[Mental disorders and diabetes mellitus (Update 2023)]

Psychiatric disorders and psychological problems are common in patients with diabetes mellitus. There is a twofold increase in depression which is associated with suboptimal glycemic control and increased morbidity and mortality. Other psychiatric disorders with a higher incidence of diabetes are cognitive impairment, dementia, disturbed eating behavior, anxiety disorders, schizophrenia, bipolar disorders and borderline personality disorder. The coincidence of mental disorders and diabetes has unfavorable influences on metabolic control and micro- and macroangiopathic complications. Improvement of therapeutic outcome is a challenge in the modern health care system. The intentions behind this position paper are to rise awareness of this special set of problems, to intensify cooperation between involved health care providers and to reduce incidence of diabetes mellitus as well as morbidity and mortality from diabetes in this patient group.

[Sex and gender-specific aspects in prediabetes and diabetes mellitus-clinical recommendations (Update 2023)]

Metabolic diseases dramatically affect the life of men and women from infancy up to old age in different and manifold ways and are a major challenge for the healthcare system. The treating physicians are confronted with the different needs of women and men in the clinical routine. Gender-specific differences affect pathophysiology, screening, diagnostic and treatment strategies of diseases as well as the development of complications and mortality rates. Impairments in glucose and lipid metabolism, regulation of energy balance and body fat distribution and therefore the associated cardiovascular diseases, are greatly influenced by steroidal and sex hormones. Furthermore, education, income and psychosocial factors play an important role in the development of obesity and diabetes differently in men and women. Males appear to be at greater risk of diabetes at a younger age and at a lower body mass index (BMI) compared to women but women feature a dramatic increase in the risk of diabetes-associated cardiovascular diseases after the menopause. The estimated future years of life lost owing to diabetes is somewhat higher in women than men, with a higher increase in vascular complications in women but a higher increase of cancer deaths in men. In women prediabetes or diabetes are more distinctly associated with a higher number of vascular risk factors, such as inflammatory parameters, unfavourable changes in coagulation and higher blood pressure. Women with prediabetes and diabetes have a much higher relative risk for vascular diseases. Women are more often morbidly obese and less physically active but may have an even greater benefit in health and life expectation from increased physical activity than men. In weight loss studies men often showed a higher weight loss than women; however, diabetes prevention is similarly effective in men and women with prediabetes with a risk reduction of nearly 40%. Nevertheless, a long-term reduction in all cause and cardiovascular mortality was so far only observed in women. Men predominantly feature increased fasting blood glucose levels, women often show impaired glucose tolerance. A history of gestational diabetes or polycystic ovary syndrome (PCOS) as well as increased androgen levels and decreased estrogen levels in women and the presence of erectile dysfunction or decreased testosterone levels in men are important sex-specific risk factors for the development of diabetes. Many studies showed that women with diabetes reach their target values for HbA_1c, blood pressure and low-density lipoprotein (LDL)-cholesterol less often than their male counterparts, although the reasons are unclear. Furthermore, sex differences in the effects, pharmacokinetics and side effects of pharmacological treatment should be taken more into consideration.

[Diabetic neuropathy and diabetic foot syndrome (update 2023)]

These are the guidelines for diagnosis and treatment of diabetic neuropathy and diabetic foot.The position statement summarizes characteristic clinical symptoms and techniques for diagnostic assessment of diabetic neuropathy, including the complex situation of the diabetic foot syndrome. Recommendations for the therapeutic management of diabetic neuropathy, especially for the control of pain in sensorimotor neuropathy, are provided. The needs to prevent and treat diabetic foot syndrome are summarized.

[Antihyperglycemic treatment guidelines for diabetes mellitus type 2 (Update 2023)]

Hyperglycemia significantly contributes to complications in patients with diabetes mellitus. While lifestyle interventions remain cornerstones of disease prevention and treatment, most patients with type 2 diabetes will eventually require pharmacotherapy for glycemic control. The definition of individual targets regarding optimal therapeutic efficacy and safety as well as cardiovascular effects is of great importance. In this guideline we present the most current evidence-based best clinical practice data for healthcare professionals.

[Diabetes mellitus and road traffic-a position paper of the Austrian Diabetes Association (update 2023)]

Public safety (prevention of accidents) is the primary objective in assessing fitness to drive a motor vehicle. However, general access to mobility should not be restricted if there is no particular risk to public safety. For people with diabetes mellitus, the Führerscheingesetz (Driving Licence Legislation) and the Führerscheingesetz-Gesundheitsverordnung (Driving Licence Legislation Health enactment) regulate important aspects of driving safety in connection with acute and chronic complications of the disease. Critical complications that may be relevant to road safety include severe hypoglycemia, pronounced hyperglycemia and hypoglycemia perception disorder as well as severe retinopathy and neuropathy, endstage renal disease and certain cardiovascular manifestations. If there is a suspicion of the presence of one of these complications, a detailed evaluation is required.In addition, the individual antihyperglycemic medication should be checked for existing potential for hypoglycemia. Sulfonylureas, glinides and insulin belong to this group and are therefore associated with the requirement of a 5-year limitation of the driver's license. Other antihyperglycemic drugs without potential for hypoglycemia such as Metformin, SGLT‑2 inhibitors (Sodium-dependent-glucose-transporter‑2 inhibitors, gliflozins), DPP-4-inhibitors (Dipeptidyl-Peptidase inhibitors, gliptins), and GLP‑1 analogues (GLP‑1 rezeptor agonists) are not associated with such a time limitation.The relevant laws which regulate driving safety give room for interpretation, so that specific topics on driving safety for people with diabetes mellitus are elaborated from a medical and traffic-relevant point of view. This position paper is intended to support people involved in this challenging matter.

