Telemedicine compared with standard care in type 2 diabetes mellitus: A randomized trial in an outpatient clinic

Introduction

Good metabolic control is important in type 2 diabetes mellitus to improve quality of life, work ability and life expectancy, and the use of telemedicine has proved efficient as an add-on to the usual treatment. However, few studies in type 2 diabetes patients have directly compared telemedicine with conventional outpatient treatment, and we wanted to evaluate whether telemedicine, compared with standard care, provides equivalent clinical outcomes.

Methods

Forty patients with type 2 diabetes mellitus allocated from October 2011–July 2012 were randomized to either treatment at home by video conferences only or standard outpatient treatment. Primary outcomes were HbA1c and blood glucose levels and secondary outcomes were 24-hour blood pressure, cholesterol levels and albuminuria. The video-telephone was a broadband solution installed and serviced by the Danish Telephone Company (TDC).

Results

The improvements in the two treatments, given as changes in percentage of telemedicine vs standard, showed significant differences in HbA1c (−15 vs −11%), mean blood glucose (−18 vs −13%) and in cholesterol (−7 vs −6%). No differences in LDL (−4 vs −6%), weight (−1 vs 2%), diastolic diurnal blood pressure (−1 vs −7%), and systolic diurnal blood pressure (0 vs −1%) were found. Nine consultations were missed in the standard outpatient group and none in the telemedicine group.

Conclusions

In the direct comparison of home video consultations vs standard outpatient treatment in type 2 diabetes mellitus, telemedicine was a safe and available option with favourable outcomes after six months treatment.

Efficacy of metformin in obese and non-obese women with polycystic ovary syndrome: a randomized, double-blinded, placebo-controlled cross-over trial

BACKGROUND

Our aim was to assess the effects of metformin on menstrual frequency, fasting plasma glucose (FPG), insulin resistance assessed as HOMA-index, weight, waist/hip ratio, blood pressure (BP), serum lipids, and testosterone levels in women with polycystic ovary syndrome (PCOS) METHODS: In a randomized, controlled, double-blinded setup, 56 women aged 18-45 with PCOS were treated with either metformin 850 mg or placebo twice daily for 6 months. After a wash-out period of 3 months participants received the alternate treatment for 6 months. The changes in the measured parameters were analysed by intention-to-treat and per protocol.

RESULTS

There were no changes in menstrual frequency. In the intention-to-treat analysis, weight and systolic BP were reduced on metformin treatment (p=0.009 and 0.047, respectively), while high-density lipoprotein (HDL) increased (p=0.001). On placebo, weight and FPG increased (p<0.05). Post-hoc subgrouping according to BMI revealed reductions in testosterone (p=0.013), FPG (p=0.018), insulin (p=0.045) and HOMA-index (p=0.022) in obese women. Per protocol analysis showed the following differences between the changes on placebo and metformin (mean (5 - 95 % percentiles): weight (-4.2 (-7.0, -1.9) kg, p<0.001), FPG (-0.23 (-0.44, -0.01) mmol/l, p=0.041), insulin (-4.17 (-8.10, -0.23) mIU/l, p=0.039) and HOMA index (-1.50 (-2.53, -0.47) mIU/l*mmol/l, p=0.006). Weight, FPG and HOMA index were lower after metformin than after placebo.

CONCLUSIONS

Metformin treatment lowered weight and systolic blood pressure and increased HDL in women with PCOS. In post-hoc analysis it increased insulin sensitivity and lowered testosterone in obese women. Non-obese women did not benefit from metformin.

Premature ovarian failure and pregnancy

SETTING

A case study of a woman with presumed premature menopause is presented.

RESULTS

After more than 4 years of premature menopause judged by subjective symptoms, bleeding history, and postmenopausal levels of gonadotropins, a woman conceived spontaneously 2 months after the start of hormone replacement treatment (HRT). Previously, ovarian stimulation with clomifen citrate had failed. She delivered prematurely due to preeclampsia and intrauterine growth retardation.

CONCLUSIONS

Reviewing the literature finds that pregnancy is reported in woman with premature ovarian failure after the use of birth-control pills, HRT, ovarian stimulation, and in spontaneous cycles. Lack of oocyte donors and prohibition of the donor technique in some countries make other options valuable when optimal infertility treatment cannot be offered.

