many articles

[Guest guest]

1.%% M 8/30 In DM, Any Protein in Urine May Signal Heart Risk

[1200pts;9yrs] The team found that any amount of measurable albumin [a

simple protein] excretion in the urine was associated with significant heart

risks in people with T2. However, the study did not prove cause & effect.

There was no link between albumin excretion levels & heart risks in a

subgroup taking drugs for high BP (ACE inhibitors) which suggests that these

drugs may help protect the hearts of DM pts with albumin in the urine &

those with normal albumin levels. AmSociety of Nephrology, news release,

Aug. 30,

2.%% Oph 119,9 Sep 2012 Longer Axial Length Is Protective of Diabetic

Retinopathy & DME Terms: Axial length (AL).. [630 eyes] Eyes with longer AL

were less likely to have DR & a lesser risk of mild & moderate but not

severe DME.

3.%% ADA 8/31 (HealthDay News) -- Using a glycated hemoglobin (HbA1c)

threshold of =6.5 % is a specific but not sensitive early indicator of T1DM

K Vehik & team studied the use of HbA1c as an alternative criterion for

impaired glucose tolerance (IGT) for T1 in high-risk pts younger than 21yrs.

[2062pts] Across the 4 studies, the positive predictive value of HbA1c

varied from 50 to 94%. " Redefining the HbA1c threshold is recommended if

used as an alternative criterion in diagnosing T1. "

4.%%SciAm 9/4 DM, Insulin & Helicobacter Pylori (HP) Eradication

[601,441pts] HP erad- defined as [series of drugs] taken 7-14days. Pts with

T2 have a significantly higher risk of gastric cancer mortality. HP

infection is the most important etiology for G cancer & its eradication can

significantly reduce G cancer.. HP erad rates in pts with T1 & T2 are 62% &

50% respectively, which are much lower than the recom-mended 80%. Also

reinfection rate is higher in T1 & it may deteriorate metabolic control,

leading to higher insulin dosage & development of DM complications.

Conclusions -This study shows a significantly higher incidence of HP

eradication in pts with T2 & in insulin users among the DM pts. In addition,

lower socioeconomic status & use of calcium channel blockers consistently

show a higher rate of HP erad but the uses of oral anti-diabetic agents do

not. The underlying causes for the link between T2 & the use of meds & HP

eradication require further investigation. BMC Gastroenterol. 2012;12(46)

5. %% MPD 9/5 Blood Sugar Levels Linked to Brain Loss The hippocampus, the

part of the brain involved in memory forming & the amygdala, a set of

neurons located deep in the brain's temporal lobe used in the processing of

emotions, have atrophies associated with higher fasting glucose levels. T2DM

has increasingly been recognized as a risk factor for loss of cognitive

ability with aging. The Australian team measured fasting glucose & did MRI

scans of the amygdala & hippocampus in 249 cognitively healthy pts av age

63. After an average of 4 yrs, intracranial volumes had fallen by 2.7%, but

only a small percentage of overall difference in intracranial volume could

explain the loss of volume in the hippocampus & amygdala. In contrast, after

controlling for age, sex, BMI, BP, and alcohol and tobacco use, glucose

levels accounted for 6-10% of atrophy in the amygdala & hippocampus, a

change of about 2% each year. This study indicated that control of glucose

levels modulates inflammatory responses & that pts with T2 are more likely

to be exposed to longer lasting & stronger inflammatory states. T2 also is

characterized by various abnormalities of the coagulation system,that can

raise the risk for cardiovascular events. These abnormalities also have been

caused by uncontrolled glucose in pts with pre-DM & in healthy volunteers

following experimentally induced hyperglycemia. An additional contributor is

psychological stress, which influences glucose levels. There is now strong

evidence that chronic increases in inflammatory responses, high stress

hormone levels, & abnormal blood coagulation activation are linked to

cerebral changes & associated decreases in cognitive function. Ca Source

reference: Cherbuin N, et al Neurology 2012;

6.%% ADA 9/6 Insulin Glargine Fails to Halt Atherosclerosis Progression in

pts with DM or pre-DM at high CV risk [1184;6.2yrs] rates of CV death,

nonfatal MI or stroke were similar between the insulin glargine & standard

care groups (18.6 vs. 16.9%) the results of GRACE are concordant with those

reported from the larger ORIGIN trial in which glargine reduced the risk of

developing T2 by 28% in pts with pre-DM, but had a neutral effect on CV

outcomes. Omega-3 fatty acids reduced triglyceride levels, but also failed

to reduce the rate of CV (N Engl J Med 2012;367).

7.%% ADA 9/4 Mobile app to support T1 patients The Lilly Glucagon mobile app

is an interactive tool designed to teach caregivers how to use severe

hypoglycemia treatment Glucagon (1-mg) for injection through simulated

practice..app is available on the iTunes store as a free download for iPhone

or iPad mobile devices.