[Hyperglycemia in critically ill]

In critical illness hyperglycemia is associated with increased mortality. Based on the currently available evidence, an intravenous insulin therapy should be initiated when blood glucose is above 180 mg/dl. After initiation of insulin therapy blood glucose should be maintained between 140 and 180 mg/dl.

[Position statement: surgery and diabetes mellitus (Update 2023)]

This position statement reflects the perspective of the Austrian Diabetes Association concerning the perioperative management of people with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antihyperglycemic and/or insulin therapy.

[Position statement: surgery and diabetes mellitus (Update 2019)]

This position statement reflects the opinion of the Austrian Diabetes Association concerning the perioperative management of patients with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antidiabetics and/or insulin therapy.

[Insulin therapy of type 2 diabetes mellitus (Update 2019)]

The present article is a recommendation of the Austrian Diabetes Association for the practical use of insulin in type 2 diabetes, including the various insulin regimens.

[Mental disorders and diabetes mellitus (Update 2019)]

Psychiatric disorders and psychological problems are common in patients with diabetes mellitus. There is a twofold increase in depression which is associated with suboptimal glycemic control and increased morbidity and mortality. Other psychiatric disorders with a higher incidence of diabetes mellitus are cognitive impairment, dementia, disturbed eating behavior, anxiety disorders, schizophrenia, bipolar disorders and borderline personality disorder. The coincidence of mental disorders and diabetes mellitus has unfavorable influences on metabolic control and micro- and macroangiopathic complications. Improvement of therapeutic outcome is a challenge in the modern health care system. The intentions behind this position paper are to rise awareness of this special set of problems, to intensify cooperation between involved health care providers and to reduce incidence of diabetes mellitus as well as morbidity and mortality from diabetes in this patient group.

[Antihyperglycemic treatment guidelines for diabetes mellitus type 2 (Update 2019)]

Hyperglycemia significantly contributes to complications in patients with diabetes mellitus. While lifestyle interventions remain cornerstones of disease prevention and treatment, most patients with type 2 diabetes will eventually require pharmacotherapy for glycemic control. The definition of individual targets regarding optimal therapeutic efficacy and safety as well as cardiovascular effects is of great importance. In this guideline we present the most current evidence-based best clinical practice data for healthcare professionals.

[Diabetic neuropathy and diabetic foot syndrome (Update 2019)]

These are the guidelines for diagnosis and treatment of diabetic neuropathy and diabetic foot. Diabetic neuropathy comprises a number of mono- and polyneuropathies, plexopathies, radiculopathies and autonomic neuropathy.The position statement summarizes characteristic clinical symptoms and techniques for diagnostic assessment of diabetic neuropathy, including the complex situation of the diabetic foot syndrome. Recommendations for the therapeutic management of diabetic neuropathy, especially for the control of pain in sensorimotor neuropathy, are provided. The needs to prevent and treat diabetic foot syndrome are summarized.

Austrian Experience with Lixisenatide Under Real-Life Conditions: A Prospective Observational Study

INTRODUCTION

Lixisenatide has been studied extensively in randomized clinical trials; however, data on its use in the real-life practice are scarce.

METHODS

This study was a prospective, 26-week, multicenter, observational study conducted in Austrian diabetes centers and office-based practices to evaluate efficacy and safety of lixisenatide under real-life conditions in patients with type 2 diabetes.

RESULTS

Out of 144 patients (mean BMI 36.4 kg/m², disease duration 12.4 years), 113 completed the documentation at 6 months and 42% received basal insulin with or without oral antidiabetic drugs. The HbA1c declined from 8.7% (72 mmol/mol) to 7.9% (63 mmol/mol) and at study end 24.8% of the patients reached an HbA1c level below 7%. Fasting and postprandial glucose after lixisenatide administration were reduced by 27 ± 58 mg/dl and 45 ± 67 mg/dl, respectively. At study end body weight (- 4.5 ± 5.4 kg), triglycerides (- 10.8 ± 105 mg/dl), systolic blood pressure (- 4.8 ± 17.1 mmHg), and LDL cholesterol (- 3.7 ± 25 mg/dl) were reduced. The most commonly reported adverse events were gastrointestinal disorders (18.8%). Forty-three patients (30%) discontinued prematurely, mostly caused by lack of efficacy, occurrence of gastrointestinal disorders, and missing reimbursement. The average dose of insulin decreased slightly by 1.5 units (from 29.4 to 27.9).

CONCLUSION

Lixisenatide demonstrated a similar efficacy and safety profile under real-life conditions as previously shown in randomized clinical trials.

FUNDING

sanofi-aventis GmbH Austria.

The role of psychosomatic medicine in intensive care units

Critically ill patients, their relatives, and intensive care staff are consistently exposed to stress. The principal elements of this exceptional burden are confrontation with a life-threatening disease, specific environmental conditions at the intensive care unit, and the social characteristics of intensive care medicine. The short- and long-term consequences of these stressors include a feeling of helplessness, distress, anxiety, depression, and even posttraumatic stress disorders. Not only the patients, but also their relatives and intensive care staff are at risk of developing such psychopathologies. The integration of psychosomatic medicine into the general concept of intensive care medicine is an essential step for the early identification of fear and anxiety and for understanding biopsychosocial coherence in critically ill patients. Preventive measures such as the improvement of individual coping strategies and enhancing the individual's resistance to stress are crucial aspects of improving wellbeing, as well as the overall outcome of disease. Additional stress-reducing measures reported in the published literature, such as hearing music, the use of earplugs and eye-masks, or basal stimulation, have been successful to a greater or lesser extent.

