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1. MW - Skin Test Predicts Microvascular Complications in Diabetes

Reuters Health Information 2008. C 2008 Reuters Ltd. Mar 25 - Skin

autofluorescence measurements can noninvasively identify T2DM patients at risk

of developing microvascular complications, Dutch researchers report. They note

that the approach reflects the level of tissue accumulation of advanced

glycation end products (AGEs),

which are indicative of cumulative glycemic and oxidative stress.

The method has already been of use in assessing total and cardiovascular

mortality risk in DM patients, [973 patients with well-controlled DM;follow-up

mean of 3.1years in 881 surviving patients] autofluorescence at baseline was

significantly higher in patients who developed any microvascular complication,

neuropathy, or microalbuminuria. Baseline autofluorescence measurements were not

predictive of the development of retinopathy. DM duration at baseline was the

only significant predictor of this complication. The team calls for further

study and longer follow-up, but conclude that this " noninvasive and time-saving

application makes the autofluorescence reader an easy clinical tool that is

useful in the outpatient clinic in risk assessment. " .. skin autofluorescence

" seems to play an important role in certain patient groups like DM or patients

receiving hemodialysis. Skin autofluorescence is related to and predictive for

morbidity and mortality in these patient groups. "

Diabetes Care 2008;31.

2.%% MW - Elevated Uric Acid Linked to Impaired Renal Function in Type 1

Diabetes 3/26/08 - Serum uric acid concentration in the high-normal range is

associated with impaired renal function in patients with T1 and no proteinuria,

according to the results of a new study. " Early renal function decline begins

before the onset of proteinuria in patients with T1, " write the researchers " The

association of elevated serum uric acid with advanced impaired renal function

prompts an examination of its role in early renal function decline in patients

before proteinuria develops. " [364 people with T1 and normoalbuminuria orT1 with

microalbuminuria (n = 311) Mean GFR was 119 mL/minute in patients with

normoalbuminuria and 99 mL/minute in patients with microalbuminuria. Renal

function was mildly or moderately impaired (< 90 mL/minute) in 10% of those with

normoalbuminuria and in 36% of those with microalbuminuria.

Lower GFR was strongly and independently associated with higher serum uric acid

concentration and higher urinary albumin excretion rate, older age, and

antihypertensive treatment, " Follow-up studies are needed to confirm that this

level of serum uric acid is a risk factor

for early renal function decline in T1 and to determine whether its

reduction would prevent the decline. "

3.%% MedlinePlus - Once-Daily Insulin Shot Proves Effective in Study

Participants preferred it to product requiring three injections a day

Mar 27, 2008 HealthDay News) -- Researchers report that a once-daily shot of

insulin appears to control blood sugar levels in people with T2DM just as well

as injecting insulin 3 times a day. The once-a-day formulation, known as insulin

glargine (Lantus), is already on the

market, as is insulin lispro (Humalog), which is taken with meals. The new,

international study found more patient satisfaction with the glargine. " This

study just confirms that insulin is effective and there are good reasons to use

insulin if oral agents are not working, " said vice president of clinical

affairs at the ADA " It's certainly not that

one is good and one is bad. " The new study did show slight benefits for insulin

glargine in terms of patient satisfaction and low blood sugar. But the study was

funded by Lantus' maker, Sanofi Aventis, and other studies funded by makers of

other insulin formulations have found slight benefits for those products, too,

she noted.

The results are published in the March 29 edition of The Lancet.

Lantus is known as a " basal " insulin analogue, meaning it is given once a day

either in the morning or at night; it lasts for about 24 hours. Insulin lispro

is shorter-acting and is administered with meals.

4.%% MW - Diabetic Ulcer Gel Linked to Increased Cancer Deaths

March 28, 2008 - A safety review of becaplermin gel (Regranex

, & ) is being conducted after study results suggested an

increased risk for cancer-related mortality,(FDA) warned healthcare

professionals yesterday. In the study, a health insurance database was used to

identify 2 groups of diabetic patients aged 19 years and older with similar

diagnoses, drug use, and use of health services from Jan 1998 through June 2003.

