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Blissett DB, Attvall S, Hellmund RA. Analysis Estimating the Potential Cost Impact of Utilizing Flash Glucose Monitoring with Optional Alarms in Swedish Adults with Diabetes with Impaired Awareness of Hypoglycaemia, Using Intensive Insulin. Diabetes Ther 2021; 12:2179-2193. [PMID: 34232483 PMCID: PMC8342735 DOI: 10.1007/s13300-021-01099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/10/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The objective of this analysis was to estimate the costs associated with using flash glucose monitoring with optional alarms as a replacement for either traditional continuous glucose monitoring (CGM) or routine self-monitoring of blood glucose (SMBG) in adults with diabetes and impaired awareness of hypoglycaemia (IAH) who use intensified insulin therapy, from a Swedish payer perspective, applying assumptions to simulate hypothetical scenarios. METHODS A simple two-state cohort Markov model was used to calculate the cost per patient treated over a 3-year period, capturing the risk of severe hypoglycaemic events requiring medical assistance and non-adherence using quarterly Markov cycles. The costs considered were those for glucose monitoring and resource use to treat severe hypoglycaemic events. Cost inputs were sourced from Swedish price lists, manufacturer data and resource use reported in the control arm of the HypoDE study. Targeted literature searches were run in PubMed to source the clinical inputs. Uncertainty in the model was considered through one-way sensitivity analysis and scenario analysis. RESULTS Over 3 years, flash monitoring with optional alarms resulted in potential cost-savings of Swedish krona (SEK) 7708 and SEK 69,908 per patient when compared to routine SMBG or CGM respectively. Sensitivity and scenario analyses were largely supportive of this conclusion with respect to SMBG, and large cost-savings were consistent across all sensitivity and scenario analyses with respect to CGM. CONCLUSION Utilizing flash monitoring with optional alarms is potentially a cost-saving treatment strategy compared to routine SMBG or traditional CGM in adults with diabetes using intensive insulin and IAH from a Swedish payer perspective. Future studies in the IAH population will help to assess more precisely the relative cost impact of flash glucose monitoring with optional alarms compared with SMBG and traditional CGM.
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Affiliation(s)
| | - Stig Attvall
- Diabetes, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Dahlqvist S, Ahlén E, Filipsson K, Gustafsson T, Hirsch IB, Tuomilehto J, Imberg H, Ahrén B, Attvall S, Lind M. Variables associated with HbA1c and weight reductions when adding liraglutide to multiple daily insulin injections in persons with type 2 diabetes (MDI Liraglutide trial 3). BMJ Open Diabetes Res Care 2018; 6:e000464. [PMID: 29527308 PMCID: PMC5841497 DOI: 10.1136/bmjdrc-2017-000464] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To evaluate variables associated with hemoglobin A1c (HbA1c) and weight reduction when adding liraglutide to persons with type 2 diabetes treated with multiple daily insulin injections (MDI). RESEARCH DESIGN AND METHODS This was a reanalysis of a previous trial where 124 patients were enrolled in a double-blind, placebo-controlled, multicenter randomized trial carried out over 24 weeks. Predictors for effect on change in HbA1c and weight were analyzed within the treatment group and with concurrent interaction analyses. Correlation analyses for change in HbA1c and weight from baseline to week 24 were made. RESULTS The mean age at baseline was 63.7 years, 64.8% were men, the mean number of insulin injections was 4.4 per day, the mean daily insulin dose was 105 units and the mean HbA1c was 74.5 mmol/mol (9.0%). The mean HbA1c and weight reductions were 12.3 mmol/mol (1.13%; P<0.001) and 3.8 kg (P<0.001) greater in liraglutide than placebo-treated persons. There was no significant predictor for greater effect on HbA1c that existed in all analyses (univariate, multivariate and interaction analyses against controls). For a greater weight reduction when adding liraglutide, a lower HbA1c level at baseline was a predictor (liraglutide group P=0.002, P=0.020 for liraglutide group vs placebo). During follow-up in the liraglutide group, no significant correlation was found between change in weight and change in HbA1c (r=0.09, P=0.46), whereas a correlation existed between weight and insulin dose reduction (r=0.44, P<0.001). CONCLUSION Weight reduction becomes greater when adding liraglutide in patients with type 2 diabetes treated with MDI who had a lower HbA1c level compared with those with a higher HbA1c level. There was no correlation between reductions in HbA1c and weight when liraglutide was added, that is, different patient groups responded with HbA1c and weight reductions. TRIAL REGISTRATION NUMBER EudraCT nr: 2012-001941-42.
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Affiliation(s)
- Sofia Dahlqvist
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
| | - Elsa Ahlén
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
- Värnamo Hospital, Värnamo, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Karin Filipsson
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Endocrinology, Skåne University Hospital, Scania, Sweden
| | - Thomas Gustafsson
- Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, Washington, USA
| | - Jaakko Tuomilehto
- Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki, Finland
- Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
- Research Division, Dasman Diabetes Institute, Dasman, Kuwait
| | - Henrik Imberg
- Statistiska Konsultgruppen, Gothenburg, Sweden
- Department of Mathematical Sciences, Chalmers University of Technology and University of Gothenburg, Gothenburg, Sweden
| | - Bo Ahrén
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Stig Attvall
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Lind
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
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Ólafsdóttir AF, Attvall S, Sandgren U, Dahlqvist S, Pivodic A, Skrtic S, Theodorsson E, Lind M. A Clinical Trial of the Accuracy and Treatment Experience of the Flash Glucose Monitor FreeStyle Libre in Adults with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:164-172. [PMID: 28263665 PMCID: PMC5359691 DOI: 10.1089/dia.2016.0392] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND In Sweden, FreeStyle Libre a flash glucose monitoring system came onto the market in 2014 as a complement to self-monitoring of blood glucose. The aim of this study was to evaluate the accuracy and treatment experience of the FreeStyle Libre system. METHODS Fifty-eight adults with type 1 diabetes used FreeStyle Libre for 10-14 days and measured capillary blood glucose levels with the HemoCue blood glucose measurement system at least six times a day simultaneously. RESULTS For the entire study period, the mean absolute relative difference (MARD) was 13.2% (95% confidence interval [CI] 12.0%-14.4%). MARD was 13.6% (95% CI 12.1%-15.4%) during week 1 and 12.7% (95% CI 11.5%-13.9%) during week 2. The mean absolute difference (MAD) for the whole study period was 19.8 mg/dL (1.1 mmol/L) (95% CI 17.8-21.8 mg/dL), including 20.5 mg/dL (1.14 mmol/L) during week 1 and 19.0 mg/dL (1.05 mmol/L) during week 2. The overall correlation coefficient was 0.96. For glucose values <72, 72-180, and >180 mg/dL (<4, 4-10, and >10 mmol/L), the MARD was 20.3% (95% CI 17.7%-23.1%), 14.7% (95% CI 13.4%-16%), and 9.6% (95% CI 8.5%-10.8%), respectively, and respective MAD values were 12.3, 17.8, and 23.6 mg/dL (0.69, 0.99, and 1.31 mmol/L). Using the 10-item visual analog scale, patients rated their experience with FreeStyle Libre as generally positive, with mean values ranging from 8.22 to 9.8. CONCLUSIONS FreeStyle Libre had a similar overall MARD as continuous blood glucose monitoring systems in earlier studies when studied in similar at-home conditions. The overall patient satisfaction was high.