[Antihyperglycemic treatment guidelines for diabetes mellitus type 2]

Hyperglycemia significantly contributes to micro- and macrovascular complications in patients with diabetes mellitus. While lifestyle interventions remain cornerstones of disease prevention and treatment, most patients with type 2 diabetes will eventually require pharmacotherapy for glycemic control. The definition of individual targets regarding optimal therapeutic efficacy and safety is of great importance. In this guideline we present the most current evidence-based best clinical practice data for healthcare professionals.

[Position statement: surgery and diabetes mellitus]

This position statement reflects the opinion of the Austrian Diabetes Association concerning the perioperative management of patients with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antidiabetics and/or insulin therapy.

[Antihyperglycaemic therapy in critically ill patients]

Hyperglycemia frequently occurs in critically ill patients resulting in major complications like an increased cardiovascular event rate or an increased incidence of infections. Based on the currently available evidence insulin therapy should be initiated in patients with blood glucose levels above 180 mg/dl. Blood glucose values should be maintained between 180 and 140 mg/dl. In surgical patients lower target values ranging from 140 to 110 mg/dl should be applied. After transition to the general ward a complete workup of diabetes mellitus should be performed.

[Position paper: Exocrine pancreatic insufficiency and diabetes mellitus]

Exocrine pancreatic insufficiency in diabetic patients is frequent. Studies based on fecal elastase-1 measurement give prevalence rates of about 50 % in type 1 and 33 % in type 2 diabetic patients. Nevertheless, not all patients report typical symptoms like diarrhea, steatorrhea and weight loss. For indirect testing the determination of fecal elastase-1 has the highest sensitivity and specificity. This test should be performed at least in all symptomatic patients. For differential diagnosis celiac disease (with a prevalence of about 3-5 % of type 1 diabetic patients), autonomic neuropathy, but also diseases like irritable colon and gastrointestinal tumors have to be taken into account. Patients with symptoms and a fecal elastase-1 < 100 µg/g should be treated with pancreas enzymes in adequate daily doses administered at main meals. Treatment improves symptoms significantly, supply with fat soluble vitamins is normalised, risk for osteoporosis is reduced. An improvement of glucose metabolism is but not seen in all studies. A pancreatogenic diabetes, also termed as type 3c diabetes, has not primarily to be treated with insulin, often-at least initially-treatment with oral antidiabetic drugs is possible and sufficient.

Diabetes mellitus and comorbid depression: improvement of both diseases with milnacipran. A replication study (results of the Austrian Major Depression Diabetes Mellitus study group)

Comorbid depression is common in patients with type 2 diabetes mellitus and is associated with greater mortality risk and a higher incidence of diabetic complications and decreased quality of life. In an earlier pilot study, we found that treatment with the serotonin norepinephrine reuptake inhibitor antidepressant, milnacipran, significantly improved metabolic parameters in diabetic patients with comorbid depression who had an antidepressant response. We sought to replicate these results in a larger cohort (n = 135). Patients received milnacipran and metformin for 6 months and metabolic parameters and depressive symptoms were measured at baseline and after 3 and 6 months. At the end of the study, 72.6% of patients had an antidepressant response (≥50% reduction of baseline Beck Depression Inventory score). Overall, there was significant improvement in the metabolic and anthropometric parameters measured. The number of patients with glycated hemoglobin > 8% (>63.9 mmol/mol), an indicator of poor metabolic control requiring intensive therapeutic intervention, decreased from 31.9% at baseline to 11.9% during the study. As found in the pilot study, levels of total cholesterol and triglycerides were only significantly decreased in antidepressant responders. Body weight was significantly reduced in both responders and nonresponders but the effect size was significantly greater in the responder group. In contrast to the pilot study, fasting blood glucose and glycated hemoglobin were significantly decreased to a similar extent in both antidepressant-responders and nonresponders. The present study thus replicates some of the original findings. The main difference between the present and the pilot study is that in the larger cohort significant reductions in fasting blood glucose and glycated hemoglobin were found in all patients irrespective of whether or not they responded to antidepressant treatment. The present data underline the importance of diagnosis and treatment of comorbid depression in patients with type 2 diabetes mellitus with milnacipran.

Diabetes mellitus and co-morbid depression: treatment with milnacipran results in significant improvement of both diseases (results from the Austrian MDDM study group)

Co-morbid depression is common in patients with diabetes mellitus and has a negative impact on diabetes self-care, adherence to treatment and the development of complications. Effective treatment of depression has been associated with improvement in metabolic parameters. We evaluated the feasibility of a two question screen for co-morbid depression in diabetic patients and studied the effect of the serotonin norepinephrine reuptake inhibitor antidepressant, milnacipran, on metabolic and psychological parameters in 64 type 2 diabetic patients with co-morbid depression. The severity of depression was evaluated using the Beck Depression Inventory (BDI). Patients received milnacipran, and diabetes was treated according to the guidelines of the Austrian Diabetes Association in a 6-month open label study. Metabolic parameters and BDI were measured at baseline and after 1, 3 and 6 months. 46 patients satisfied the criteria for an antidepressant response (reduction of baseline BDI score of at least 50%). Hemoglobin A1c, fasting blood glucose, body mass index, total and LDL-cholesterol and serum triglyceride levels were all significantly decreased in these patients at the end of the study whereas in antidepressant non-responders these parameters were not significantly changed. Diagnosis and treatment of depression is an important factor for the improvement of metabolic control in patients with type 2 diabetes and co-morbid depression.