One group had been prescribed becaplermin gel, and the other had not. Analysis

revealed an overall increase in the number of cancer deaths among patients who

had been prescribed the gel 3 or more times for diabetic foot and leg ulcers.

Insufficient information was available to determine whether there was an

increase in the incidence of new cancers. The findings supported those of a

long-term study completed by the manufacturer in 2001, which also showed more

cancers in patients using becaplermin compared with those who did not. While the

review is ongoing, the FDA recommends that healthcare professionals discuss the

potential risks and benefits of becaplermin gel with their patients.

Becaplermin 0.01% gel is a recombinant form of human platelet-derived growth

factor that is indicated for the treatment of lower extremity DM neuropathic

ulcers

with an adequate blood supply that extend into the subcutaneous tissue or

beyond. Adverse events associated with use of becaplermin gel should be reported

to the FDA's MedWatch reporting program 1-800-FDA-1088 fax 1-800-FDA-0178,

www.fda.gov/medwatch or by mail to 5600 Fishers Lane, Rockville, MD

20852-9787.

5.%% WebMD - New Gene Hot Spots for Type 2 Diabetes Multiple Genes Play Role in

Susceptibility to T2DM March 31, 2008 -- Researchers are six steps closer to

finding a genetic fingerprint

to identify people particularly susceptible to T2. To climb the six steps, an

international consortium of researchers crunched data

from three studies of some 2.2 million single DNA changes across the entire

genomes of more than 10,000 people, with replication testing in separate samples

of up to 54,000 people. In the end, they found 6 new genetic variations that

each increase a person's risk of T2. With these additions, there are now 16

genetic variations independently linked

to type 2 diabetes risk. None of the 16 gene variations causes DM. In fact, each

contributes only slightly . But the more of these variations researchers find,

the closer they are to finding a genetic fingerprint for diabetes risk. " By

combining information from the large number of genes now implicated in DM risk,

it may be possible to use genetic tools to identify people at unusually high or

low risk of diabetes, " study researcher D. Altshuyler, MD, PhD, of Mass General

Hospital, MIT, and Harvard says in a news release. " However, until we know

how to use this information to prompt beneficial changes in people's treatment

or lifestyle, widespread genetic testing would be premature. " Interestingly, the

genetic variant that carried the highest diabetes risk has also been found to

predispose men to prostate cancer.It's hard to know what to make of that

association -- other than the fact that this gene is also linked to low blood

sugar in fetuses and newborns. The other 5 new genes linked to T2DM risk also

offer clues to the cause of diabetes . They encode proteins that play roles in:

Disruption of the normal life cycle of cells Pancreatic cancer Cell death

Pancreatic function The development of pancreatic stem cells

" Each of these genes, therefore, provides new clues to the processes that go

wrong when DM develops, and each provides an opportunity for the generation of

new approaches for treating or preventing this condition, " The study appears in

the March 30 advance online issue of Nature Genetics. C 2008 WebMD, LLC. All

rights reserved.

6.%% MW - Diabetics' Cardiovascular Risk Similar to That of Nondiabetics With

Prior MI Reuters Health Information 2008. C 2008 Reuters Ltd. Mar 31 - DM

patients requiring glucose-lowering therapy

are as likely as nondiabetics with a history of MI to experience a major

cardiovascular event, Danish researchers report. Based on this finding, they

conclude that " requirement for glucose-lowering therapy should prompt intensive

prophylactic treatment for cardiovascular diseases. " [population-based study 3.3

million residents at least 30 years of age]. 2.2% of subjects had diabetes and

2.4% had a prior MI.

Compared with men without DM or a prior MI, those with diabetes only and those

with a prior MI only were 2.32- and 2.48-times more likely, respectively, to

experience the composite endpoint of MI, stroke, and cardiovascular death. The

corresponding hazards ratios in women were 2.48 and 2.71. No significant

difference in the risks was seen based on diabetes type, the report indicates.