8.%% M 9/10 Increased Mortality of Patients With DM Reporting Severe

Hypoglycemia [1020adults;5yrs;T1 & T2] retrospective study. Mild hypoglycemia

was defined as symptoms managed without assistance & severe hypo as symptoms

requiring external assistance. Conclusion, hypoglycemia is common in pts

with T1 & T2, increasing in prevalence with disease duration & higher HbA1c.

Pt-reported severe hypo is associated with 3.4-fold increase in 5-year

mortality. Self-report of severe hypoglycemia is therefore an important

prognostic indicator that should be included in the clinical assessment of

each pt with DM. Diabetes Care. 2012;35(9)

9.%% M 9/12 Study looked at metabolic activation of the innate immune system

governed by interleukin(IL)-1-? which contributes to cell failure in T2.

Gevokizumab is a monoclonal anti-IL-1? antibody. The study evaluated the

safety & biological activity of Gev. in pts with T2. RCT study [98pts]

randomly assigned to Gev or placebo] Results showed that the drug was well

tolerated with no serious adverse events. There was 1 hypo event which

resulted in an insulin Rx. Conclusion this new antibody improved glycemia,

via restored insulin production & it reduced inflammation in pts with T2.

This therapeutic agent may be able to be used on a once-every-month or

longer schedule. Ca Diabetes Care 2012; 35(8)

10.%% M 9/12 Scientists ID Gene for Insulin Sensitivity An Oxford team has

discovered the single gene that causes insulin sensitivity. This term refers

to how well the body uses the hormone insulin, to regulate glucose (sugar)

in the blood. The opposite is insulin resistance [iR], which means the body

does not use insulin properly. IR is a major feature of T2DM. The insulin-

producing cells in the pancreas may be working hard & pumping out lots of

insulin, but the body's cells no longer respond. Study leader Dr. A Gloyn

said finding a genetic cause of insulin sensitivity, gives a new window on

the biological processes involved. This understanding could be important in

developing new drugs that restore insulin sensitivity in T2. [15contrls & 15

pts w Cowden syn caused by mutations in the PTEN gene]. " PTEN is a gene that

is heavily involved in processes for both cell growth & metabolism, " first

author A Pal said. Results --pts with Cowden syndrome had significantly

higher insulin sensitivity as a result of heightened activity in the

insulin-signaling pathway. After expanding the comparison to more than 2,000

pts, the team confirmed that people with Cowden syn had more fat & higher

rates of obesity. This was a surprise since normally insulin sensitivity

goes with being lean. EX & a healthy diet remain the best ways to avoid DM

the team stressed. If left untreated, the disease can lead to heart disease,

stroke, nerve damage & blindness. Ca-dw N Eng J Med 9/13

11.%% M 9/12 Hispanics May Face Higher Risk for T2 Hispanics are more likely

to store fat in their pancreas, but less likely to be able to produce more

insulin to compensate for this excess fat, putting them at higher risk for

T2 " Not all pts who are overweight or obese & who have insulin resistance go

on to develop DM " R Bergman author, said " If we can determine who is most

likely to develop DM & why, then we can make strides toward preventing it in

individuals. " The team used a noninvasive medical imaging technique -

magnetic resonance spectroscopy [MRS ] to measure the amount of fat in the

organs of white, black & Hispanic pts all of whom were equally over-weight &

shared many of the symptoms of pred-DM. 26 mil in the US have DM & 79 mil

more are prediabetic. DM is the 7th-leading cause of death in the US & a

major cause of heart disease & stroke. Diab Care 9/17/12

12.%% JH 9/27 How to Get More Accurate Finger Stick Readings

Clean hands may lead to a more reliable blood glucose [bG] reading 123 pts w

DM underwent G testing on 2 drops of blood in four scenarios. (1) without

washing their hands (2) after handling fruit (3) after handling fruit, then

washing their hands (4) with pressure put on a freshly washed finger.

Results were compared with a control measurement of the average reading for

the first 2 drops after wash-ing hands. Not washing hands led to a 10% or

more difference in G level 11% of pts in the first drop & 4% in the second

drop vs controls. Handling fruit & not washing hands led to 10% or higher G

concen-trations in the first drop in 88% of pts but in only 11% on second

drop vs controls. Squeezing a freshly washed finger also caused unreli-able

readings. Our advice. Before testing your BG, it's best to wash your hands

with soap & water & dry them. Use the first drop of blood but don't squeeze

your finger to make the drop appear. If you can't wash your hands first &

you haven't been handling sugary products, it's okay to test the second drop

of blood after wiping away the first drop. study reported in DiabCare vol

34,

13.%%ADA 9/11 New Insulin Degludec-Aspart Combo May Offer Advantages T1

diabetics who took a new combo formulation of insulins degludec & aspart

(IDegAsp) [Ryzodeg] at their main meal, with insulin aspart (IAsp) at other

meals, had better nocturnal glycemic control than pts on basal-bolus therapy

with insulin detemir (IDet) & IAsp. [548pts;26wks] random assigment to Rx.