Laparoscopic ovarian drilling as first line of treatment in infertile women with polycystic ovary syndrome

Laparoscopic ovarian drilling (LOD) is used as a first line of treatment, as a second line of treatment after patients have proved resistant to clomiphene or as a third line of treatment after failed ovulation induction with gonadotropins. We present the postoperative pregnancy rates of 57 women to evaluate a potential optimal time of LOD together with the other treatment regimens of infertile women with polycystic ovary syndrome (PCOS). Data on the preoperative and operative treatment, and background data were evaluated for their influence on pregnancy rates. The pregnancy rate was 61% among women with PCOS who had LOD. No difference was found in the clinical data between the women who became pregnant and those who did not. Likewise, no difference was found between the women who had pre- and/or postoperative medical ovulation treatment and those who had none. The median time to pregnancy after LOD was 135 days. LOD alone resolves infertility within 4-6 months in 50-60% of couples. A strategy with diagnostic laparoscopy and LOD as the first line of treatment of infertility in women with PCOS will shorten the time to pregnancy for many women, reduce the need for medical ovulation induction and enable diagnosis of those women with anatomic infertility, who can achieve pregnancy only by in vitro fertilization treatment.

[Feeling of illness after hysterectomy. Women's own assessment]

INTRODUCTION

The aim of the study was to investigate the time interval from the operation to no feeling of illness at all in a population of women, who had undergone a total abdominal or vaginal hysterectomy.

MATERIAL AND METHODS

Data on 361 women who had had a total abdominal or vaginal hysterectomy during the period, 1.1.1998 to 31.3.1999 were collected from a regional database. Those born before 1.1.1940, presented with a genital malignancy, had a diagnosis of genital prolapse, or received surgery in addition to the hysterectomy were excluded. Four months after the hysterectomy, all the women were sent a questionnaire asking about the time of returning to work and the complete absence of any feeling of illness. This information was related to selected perioperative data. Women who had had a total abdominal hysterectomy were not statistically comparable with those who had had a vaginal hysterectomy.

RESULTS

A total of 313 women participated (87%). After a total abdominal hysterectomy, 92%, 80%, and 35% had a subjective feeling of illness at four, six, and ten weeks, respectively. The median duration of feeling ill was nine weeks. The figures after a vaginal hysterectomy were 85%, 71%, and 18%, with a median duration of feeling ill of seven weeks. Only peroperative blood loss and the presence of postoperative complications related statistically to the duration of feeling ill.

CONCLUSION

The interval between the operation and no feeling of illness at all after a total abdominal or vaginal hysterectomy is longer than was formerly believed. Further investigation is recommended.

Ambulatory blood pressure as predictor of preeclampsia in diabetic pregnancies with respect to urinary albumin excretion rate and glycemic regulation

BACKGROUND

Twenty-four-hour ambulatory blood pressure was evaluated as a predictor of preeclampsia in women with insulin-dependent diabetes mellitus with respect to urinary albumin excretion rate and glycemic regulation.

METHODS

One hundred and fifty-one women with insulin-dependent diabetes mellitus were consecutively recruited from the outpatient maternity ward for 24 hour ambulatory blood pressure measurement with a portable monitor (SpaceLab 90207). Blood pressure was measured three times during pregnancy and once after delivery. Evaluation was performed with receiver-operator-characteristics curves in primiparous women. Stratified analysis and multiple regression was applied with respect to urinary albumin excretion rate, HbA1c, age, duration of diabetes mellitus, uric acid, and BMI.

RESULTS

The incidence of preeclampsia was significantly associated with increasing urinary albumin excretion rate, primiparity, and ambulatory blood pressure. Ambulatory blood pressure was associated with HbA1c throughout pregnancy adjusted for urinary albumin excretion rate. The ambulatory blood pressure was higher from first trimester throughout pregnancy in women developing preeclampsia compared to women who did not have preeclampsia. The best sensitivity and specificity for predicting preeclampsia in primiparous women were at cut-off values of systolic and diastolic day ambulatory blood pressure above 122 and 74 mmHg, respectively. The relative risk of preeclampsia was significantly higher when ambulatory blood pressure was above the cut-off values and increased further with higher urinary albumin excretion rate.

CONCLUSIONS

The relationship between ambulatory blood pressure and preeclampsia is not confined to women with macroalbuminuria but is also present in women with normo- and microalbuminuria. Poor glycemic control and increased urinary albumin excretion rate is associated with preeclampsia when ambulatory blood pressure is above cut-off values of 122/74 mmHg (systole/diastole). Ambulatory blood pressure is a reliable measurement for prediction of preeclampsia in primiparous women with insulin-dependent diabetes mellitus.