While DM may have a cardiovascular risk on par with that of nondiabetics with a

prior MI, when they have an MI, " they are twice as likely to die as

non-diabetics, " . DM patients who require glucose-lowering agents should also be

given antiplatelet therapy, statins, and other medications that have been shown

to help prevent cardiovascular

events in this group, the researchers conclude. Circulation 2008.

7.%% ONTARGET: Telmisartan Shows Similar Benefit to Ramipril in High-Risk

Vascular Disease/Diabetes Patients Heartwire 2008. C 2008 Medscape Mar 31, 2008

- The angiotensin receptor blocker (ARB) telmisartan was " noninferior " to the

ACE inhibitor ramipril in patients with vascular disease or high-risk diabetes

in the landmark

ONTARGET trial. However, the combination of the two drugs was associated with

more adverse events without an increase in benefit.

The Lead investigator of the trial, Dr S Yusuf, commented: " This study is of

clinical importance because it demonstrates that telmisartan is an effective and

safe alternative to ramipril. This means both patients and physicians have

choices and can use telmisartan where appropriate with a high degree of

confidence. " In the paper, the team explains that previous studies such as HOPE

have shown that ACE inhibitors reduce cardiovascular morbidity and mortality in

patients with vascular disease or high-risk diabetes. They note that ACE

inhibitors do not block the production of all angiotensin II and have the

additional action of enhancing bradykinin, which leads to the side effects of

cough and angioedema. They therefore conducted the current study to test whether

an ARB (which blocks the effects of angiotensin II without enhancing bradykinin)

was similarly effective to

an ACE inhibitor and whether the combination of an ACE inhibitor and an ARB may

be superior. [25,620 patients with coronary heart disease or DM plus additional

risk factors; over age of 55 without heart failure; follow-up 55months. Results

showed that mean BP was lower in the telmisartan and the combination-therapy

group than in the ramipril group. At the end of the study, the primary end point

(a composite of cardiovascular death, MI, stroke, or hospitalization for heart

failure) had occurred in a similar number of patients in all three groups of

patients. Compared with the ramipril group, telmisartan patients had lower rates

of cough and angioedema and a higher rate of hypotensive symptoms, and patients

given the combination treatment had higher rates of hypotensive symptoms,

syncope, renal dysfunction, and hyperkalemia, with a trend toward an increased

risk of renal function requiring dialysis.

An accompanying editorial comments: " As the fourth and largest comparative

trial, the ONTARGET study confirms, beyond doubt, that angiotensin receptor

blockers are not better than ACE inhibitors at reducing fatal and nonfatal

cardiovascular events. " But he says the ONTARGET trial shows that telmisartan

provides a similar benefit to that of a proven ACE inhibitor, a result that was

also found with

valsartan vs captopril in the VALIANT trial in MI patients. He adds: " However,

because ARBs are more costly than ACE inhibitors and are not better tolerated

overall, their primary value is as an alternative for patients who cannot

tolerate ACE inhibitors because of cough. "

N Engl J Med 2008: 358.

8.%% MW -The Role of Incretin-Based Therapies: Reconstructing Treatment

Approaches in Type 2 Diabetes 3/25/08 The effective management of type 2

diabetes mellitus (T2DM) is a constant challenge to physicians. It is an

epidemic which places a huge burden on national economies and medical care

systems with its acute and chronic complications. The International Diabetes

Federation estimates that the global diabetic population is 246 million people

and that 7.3% of the world's population, ages 20-79, have DM. These

numbers are expected to grow significantly in the next few decades. Even with

access to numerous hypoglycemic drugs and counseling in life-style changes, it

is estimated that 2 of every 3 T2 patients are unable to reach the hemoglobin

A1c (HbA1c) target of less than 7% set by the (ADA). The availability of newer

drugs such as the incretin mimetics and the dipeptidyl peptidase-IV (DPP-4)