Association of low-grade inflammation with nephropathy in type 2 diabetic patients: role of elevated CRP-levels and 2 different gene-polymorphisms of proinflammatory cytokines

BACKGROUND

Chronic inflammatory processes are thought to play a key role in the development of micro- and macrovascular complications in type 2 diabetes mellitus. An association between low -grade inflammation and type 2 diabetes has been described in some studies. We assayed the association of two frequent polymorphisms in proinflammatory cytokines: the interleukin 6 G(-174)C promoter polymorphism [IL-6G(-174)C], the exon 2 interleukin receptor antagonist insertion deletion polymorphism [IL1RA]) and serum CRP levels with the prevalence of diabetic nephropathy in patients suffering from type 2 diabetes mellitus.

SUBJECTS AND METHODS

A total of 141 patients with type 2 diabetes mellitus, with and without diabetic nephropathy was genotyped for the above mentioned polymorphisms: 66 with normoalbuminuria, 31 with microalbuminuria and 44 with macroalbuminuria. CRP levels were analysed by a high sensitivity - immunnephelometric assay.

RESULTS

While a significant association be-tween macroalbuminuria and CRP could be observed (p<0,015), no associations were found between IL-6G(-174)C or IL1RA genotype and any stage of nephropathy. CRP-levels were similar in the 3 different IL-6G(-174)C genotypes as well as in the 2 IL1RA genotypes.

CONCLUSIONS

In type 2 diabetic subjects elevated CRP levels are associated with an increased prevalence of albuminuria. The two investigated proinflammatory polymorphisms do not seem to contribute to initiation of nephropathy in type 2 diabetic patients but we cannot exclude effects of these polymorphisms on course of nephropathy.

Improvement of glucose tolerance in type 2 diabetic patients: traditional vs. modern insulin regimens (results from the Austrian Biaspart Study)

OBJECTIVE

Major advantages of modern insulin regimens containing premixed insulin analogues in comparison to traditional insulin regimens have not been evaluated yet. The aim of the present study was to investigate whether meal-related (breakfast, lunch, dinner) application of biphasic insulin aspart 30 (BIAsp 30) provides better glycaemic control than administration of biphasic human insulin 30 (BHI 30) twice per day.

RESEARCH DESIGN AND METHODS

In a multi-centre, randomized, open-label parallel trial, a total of 177 patients with type 2 diabetes mellitus were exposed to the two different insulin regimens described above over a study period of 24 weeks. HbA1c and glycemic exposure parameters were measured at predefined intervals.

RESULTS

The mean difference between treatment groups in HbA1c after 24 weeks of treatment was 0.08% (p = 0.6419). Analysing the 7-point blood-glucose (BG) profiles, significant differences in BG levels were observed after lunch (156 vs. 176 mg/dl, p = 0.0289), before dinner (142 vs. 166 mg/dl p = 0.006) and after dinner (154 vs. 182 mg/dl p = 0.002) in favour of BIAsp 30 insulin. Prandial BG increment was lower in the BIAsp 30 group at breakfast (p = 0.057) and lunch (p < 0.0005). No difference was found regarding safety parameters in the two treatment groups.

CONCLUSIONS

This study demonstrates that meal-related BIAsp 30-insulin maintains postprandial BG control more effectively than traditional BHI 30 insulin twice per day in type 2 diabetic patients.

PAI-1 4G/5G insertion/deletion promoter polymorphism and microvascular complications in type 2 diabetes mellitus

BACKGROUND

Plasminogen activator inhibitor-1 (PAI-1) plays an important role in the regulation of fibrinolysis and extracellular matrix turnover. PAI-1 4G/5G insertion/deletion polymorphism in the PAI-1 promoter region has been shown to modulate PAI-1 plasma levels. We investigated the relationship between this polymorphism and the prevalence of diabetic nephropathy and retinopathy in patients with type 2 diabetes in the Austrian population.

PATIENTS AND METHODS

147 consecutive patients with type 2 diabetes mellitus (96 men, 51 women; median age, 65 years; IQR, 59-71) were analyzed for the PAI-1 4G/5G genotype.

RESULTS

The genotype distribution in the individuals tested was as follows: 17% (n = 25) 5G/5G, 54% (n = 80) 4G/5G, and 29% (n = 42) 4G/4G. Patients homozygous for allele 4G had a significantly higher risk of diabetic proliferative retinopathy than patients without signs of diabetic retinopathy or nonproliferative retinopathy (OR, 7.3; 95% CI, 1.4-38.8; P = 0.02). No significant associations were observed between the PAI-1 genotype and the presence of albuminuria.

CONCLUSION

According to our results, diabetic proliferative retinopathy might be associated with the prevalence of PAI-1 genotype 4G/4G.

The value of the Rydel-Seiffer tuning fork as a predictor of diabetic polyneuropathy compared with a neurothesiometer

AIMS

The aim of the study was to investigate the predictive value of the Rydel-Seiffer tuning fork for detecting diabetic neuropathy and to compare it with an electronic neurothesiometer.

METHODS

In 2022 consecutive diabetic subjects, peripheral polyneuropathy was diagnosed by vibration perception threshold (VPT) at the tip of both great toes using a 128-Hz tuning fork and a neurothesiometer, by simple bedside tests and by the presence of neuropathic symptoms. These evaluations were further combined to diagnose peripheral nerve dysfunction (abnormal bedside tests) and symptomatic neuropathy. VPT was also measured in 175 non-diabetic control subjects to define normal values.