Association of polymorphism of methylene-tetrahydro-folate-reductase with urinary albumin excretion rate in type 1 diabetes mellitus but not with preeclampsia, retinopathy, and preterm delivery

AIM

The genetic setting is a potential risk factor for dysfunction of vascular endothelial cells. The prevalence of polymorphism in the methylene-tetrahydro-folate-reductase (MTHFR) gene (677C-->T) was evaluated in diabetic pregnancy complicated by preeclampsia, nephropathy, retinopathy, and preterm delivery. The role of hyperhomocysteinemia in microangiopathy in diabetes mellitus has been debated and is mainly seen with reduced activity of the MTHFR gene. A polymorphism in the gene for MTHFR is identified causing this phenomenon.

DESIGN

Two hundred and sixty-eight pregnant women with type 1 diabetes mellitus were recruited. Two hundred and thirty-three women were successfully analyzed for MTHFR gene polymorphism 677C-->T and compared to the incidence of the polymorphism in the background population (n=1084). The pregnancy data charts were reviewed retrospectively.

RESULTS

The frequency of the MTHFR polymorphism in the background population was 29% and the heterozygozity 42%. The women with type 1 diabetes mellitus had a higher frequency of the MTHFR polymorphism with 52% heterozygotes and 9% homozygotes than had the background population (heterozygotes, background vs. type 1 diabetes mellitus: chi(2)=14, df=1, p<0.0002). The odds ratio for heterozygozity of the MTHFR polymorphism was 1.8 (95% Cl: 1.3-2.4) in women with type 1 diabetes mellitus. Women with either micro- or macroalbuminuria had a higher frequency of MTHFR polymorphism with 61% heterozygotes and 3% homozygotes than had the background population (heterozygotes: chi(2)=8.9, df=1, p<0.01). The odds ratio for heterozygozity of the MTHFR polymorphism was 2.3 (95% CI: 1.4-4) in women with type 1 diabetes mellitus.

CONCLUSION

An association was demonstrated between the MTHFR polymorphism and type 1 diabetes mellitus as well as increasing albumin excretion rate in pregnant women.

Serum leptin levels in pregnant women with type 1 diabetes mellitus

BACKGROUND

Leptin is an important weight regulator and during pregnancy leptin is not only synthesized in adipose tissue but also in the placenta.

AIM

To examine changes in serum leptin levels in women with type 1 diabetes mellitus during pregnancy and post delivery in relation to concomitant changes in maternal body weight, birth weight, glycemic control, and blood pressure.

METHODS

Non-fasting serum leptin from 45 women with type 1 diabetes mellitus were studied consecutively throughout pregnancy and 3 months post partum.

RESULTS

Serum leptin was positively associated with HbA1c in week 18, 22 and 30 (r=0.38, 0.41, and 0.54, respectively, p<0.05, adjusted for body weight). Moreover, serum leptin correlated positively with maternal body weight and BMI (0.45<r<0.66, p<0.05). Serum leptin was significantly lower after delivery than during pregnancy where the levels showed no change from gestational week 14 to week 38. In obese women (BMI >25 kg/m2), the changes during pregnancy and the level of serum leptin were significantly greater compared to lean women (p<0.05). The women with low ambulatory blood pressure (lower tertile, mean arterial blood pressure <83.4 mmHg) showed the lowest level of serum leptin throughout pregnancy and it changed significantly differently from the women with higher blood pressure (p<0.05).

CONCLUSION

Changes in serum leptin levels of pregnant women with type 1 diabetes mellitus were associated with parallel changes in maternal body weight and glycemic control. Women with low blood pressure had the lowest serum leptin levels throughout pregnancy.

Effect of a high monounsaturated fatty acid diet on blood pressure and glucose metabolism in women with gestational diabetes mellitus

OBJECTIVE

The effect of a diet rich in monounsaturated fatty acids (MUFA) on blood pressure, glycemic control, lipids and insulin sensitivity was evaluated in women with gestational diabetes mellitus.

DESIGN AND METHODS

A randomized, unpaired diet intervention was performed in 27 women with gestational diabetes mellitus in an outpatient clinic. After randomization the women received either a high-carbohydrate diet (H-CHO) or a high-MUFA diet (H-MUFA) from the 33rd gestational week of pregnancy. Outcome measures were 24 h ambulatory blood pressure, blood lipids, glycemic control and insulin sensitivity estimated by an intravenous glucose tolerance test.

RESULTS

The 24 h diastolic blood pressure increased more in the H-CHO group than in the H-MUFA group (P<0.04).