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Affiliation(s)
- Arndís F. Ólafsdóttir
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Stig Attvall
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ulrika Sandgren
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sofia Dahlqvist
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
| | | | - Stanko Skrtic
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- AstraZeneca R&D, Mölndal, Sweden
| | - Elvar Theodorsson
- Departments of Laboratory Medicine and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Marcus Lind
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
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Andelin M, Kropff J, Matuleviciene V, Joseph JI, Attvall S, Theodorsson E, Hirsch IB, Imberg H, Dahlqvist S, Klonoff D, Haraldsson B, DeVries JH, Lind M. Assessing the Accuracy of Continuous Glucose Monitoring (CGM) Calibrated With Capillary Values Using Capillary or Venous Glucose Levels as a Reference. J Diabetes Sci Technol 2016; 10:876-84. [PMID: 26810924 PMCID: PMC4928217 DOI: 10.1177/1932296815626724] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Using the standard venous reference for the evaluation of continuous glucose monitoring (CGM) systems could possibly negatively affect measured CGM accuracy since CGM are generally calibrated with capillary glucose and venous and capillary glucose concentrations differ. We therefore aimed to quantify the effect of using capillary versus venous glucose reference samples on estimated accuracy in capillary calibrated CGM. METHODS We evaluated 41 individuals with type 1 diabetes mellitus (T1DM) using the Dexcom G4 CGM system over 6 days. Patients calibrated their CGM devices with capillary glucose by means of the HemoCue system. During 2 visits, capillary and venous samples were simultaneously measured by HemoCue and compared to concomitantly obtained CGM readings. The mean absolute relative difference (MARD) was calculated using capillary and venous reference samples. RESULTS Venous glucose values were 0.83 mmol/L (15.0 mg/dl) lower than capillary values over all glycemic ranges, P < .0001. Below 4 mmol/l (72 mg/dl), the difference was 1.25 mmol/l (22.5 mg/dl), P = .0001, at 4-10 mmol/l (72-180 mg/dl), 0.67 mmol/l (12.0 mg/dl), P < .0001 and above 10 mmol/l (180 mg/dl), 0.95 mmol/l (17.1 mg/dl), P < .0001. MARD was 11.7% using capillary values as reference compared to 13.7% using venous samples, P = .037. Below 4 mmol/l (72 mg/dl) MARD was 16.6% and 31.8%, P = .048, at 4-10 mmol/l (72-180 mg/dl) 12.1% and 12.6%, P = .32, above 10 mmol/l (180 mg/dl) 8.7% and 9.2%, P = .82. CONCLUSION Using capillary glucose concentrations as reference to evaluate the accuracy of CGM calibrated with capillary samples is associated with a lower MARD than using venous glucose as the reference. Capillary glucose concentrations were significantly higher than venous in all glycemic ranges.
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Affiliation(s)
- Mervi Andelin
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
| | - Jort Kropff
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | | | - Jeffrey I Joseph
- Department of Anaesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Stig Attvall
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Elvar Theodorsson
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Sweden
| | | | | | - Sofia Dahlqvist
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
| | - David Klonoff
- Diabetes Research Institute, Mills-Peninsula Health Services, San Mateo, CA, USA
| | - Börje Haraldsson
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Marcus Lind
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Westlund K, Attvall S, Nilsson R, Jensen OC. Telemedical Maritime Assistance Service (TMAS) to Swedish merchant and passengers ships 1997–2012. Int Marit Health 2016; 67:24-30. [DOI: 10.5603/imh.2016.0006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/18/2016] [Indexed: 11/25/2022] Open
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Lind M, Hirsch IB, Tuomilehto J, Dahlqvist S, Ahrén B, Torffvit O, Attvall S, Ekelund M, Filipsson K, Tengmark BO, Sjöberg S, Pehrsson NG. Liraglutide in people treated for type 2 diabetes with multiple daily insulin injections: randomised clinical trial (MDI Liraglutide trial). BMJ 2015; 351:h5364. [PMID: 26512041 PMCID: PMC4624838 DOI: 10.1136/bmj.h5364] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
STUDY QUESTION What are the effects of liraglutide, an incretin based treatment, on glycaemic control in people with type 2 diabetes treated with multiple daily insulin injections? METHODS The study was a randomised, double blind, placebo controlled trial with a parallel group design carried out at 13 hospital based outpatient clinics and one primary care unit in Sweden. Patients were considered eligible for inclusion if they had type 2 diabetes and inadequate glycaemic control (HbA1c concentrations ≥ 58 mmol/mol (7.5%) and ≤ 102 mmol/mol (11.5%)), a body mass index of 27.5-45 kg/m(2), and required multiple daily insulin injections. Overall, 124 participants were randomised 1:1 to subcutaneous liraglutide or placebo by minimisation allocation. The main outcome measure was change in HbA1c level from baseline to week 24. STUDY ANSWER AND LIMITATIONS Liraglutide was associated with a significant reduction of 16.9 mmol/mol (1.5%) in HbA1c versus 4.6 mmol/mol (0.4%) for placebo, difference -12.3 mmol/mol (95% confidence interval -15.8 to -8.8 mmol/mol; -1.13%, -1.45 to -0.81 mmol/mol). Body weight was significantly reduced in participants in the liraglutide compared with placebo group (3.8 v 0.0 kg, difference -3.8, -4.9 to -2.8 kg), and total daily insulin doses were significantly reduced, by 18.1 units and 2.3 units (difference -15.8, -23.1 to -8.5 units). Reductions in mean and standard deviation of glucose levels estimated by masked continuous glucose monitoring were significantly greater in the liraglutide group than placebo group (-1.9 and -0.5 mmol/L). Neither group experienced severe hypoglycaemic events nor were there any significant differences in symptomatic or asymptomatic non-severe hypoglycaemia (<4.0 or <3.0 mmol/L). The mean number of non-severe symptomatic hypoglycaemic events (<4.0 mmol/L) during follow-up was 1.29 in the liraglutide group and 1.24 in the placebo group (P=0.96). One of the study's limitations was its relatively short duration. Sustained effects of liraglutide have, however, been found over lengthier periods in connection with other treatment regimens. Cardiovascular safety and potential adverse events during longer exposure to liraglutide need to be evaluated. Nausea was experienced by 21 (32.8%) participants in the liraglutide group and 5 (7.8%) in the placebo group and 3 (5%) and 4 (7%) participants in these groups, respectively, had any serious adverse event. WHAT THIS STUDY ADDS Adding liraglutide to multiple daily insulin injections in people with type 2 diabetes improves glycaemic control without an increased risk of hypoglycaemia, reduces body weight, and enables patients to lower their insulin doses. FUNDING, COMPETING INTERESTS, DATA SHARING This study was an investigator initiated trial, supported in part by Novo Nordisk and InfuCare. Potential competing interests have been reported and are available on the bmj.com. STUDY REGISTRATION EudraCT 2012-001941-42.
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Affiliation(s)
- Marcus Lind
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden Department of Medicine, Uddevalla Hospital, NU Hospital Group, 451 80 Uddevalla, Sweden
| | | | - Jaakko Tuomilehto
- Centre for Vascular Prevention, Danube-University, Krems, Austria; Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki, Finland; Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sofia Dahlqvist
- Department of Medicine, Uddevalla Hospital, NU Hospital Group, 451 80 Uddevalla, Sweden
| | | | | | - Stig Attvall
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | - Stefan Sjöberg
- Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine, Halland County Hospital, Halmstad, Sweden
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Clements M, Matuleviciene V, Attvall S, Ekelund M, Pivodic A, Dahlqvist S, Fahlén M, Haraldsson B, Lind M. Predicting the effectiveness of insulin pump therapy on glycemic control in clinical practice: a retrospective study of patients with type 1 diabetes from 10 outpatient diabetes clinics in Sweden over 5 years. Diabetes Technol Ther 2015; 17:21-8. [PMID: 25470010 DOI: 10.1089/dia.2014.0139] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Multicenter long-term studies of predictors for the effectiveness of continuous subcutaneous insulin infusion (CSII) in clinical practice are lacking. We hypothesized that there are substantially greater reductions in hemoglobin A1c (HbA1c) in patients with poor glycemic control and that other predictors may also exist. SUBJECTS AND METHODS We used data from 10 outpatient diabetic clinics in Sweden and studied CSII treatment over 5 years. Patients with HbA1c values available ≤ 6 months before starting CSII and at 5 years were included (n = 272, 82% of CSII patients) along with 2,437 contemporaneous controls on multiple daily insulin injections (MDI). Baseline variables evaluated were age, sex, diabetes duration, insulin dose, body mass index (BMI), HbA1c at baseline, and outpatient clinical care unit. RESULTS At 5 years, significantly greater reductions in HbA1c by CSII compared with MDI were found for patients with higher baseline HbA1c (P = 0.032) and lower baseline BMI (P = 0.013). For baseline HbA1c levels of 7.0%, 8.0%, and 9.0% and a BMI of 25 kg/m(2), the reduction in HbA1c level by CSII was 0.08% (difference not significant), 0.16% (95% confidence interval, 0.03-0.29%), and 0.25% (95% confidence interval, 0.11-0.39%), respectively. Corresponding analyses for the change in HbA1c level from start to 1 and 2 years revealed a significant interaction of insulin pump therapy only with baseline HbA1c levels (P < 0.001 and P = 0.030, respectively). The interaction term between outpatient clinical care unit and CSII treatment was statistically significant for some care units, with some care units demonstrating a benefit from CSII and others demonstrating a detriment. CONCLUSIONS Patients with high HbA1c levels have a greater probability of improved HbA1c after initiating pump therapy, but effects remain relatively modest even for patients with poor control. Factors predicting successful insulin pump use need further study.