RESULTS

VPT was normal in 1917 subjects and abnormal in 105 (5.2%) patients when measured by the tuning fork. Patients with an abnormal vibration test were significantly (P < 0.0001) older than subjects with a normal vibration sense, while diabetes duration and HbA(1c) of the former were also significantly elevated. The same was true for the percentages of an abnormal 10-g monofilament test (66.7% vs. 7.2%, P < 0.0001) and a missing Achilles' tendon reflex (68.6% vs. 24.8%, P < 0.0001). Finally, the VPT measured by the neurothesiometer was 2.5 times higher in patients with an abnormal tuning fork test (32.0 +/- 9.8 vs. 12.5 +/- 6.4 V, P < 0.0001). The plot of the difference of both methods against their mean yielded a good agreement of the two VPT measurements, and the tuning fork had a high sensitivity and positive predictive value for the diagnosis of abnormal bedside tests and for symptomatic neuropathy.

CONCLUSION

The tuning fork reliably detected peripheral neuropathy in comparison with the neurothesiometer. A tuning fork is a useful screening test for diabetic neuropathy.

Evaluation of a new insulinotropic agent by using an innovative technology: efficacy and safety of nateglinide determined by continuous glucose monitoring

Nateglinide, a new insulinotropic agent, specifically targets prandial glycemic excursions. Recently, innovative technologies have become available that provide the possibility to measure 72-h blood glucose values continuously. The aim of this study was to evaluate the effects of nateglinide on 24-h blood glucose profiles in diabetic patients. Eighteen patients with type 2 diabetes mellitus--seven on diet only and 11 on metformin monotherapy--participated in the study. Mean age was 60 years, mean diabetes' duration was 7.4 years, and mean hemoglobin A1c was 8.4%. They underwent a 72-h glucose monitoring using a continuous glucose monitoring system (CGMS, Medtronic MiniMed, Northridge, CA) under their usual diabetes therapy and a standardized breakfast. After this period, therapy with nateglinide, 120 mg three times a day before meals, was initiated. Three days later patients again underwent 72-h glucose monitoring. Mean blood glucose values and mean fasting blood glucose values decreased significantly, from 172 mg/dL before to 131 mg/dL (P< 0.0004) and from 172 mg/dL before to 126 mg/dL (P< 0.0005), respectively, with nateglinide therapy. Postprandial hyperglycemia, expressed as mean blood glucose over a time period of 2 h after a meal, declined significantly after all three daily meals. The number of blood glucose values above 140 mg/dL decreased from 207 without to 98 during nateglinide therapy. Nateglinide was not associated with hypoglycemia or other adverse events. We found in this study, using CGMS, that nateglinide has a glucose-lowering potency that not only affects postprandial hyperglycemia, but also overnight and fasting blood glucose values.

[The diabetic foot]

These are the guidelines for preventive care, diagnosis and treatment of diabetic foot syndrome. Diabetic neuropathy, peripheral vascular disease, bone deformity and altered biomechanics are foot-related risk conditions. The position statement is focused on screening methods and recommendations for clinical care for diabetics, who currently have no foot ulcers. A decision pathway is offered with respect to diagnosis and management of diabetic patients at increased risk or who manifest injuries.

[Diabetic neuropathy]

These are the guidelines for diagnosis and treatment of diabetic neuropathy. This diabetic late complication comprises a number of mono- and polyneuropathies, plexopathies, radiculopathies and autonomic neuropathy. The position statement summarizes characteristic clinical symptoms and techniques for diagnostic assessment of diabetic neuropathy. Recommendations for the therapeutic management of diabetic neuropathy, especially for the control of pain in sensorimotoric neuropathy, are provided.

Transfer of knowledge from the specialist to the generalist by videoconferencing: effect on diabetes care

We conducted a 12-month prospective interventional study of videoconferencing between primary and secondary care. A treatment network consisting of a diabetes specialist and four general practitioners was established. The communications medium was PC-based videoconferencing via ISDN at 128 kbit/s. A total of 154 type 2 diabetic patients entered the study. The specialist was contacted 94 times via videoconferencing. Metabolic and haemodynamic parameters were significantly improved over the course of the study: the mean HbA1c level fell from 8.1% to 7.8%, systolic blood pressure from 156 to 148 mmHg and diastolic blood pressure from 88 to 83 mmHg. The study demonstrated that therapeutic counselling by videoconferencing is feasible in diabetes care and suggests that it reduces hospital admissions and improves the quality of care.

Circulating and urinary transforming growth factor beta1, Amadori albumin, and complications of type 1 diabetes: the EURODIAB prospective complications study

OBJECTIVE

Transforming growth factor (TGF)-beta1 is overexpressed in diabetes as a consequence of hyperglycemia and the creation of early glycated end products and may be responsible for the characteristic structural renal changes associated with diabetes. We sought to examine the role of both urinary and circulating TGF-beta1 and its promoter Amadori albumin in the vascular complications of type 1 diabetes.

RESEARCH DESIGN AND METHODS

The present article reports on a nested case-control study from the EURODIAB Prospective Complications Study of Europeans with type 1 diabetes. Case subjects (n = 356) were all individuals with one or more complications of diabetes; control subjects (n = 185) were all individuals with no evidence of complications.

RESULTS

Urinary TGF-beta1 and Amadori albumin were elevated in patients with micro- or macroalbuminuria. Standardized regression effects (SREs) for macroalbuminuria versus normoalbuminuria were 2.45 (95% CI 1.88-3.18, P = 0.0001 for urinary TGF-beta1) and 1.67 (1.34-2.07, P = 0.001 for Amadori albumin). The SRE for urinary TGF-beta1 remained statistically significant when adjusted for HbA(1c), Amadori albumin, and blood pressure. Circulating TGF-beta1 was elevated in individuals with proliferative retinopathy compared with individuals without retinopathy (SRE 1.29 [1.07-1.550], P = 0.007). This result was attenuated to 1.16 (0.95-1.43, P = 0.2) in the multivariate model, largely because of HbA(1c).