CONCLUSIONS

After 5 weeks of treatment with a MUFA-enriched diet, no increase in 24 h diastolic blood pressure and no adverse effects on blood lipids were seen. The favorable effect on the blood pressure by the MUFA diet is a possible non-medication treatment. The H-MUFA diet had no advantage to the H-CHO diet in ameliorating the decline of insulin sensitivity in third term of pregnancy in GDM.

Granulosa Cell Tumor of the Ovary: A Population-Based Study of 37 Women with Stage I Disease

OBJECTIVES

The goal of this work was to evaluate clinical and pathological findings, surgical procedures, and postoperative treatment in women with stage I granulosa cell tumor.

METHODS

Data for 49 women with granulosa cell tumor were collected retrospectively. All pathological sections and findings were reviewed from diagnosis until recently. Follow-up data were collected from the general practitioner, hospital records, or death certificate. Fisher's exact test, Student's t test, Mann-Whitney test, and Kaplan-Meier survival analysis were applied, as appropriate.

RESULTS

Thirty-seven women of median age 58 years (range, 33-82) were diagnosed in stage I. Follow-up time was 8 years (range, 8 months to 26 years). The estimated survival for stage I was 93% at 5 years, 84% at 10 years, and 62% at 20 years; the actual survival rates were 94, 82, and 62% after 5, 10, and 20 years, respectively. Primary treatment consisting of total abdominal hysterectomy and bilateral salpingo-oophorectomy was associated with improved survival (P < 0.05) and tended to be associated with longer relapse-free interval (P < 0.06). The 10-year survival rate was 40% in postmenopausal women operated conservatively and more than 90% for the extensively treated women (P < 0.05). Evidence of increased estrogen secretion was found more often in postmenopausal woman as compared with premenopausal women (P < 0.01) but did not affect survival. No pathological parameter correlated with prognosis.

CONCLUSION

Granulosa cell tumor is a tumor of unquestionable malignant potential and has a tendency for late relapses. Long-time follow-up is recommended.

Macrosomia associated with maternal serum insulin-like growth factor-I and -II in diabetic pregnancy

OBJECTIVE

To determine the possible relation between maternal serum insulin-like growth factor I and II (IGF-I and IGF-II) in women with insulin-dependent diabetes mellitus and fetal macrosomia.

METHODS

This was a prospective, observational study of 45 pregnant women with insulin-dependent diabetes mellitus without overt nephropathy, examined in an outpatient, antenatal diabetic clinic. Maternal venous serum samples were collected from week 14 every fourth week until week 30, and every other week until delivery. Levels of IGF-I and -II were measured in maternal serum by immunoassays. The repeated measurements were tested with two-way analysis of variance. The outcome measures were birth weight and serum IGF-I, IGF-II, IGF binding protein (BP)-3, and IGFBP-3 proteases. Before the study, minimum sampling size was calculated as 14 subjects in each group if a difference in IGF-I of 50 microg/L was to be detected with an estimated standard deviation of 40, a two-sided P value (alpha) of.05, and a power of 90 (beta =.1).

RESULTS

Increasing levels of IGF-I and -II were significantly associated with the birth-weight groups: The higher the birth-weight ratio, the higher the levels of IGF-I and -II (P <.01).

CONCLUSION

Macrosomia in diabetic pregnancy is associated with high levels of maternal IGF-I and -II.

Diabetic retinopathy in pregnancy during tight metabolic control

BACKGROUND

The relation between retinopathy and the parameters: 24-h blood pressure, glucose control, albuminuria, and outcome of pregnancy was studied before, during, and after pregnancy in women with insulin-dependent diabetes mellitus on tight metabolic control during pregnancy.

METHODS

Prospective study of 112 pregnant women with insulin-dependent diabetes mellitus followed with fundus photography at the Department of Ophthalmology, Arhus University Hospital. Changes in retinopathy were related to 24-h blood pressure, blood glucose, albuminuria, and adverse perinatal outcome.

RESULTS

There was an association between grade of retinopathy and HbAlc before (Spearman's rho=0.49, p<0.04) and after pregnancy (Spearman's rho=0.42, p<0.02), but no such correlation was found at any examination during pregnancy where glycemia was kept tight. Those women who had progression of retinopathy during or after pregnancy had significantly earlier onset of diabetes mellitus (14+/-8 years, range 1-27) than those women with improvement or no progression of retinopathy (19+/-8 years, range 1-36, p<0.04). No association was found between progression of retinopathy and HbA1c, blood pressure, adverse perinatal outcome or any of the other variables studied.