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Affiliation(s)
- Mark Clements
- 1 Children's Mercy Hospital and University of Missouri-Kansas City , Kansas City, Missouri
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Matuleviciene V, Joseph JI, Andelin M, Hirsch IB, Attvall S, Pivodic A, Dahlqvist S, Klonoff D, Haraldsson B, Lind M. A clinical trial of the accuracy and treatment experience of the Dexcom G4 sensor (Dexcom G4 system) and Enlite sensor (guardian REAL-time system) tested simultaneously in ambulatory patients with type 1 diabetes. Diabetes Technol Ther 2014; 16:759-67. [PMID: 25233297 PMCID: PMC4201312 DOI: 10.1089/dia.2014.0238] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) is a tool widely used in the treatment of patients with type 1 diabetes. The purpose of the current study was to evaluate whether accuracy and patient treatment satisfaction differ between the Enlite™ (Medtronic MiniMed, Inc., Northridge, CA) and Dexcom(®) (San Diego, CA) G4 PLATINUM CGM sensors. SUBJECTS AND METHODS Thirty-eight ambulatory patients with type 1 diabetes used the Dexcom G4 and Enlite sensors simultaneously for a minimum of 4 and maximum of 6 days. Patients measured capillary glucose levels with a HemoCue(®) (Ängelholm, Sweden) system six to 10 times a day. In addition, two inpatient studies were performed between Days 1-3 and 4-6. RESULTS The mean absolute relative difference (MARD) in blood glucose for the Dexcom G4 was significantly lower (13.9%) than for the Enlite sensor (17.8%) (P<0.0001). The corresponding MARDs for Days 1-3 were 15.0% versus 19.4% (P=0.0027) and 13.6% versus 15.9% (P=0.026) for Days 4-6. For glucose levels in the hypoglycemic range (<4.0 mmol/L), the MARD for the Dexcom G4 was 20.0% compared with 34.7% for the Enlite (P=0.0041). On a visual analog scale (VAS) (0-100), patients rated the Dexcom G4 more favorably than the Enlite in 12 out of the 13 user experience questions. For example, more patients rated their experience with the Dexcom G4 as positive (VAS, 79.7 vs. 46.6; P<0.0001) and preferred to use it in their daily lives (VAS, 79.1 vs. 42.1; P<0.0001). CONCLUSIONS The Dexcom G4 sensor was associated with greater overall accuracy than the Enlite sensor during initial (Days 1-3) and later (Days 4-6) use and for glucose levels in the hypoglycemic range. Patients reported a significantly more positive experience using the Dexcom G4 than the Enlite.
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Affiliation(s)
| | - Jeffrey I. Joseph
- Department of Anesthesiology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mervi Andelin
- Department of Medicine, NU-Hospital Organization, Uddevalla, Sweden
| | | | - Stig Attvall
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Sofia Dahlqvist
- Department of Medicine, NU-Hospital Organization, Uddevalla, Sweden
| | - David Klonoff
- Diabetes Research Institute, Mills-Peninsula Health Services, San Mateo, California
| | - Börje Haraldsson
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Lind
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, NU-Hospital Organization, Uddevalla, Sweden
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Olausson EA, Grundin H, Isaksson M, Brock C, Drewes AM, Attvall S, Simrén M. Postprandial plasma glucose response and gastrointestinal symptom severity in patients with diabetic gastroparesis. J Diabetes Sci Technol 2014; 8:881-8. [PMID: 24876417 PMCID: PMC4764220 DOI: 10.1177/1932296814531098] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastroparesis is a well-known diabetic complication. The pathogenesis is not fully understood. However, it is important to early diagnose these patients. This study evaluated the plasma glucose response after a test meal, and gastrointestinal (GI) symptom severity in patients with clinical suspicion of diabetic gastroparesis, and assessed its usefulness to predict gastroparesis. In all, 83 subjects with insulin-treated diabetes mellitus (DM) type 1 and 2 were included; 53 subjects had gastroparesis and 30 had normal gastric emptying determined by gastric scintigraphy. GI symptom severity during the preceding 2 weeks was evaluated with a validated questionnaire. The test meal consisted of 100 g meat, 40 g pasta, 150 g carrot, and 5 g oil. The subjects ingested the meal under fasting conditions, and plasma glucose was followed during 180 minutes. Patients with gastroparesis demonstrated a blunted plasma glucose response after a test meal versus patients with normal gastric emptying (P < .005), reflected by lower maximum increase in plasma glucose response and incremental area under the curve of the plasma glucose, but a similar time to the maximum plasma glucose level. All GI symptoms were more severe in patients with gastroparesis. GI symptom severity had the best discriminative value to identify patients with gastroparesis with an area under the receiver operating curve of 0.83 (optimal cutoff: sensitivity 87%, specificity 80%). Patients with diabetic gastroparesis have a blunted postprandial plasma glucose response. Combining this information with the presence of GI symptoms can help clinicians identify diabetic patients with gastroparesis.
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Affiliation(s)
- Eva A Olausson
- Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Håkan Grundin
- Department of Radiation Physics, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Isaksson
- Department of Radiation Physics, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christina Brock
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Stig Attvall
- Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Olausson EA, Störsrud S, Grundin H, Isaksson M, Attvall S, Simrén M. A small particle size diet reduces upper gastrointestinal symptoms in patients with diabetic gastroparesis: a randomized controlled trial. Am J Gastroenterol 2014; 109:375-85. [PMID: 24419482 DOI: 10.1038/ajg.2013.453] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/19/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Gastroparesis is a well-known complication to diabetes mellitus (DM). Dietary advice is considered to be of importance to reduce gastrointestinal (GI) symptoms in patients with diabetic gastroparesis, but no randomized controlled trials exist. Our aim was to compare GI symptoms in insulin treated DM subjects with gastroparesis eating a diet with small particle size ("intervention diet") with the recommended diet for DM ("control diet"). METHODS 56 subjects with insulin treated DM and gastroparesis were randomized to the intervention diet or the control diet. The patients received dietary advice by a dietitian at 7 occasions during 20 weeks. GI symptom severity, nutrient intake and glycemic control were measured before and after the intervention. RESULTS A significantly greater reduction of the severity of the key gastroparetic symptoms-nausea/vomiting (P=0.01), postprandial fullness (P=0.02) and bloating (P=0.006)-were seen in patients who received the intervention diet compared with the control diet, and this was also true for regurgitation/heartburn (P=0.02), but not for abdominal pain. Anxiety was reduced after the intervention diet, but not after the control diet, whereas no effect on depression or quality of life was noted in any of the groups. A higher fat intake in the intervention group was noted, but otherwise no differences in body weight, HbA1c or nutrient intake were seen. CONCLUSIONS A small particle diet improves the key symptoms of gastroparesis in patients with diabetes mellitus. (ClinicalTrials.gov NCT01557296).