The nocturnal hypo rate was 37% lower with IDegAsp than Idet. There were

fewer daily injections with IDegAsp (3 vs 4-5) & the total insulin dose was

13% lower. However, weight gain was 1 kg greater. Dr.Hirsch added, " We can't

comment how this coformulation would perform with tighter levels of glucose

control & A1C less than 7%. Nevertheless, for some T1 pts who may do better

with a [combo as above] the same benefit of reduced nocturnal hypo can be

expected. " Novo-Nordisk funded the study. Diabetes Care 2012.

14.%% MPD 9/17 Gastric Bypass Not Best for Weight Loss? A rela-tively rarely

used bariatric procedure (duodenal switch) resulted in better control of

weight & comorbidities than the gold standard gastric bypass. However DS

surgery is associated wtih higher early risks, including infection & the

need for reoperation, compared with gastric bypass. Nonetheless, the team

concluded biliopancreatic diversion with DS may be a useful alternative to

gastric bypass. Data from 1,545 DS pts & 77,406 w gastric bypass " further

studies of this procedure to determine the optimal pt selection, technique,

& longer -term risks vs outcomes are warranted. " DW, et al Arch Surg

2012;147(9)

15.%% ADA 9/17 White Matter Structural Changes ID'd in Children With T1DM

Children with T1 have significant structural differences in the white matter

of their brain compared to healthy children, which correlates with

hemoglobin A1c(HbA1c) values. To examine clinical correlates of cognitive

abilities & white matter microstructural changes in [this group] T Ay & team

Stanford U School Med used diffusion tensor imaging (DTI) scans &

neurocognitive testing [22pts; age 3-10yrs;14ctrls] children with T1 had

significantly lower axial diffusivity (AD) values in the temporal & parietal

lobe regions, vs that of healthy controls. There were no significant

dirrerences between the grps in fractional anisotropy & radial diffusivity

(RD). There was a significant, positive correlation between time-weighted

HbA1c & RD within the DM group. A higher, time-weighted HbA1c value also

correlated with reduced overall intellectual functioning. In addition, white

matter structural differences (as measured by RD) were signifi-cantly

correlated with their HbA1c values. CA Sept. 10 in Diab Care

16.%% Diabetes raises risk of UTIs Patients with T2DM have a 60% increased

risk of developing a UTI, Urinary Tract Infection, compared with those

without DM, concludes new research in UK. [135,000pts; equal # cntrls;] the

adjusted 2year risk of UTI for all pts with DM was 61% higher than matched

controls. The absolute incidence of UTI among pts with DM was 46.9 per 1,000

person years, vs 29.9/1,000 person years in pts without DM. Results confirm

that pts with DM are at an increased risk of developing UTIs across all age

categories. CA J DiabComplications, online 13 Aug 2012

17.%% NatRevEndo Oct2012 Metabolic neuroimaging of the brain in DM &

hypoglycaemia - Functional neuroimaging techniques can be used to study

changes in regional brain activation, using changes in markers such as

regional cerebral perfusion & rates of glucose uptake or metabolism. These

approaches are shedding new light on 2 major health problems: the increasing

burden of T2 driven by the rising prevalence of insulin resistance & obesity

& recurrent intract-able problematic hypoglycaemia. Some pts with DM lose

awareness of being hypoglycaemic, which puts them at risk of severe hypo as

they are unlikely to take action to prevent the condition worsening.

Involvement of cortico-limbic brain, the hypothalamus & centers serving

higher executive functions has been shown in both situations & has

implications for therapy. Understanding these dysregulations could enable

the development of new interventions. Yee-Seun Cheah et al;

18.%% ADA 9/26 3 Drugs Similar in Efficacy for Neuropathic Pain in Diabetes

In the treatment of patients with chronic diabetic peripheral neuropathic

pain (DPNP), there are no significant differences in pain-relief efficacy

between amitriptyline, duloxetine, and pregabalin; however, pregabalin

improves sleep continuity and duloxetine improves daytime functioning. J

Boyle & team in UK conducted a randomized, double-blind, parallel-group

study [83 T1 & 2 pts w DPNP] The team found that all 3 meds improved pain

compared with placebo

but no statistically significant between-group difference was seen.

Pregabalin was associated with improved sleep continuity, while duloxetine

increased wake & reduced total sleep time. Despite its negative effect on

sleep, duloxetine improved central nervous system arousal and performance on

sensory motor tasks. Pregabalin was associated with a significantly higher

number of adverse events compared with the other drugs. In this short,

28-day dosing study, there was no evidence of improved quality of life.