CONCLUSIONS

Tight glycemic control during pregnancy is recommendable to avoid progression of retinopathy. Attention should be given to the period after delivery where the tight regulation may be difficult to achieve. IDDM women should be encouraged to plan pregnancies early in life.

Birthweight in women with potential gestational diabetes mellitus--an effect of obesity rather than glucose intolerance?

BACKGROUND

The purpose was to compare the influence of varying levels of glycemia on the perinatal outcome.

METHODS

The data charts of 383 women screened for gestational diabetes mellitus with an oral glucose tolerance test during two birthyears were retrospectively evaluated. In 55 women gestational diabetes mellitus was diagnosed and treated with diet. The non-diabetic women (n=328) were subdivided into a borderline diabetes group (n=74) and a normal group (n= 254) on the basis of the oral glucose tolerance test result. The birth registry of 8196 singleton pregnancies from The Perinatal Research Unit at Skejby University Hospital served as the background population.

RESULTS

Birthweight was highest in the borderline group. Weight increase during pregnancy was larger in the non-diabetic than the gestational diabetic women (15 vs. 8 kg p<0.01). The women with less increase of body weight delivered neonates with lower birthweight than those with higher increase. Birthweight was associated with maternal weight during pregnancy (p<0.01). Birthweight ratio increased with increasing glucose intolerance. Vaginal delivery rate was less and cesarean section rate higher in women with gestational diabetes mellitus compared to the non-diabetic women. No significant difference was found in the incidence of hypertensive disorders during pregnancy or neonatal morbidity.

CONCLUSIONS

Even minor hyperglycemia is associated with increasing birthweight. Birthweight is reduced in GDM when dietary treatment is instituted and effect on weight gain is achieved.

Phosphorylated insulin-like growth factor binding protein 1 is increased in pregnant diabetic subjects

During pregnancy, IGFs and their binding proteins (IGFBPs) are important for the growth of fetal and maternal tissues. IGFBP-1 normally circulates as a single, highly phosphorylated species (hpIGFBP-1). However, in pregnancy there are lesser phosphorylated isoforms (lpIGFBP-1) with decreased affinity for IGF-I, allowing for increased IGF bioavailability. Because regulation of IGFBP-1 is abnormal in type 1 diabetes, we examined the impact of this on IGFBP-1 and its phosphorylation status in diabetic pregnancy. We assessed IGFBP-1 in relation to birth weight, maternal weight gain, duration of diabetes, glycemic control, and the presence or absence of retinopathy in 44 diabetic and 11 nondiabetic subjects. We found that in type 1 diabetic patients there was a significant negative relationship between hpIGFBP-1 and birth weight (r = -0.42, P < 0.01) and between the ratio of hpIGFBP-1 to lpIGFBP-1 and birth weight (r = -0.38, P = 0.02) by week 18 of gestation. Multiple regression analysis confirmed that hpIGFBP-1 was the best single predictor of birth weight (R2 = 0.3, P = 0.001) in diabetic subjects using models including other parameters known to influence fetal size. In contrast to hpIGFBP-1 levels, lpIGFBP-1 levels were not associated with birth weight, but were significantly related to initial maternal BMI and maternal weight throughout gestation in diabetic subjects (r = -0.57, P < 0.001). hpIGFBP-1 levels were positively related to duration of diabetes (r = 0.38, P < 0.01). Diabetic subjects had significantly higher hpIGFBP-1 and lpIGFBP-1 levels than nondiabetic subjects (hpIGFBP-1: 215 +/- 21 vs. 108 +/- 13 microg/l, P = 0.01; lpIGFBP-1: 139 +/- 12 vs. 66 +/- 5 microg/l, P < 0.001), but the ratio of hpIGFBP-1 to lpIGFBP-1 was similar in both groups (2.1 +/- 0.3 [diabetic] vs. 1.7 +/- 0.2 [nondiabetic], NS). In summary, maternal IGFBP-1 levels were higher in diabetic than in normal pregnancies. Diabetic subjects with prolonged duration of diabetes and retinopathy had higher total IGFBP-1 levels than those with shorter disease duration. Thus hpIGFBP-1 in diabetic pregnancy is positively related to the duration of diabetes and inversely related to fetal growth, with lpIGFBP-1 being related to maternal weight and BMI. The ratio of hpIGFBP-1 to lpIGFBP-1 may be a more robust indicator of fetal outcome, since it was consistent between diabetic and nondiabetic subjects. Measurement of the different phosphorylated isoforms of IGFBP-1 may increase the usefulness of IGFBP-1 as a predictor of fetal growth in both normal and diabetic pregnancy.