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Affiliation(s)
- Eva A Olausson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska, Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stine Störsrud
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska, Academy, University of Gothenburg, Gothenburg, Sweden
| | - Håkan Grundin
- Department of Radiation Physics, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Isaksson
- Department of Radiation Physics, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stig Attvall
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska, Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska, Academy, University of Gothenburg, Gothenburg, Sweden
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Lilja M, Jansson S, Alvarsson M, Aldrimer M, Nordin G, Attvall S. [HbA1c will complement other methods in the diagnosis of diabetes. Coordinated introduction in Sweden in January 2014]. Lakartidningen 2013; 110:2246-2248. [PMID: 24494398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Mikael Lilja
- Kliniskt forsknings-centrum, Ostersund, Umeå universitet.
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Westlund K, Attvall S, Blohm L. Swedish radiomedical – Passenger cases 2007, 2009, 2011, 2012. A descriptive study. ARCH MAL PROF ENVIRO 2013. [DOI: 10.1016/j.admp.2013.07.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Carlsson BM, Attvall S, Clements M, Gumpeny SR, Pivodic A, Sternemalm L, Lind M. Insulin pump-long-term effects on glycemic control: an observational study at 10 diabetes clinics in Sweden. Diabetes Technol Ther 2013; 15:302-7. [PMID: 23537418 DOI: 10.1089/dia.2012.0286] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM This study examined long-term effects of continuous subcutaneous insulin infusion (CSII) in clinical practice on glycemic control in patients with type 1 diabetes. SUBJECTS AND METHODS We evaluated all type 1 diabetes patients at 10 diabetes outpatient clinics in Sweden who had been treated with CSII for at least 5.5 years and had valid glycated hemoglobin (HbA1c) data before starting pump use and at 5 years ± 6 months. Controls treated with multiple daily insulin injections (MDI) over a time-matched period were also evaluated. RESULTS There were 331 patients treated with CSII at least 5.5 years at the 10 clinics. Of these, 272 (82%) fulfilled the inclusion criteria. Patients treated with CSII were younger than those treated with MDI (mean age, 38.6 vs. 45.6 years; P<0.001), more were women (56% vs. 43%; P<0.001), and diabetes duration was shorter (mean, 15.1 years vs. 20.1 years; P<0.001). After adjusting for variables differing at baseline and influencing the change in HbA1c over the study period, the reduction in HbA1c remained statistically significant at 5 years and was estimated to be 0.20% (95% confidence interval [CI] 0.07-0.32) (2.17 mmol/mol [95% CI 0.81-3.53]) (P=0.002). The corresponding adjusted reduction at years 1 and 2 was 0.42% (95% CI 0.31-0.53) (4.59 mmol/mol [95% CI 3.41-5.77]) (P<0.001) and 0.43% (95% CI 0.31-0.55) (4.71 mmol/mol [95% CI 3.38-6.04]) (P<0.001), respectively. The effect of insulin pump use versus controls on HbA1c decreased significantly with time (P<0.001). CONCLUSIONS Use of CSII in clinical practice in Sweden is associated with an approximately 0.2% (2 mmol/mol) reduction in HbA1c after 5 years.
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Olausson EA, Brock C, Drewes AM, Grundin H, Isaksson M, Stotzer P, Abrahamsson H, Attvall S, Simrén M. Measurement of gastric emptying by radiopaque markers in patients with diabetes: correlation with scintigraphy and upper gastrointestinal symptoms. Neurogastroenterol Motil 2013; 25:e224-32. [PMID: 23316944 DOI: 10.1111/nmo.12075] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Scintigraphy, the gold standard to measure gastric emptying, is expensive and not widely available. Therefore, we compared emptying of radiopaque markers (ROM) from the stomach, by use of fluoroscopy, with scintigraphy in patients with insulin-treated diabetes. METHODS On the same day we measured gastric emptying of 20 ROM using fluoroscopy and scintigraphic emptying of a standard solid meal. The subjects also completed a validated gastrointestinal (GI) symptom questionnaire. KEY RESULTS We included 115 patients with insulin-treated diabetes (median age 53, range 21-69 years; 59 women). A moderately strong correlation was demonstrated between scintigraphic (% retained at 2 h) and ROM emptying (markers retained at 6 h) (r = 0.47; P < 0.0001). Eighty-three patients had delayed gastric emptying with scintigraphy, whereas only 29 patients had delayed emptying of ROM. Of the 29 patients with delayed emptying of ROM, 28 also had delayed scintigraphic emptying. The sensitivity and specificity of the ROM test was 34% and 97%, respectively. Significant correlations were only noted between scintigraphic gastric emptying and GI symptom severity, with the strongest correlations for fullness/early satiety (r = 0.34; P < 0.001) and nausea/vomiting (r = 0.30; P < 0.001). CONCLUSIONS & INFERENCES A gastric emptying test with ROM is a widely available screening method to detect delayed gastric emptying in patients with diabetes, where a positive result seems reliable. However, a normal ROM test does not exclude delayed gastric emptying, and if the clinical suspicion of gastroparesis remains, scintigraphy should be performed. Results from scintigraphy also correlate with GI symptom severity, which ROM test did not.
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Affiliation(s)
- E A Olausson
- Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Jendle J, Alvarsson M, Hanås R, Attvall S. [Measuring blood ketones--when, where and how]. Lakartidningen 2012; 109:2031-2032. [PMID: 23240313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Johan Jendle
- Endokrin-och Diabetescentrum, Centralsjukhuset, Karlstad.
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16
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Nilsson PM, Leósdóttir M, Attvall S. [Glucose control is a strategy for cardiovascular prevention]. Lakartidningen 2012; 109:1549-1551. [PMID: 23016238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Jendle J, Adolfsson P, Attvall S, Ornhagen H. [Diving in diabetes possible but not without risks]. Lakartidningen 2011; 108:2230-2231. [PMID: 22165185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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18
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Anderson J, Attvall S, Sternemalm L, Pivodic A, Fahlén M, Hanås R, Ekeroth G, Lind M. Effect on glycemic control by short- and long-term use of continuous glucose monitoring in clinical practice. J Diabetes Sci Technol 2011; 5:1472-9. [PMID: 22226268 PMCID: PMC3262717 DOI: 10.1177/193229681100500622] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In Sweden, patients with diabetes mellitus frequently receive short-term (<3 months) continuous glucose monitoring (CGM) to study glucose patterns or long-term CGM to treat poor glycemic control or severe hypoglycemia. The effects of CGM on glycemic control in clinical practice in relation to indication and duration of use has not been completely studied. METHODS Patients with diabetes, among which 99% were diagnosed as type 1, receiving CGM at 10 outpatient clinics in Sweden were studied retrospectively. Long-term use of CGM was defined as ≥ 3 months use of CGM and short-term as <3 months. A control group matched on start date and date of latest value 3 months after the start was selected for both long- and short-term groups. RESULTS In 34 long-term users of CGM, over a mean follow-up of 1.1 years, the adjusted mean difference of hemoglobin A1c (HbA1c) compared with controls (n = 408) was -0.76 (95% confidence interval -1.17; -0.33, p < .001). Long-term users with indications for high HbA1c (n = 15) had a reduction of 1.2% in HbA1c from 10.1 to 8.9% (p = .003), whereas patients with hypoglycemia as their indication (n = 16) decreased by 0.3% (p = .17). Nonsevere hypoglycemic events decreased in long-term users within the same follow-up period (p = .004). Short-term users showed no statistically significant improvement in HbA1c compared with controls at 1.1 years (n = 41), p = .85 or at 2.6 years (n = 43), p = .19. CONCLUSION Long-term CGM use was associated with improved glycemic control in clinical practice and a reduction in nonsevere hypoglycemic events, whereas short-term use had no effect on HbA1c. The effect on glycemic control varied by indication.