CONCLUSIONS

Elevated levels of urinary TGF-beta1 in macroalbuminuria were associated with elevations in Amadori albumin and HbA(1c) and also in blood pressure. In contrast, only circulating TGF-beta1 was related to proliferative retinopathy, and HbA(1c) largely accounted for this. These findings may indicate novel pathways for understanding mechanisms and therapeutic interventions.

Trends in hypertension management in Type I diabetes across Europe, 1989/1990 - 1997/1999

AIMS/HYPOTHESIS

Our aim was to examine the change in the management of hypertension in patients with Type I (insulin-dependent) diabetes mellitus in Europe, between 1989-1990 and 1997-1999.

METHODS

Seven-year changes in hypertension treatment and control (defined as blood pressure <130/85 mmHg) were examined in a large sample of Type I diabetic patients recruited from 26 centres involved in the EURODIAB Prospective Complications Study. Hypertension was defined as a systolic and/or diastolic blood pressure greater than 140 and/or 90 mmHg respectively, and/or use of blood pressure lowering drugs.

RESULTS

Of 1866 Type I diabetic patients, 412 had hypertension at baseline and 631 at follow-up. A greater proportion of hypertensive patients were treated at follow-up (69% vs 40%, p<0.0001), which persisted after adjustment for age or centre. Of those who were treated, a modest increase in the proportion of those controlled for hypertension was found (41% vs 32%, p=0.048), which disappeared after adjustment for age. Among hypertensive patients with albuminuria, the proportions treated also increased, from 35% to 76% ( p<0.0001) in microalbuminuric and 64% to 95% ( p<0.0001) in macroalbuminuric patients. Control of hypertension in albuminuric patients did not change significantly and was below 50%. The use of more than one anti-hypertensive drug increased over a 7-year period, from 19% to 33% ( p<0.0001), and a marked increase was shown in the proportion of those taking an ACE inhibitor (from 57% to 82%, p<0.0001).

CONCLUSION/INTERPRETATION

The management of hypertension in Type I diabetic patients across Europe has improved over a 7-year follow-up period. Optimal levels of blood pressure treatment and optimal levels of control have not yet been achieved.

[Reduction of cardiovascular morbidity and mortality by combined antihypertensive drug therapy in patients with type 2 diabetes mellitus]

The coexistence of diabetes mellitus in hypertensive patients doubles the number of cardiovascular events (relative risk: 1.73-2.77) and cardiovascular mortality (relative risk: 2.25-3.66). Therapeutic interventions concentrating on elevated blood glucose alone for prevention of late complications were not effective in essential reduction of cardiovascular morbidity and mortality. For that reason therapies, focussing on other macrovascular risk factors, did increase significantly in the last decade. Strategies for reduction of the macrovascular risk include the aggressive treatment of hypertension. In the now published hypertension intervention studies in diabetic patients many different objectives were studied. As we already know, lowering of blood pressure does reduce cardiovascular risk. The optimal blood pressure threshold is not known yet, but of major interest. To find the most effective antihypertensive agent and the most effective combination therapy for diabetic patients, the most frequently used antihypertensive agents were compared with each other. Very interesting are the special effects of some substances, which exceed the lowering of blood pressure, like effects on the endothelinn or on coagulation disturbances. These protective and antiatherosclerotic effects could possibly get relevance even in normotensive patients. Concerning this special question, ACE-inhibitors and Angiotensin II receptor antagonists are getting more and more in the focus of interest and seem to be superior compared to other substances. Concluding the existing evidence from hypertension studies the following recommendations can be deduced: Diabetic patients with at least one additional cardiovascular risk factor should get an ACE-inhibitor in combination with other antihypertensive agents or as monotherapy. For combination therapy all the available antihypertensive agents are appropriate and can lower blood pressure adequately.

[Platelet aggregation inhibitors in diabetes mellitus]

Major cardiovascular complications and ischemic events occur more frequently in diabetic than nondiabetic patients. Platelets of diabetic patients are found in a permanent prethrombotic state. Platelet activation and aggregation with resultant arterial thrombus formation, are the central mechanisms in the pathophysiology of acute coronary syndromes. Over the past two decades aspirin was the leading antithrombotic agent for reduction of thrombotic events and efficacy was proven in many studies. The main study concerning the aspirin question was the "Antiplatelet Trialist's Collaboration-Study", where a successful risk reduction for vascular events of 25%-34% was observed with daily dosis between 75 and 325 mg. In the last years some new, very effective drugs have been developed. Clopidogrel, a thienopyridine was studied in the CAPRIE trial and compared with aspirin. A small advantage could be proved for clopidogrel. The development of inhibitors of fibrinogen, binding to the platelet glykoprotein IIb/IIIa receptor has expanded the therapeutic spectrum for the treatment of thrombotic disorders. Especially in diabetic patients a significant benefit of these new drugs was demonstrated in various clinical indications. The newest results show the clear advantage of combining thrombolytic agents with the glycoprotein IIb/IIIa receptor antagonists in reperfusion after myocardial infarction. In conclusion the main message is, that diabetic patients do need antithrombotic therapy earlier than nondiabetic patients, that efficient drugs are available and that a primary prevention should be considered in this special patient group.