19.%% M 9/25 How to Use New T2DM Diabetes Guidelines ADA/EASD Position

Statement 'Translated' for Clinicians Anne s, MD, CDE

Director Clinical Diabetes Programs at USC was part of the committee who

wrote the position statement. The first big position addressed was

lifestyle. Dr. P thinks that lifestyle is a cornerstone to DM care. Part of

lifestyle is putting in place a plan for EX, & if needed, a plan for weight

loss. Beyond weight loss there is always a need for some types of

medication. In the position statement, metformin was the first med named.

Metformin helps in nearly every facet of the T2 syndrome. It lowers BS

levels, & even helps reduce cardiovascular risk. However many pts experience

gastrointestinal side effects which limit its use. Dr. P states that she

normally starts a pt on a low dose & advances slowly to 50 mg for 2 wks, 100

mg for the next 2 wks. Another choice mentioned in the clinician's statement

is a sulfonylurea agent (1), a DPP-4 inhibitor (2), or a glucagon-like

peptide-1 GLP-1 receptor agonist(3), insulin(4), or a thiazolidine-dione(5)

[TZD] . For all of these agents, Dr.s, uses 2 different criteria. If

the main goal is to lose weight the choice would be a GLP-1 receptor

agonist. When it comes to maintaining wt & avoiding hypo, either the DPP-4

inhibitor or the GLP-1 receptor agonist will be effective. A DPP-4 inhibitor

is a little easier because it is in pill form rather than injection & has

very few side effects. If a pt's A1c is 7.5% & they want to get it below 7%,

then adding a DPP-4 inhibitor makes a lot of sense. In regards to cost, both

are expensive & have been on the market a relatively short time so we don't

have data on long-term follow-up.

Moving on to other choices, there are sulfonylurea agents. They have been

around a long time. They are associated with reduction in both micro- &

macro-vascular events. She writes about these agents with the caveats that

they have been connected with progressive beta-cell failure. The beauty of

the sulfony agents is not only that they lower BS levels, but they are very

inexpensive & have a long- term history. These agents are useful in pts who

are very hyperglycemic or when the cost of some of these other agents is

prohibitive. TZDs (5) help preserve beta-cell function & Dr. s states

she tends to use them in a very low dosage. She sees a marked improvement in

blood glucose levels.. They don't cause hypo, but need to be balanced with

the risk for weight gain & fluid retention. In the US, the TZDs remain

expensive. This drug can be assoc with osteoporosis, macular edema, &

congestive heart failure. ..using a lower dose seems to produce fewer side

effects. You can add insulin at this point, Dr. P s states she may add basal

insulin to metformin. You can add almost any overnight insulin to get the

fasting blood sugar down & then continue the metformin as an oral agent.

The next treatment step involves more complicated math because you want to

add drugs that make sense with the drugs that the pt is already taking. Dr.

P tends use lower doses of pioglitazone & sulfony agents, keeping the pt on

the 2 drugs they used initially. She tends to take away the sulfonylurea

agent but adds mealtime insulin..for the biggest meal. Additionally She

gives her pts the option of bariatric surgery, which fits in as an important

way to get pts to target on less medication. We now have enough tools, to

get patients to target BS levels. At the same time, they need to pay

attention to treating their lipids, as well as their BP, to create a

combination that hopefully will maximize lives & their overall outcomes. CA

%% Abbreviations-acronyms fup-follow up; pt - patient/participant ;

DM - diabetes Mellitus; T1- type 1 DM;T1A -autoimmune T1; T2 - type 2; DME -

diabetic macular edema;DR - DM retinopathy; BS/BG- blood sugar/glucose;

HA1C, glycated hemoglobin A1C; BP -blood pressure; CVD - cardio-vascular

disease; IR- insulin resistance; OCT-optical coherence tomography; BCVA -

best corrected visual acuity; RYGB- Roux-en-Y gastric bypass; RCT

-Randomized controlled trial; ADA - Am Diab Ass;J- Joslin DMCenter; M-

Medscape Web MD; MA- Medline Abstract, MP- Medline Plus; MPD - Med Page

Today; NEI - Nat Eye Institute;SciA-Scientific Amer. Definitions via online

Medical dictionaries. Disclaimer, I am a BSN RN but not a diabetic or

diabetic educator. Assistant Editor: Cam Acker, 50yr DM survivor. Reports

excerpted unless otherwise noted. [translations/explanations by thl] This

project is done as a courtesy to the blind/visually impaired & diabetic

communities. Dawn Wilcox RN BSN Coordinator The Health Library at Vista

Center; an affiliate of the Stanford Hospital Health Library. contact above

e-mail or thl@...