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Affiliation(s)
- Jenny Anderson
- Department of Medicine, NU-Hospital OrganizationTrollhättan, Sweden
| | - Stig Attvall
- Institute of Medicine, Sahlgrenska Academy, University of GothenburgGothenburg, Sweden
- Diabetes Section, Sahlgrenska University HospitalGothenburg, Sweden
| | | | | | - Martin Fahlén
- Department of Medicine, Kungälvs HospitalKungälv, Sweden
| | - Ragnar Hanås
- Department of Pediatrics, NU-Hospital OrganizationUddevalla, Sweden
| | | | - Marcus Lind
- Department of Medicine, NU-Hospital OrganizationTrollhättan, Sweden
- Institute of Medicine, Sahlgrenska Academy, University of GothenburgGothenburg, Sweden
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Svenningsson I, Marklund B, Attvall S, Gedda B. Type 2 diabetes: perceptions of quality of life and attitudes towards diabetes from a gender perspective. Scand J Caring Sci 2011; 25:688-95. [DOI: 10.1111/j.1471-6712.2011.00879.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Gothefors D, Adolfsson R, Attvall S, Erlinge D, Jarbin H, Lindström K, von Hausswolff-Juhlin YL, Morgell R, Toft E, Osby U. Swedish clinical guidelines--prevention and management of metabolic risk in patients with severe psychiatric disorders. Nord J Psychiatry 2010; 64:294-302. [PMID: 20662682 DOI: 10.3109/08039488.2010.500397] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Individuals with severe psychiatric disorders are more likely than the population at large to develop metabolic derangements such as overweight and diabetes. Cardiovascular disease is also more frequently seen in this group. Contributing factors may include inappropriate diet or lack of physical activity, but antipsychotic medication may also play a role. Seven Swedish specialist medical societies have collaborated in formulating a set of concise clinically applicable guidelines-reproduced here in modified form-for the prevention and management of metabolic risk in this patient group. The importance of implementation is emphasized.
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Nilsson PM, Attvall S. [Intensive glucose control in type 2 diabetes is beneficial]. Lakartidningen 2009; 106:2198. [PMID: 19817174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Peter M Nilsson
- Institutionen för kliniska vetenskaper, Universitetssjukhuset MAS, Malmö.
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Olausson EA, Alpsten M, Larsson A, Mattsson H, Andersson H, Attvall S. Small particle size of a solid meal increases gastric emptying and late postprandial glycaemic response in diabetic subjects with gastroparesis. Diabetes Res Clin Pract 2008; 80:231-7. [PMID: 18237818 DOI: 10.1016/j.diabres.2007.12.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Accepted: 12/08/2007] [Indexed: 01/15/2023]
Abstract
Our goal was to investigate if food of small particle size increases the gastric emptying rate and lessens the fall in postprandial blood glucose in seven subjects with Type 1 diabetes and gastroparesis. Two solid meals of identical composition but of different particle size, with 5MBq (99m)Tc added to the meals, were ingested in randomized order in seven subjects with Type 1 Diabetes Mellitus and gastroparesis and seven healthy subjects. During 180min blood glucose and insulin concentrations were measured and gastric emptying of the ingested meals was registered by a gamma camera. The lag phase in the stomach was significantly shorter, the radioactivity remaining in the stomach after 120min (T(120)) was significant less and the postprandial blood glucose dip was less and of shorter duration after a small particle (SP) meal, compared to a large particle (LP) meal in diabetic subjects. Gastric emptying did not differ significantly between groups after an SP meal. Food of small particle size increases the gastric emptying rate and reduces the postprandial blood glucose dip in both magnitude and duration in Type 1 diabetic subjects with gastroparesis, which is likely to be of importance in achieving good metabolic control.
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Affiliation(s)
- Eva A Olausson
- Diabetic Centre, Institute of Internal Medicine, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden
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Abstract
BACKGROUND Although metformin is widely used in the management of type 2 diabetes, its mechanism(s) of action is not fully known, and there have been remarkably few reports on short-term effects of the drug. Here, we examined the early effects on glucose and lipid metabolism and on certain adipose tissue and inflammatory markers during treatment for 28 days. METHODS Twenty-one patients were randomized to metformin (n = 16) or placebo (n = 5) and studied at baseline, 1, 2 and 4 weeks with blood sampling and oral glucose tolerance tests (OGTT). The active group received 500 mg metformin daily in the first week, 500 mg twice daily during week 2 and 1000 mg twice daily during weeks 3 and 4. RESULTS After 7 days of treatment, a reduced area under curve (AUC) for glucose at OGTT with no change in AUC for insulin levels was observed compared to baseline. Insulin sensitivity, as derived from the OGTT by Gutt's index, was increased. Reductions in fasting plasma glucose, total cholesterol and low-density lipoprotein cholesterol appeared after 14 days, and reductions in triglycerides, plasminogen activator inhibitor-1 (PAI-1) and leptin after 28 days of treatment. There were no changes in body weight, adiponectin or C-reactive protein. Compared with placebo, the changes between day 0 and day 28 differed significantly with regard to AUC for glucose at OGTT and Gutt's index, and showed strong trends for PAI-1 and leptin. CONCLUSIONS The data demonstrate that in type 2 diabetes, metformin rapidly affects glucose handling without changing the concentrations of insulin. Reductions in PAI-1 and leptin levels indicate that the early effects of metformin involve also the adipose tissue.
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Abstract
BACKGROUND Although metformin is widely used in the management of type 2 diabetes, its mechanism(s) of action is not fully known, and there have been remarkably few reports on short-term effects of the drug. Here, we examined early effects on glucose and lipid metabolism, and on certain adipose tissue and inflammatory markers during treatment for 28 days. METHODS Twenty-one patients were randomized to metformin (n = 16) or placebo (n = 5) and studied at baseline, 1, 2 and 4 weeks with blood sampling and oral glucose tolerance tests (OGTT). The active group received 500 mg metformin daily in week 1, 500 mg twice daily in week 2 and 1000 mg twice daily in week 3 and 4. RESULTS After 7 days of treatment, a reduced area under curve (AUC) for glucose at OGTT with no change in AUC for insulin levels was observed compared with baseline. Insulin sensitivity, as derived from the OGTT by Gutt's index, was increased. Reductions in fasting plasma glucose, total and LDL-cholesterol appeared after 14 days, and reductions in triglycerides, plasminogen activator inhibitor-1 (PAI-1) and leptin after 28 days of treatment. There were no changes in body weight, adiponectin or C-reactive protein. Compared with placebo, the changes between day 0 and day 28 differed significantly with regard to AUC for glucose at OGTT and Gutt's index, and showed strong trends for PAI-1 and leptin. CONCLUSIONS The data demonstrate that in type 2 diabetes metformin rapidly affects glucose handling without changing the concentrations of insulin. Reductions in PAI-1 and leptin levels indicate that the early effects of metformin involve also the adipose tissue.
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Abstract
This publication is a summary of the presentations given at the First JIM Grand Round held at the Sahlgrenska University Hospital on 15 March 2006. The Grand Round was based on two case reports; a patient with type 2 diabetes and pronounced macrovascular disease and another patient with early microvascular disease combined with the macrovascular complications. The pathogenesis of the vascular complications and the current treatment regimens were discussed in relation to the history and examinations performed in these patients.
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Affiliation(s)
- U Smith
- The Lundberg Laboratory for Diabetes Research, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden.
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Båvenholm P, Attvall S, Nilsson PM. [Lipid-lowering cardiovascular prevention in type 2-diabetes. Statins are effective according to the FIELD study]. Lakartidningen 2006; 103:2462-6. [PMID: 17002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Peter Båvenholm
- Akutmedicinska Divisionen, Karolinska Universitetssjukhuset Solna, Stockholm.