inhibitors has grown the therapeutic armamentarium for T2DM, providing the

possibility of further improved glycemic control that may eventually lead to a

positive impact on the seemingly inevitable complications of T2DM. The morbidity

and mortality associated with diabetic complications contribute to a large

proportion of patients with chronic illnesses. T2DM is responsible for 44% of

new cases of kidney failure diagnosed each year, cardiac disease and stroke

cause

65% of deaths amongDM patients, more than 60% of lower limb amputations occur in

people with DM, and [it] is the leading cause of blindness among adults. The

main objectives in the treatment of DM nclude prevention or slowing of disease

progression, including the prevention of microvascular and macrovascular

complications, as well as improving mortality. It is now recognized that the

onset of T2DM may occur up to 10 years prior to clinical diagnosis. Indeed, it

is postulated that nearly one third of all people with diabetes are not

yet diagnosed because of the insidious nature of the disease..It has been

demonstrated that abnormalities in insulin secretion and insulin sensitivity are

present long before T2 develops. Moreover, both insulin resistance and failing

insulin secretion are progressive over the course of many years. In summary,

the incretin mimetics have been shown to be effective in sustaining glycemic

control together with gradual but continuous reductions in body weight and

improvements in beta-cell function. In the case of exenatide [byetta], data are

now available, showing that the efficacy persists for up to 3 years. Side

effects are generally mild to moderate in severity. . there is a noticeable

increase in the number of reports of nausea, although these reports do seem to

decrease over time. Although the ADA treatment algorithm was published only

recently, the availability, safety, and proven effects of these newer agents,

the DPP-4 inhibitors and the incretin mimetics, would suggest that they should

be incorporated into a revised treatment algorithm in the near future. Both

classes represent a novel strategy for improving the imbalance of glucose

homeostasis that occurs in T2 and for restoring normal physiology. The

introduction of these new agents may have a dramatic impact and unprecedented

impact on T2DM as true disease-modifying agents, perhaps improving or preventing

complications and ultimately improving mortality as the progression of the

disease is delayed or potentially reversed.

9.%% MW - Better Diabetes Foot Care Leads to Fewer Amputations

(Reuters Health) Mar 27 - Following an initiative to provide better diabetes

foot care in the South Tees area of northeastern England, rates of

diabetes-related lower extremity amputations fell substantially. The team

identified all cases of lower extremity amputation (LEA) in the region. Of the

454 LEAs (66.3% in men) identified, 223 were related to diabetes (49.1%). Among

DM patients, LEA rates decreased from 564.3 per 100,000 persons with diabetes in

the first year to 176.0/100,000 in the fifth year. Over the same time

period, non-diabetes-related LEA rates increased from 12.3 to 22.8 per 100,000

persons without diabetes. " These diverging trends mark a significant improvement

in care for patients with diabetic foot disease as a result of better organized

diabetes care, " the team writes.

Diabetes Care 2008;31.

10.%% MW - Aerobic Exercise Boosts Peripheral Insulin Sensitivity in Type 2

Diabetics (Reuters Health) Mar 27 - The improvement in whole-body insulin

sensitivity seen in T2 diabetics who engage in aerobic exercise is due to gains

in peripheral, not hepatic, insulin sensitivity, study findings indicate.

Researchers from the depart of molecular physiology at Vanderbilt University and

Ohio State U. determined the effect of 7 days of aerobic exercise training on

peripheral and hepatic insulin sensitivity in 18 obese, mildly diabetic adults.

.. all study subjects discontinued their diabetes medications and then maintained

an isocaloric diet consisting of 50% carbohydrate, 30% fat, and 20% protein for

15 days. During the second week, 9 randomly selected subjects also walked on a

treadmill for 50 minutes daily at 70% of maximum oxygen consumption. " In

response to our 1-week exercise training protocol

that involved moderate intensity walking, there was a fairly large increase in

insulin's ability to stimulate glucose uptake by the whole body and muscle.