Pharmacokinetic and oral bioavailability of andrographolide from Andrographis paniculata fixed combination Kan Jang in rats and human

Validated analytical methods (HPLC, CE and GC-MS) for determining the amount of andrographolide (AND) in the blood plasma of rats and human volunteers following the oral administration of Andrographis paniculata extract (APE) and Andrographis paniculata fixed combination Kan Jang tablets were developed and used for the pharmacokinetic study. Andrographolide was quickly and almost completely absorbed into the blood following the oral administration of APE at a dose of 20 mg/kg body wt. in rats. Its bio-availability, however, decreased four-fold when a 10-times-higher dose was used. Since a large part (55 %) of AND is bound to plasma proteins and only a limited amount can enter the cells, the pharmacokinetics of AND are described well by a one-compartment model. Renal excretion is not the main route for eliminating AND. It is most likely intensely and dose dependently metabolized. Following the oral administration of four Kan Jang tablets (a single therapeutic dose, equal to 20 mg of AND) to humans, maximum plasma levels of approximately 393 ng/ml (approx. 1.12 microM) were reached after 1.5-2 hours, as quantified using a UV diode-array detection method. Half-life and mean residence times were 6.6 and 10.0 hours, respectively. AND pharmacokinetics in humans are explained well by an open two-compartment model. The calculated steady state plasma concentration of AND for multiple doses of Kan Jang (after the normal therapeutic dose regimen, 3 x 4 tablets/day, about 1 mg AND/kg body wt./day) was approximately 660 ng/ml (approx. 1.9 microM), enough to reveal any anti-PAF effect, particularly after drug uptake when the concentration of AND in blood is about 1342 ng/ml (approx. 3.8 microM, while for anti-PAF effect EC50 - 5 microM).

ACE gene polymorphism and proliferative retinopathy in type 1 diabetes: results of a case-control study

OBJECTIVE

To evaluate the relationship between the ACE insertion/deletion polymorphism and proliferative diabetic retinopathy in patients with type 1 diabetes of long duration. Based on epidemiological and pathophysiological findings, risk factors apart from glycemic control and duration of disease are likely to be involved in the development of proliferative retinopathy.

RESEARCH DESIGN AND METHODS

In this case-control study, we compared 81 patients with longstanding (> or =20 years) type 1 diabetes who had nonproliferative (mild or moderate background) retinopathy with 95 patients with diabetes of similar duration and HbA1c who had proliferative retinopathy. To avoid the confounding effect of nephropathy, patients with overt nephropathy were excluded, and microalbuminuria was introduced into the multiple logistical regression model. The polymorphic region in intron 16 of the ACE gene (17q23) was analyzed using the polymerase chain reaction.

RESULTS

The ACE genotype distribution in patients with proliferative retinopathy (DD 39.4%, ID 48.9%, II 11.7%) was significantly different (P < 0.001) from that of patients with nonproliferative retinopathy (DD 17.3%, ID 54.3%, II 28.4%). In a multiple logistical regression analysis, the adjusted relative risk for proliferative retinopathy in a patient with a DD genotype compared with a patient with an II genotype was 6.6 (95% CI 2.2-19.5), P = 0.0026. In addition to genotype, systolic blood pressure (odds ratio 1.027 [95% CI 1.0-1.1], P = 0.0093) but not microalbuminuria (< or =20 vs. > or =20 microg/min) reached statistical significance in the multiple regression model. Because subjects were matched regarding diabetes duration and HbA1c, we did not interpret the respective parameter estimates.

CONCLUSIONS

These data provide evidence that deletion in the ACE gene is associated with the prevalence of proliferative retinopathy in type 1 diabetes and suggest that the DD genotype confers susceptibility to proliferative retinopathy independent of diabetic nephropathy

[Effect of nutrition on microalbuminuria in patients with type 1 diabetes: prospective data evaluation over 5 years]

The possible influence of dietary components on the progression or regression of microalbuminuria (MA) in type 1 diabetic patients was investigated prospectively over 5 years. The dietary intake of 47 patients with type 1 diabetes and MA (20-200 micrograms/min.), well instructed in diabetes management was observed in bimonthly intervals. Accuracy of 4-day diet protocols was verified by comparing the amount of documented protein intake with the measured nitrogen excretion. Non compliance was defined as deviation more than 30% between both values. These patients were eliminated from the study. Data from 37 patients with good compliance over a 5 year period have been used for multiple stepwise regression analysis. Taking into consideration Body mass index (BMI), blood pressure, HbA1c and time, MA was used as dependent variable, 16 dietary variables with a bivariate significance p < 0.05 as independent variables. The regression analysis (R2 = 0.589, p = 0.0015) showed clear associations between MA and the amount of salt intake (beta = 0.683, p < 0.002), saturated fatty acids (beta = 0.342, p = 0.029) and the amount of consumed mono- and disaccharides (beta = 0.479, p = 0.018). There was no significant association with the amount of protein intake (beta = 0.319, p = 0.152). Looking at the fatty acids in particular there were significant associations to MA with myristic acid, arachidonic acid and negatively with linoleic acid. Splitting the data in tertiles according to the amount of salt intake (I: < 6 g/d, II: 6-10 g/d, III: > 10 g/d) we could show in addition to the overall effect an intraindividual influence on the amount of MA (MA-means +/- SD: I: 45 +/- 56 micrograms/min., II: 61 +/- 59, III: 81 +/- 74, p < 0.001 between the groups). There were no significant differences between the groups in mean blood pressure, HbA1c and BMI.

Effect of lisinopril on progression of retinopathy in normotensive people with type 1 diabetes. The EUCLID Study Group. EURODIAB Controlled Trial of Lisinopril in Insulin-Dependent Diabetes Mellitus

BACKGROUND

Retinopathy commonly occurs in people with type 1 diabetes. Strict glycaemic control can decrease development and progression of retinopathy only partially. Blood pressure is also a risk factor for microvascular complications. Antihypertensive therapy, especially with inhibitors of angiotensin-converting enzyme (ACE), can slow progression of nephropathy, but the effects on retinopathy have not been established. We investigated the effect of lisinopril on retinopathy in type 1 diabetes.