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Nilsson PM, Attvall S, Båvenholm P. [Good prevention of type 2 diabetes with lipid-lowering statin therapy. Intervention studies support active treatment of risk patients]. Lakartidningen 2004; 101:3798, 3801-2, 3804. [PMID: 15609534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Mjörnheim AC, Finizia C, Blohmé G, Attvall S, Lundell L, Ruth M. Gastrointestinal symptoms in type 1 diabetic patients, as compared to a general population. A questionnaire-based study. Digestion 2004; 68:102-8. [PMID: 14593236 DOI: 10.1159/000074523] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2001] [Accepted: 05/14/2003] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To examine the prevalence of gastrointestinal (GI) symptoms in patients with type 1 diabetes as compared to age- and sex-matched controls. METHOD 395 patients with type 1 diabetes, registered at the diabetes outpatient unit at the Sahlgrenska University Hospital, were studied by use of a GI symptom questionnaire. They were randomly selected within 10-year age intervals from 20 to 69 years. Age- and sex-matched controls (n=242) were sampled from a cohort recruited from the general population. RESULTS While the study populations were well matched with regard to age, sex and body mass index (BMI), the diabetic population comprised more smokers and reported symptoms of respiratory and ischemic heart disease more frequently. Symptoms of heartburn, acid regurgitation, nausea and vomiting were significantly more frequent and intense in the diabetic cohort. The occurrence of GI symptoms co-varied with the presence of respiratory and cardiac symptoms but was not predicted by age, glycosylated haemoglobin (HbA1c) levels or the presence of peripheral neuropathy. CONCLUSION Patients with diabetes type 1 had more frequent and intense upper and lower GI symptoms than age- and sex-matched controls, especially if only moderate and severe symptoms were considered. The presence of symptoms was related to lifestyle factors but not to the degree of diabetes control as expressed by the level of HbA1c and the presence of peripheral neuropathy.
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Attvall S, Eliasson B, Nilsson P. [Increased risk of cardiovascular diseases and diabetes in mentally ill persons. Life style is a contributing factor]. Lakartidningen 2003; 100:2353-5. [PMID: 12899026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Affiliation(s)
- Stig Attvall
- DiabetesCentrum, Sahlgrenska Universitetssjukhuset/Sahlgrenska, Göteborg.
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Abstract
OBJECTIVES Validation of a novel glucose-insulin-potassium (GIK) infusion algorithm to optimize metabolic control in hospitalized diabetic patients. SUBJECTS We randomized 33 diabetic patients admitted to Sahlgrenska University Hospital with acute internal medicine diseases to either GIK infusion or multiple injection therapy (MIT). The GIK infusion rate and the MIT were controlled according to special algorithms. The treatment efficacy was evaluated through comparisons of capillary blood glucose eight times on day 2 of the study. RESULTS The GIK infusion led to significantly lower mean blood glucose when compared with MIT [10.1 (9.0-11.2) vs. 12.3 (9.3-14.4) mmol L(-1), median and interquartile range, P < 0.01]. Four episodes of hypoglycaemia without loss of consciousness were recorded in the GIK group whereas no hypoglycaemic event occurred in the MIT group. A mean of 1 (1-3) episodes of blood glucose levels above 12.0 mmol L(-1) were recorded in the GIK group compared with 3.5 (1.5-5.0) in the MIT group, P < 0.01. CONCLUSIONS The algorithm used for the GIK infusion gave an acceptable level of metabolic control and this insulin infusion protocol is safe enough to be used by the nursing staff on a general internal medicine ward.
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Affiliation(s)
- M Bonnier
- Lundberg Laboratory for Diabetes Research, Centre for Diabetes, Sahlgrenska University Hospital, S-413 45 Gothenburg, Sweden.
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Nilsson P, Attvall S, Weiss L. [Ambitious American guidelines for control of risk factors in diabetes. Was the aim put too high?]. Lakartidningen 2003; 100:26-30. [PMID: 12572133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Affiliation(s)
- Peter Nilsson
- Avdelningen för medicin, Universitetssjukhuset MAS, Malmö.
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Nilsson P, Attvall S. [Angiotensin II receptor antagonists reduce the development of nephropathies in type 2 diabetes. Three new studies are of interest, but don't answer all questions]. Lakartidningen 2001; 98:4960-2. [PMID: 11816896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- P Nilsson
- Avdelningen för medicin, Universitetssjukhuset MAS, Malmö.
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Nilsson P, Attvall S, Eriksson J. [Evidence-based diabetology and patients' self care--patient education is more than just blood glucose self-monitoring]. Lakartidningen 2001; 98:2501-2. [PMID: 11433987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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Bokemark L, Wikstrand J, Attvall S, Hulthe J, Wedel H, Fagerberg B. Insulin resistance and intima-media thickness in the carotid and femoral arteries of clinically healthy 58-year-old men. The Atherosclerosis and Insulin Resistance Study (AIR). J Intern Med 2001; 249:59-67. [PMID: 11168785 DOI: 10.1046/j.1365-2796.2001.00735.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine whether insulin resistance was associated with ultrasound-assessed measures of atherosclerosis in men with varying degrees of obesity. DESIGN A random selection of subjects from the general population were divided into quintiles of a body mass index/blood glucose score that was shown to be a valid and reproducible index of the degree of insulin sensitivity as assessed by the clamp technique. Every fourth man in quintiles 1 and 5 and every 20th man in quintiles 2-4 (in total, 104 men) were selected for an ultrasound examination of the carotid and femoral arteries and a euglycaemic hyperinsulinaemic clamp examination, adjusted for fat-free mass. SETTING A university hospital. SUBJECTS A total of 104 clinically healthy 58-year-old men of Swedish ancestry. RESULTS The mean common carotid artery intima-media thickness (IMT), but not the common femoral IMT, correlated significantly with glucose infusion rate (GIR) (r = - 0.20, P < 0.05), systolic blood pressure (r = 0.20, P < 0.05), pulse pressure (r = 0.23 P < 0.01), heart rate (r = 0.20, P < 0.05), HDL cholesterol (r = - 0.18, P < 0.05), log triglycerides (r = 0.28, P < 0.01), apoA1 (r = - 0.20, P < 0.05), apoB (r = 0.21, P < 0.05), LDL particle size (r = - 0.22, P < 0.05) and plasma insulin (r = 0.20, P < 0.05). In a multiple regression, common carotid IMT was independently associated with log triglycerides (beta = 0.25, P = 0.012) and pulse pressure (beta = 0.21, P = 0.031) (R2 = 8.7%, P = 0.005) CONCLUSIONS Insulin sensitivity, measured with the gold standard euglycaemic hyperinsulinaemic clamp method, showed similar associations with ultrasound-assessed measures of atherosclerosis in the carotid arteries as established cardiovascular risk factors, but only triglycerides and pulse pressure contributed independently to the variability in the common carotid intima-media thickness.
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Affiliation(s)
- L Bokemark
- Department of Medicine and Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska University Hospital, Göteborg, Sweden.
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Bergh AL, Persson LO, Attvall S. Psychometric properties of the Swedish version of the Well-Being Questionnaire in a sample of patients with diabetes type 1. Scand J Public Health 2000; 28:137-45. [PMID: 10954141 DOI: 10.1177/140349480002800210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of the present investigation was to further test the psychometric properties of a Swedish version of the Well-Being Questionnaire (WBQ) in order to determine whether it could be suitable for measuring health-related quality of life among type 1 diabetic patients. METHODS In total, 94 patients who fulfilled the inclusion criteria were selected for the study and of these 85% participated. Reliability was tested with Cronbach's alpha coefficient and the internal validity by means of principal component analysis and multitrait analysis. To test the external validity, comparisons were made with two other questionnaires, the Short form-36 and a Swedish Mood Adjective Check List. RESULTS The results show that, above all, the Swedish version of the WBQ measures psychological well-being, and thus must also be complemented with scales that measure other consequences of the illness and/or treatment, i.e. physical symptoms. The questionnaire has low discriminatory validity between subscales, which casts doubt on the appropriateness of using the four subscales as separate measures. The two scales measuring anxiety and depression are not sensitive enough for use among type 1 diabetics without complications and high or normal levels of psychological well-being. CONCLUSIONS The Well-Being Questionnaire alone does not give any more information about subjective health status among type 1 diabetic patients than, for example, the generic SF-36.