However, within the same time frame, the exercise training did not improve

insulin's ability to stimulate decreases in

liver glucose production. " It is likely, the researcher added, that in the

absence of caloric restriction, it takes more than a week to improve hepatic

insulin sensitivity in people with diabetes. It is also worth noting, they

said, that, despite discontinuation of DM medications, the fasting blood glucose

values did not change over the intervention

period -- so glucose metabolism can improve within one week of starting an

exercise program. " In particular, blood glucose after a meal may be improved due

to improved muscle glucose uptake, despite not showing a change in the fasting

blood glucose level, "

J Clin Endocrinol Metab 2008;93:771-778.

11.%% Dutch Program Spurs Diabetics to Seek Care for Infections

(Reuters Health) Mar 26 - A Dutch team has developed an educational program that

effectively teaches type 2 diabetics to seek healthcare for urinary tract

infections (UTIs), lower respiratory tract infections (LRTIs) and other types of

infectious conditions that require medical treatment. The program consists of a

leaflet, a Website, an initial group meeting and one-on-one consultations. The

team assigned 468 patients with T2 between the ages of 44-85 to the intervention

and 472 to a control group, and assessed the educational effects of the program

5 months later. To meet the definition of positive health-seeking behavior,

patients needed a score of at least 7 out of a possible 9 determinants. At

baseline, 28% of the intervention group and 27% of controls had a score of at

least 7. After the educational program, the corresponding rates were 53% and

32%. " Our educational program positively influenced determinants of

health-seeking behavior for common infections in patients with T2,the team

concludes. Diabetes Care 2008;31.

12.%% MW -Simvastatin and Fenofibrate Better Than Either Alone for Mixed

Dyslipidemia in Diabetics (Reuters Health) Mar 24 - Combination therapy with

simvastatin and fenofibrate is better than monotherapy with either drug for

treating mixed dyslipidemia in patients with T2DM. " I believe every diabetic

should be initially treated with a statin, with an LDL goal of at least 100 and

probably even 70 would be better, " Dr. J.B. Muhlestein told Reuters Health. " I

secondarily also look at triglycerides and HDL. I then target

additional lipid therapy based on which of these three lipid values remain the

most off-goal. " The team investigated the effects of simvastatin alone,

fenofibrate alone, and the combination of simvastatin and fenofibrate on lipid

subparticles in 498 patients with T2 without coronary heart disease. Combination

therapy reduced dense VLDL cholesterol significantly more than did fenofibrate

or simvastatin monotherapy, they found. Simvastatin lowered intermediate density

lipoprotein (IDL) cholesterol significantly more than did fenofibrate. The

percentage of LDL cholesterol pattern B constituting total LDL cholesterol was

significantly reduced by fenofibrate and by the combination, but not by

simvastatin.

Similarly, fenofibrate and the combination (but not simvastatin) significantly

increased the percentage of buoyant LDL cholesterol constituting total LDL

cholesterol. " Thus, " the investigators say, " fenofibrate and combination therapy

favored the shift from LDL cholesterol pattern B to the more buoyant, less

atherogenic LDL cholesterol. " Patients with higher triglyceride levels tended to

experience greater reductions in LDL cholesterol pattern B and dense VLDL

cholesterol with treatment, they note. " Diabetic dyslipidemia appears to be a

very important contributor to the overall

cardiovascular risk associated with DM, " Dr. Muhlestein explained. " This risk

comes from the combination of elevated LDL, elevated triglycerides, and low HDL.

Aggressive treatment of this mixed dyslipidemia may be very important in saving

the lives of our diabetic patients. " " We are now testing a possible benefit of

triple drug lipid therapy in diabetics, comparing the double combination of

simvastatin + fenofibrate with the triple combination of simvastatin + ezetimibe

+ fenofibrate, " he commented. Am J Cardiol 2008;101.