METHODS

As part of a 2-year randomised double-blind placebo-controlled trial, we took retinal photographs at baseline and follow-up (24 months) in patients aged 20-59 in 15 European centres. Patients were not hypertensive, and were normoalbuminuric (85%) or microalbuminuric. Retinopathy was classified from photographs on a five-level scale (none to proliferative).

FINDINGS

The proportion of patients with retinopathy at baseline was 65% (117) in the placebo group and 59% (103) in the lisinopril group (p = 0.2). Patients on lisinopril had significantly lower HbA1c at baseline than those on placebo (6.9% vs 7.3 p = 0.05). Retinopathy progressed by at least one level in 21 (13.2%) of 159 patients on lisinopril and 39 (23.4%) of 166 patients on placebo (odds ratio 0.50 [95% CI 0.28-0.89], p = 0.02). This 50% reduction was the same when adjusted for centre and glycaemic control (0.55 [0.30-1.03], p = 0.06). Lisinopril also decreased progression by two or more grades (0.27 [0.07-1.00], p = 0.05), and progression to proliferative retinopathy (0.18 [0.04-0.82], p = 0.03). Progression was not associated with albuminuric status at baseline. Treatment reduced retinopathy incidence (0.69 [0.30-1.59], p = 0.4).

INTERPRETATION

Lisinopril may decrease retinopathy progression in non-hypertensive patients who have type 1 diabetes with little or no nephropathy. These findings need to be confirmed before changes to clinical practice can be advocated.

Evaluation of risk factors for the development of nephropathy in patients with IDDM: insertion/deletion angiotensin converting enzyme gene polymorphism, hypertension and metabolic control

Diabetic nephropathy represents a major complication in patients with insulin-dependent diabetes mellitus (IDDM). Intervention trials using angiotensin-converting enzyme (ACE) inhibitors have pointed towards the important pathogenetic role of the renin-angiotensin system. Recently an insertion/ deletion (I/D) polymorphism for the gene encoding the ACE has been described, the deletion type being associated with higher plasma ACE levels. As the intrarenal renin-angiotensin system might also be activated in this setting, we determined the ACE genotype together with other risk factors for the development of diabetic nephropathy in 122 patients with IDDM from a single centre with (n = 63) and without (n = 59) nephropathy. Long-term glycaemic control was evaluated using mean HbA1c values from the last 10 years. The two patient group were comparable with regard to duration of diabetes and glycaemic control as assessed by current HbA1c values. However, mean long-term HbA1c values were significantly higher in patients with diabetic nephropathy as was systemic blood pressure. The DD genotype was more prevalent in patients with renal disease. In the subgroup of patients who had had diabetes for more than 20 years (n = 90), the DD genotype was even more frequent in patients with nephropathy, and blood pressure and long-term HbA1c values were also higher in patients with renal disease. Logistic regression analysis revealed long-term glycaemic control, blood pressure and the ACE genotype to be independent risk factors for the prevalence of diabetic nephropathy.

No effect of naloxone on ventilatory response to progressive hypercapnia in IDDM patients

The ventilatory response to hyperoxic progressive hypercapnia was examined by comparing 3 test groups: 7 diabetic patients with AN, 8 diabetic patients without AN, and 8 normal control subjects. In each group, a significant linear correlation was found between PaCO2 and VE. The slopes of the regression curves relating PaCO2 to VE were significantly steeper in the healthy control subjects and diabetic patients without AN than in those with AN (P < 0.01). We conclude that the ventilatory response to progressive hypercapnia is reduced in diabetic patients with AN. By analyzing the power spectrum and the amplitude behavior of the diaphragmatic EMG (calculated from the fc and RMS, respectively), we could exclude a disturbance of neural descending pathways and respiratory muscle dysfunction as possible causal mechanisms for the impaired ventilatory response to increasing CO2. By using lung function analysis, causal factors such as alterations in respiratory system mechanics also could be excluded. As diabetes is known to affect the endogenous opioid system, which, in turn, affects the ventilatory response to CO2, naloxone, as a specific opioid antagonist, was administered in all 3 test groups. Naloxone produced a significant increase of ventilatory response to hypercapnia in the healthy control subjects (P < 0.01), but produced no effect in either of the diabetic groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Recurrent hypoglycemia and lactate acidosis in non-Hodgkin's lymphoma]

Two weeks after partial resection of the small intestine for an intra-abdominal stenosing centroblastic non-Hodgkin lymphoma, a 65-year-old man began to experience recurrent attacks of hypoglycaemia (down to 30 mg/dl) together with lactic acidosis (lactate 5.13 mmol/l), tachycardia and sensations of heat. Very high parenteral glucose input (up to 750 g/day) was necessary to maintain normal blood sugar levels. There was close correlation between the level of glucose consumption and the degree of lactic acidosis. After chemotherapy the abnormalities improved, but recurred as the neoplasm proliferated once more. An endocrine mechanism for the hypoglycaemic attacks was excluded by the low serum concentrations of insulin and of "insulin-like growth factors" I and II and by the fact that the levels of glucagon, glucocorticoids, growth hormone and thyroid hormone were within the normal ranges. There were pleural and peritoneal effusions containing large numbers of tumour cells. Investigated in vitro, the fluids showed a decline in glucose and a rise in lactate concentration. Studies with an artificial pancreas also showed that glucose utilization rate in vivo was increased to four times the normal and that it could be raised still further by insulin stimulation. These findings provide evidence of direct consumption of glucose by the tumour cells in the form of abnormally increased anaerobic glycolysis.