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Affiliation(s)
- A L Bergh
- The Department of Health Science, University of Göteborg, Sweden.
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36
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Bokemark L, Frödén A, Attvall S, Wikstrand J, Fagerberg B. The euglycemic hyperinsulinemic clamp examination: variability and reproducibility. Scand J Clin Lab Invest 2000; 60:27-36. [PMID: 10757451 DOI: 10.1080/00365510050185010] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The aim was to examine the reproducibility of the euglycemic hyperinsulinemic clamp method. From a random population sample of 60-year-old clinically healthy men, 32 subjects with varying degrees of insulin sensitivity were recruited. Conventional 2-h clamp examinations were carried out at an interval of 2 weeks. Insulin was infused intravenously (priming for 10 min and thereafter 1.0 mU/kg body wt/min). Glucose was infused concomitantly aiming at a whole blood glucose of 5 mmol/L. The glucose infusion rate (GIR) was adjusted for body weight or fat free mass (FFM), the latter measured with dual-energy X-ray absorptiometry. During the final hour of each examination (60-120 min) the mean whole blood glucose concentrations were 5.06+/-0.15 and 5.09+/-0.17 mmol/L, respectively. Of the different time intervals studied, the glucose infusion rate during the final hour (GIR60-120) showed the highest correlation and lowest coefficient of variation (GIR60-120 adjusted by FFM: r=0.70, coefficient of variation=14.7%). Adjustment of GIR for weight instead of FFM underestimated insulin sensitivity in obese men. GIR60-120 adjusted for FFM tended to increase during the second examination. The measurement error was constant across all GIR. In summary, the euglycemic hyperinsulinemic clamp method has a coefficient of variation around 15%. The glucose infusion rate should be adjusted for fat free mass.
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Affiliation(s)
- L Bokemark
- Department of Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
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Bergh AL, Persson LO, Attvall S. Psychometric properties of the Swedish version of the WellBeing Questionnaire in a sample of patients with diabetes type 1. Scand J Public Health 2000. [DOI: 10.1080/713797394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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38
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Attvall S, Smith U. [Approved national guidelines for diabetic care. Diabetes Center, Sahlgrenska University Center, Gothenburg, Sweden]. Lakartidningen 1999; 96:3994-5. [PMID: 10526454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- S Attvall
- Diabetescentrum, Sahlgrenska Universitetssjukhuset/Sahlgrenska, Göteborg
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Blohmé G, Attvall S. [Self monitoring in diabetic care is essential. Follow routine of blood glucose level measurements]. Lakartidningen 1998; 95:5163-4. [PMID: 9842188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- G Blohmé
- Diabetescentrum, Sahlgrenska Universitetssjukhuset/Sahlgrenska, Göteborg
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40
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Nilsson P, Attvall S, Eliasson M. [More active therapy in diabetes type 2 is justified by findings in a break-through study. 20-year follow-up of over 5000 patients]. Lakartidningen 1998; 95:4983-4, 4987. [PMID: 9835711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- P Nilsson
- Kliniska forskningsenheten, Universitetssjukhuset MAS, Malmö
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Karlsson AK, Elam M, Friberg P, Sullivan L, Attvall S, Lönnroth P. Peripheral afferent stimulation of decentralized sympathetic neurons activates lipolysis in spinal cord-injured subjects. Metabolism 1997; 46:1465-9. [PMID: 9439544 DOI: 10.1016/s0026-0495(97)90149-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Spinal cord-injured (SCI) subjects exhibit a normal lipolytic rate despite the failure of centrally mediated sympathoexcitatory stimuli to activate lipolysis. Peripheral afferent stimulation below the lesion level induces an exaggerated autonomic reaction in SCI with lesion levels above T5, ie, so-called autonomic dysreflexia. The metabolic effects of induced dysreflexia were investigated in five SCI subjects (age, 35 +/- 8 years; duration of paresis, 15 +/- 7.5 years [mean +/- SD]; lesion level, T3 to T4, n = 2, C7, n = 3) following bladder stimulation. Subcutaneous glycerol concentrations were measured by microdialysis above and below the lesion level. Diurnal plasma noradrenaline (NA) and adrenaline levels were continuously monitored in seven SCI subjects (lesion level T3 to T4, n = 2; C4 to C7, n = 5). Bladder stimulation resulted in an increased mean arterial pressure ([MAP] 81 +/- 8 to 114 +/- 11 mm Hg, P < .05), a decreased heart rate (70 +/- 3 to 54 +/- 4 beats/min, P < .05), and an increased plasma NA (0.70 +/- 0.49 v 3.27 +/- 1.56 nmol/L, P < .05). Interstitial glycerol was increased in the decentralized region (89 +/- 12 to 135 +/- 21 mumol/L, P < .05), whereas no reaction was found in the centrally innervated region. Plasma concentrations of glycerol and insulin increased. Diurnal monitoring showed periods of increased plasma NA sufficient to induce lipolysis (> 1.4 nmol/L) during 20% of the registration period. The data suggest that peripheral afferent stimulation below the lesion level increases NA release and activates lipolysis and that frequent episodes of activation are found in SCI subjects with tetraplegia or high paraplegia.
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Affiliation(s)
- A K Karlsson
- Department of Neurology, University of Göteborg, Sweden
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42
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Nilsson P, Attvall S. [How to handle the question of screening in diabetes?]. Lakartidningen 1997; 94:3595. [PMID: 9411100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Attvall S, Nilsson P. [Guidelines for quality assurance in diabetic care. The target is a uniform care, fewer complications]. Lakartidningen 1997; 94:3243-5. [PMID: 9379789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- S Attvall
- Diabetescentrum, Sahlgrenska Universitetssjukhuset/Sahlgrenska, Göteborg
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Abstract
Cigarette smokers have recently been shown to exhibit insulin resistance, dyslipidaemia and markers of the insulin resistance syndrome (IRS). The aim of this study was to examine the effects of smoking cessation on insulin sensitivity and IRS. Forty male, non-obese healthy smokers participated in this open parallel study with 8 weeks of follow-up. Seventeen subjects were able to stop smoking, while 23 subjects continued to smoke and served as a controls group. Anthropometric and metabolic data were measured. Degree of insulin sensitivity was determined with the euglycaemic hyperinsulinaemic clamp technique. Smoking cessation increased insulin sensitivity and improved the lipoprotein profile in spite of a modest increase in body weight. Initial smoking habits correlated positively with the increase in BMI as well as the improvements in the metabolic variables after smoking cessation. These data support the view that smoking causes insulin resistance and IRS, and also demonstrate that the beneficial metabolic effects of smoking cessation override the effects of an accompanying modest increase in body weight.
