitro germination (emergence of sprouts) of encapsulated buds ranged from 16.7% to 81.8% on different media after 5 weeks of incubation. Normal plantlets with an average shoot length of 2.3 cm and 1.7 cm root length were successfully transplanted into unsterilized soil without any hardening process. These plantlets showed no symptoms of ginger yellows disease and the causal fungal pathogen failed to grow out on culture media (used as a diagnostic test).

Variations in blood pressure of adolescents in relation to sex and social factors in a rural area of Haryana

Adolescent students of a rural block were studied to find out variation in blood pressure in relation to sex, caste and socioeconomic status. Females had significantly higher mean values of blood pressure; both systolic and diastolic. There was significant variation in systolic blood pressure amongst adolescents of various socio- economic classes. Prevalence of systolic hypertension (95 percentile) was higher in adolescents of upper middle social class and diastolic hypertension in Prestige castes. It is suggested that screening for hypertension should be done at school leaving age and high risk adolescents should be advised about periodic check-up, proper diet, salt restrictions and exercise so that frank hypertension could be prevented in adulthood.

Insulin resistance in the regulation of lipolysis and ketone body metabolism in non-insulin dependent diabetes is apparent at very low insulin concentrations

The insulin sensitivity of intermediary metabolism was studied in 8 non-obese men with well-controlled diet-treated non-insulin dependent diabetes (NIDDM) using a low dose incremental insulin infusion (basal, 0.005 and 0.01 U/kg h-1). Results were compared to 8 healthy male control subjects matched (NIDDM vs. controls, mean +/- S.E.M.) for age (56 +/- 3 vs. 54 +/- 3 years, NS) and body mass index (24.6 +/- 0.7 vs. 25.3 +/- 0.5 kg/m2, NS). Basal fasting concentrations of insulin (4.7 +/- 0.8 vs. 3.2 +/- 0.8 mU/l, NS), glucose, total ketone bodies (TKB), and non-esterified fatty acids (NEFA) were not significantly different between the groups but glycerol concentrations were significantly elevated in NIDDM patients (0.072 +/- 0.007 vs. 0.049 +/- 0.003 mmol/l, P < 0.05). During incremental insulin infusion, plasma insulin concentrations rose to 12.8 +/- 1.5 vs. 10.0 +/- 1.0 mU/l in NIDDM patients vs. control and metabolite concentrations fell significantly (P < 0.001). Significant linear dose-response relationships were found between plasma insulin (log) and glucose, TKB (log), NEFA, and glycerol concentrations by analysis of variance applied to regression (all P < 0.001). For glucose and TKB (log), the group regression lines were parallel but were significantly right-shifted in the NIDDM group (P < 0.001). In contrast, the relationships of insulin (log) and both glycerol and NEFA concentrations converged over the observed range of insulin concentrations. Significant displacement of glycerol and NEFA dose-response relationships were found in NIDDM patients at an insulin concentration of 5 mU/l (P < 0.001) but not at 12.5 mU/l.(ABSTRACT TRUNCATED AT 250 WORDS)

Nosocomial stroke

Nosocomial stroke occurs during hospitalization for unrelated problems. Increased understanding of this relatively ignored entity may provide the key to improved stroke prophylaxis for the hospitalized patient at risk and provide clues to the precipitants of stroke in the general population. We compared nosocomial stroke to stroke occurring outside the hospital in a mixed prospective and retrospective analysis of 372 consecutive strokes occurring over 2 years. We excluded nosocomial stroke associated with cardiac bypass surgery, carotid endarterectomy, and cerebral angiography for cerebrovascular disease because of the known associations of these procedures with stroke. Of our 372 strokes, 47 were nosocomial. There were no significant age and sex differences between nosocomial stroke and stroke admissions. Nosocomial stroke patients were significantly more likely than stroke admission patients to be normotensive (p = 0.001), diabetic (p = 0.01), and have cardiac disease (p = 0.03). Nosocomial stroke patients were significantly less likely to have brain hemorrhages (p = 0.001), lacunar infarcts (p = 0.03), or infarcts of undetermined cause (p = 0.047). Half of the nosocomial stroke patients died versus 11% of stroke admission patients. Nosocomial stroke differs in stroke type, associated diseases, and prognosis from stroke occurring outside the hospital.

Prevalence of haemochromatosis amongst patients with diabetes mellitus

Four hundred and six white caucasian patients with diabetes mellitus (243 male, mean age 54 +/- 16 (SD) years) were screened for haemochromatosis. Four patients had a fasting transferrin saturation > 62% and all were HLA A3 positive. Two were probable homozygotes for haemochromatosis and two heterozygotes. Homozygote haemochromatosis prevalence in this diabetic population was therefore 2/406 (0.0049) which is identical to that reported in the general population. These findings do not support a genetic relationship between the two conditions.

Effects of morbid obesity on insulin clearance and insulin sensitivity in several aspects of metabolism as assessed by low-dose insulin infusion

Obesity is associated with impaired insulin action in glucose disposal, but not necessarily in other aspects of intermediary metabolism or insulin clearance. Sixteen morbidly obese and 14 normal-weight subjects (body mass index, 51.2 +/- 11.5 v 22.1 +/- 2.2 kg.m-2; mean +/- SD) were studied with sequential, low-dose, incremental insulin infusion with estimation of glucose turnover. In obese patients, basal plasma insulin was higher (10.5 +/- 3.8 v 2.4 +/- 3.0 mU.L-1, P less than .001) and remained elevated throughout infusion (F = 492, P less than .001), as did C-peptide (F = 22.7, P less than .001). Metabolic clearance rate for insulin (MCRI) at the highest infusion rate was similar (1,048 +/- 425 v 1,018 +/- 357 mL.m-2.min-1, NS). Basal hepatic glucose production in obese subjects was less than in normal-weight subjects (270 +/- 108 v 444 +/- 68 mumol.m-2.min-1, P less than .01), as was the basal metabolic clearance rate for glucose (MCRG, 77 +/- 26 v 108 +/- 31 mL.m-2.min-1, P less than .05). Insulin infusion caused blood glucose to decrease less in the obese patients (1.4 +/- 0.5 v 1.9 +/- 0.5 mmol.L-1, P less than .05); hepatic glucose production was appropriately suppressed in them by hyperinsulinemia, but their insulin-mediated glucose disposal was reduced (1.67 [0.79] v 4.45 [2.13] mL.m-2.min-1/mU.L-1, P less than .01). Concentrations of nonesterified fatty acids (NEFA), glycerol, and ketones were elevated throughout the insulin infusions in obese patients, despite the higher insulin concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)