Pregnancies complicated by diabetic proliferative retinopathy

BACKGROUND

To examine retinal and pregnancy outcome in insulin-dependent diabetic women with proliferative retinopathy and assess the effect of albuminuria on morbidity.

METHODS

The records of 26 women with known proliferative retinopathy before pregnancy were studied retrospectively in the prepregnancy period, during pregnancy, and after delivery. Perinatal and maternal morbidity was studied using ophthalmic, obstetric and pediatric records.

RESULTS

Seven pregnancies were delivered preterm (27%). Serious neonatal morbidity occurred in five pregnancies (19%). Perinatal survival was 88%. Laser treatment was given prior to pregnancy to 54%, during pregnancy to 27% and after delivery to 31% of the women. Laser treatment during pregnancy was more common in those with no prior photocoagulation and in White class F/R. Low birthweight was more frequently associated with nephropathy and proliferative retinopathy compared to retinopathy alone (p<0.05). Recent hemorrhage, maculopathy or glaucoma was found in 14 (54%) of the women. Blindness developed unilaterally in two women.

CONCLUSIONS

Perinatal morbidity was associated with nephropathy rather than retinopathy. The incidence of hemorrhage, maculopathy or glaucoma was similar in White classes R and F/R.

[Saturated and monounsaturated fats in patients with insulin-dependent diabetes. Different effects on blood glucose and insulin response in NIDDM]

To compare the metabolic effect of co-ingestion of saturated and monounsaturated fat with potato, 12 NIDDM subjects received 300 g mashed potato alone or in combination with 40 g olive oil, 50 g butter or 100 g butter, respectively. Blood glucose response area to potatoes with 100 g butter (448 +/- 68 mmol/L x 240 min) was significantly lower than to the four other meals: 596 +/- 63 (potato alone), 649 +/- 82 (potato + 40 g olive oil), 587 +/- 80 (potato + 50 g butter), and 604 +/- 81 (potato + 80 g olive oil) mmol/L x 240 min, p < 0.05, respectively. The insulin response was significantly increased by adding 50 g and 100 g butter, whereas no effect after addition of 40 g and 80 g olive oil was found. The free fatty acid (FFA) level was higher when 100 g butter was added to the potato meal than without (0.67 +/- 0.05 vs 0.48 +/- 0.07 mmol/L, p < 0.05). The triglyceride response increased dose-dependently with the fat content of the meals irrespective of the type of fat. In conclusion butter increases the insulin response in patients with NIDDM more than olive oil, and large amounts also increase FFA and triglyceride levels.

[Changes in glucose metabolism in gestational diabetes mellitus during and after pregnancy]

Twenty-nine pregnant women with gestational diabetes mellitus (GDM) diagnosed before the 34th gestational week had three intravenous glucose tolerance tests (IVGTT) performed during pregnancy and a follow-up with OGTT post partum. The women with a normal OGTT post partum had a significant decrease in fasting serum glucose from the 33rd to the 38th week in pregnancy (4.8-->4.0 mmol/l, p < 0.05). However, the women with a diabetic/borderline OGTT showed no decrease in fasting serum glucose during the same period (5.1-->5.0 mmol/l). The K-value (the diminution rate of blood glucose) of the IVGTT in week 38 was significantly lower in women with puerperal diabetic/borderline OGTT compared with women with a normal post partum OGTT (1.05 +/- 0.07 vs. 1.32 +/- 0.08 -10(2) x mmol/l x min-1, respectively, p < 0.05). Diabetic or borderline diabetic OGTT in the first week post partum was significantly associated with a decrease in the K-value from week 33 to 38 (p < 0.05). Early diagnosis of GDM was found to be associated with a pathological OGTT post partum (p < 0.05). Five of 22 women (23%) with previous GDM had a diabetic and one (5%) a borderline OGTT at follow-up four to thirteen months post partum. High fasting serum glucose levels during the last trimester in GDM can identify the women at risk of diabetic/borderline OGTT post partum.