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Affiliation(s)
- B Eliasson
- Lundberg Laboratory for Diabetes Research, Department of Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
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45
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Gudbjörnsdóttir S, Fowelin J, Elam M, Attvall S, Bengtsson BA, Mårin P, Lönnroth P. The effect of metoprolol treatment on insulin sensitivity and diurnal plasma hormone levels in hypertensive subjects. Eur J Clin Invest 1997; 27:29-35. [PMID: 9041374 DOI: 10.1046/j.1365-2362.1997.670617.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To evaluate the effect of metoprolol on insulin sensitivity and diurnal plasma hormone levels, seven mildly hypertensive subjects were investigated (four men and three women, age 52 +/- 8, body mass index 25.4 +.- 1.9, mean +/- SD). The study had a placebo-controlled, double-blind, crossover design with 6 weeks' metoprolol treatment (100 mg b.i.d) vs. placebo. At the end of each treatment period 24-h blood samples were collected continuously for diurnal analysis of hormone levels and a hyperinsulinaemic euglycaemic clamp combined with [3-3H]-D-glucose infusion was performed. Insulin sensitivity was evaluated by means of three different methods: diurnal plasma insulin and glucose levels; glucose consumption; and insulin sensitivity index during euglycaemic clamp conditions. Fasting blood glucose and insulin concentrations as well as mean plasma diurnal levels of insulin, growth hormone, testosterone and cortisol were similar after placebo and metoprolol treatment, whereas noradrenaline and adrenaline levels were significantly increased after metoprolol. During the clamp, plasma insulin was significantly higher after metoprolol treatment than after placebo treatment (56 +/- 3 vs. 64 +/- 2 mU L(-1), P < 0.05). Consequently, the insulin sensitivity index [glucose infusion rate (GIR)/ plasma insulin] was lower after metoprolol treatment (16.1 +/- 2.6 vs. 10.2 +/- 1.2, P < 0.05), although GIR was not significantly changed. We suggest that the insulin sensitivity index may not accurately reflect the insulin effect as the plasma level of insulin was significantly increased during insulin infusion but not at 24 h, possibly because of alteration of distribution and/or degradation rate of exogenous insulin. Thus, the likelihood of metoprolol inducing insulin resistance in hypertensive subjects may be less than previously proposed.
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Affiliation(s)
- S Gudbjörnsdóttir
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Herlitz H, Widgren B, Urbanavicius V, Attvall S, Persson B. Stimulatory effect of insulin on tubular sodium reabsorption in normotensive subjects with a positive family history of hypertension. Nephrol Dial Transplant 1996. [DOI: 10.1093/oxfordjournals.ndt.a027065] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Herlitz H, Widgren B, Urbanavicius V, Attvall S, Persson B. Stimulatory effect of insulin on tubular sodium reabsorption in normotensive subjects with a positive family history of hypertension. Nephrol Dial Transplant 1996; 11:47-54. [PMID: 8649652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Insulin resistance and hyperinsulinaemia has been suggested as a pathogenetic mechanism in hypertension. METHODS In this investigation the renal response to insulin was studied in normotensive subjects with a positive family history of hypertension in two generations (n = 14), in one weight-matched (n = 11) and one lean (n = 13) control group. During hyperinsulinaemia (euglycaemic hyperinsulinaemic clamp technique) we determined renal haemodynamics (clearances of 51Cr-EDTA and PAH) and urinary sodium excretion. Lithium clearance was used to estimate the segmental tubular reabsorption of sodium. RESULTS In subjects with a positive family history of hypertension, hyperinsulinaemia did not influence renal plasma flow (RPF) or glomerular filtration rate (GFR) but urinary sodium excretion decreased by 50%. Estimated proximal tubular sodium reabsorption was unaffected by insulin while estimated distal fractional sodium reabsorption increased, P < 0.01. At the end of the clamp a low-dose infusion of angiotensin II (0.1 ng/kg per min) was superimposed. GFR and RPF then decreased significantly concomitant with urinary excretion of sodium. In control subjects hyperinsulinaemia caused an unchanged GFR in both groups, increased RPF in the lean control group and 15-25% reduction in sodium excretion. No alteration was seen in estimated proximal tubular sodium reabsorption, but estimated distal tubular sodium reabsorption increased (P < 0.05) in the lean control group. Angiotensin II elicited a further increase in distal fractional tubular sodium reabsorption in both groups (P < 0.05). CONCLUSION In normotensive subjects with a positive family history of hypertension, in contrast to control subjects without such history, hyperinsulinaemia caused a marked decrease in urinary sodium excretion in presence of unchanged RPF and GFR indicating a renal tubular effect of insulin located at distal site of the renal tubules. Angiotensin II caused further sodium retention, probably due to an effect on renal haemodynamics.
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Affiliation(s)
- H Herlitz
- Department of Nephrology, Sahlgrenska University Hospital, University of Göetborg, Sweden
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Attvall S, Abrahamsson H, Schvarcz E, Berne C. [Gastric emptying is important for the patients with diabetes]. Lakartidningen 1995; 92:4166, 4169, 4171-2. [PMID: 7475536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- S Attvall
- medicinska kliniken, Sahlgrenska sjukhuset, Göteborg
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Abstract
To characterize its insulin-antagonistic effect, growth hormone (GH) was infused at variable rates (24, 12 or 6 mU kg-1 min-1) for 1 h in 7 IDDM patients. Saline infusion was used as control (C) and all patients participated in all studies. The effect of insulin was measured with the euglycaemic clamp technique for 6 h combined with d-(3-3H)-glucose to evaluate glucose turnover. The insulin levels during the clamps were similar in all studies (23 +/- 3 mU l-1). The infusions produced peak GH levels of (24 rate = 24) 157 +/- 11, (12 rate = 12) 76 +/- 7, and (6 rate = 6) 45 +/- 8 mU l-1 (mean +/- SEM). The insulin-antagonistic effect of GH on glucose uptake was seen after 2 h and was at a maximum 4 to 5 h after the start of the GH infusion (difference in glucose infusion rate between C and 24 was 1.7 +/- 0.4 mg kg-1 min-1, p < 0.01). The resistance was due to a less pronounced effect of insulin to both inhibit rate of appearance and to stimulate rate of disappearance. Infusion of GH at 12 mU kg-1 min-1 induced a less pronounced insulin resistance both with regards to maximal effect (glucose infusion rate C - GH 1.4 +/- 0.5 mg kg-1 min-1, p < 0.05) and duration (3 h). At 6 mU kg-1 min-1, a clear GH-induced insulin-antagonistic effect was only seen during the third hour of the clamp (glucose infusion rate C-GH 1.3 +/- 0.5 mg kg-1 min-1, p < 0.05). GH infusion impaired the effect of insulin to lower both the levels of free fatty acids (NEFA) and glycerol between 2 and 5 h after the start of the infusion (NEFA, C:110 +/- 29, 24:303 +/- 95, p < 0.05: glycerol, C:32 +/- 4, 24:50 +/- 7 mumol l-1, p < 0.05). The present study therefore demonstrates that the insulin-antagonistic effect of GH in IDDM is related to the plasma levels both with regard to duration and response. The results also indicate that GH impairs the effect of insulin on lipolysis in IDDM after physiological peaks.
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Affiliation(s)
- J Fowelin
- Lundberg Laboratory for Diabetes Research, Sahlgrenska University Hospital, Göteborg University, Sweden
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Agewall S, Fagerberg B, Attvall S, Wendelhag I, Urbanavicius V, Wikstrand J. Carotid artery wall intima-media thickness is associated with insulin-mediated glucose disposal in men at high and low coronary risk. Stroke 1995; 26:956-60. [PMID: 7762045 DOI: 10.1161/01.str.26.6.956] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE The aim of this investigation was to examine the relationship between insulin sensitivity and intima-media thickness in the common carotid artery. METHODS Ultrasound examinations of the common carotid artery and hyperinsulinemic euglycemic clamp examinations were performed in a group (n = 25) of men aged 57 to 77 years at high risk for atherosclerotic disease (hypertension and at least one of the following factors: hypercholesterolemia and/or smoking) and in an age-matched low-risk group (n = 23) with no cardiovascular risk factors. Subjects with cardiovascular disease or diabetes mellitus were excluded. RESULTS A significant negative relationship between insulin sensitivity index and common carotid maximum intima-media thickness was observed in both the high-risk group (r = -.45, P < .05) and in the low-risk group (r = -.59, P < .01). CONCLUSIONS Our results suggest that an increase in intimamedia thickness, as a possible expression of early atherosclerosis, is negatively related to insulin sensitivity.
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Affiliation(s)
- S Agewall
- Department of Medicine, Sahlgrenska University Hospital, Göteborg University, Sweden
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