13.%% Metformin May Delay Onset of Diabetes in At-Risk Subjects

(Reuters Health) Mar 24 - In non-diabetics who are at risk for developing

diabetes, treatment with metformin leads to modest improvements in weight, lipid

profiles and fasting glucose, and substantial reductions in insulin resistance

and new-onset of DM , results of a meta-analysis indicate. A team from Stanford

University School of Medicine, pooled data from 31 trials that compared

metformin with placebo or no treatment in 4570 adults at risk for diabetes

followed for 8267 patient-years. Metformin treatment, compared with placebo or

no treatment, reduced body mass index

by 5.3%, fasting glucose by 4.5%, fasting insulin by 14.4%, and calculated

insulin resistance by 22.6%, according to the report. Metformin treatment also

reduced triglycerides and LDL cholesterol by 5.3% and 5.6%, respectively, and

increased HDL cholesterol by 5.0% compared with placebo or no treatment. " The

incidence of new-onset diabetes was reduced by 40% (odds ratio, 0.6), with an

absolute risk reduction of 6%, during a mean trial duration of 1.8 years, " the

investigators found. They think metformin could be added to diet and exercise if

these lifestyle modifications alone are not sufficient to reduce the risk of DM

in at-risk individuals.

" Future long-term trials will be needed to show that the metabolic benefits of

metformin treatment result in a reduction in cardiovascular morbidity and

mortality, " Am J Med 2008;121.

14.%% http://www.ophsource.org/ Ophthalmology Volume 115,Issue 4 (April 2008)

A Randomized, Double-Masked, Placebo-Controlled Clinical Trial of Multivitamin

Supplementation for Age-Related Lens Opacities

: Clinical Trial of Nutritional Supplements and Age-Related Cataract Report No.

3 Objective - To evaluate the effect of a multivitamin/ mineral supplement on

development or progression of age-related lens opacities. Randomized,

double-masked, single center, placebo-controlled clinical trial. [1020

participants, 55 to 75 years old and with early or no cataract, randomly

assigned to a daily tablet of a multivitamin/mineral formulation or a placebo.

Participants were observed for an average of 9.0 years. There was a decrease in

total lens events in participants assigned to the multivitamin/mineral

formulation compared with those assigned to the placebo Conclusions - Lens

events were less common in participants who took the multivitamin/mineral

formulation, but treatment had opposite effects on the development or

progression of nuclear and PSC opacities, the 2 most visually important opacity

subtypes.

15.%% Ophthalmology Volume 115,Issue 4 (April 2008)

Vitreous Levels of Reactive Oxygen Species in Proliferative Diabetic Retinopathy

Objective - To investigate vitreous levels of reactive oxygen species (ROS) in

patients with proliferative diabetic retinopathy (PDR) and analyze ROS levels

among different groups of PDR patients. Retrospective case-control study. [39

eyes of 39 patients with PDR and 16 eyes of 16 non-PDR patients (control group)

that underwent primary vitrectomy for complications of PDR and other conditions

(control group), with a follow-up time = 12 months. Conclusions - Reactive

oxygen species levels were significantly elevated in the vitreous fluid of PDR

patients, and patients with a more advanced clinical PDR appearance had higher

ROS levels. These findings suggest an association between ROS and the

pathogenesis of PDR. Reactive oxygen species might be correlated with PDR

severity.

Abbreviations: DM - diabetes Mellitus;T1DM - type 1 diabetes mellitus T2DM -

type 2; ADA - Amer Diabetes Asso; AFB - Amer Foundation for the Blind BP -

blood pressure;HTN - hypertension; MW Medscape Web MD; FDA Federal Drug

Administration; NIH - National Institutes of Health; VA - Veterans

Administration. MNTD- Medical News Today Definitions - Dorlands 31st Ed and

Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic educator.

Reports are excerpted unless otherwise noted. This project is done as a courtesy

to the blind/visually impaired and diabetic communities. Dawn Wilcox Coordinator

The Health Library at Vista Center contact above e-mail or thl@...

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