Increased levels of serum fibroblast growth factor-2 in diabetic pregnant women with retinopathy

Fibroblast growth factor-2 (FGF-2) is a potent mitogen and angiogenic factor normally absent from the adult circulation. We have previously shown that it appears in normal maternal serum and that circulating FGF-2 levels are elevated in pregnancies complicated by diabetes. This study was performed to determine whether serum FGF-2 is more abundant in pregnant diabetic women with retinopathy than in those without. Serum was collected monthly between 14-30 weeks gestation and every 2 weeks from then until delivery (35-38 weeks) from 36 women with type 1 diabetes. FGF-2 was extracted by heparin-Sepharose affinity chromatography and quantified by specific RIA. Patients were divided according to the White classification of diabetes. In 17 women without retinopathy (White groups B, C, and D0), immunoreactive FGF-2 was detectable at 14 weeks (mean +/- SEM, 154 +/- 39 pmol/L), was maximal after 26 weeks (306 +/- 38 pmol/L), after which values steadily declined to term (212 +/- 48 pmol/L). In 19 women with simplex or proliferative retinopathy (White groups D+ and R), circulating levels of FGF-2 were significantly greater between 22-32 weeks gestation (22 weeks, 480 +/- 102 vs. 239 +/- 38 pmol/L; P < 0.05). Serum FGF-2 was significantly correlated with hemoglobin A1c levels at 22, 30, and 34 weeks gestation. The mean birth weight of the infants did not significantly differ between groups. Macroalbuminuria was absent in all patients, and creatinine clearance and blood pressure did not significantly differ between the two groups. The results suggest that serum FGF-2 is substantially elevated in pregnant diabetic women with retinopathy in second and early third trimesters. It is unlikely that in these patients this was primarily due to altered FGF-2 clearance, but may relate to excessive production by the utero-placental compartment. The high circulating levels of FGF-2 may be causally related to the development of diabetic retinopathy.

Differential effects of saturated and monounsaturated fat on blood glucose and insulin responses in subjects with non-insulin-dependent diabetes mellitus

To compare the metabolic effect of coingestion of saturated and monounsaturated fats with potato, 12 subjects with non-insulin-dependent diabetes mellitus (NIDDM) received 300 g mashed potato alone or in combination with 40 g olive oil, 80 g olive oil, 50 g butter, or 100 g butter, respectively. The blood glucose response area to potatoes with 100 g butter (448 +/- 68 mmol.240 min/L) was significantly lower than after the four other meals: 596 +/- 63 (potato alone), 649 +/- 82 (potato + 40 g olive oil), 587 +/- 80 (potato + 50 g butter), and 604 +/- 81 (potato + 80 g olive oil) nmol.240 min/L, P < 0.05, respectively. The insulin response was significantly increased by adding 50 and 100 g butter, whereas addition of 40 and 80 g olive oil had no effect. The fatty acid concentration was higher when 100 g butter was added to the potato meal than when it was not (0.67 +/- 0.05 compared with 0.48 +/- 0.07 mmol/L, P < 0.05). Fatty acid concentrations were similar to those found for the other meals. The triacylglycerol response increased in a dose-dependent manner with the fat content of the meals irrespective of the type of fat. We conclude that butter increases the insulin response more than does olive oil, and large amounts of butter also increase fatty acid and triacylglycerol concentrations.

Renal growth during pregnancy in insulin-dependent diabetic women. A prospective study of renal volume and clinical variables

Kidney volume was measured during pregnancy in insulin-dependent diabetic women by an ultrasound technique and prognostic value of these measurements evaluated. A prospective study was performed on 87 pregnant women with insulin-dependent diabetes attending the maternity clinic of Aarhus Kommunehospital. Patients with proliferative retinopathy alone, hydronephrosis, or nephrotic syndrome were excluded. The patients were grouped according to onset and duration of diabetes and to vascular lesions; group I (n = 35, White class B+C), group II (n = 11, White class D0), group III (n = 26, White class D+), and group IV (n = 15, White class F+F/R). The patients visited the hospital every 2 weeks during pregnancy for general obstetric and glycaemic control and blood sampling. The volume of both kidneys was measured by a computerized nephrosonograph during the three terms of pregnancy, the puerperium and 4 months postpartum. The kidney volume increased significantly in all four groups from first to third trimester. In the third trimester the kidney volumes were 375 +/- 68 ml (I), 341 +/- 50 ml (II), 362 +/- 63 ml (III), and 343 +/- 54 ml (IV). The kidney volume in the third trimester was positively correlated with creatinine clearance (r = 0.33, P < 0.01) and inversely correlated with creatinine in serum (r = -0.27, P = < 0.02). Total kidney volume decrease (in percent) defined as the difference of maximal volume and value at 4 months postpartum was inversely correlated to albuminuria in the third trimester (r = -0.25, P < 0.05) and vascular lesions of the patients: (mean +/- SEM) 37 +/- 4% (I), 25 +/- 7% (II), 19 +/- 5% (III), and 11 +/- 7% (IV), P < 0.01. In the puerperium, kidney volume decreased significantly from third trimester in groups I, II, and III, whereas we observed no change in group IV. Six of 15 women in groups II and III with kidney volume < 300 ml and normoalbuminuria in the first trimester developed persistent microalbuminuria after pregnancy (P < 0.02). The renal volume in insulin-dependent diabetic women increases significantly during pregnancy and is inversely related to the vascular lesions of the patients. The decrease in renal volume after pregnancy is related to the albuminuria at the end of pregnancy. Women with longstanding diabetes, White class D (= groups II+III), and kidney volume < 300 ml in the first trimester have a high risk of developing permanent microalbuminuria after pregnancy.

Effects of postprandial exercise on glycemic response in IDDM subjects. Studies at constant insulinemia

OBJECTIVE

To determine the influence of postprandial exercise on blood glucose responses in insulin-dependent diabetes mellitus (IDDM) subjects.

RESEARCH DESIGN AND METHODS

Two identical test meals were served with a 7-day interval. On one occasion, a 30-min cycle exercise was performed 15 min after the meal. Patients had achieved normoglycemia by means of an artificial pancreas (Biostator) before the meals, which also ensured constant insulin infusion in the study periods. Seven IDDM subjects attending the outpatient clinic at Aarhus Kommunehospital were studied.

RESULTS

The 30 min of cycling reduced postprandial blood glucose response areas by 34 +/- 12% (P < 0.01) from 638 +/- 30 to 492 +/- 61 mmol/l x 180 min (P < 0.03), whereas similar peak blood glucose values were found (13.7 +/- 0.3 vs. 12.0 +/- 1.3 mmol/l).

CONCLUSIONS

Thirty minutes of moderate exercise done postprandially reduces the blood glucose response to 50 g carbohydrate by about one-third.

The rôle of ultrasound scan in childhood ovarian tumors

Seven cases with childhood ovarian tumors are presented. All underwent an ultrasound scan which gave the the preliminary diagnosis of ovarian tumor. Treatment differs according to the status of the child and whether malignity is involved. The numerous differential diagnoses must be kept in mind. The management of children with an unexplained abdominal mass should include an ultrasound scan.

[Granulosa cell tumor. A 30-year material from a central hospital]

During a 30-years period seventeen women were correctly diagnosed as having a granulosa cell tumour. Two died of the tumour, while six women died of other causes. No pathological features correlated to prognosis. A conservative surgical approach to preserve fertility is not recommended; of the three fertile women in our group one died of the disease and another one had two relapses within three years. Eleven tumours showed evidence of increased oestradiol production, and this proved useful as a tumour marker. Follow up is rarely performed unless relapse occurs.

[Repeated pregnancy in a patient with diabetes, nephrotic syndrome and hydronephrosis in an earlier pregnancy]

Prepregnancy counselling for diabetics includes an assessment of the metabolic condition,-and if present-angiopathy and nephropathy. Complications in previous pregnancies worsen the prognosis, particularly if they involve the kidneys. A case story is presented of a diabetic woman (White group F/R), who in her first pregnancy had shown several signs of increasing nephropathy. At the beginning of her third pregnancy her diabetes is badly regulated and her kidneys show signs of nephrosclerosis. Nevertheless, the pregnancy runs relatively smoothly until the thirty-third week where she delivers prematurely. The case story shows the difficulties in predicting the course of present and future pregnancies in a diabetic with angio- and nephropathy.

[Clinical trial of 2 highly sensitive pregnancy tests--Tandem ICON HCG-urine and OPCO One-step Pacific Biotech]

The highly sensitive pregnancy test, Tandem ICON HCG-urine, was compared with OPCO "One-step" Pacific Biotech in the gynecological and obstetrical department of Randers Hospital. The purpose was to determine the test specificity and sensitivity of the pregnancy tests in women with possible pregnancies. The test sensitivities were found to be 0.83 and 0.63 for ICON and ONE, respectively. We experienced one and four cases of negative pregnancy tests and ectopic pregnancies with ICON and ONE, respectively. In all cases, the diagnosis of ectopic pregnancy was suspected by other means and the patients submitted to operation. The ICON test showed its supremacy in diagnosis while ONE was easier and cheaper.

[Serum estradiol as a marker in recurrent granulosa-theca-cell tumor]

A case of a granulosa-theca-cell tumour of the ovary in a 39-year-old woman is reported. Despite benign histology and apparently radical operation, tumor growth relapsed twice before apparent cure. Oestradiol in serum proves valuable as a tumour marker and correlates well with tumour relapse.