Elliot J. Rayfield

Infection and diabetes: The case for glucose control☆

This review summarizes data concerning the host resistance to infection in diabetes and the influence of an acute infection upon the endocrinologic-metabolite status of the diabetic patient. While it is well known that acute infections lead to difficulty in controlling blood sugar levels and the infection is the most frequently documented cause of ketoacidosis, controversy persists as to whether or not patients with diabetes mellitus are more susceptible to infection than age- and sex-matched nondiabetic control subjects. Our data obtained from the charts of 241 diabetic patients who were being followed as outpatients show a striking direct correlation between the overall prevalence of infection (p less than 0.001) and the mean plasma glucose levels (representing three or more fasting glucose determinations taken at times when no evidence of infection existed). There is a significant diminution in intracellular bactericidal activity of leukocytes with Staphylococcus aureus and Escherichia coli in subjects with poorly controlled diabetes in comparison with the control group. Serum opsonic activity for both Staph. Aureus and E. coli were significantly lower than in the control subjects. Taken together, the results from published reports as well as our data suggest to us that good control of blood sugar in diabetic patients is a desirable goal in the prevention of certain infections (Candida vaginitis, for example) and to ensure maintenance of normal host defense mechanisms that determine resistance and response to infection.

Inflammatory mediators are induced by dietary glycotoxins, a major risk factor for diabetic angiopathy

Diet is a major environmental source of proinflammatory AGEs (heat-generated advanced glycation end products); its impact in humans remains unclear. We explored the effects of two equivalent diets, one regular (high AGE, H-AGE) and the other with 5-fold lower AGE (L-AGE) content on inflammatory mediators of 24 diabetic subjects: 11 in a 2-week crossover and 13 in a 6-week study. After 2 weeks on H-AGE, serum AGEs increased by 64.5% (P = 0.02) and on L-AGE decreased by 30% (P = 0.02). The mononuclear cell tumor necrosis factor-α/β-actin mRNA ratio was 1.4 ± 0.5 on H-AGE and 0.9 ± 0.5 on L-AGE (P = 0.05), whereas serum vascular adhesion molecule-1 was 1,108 ± 429 and 698 ± 347 ng/ml (P = 0.01) on L- and H-AGE, respectively. After 6 weeks, peripheral blood mononuclear cell tumor necrosis factor-α rose by 86.3% (P = 0.006) and declined by 20% (P, not significant) on H- or L-AGE diet, respectively; C-reactive protein increased by 35% on H-AGE and decreased by 20% on L-AGE (P = 0.014), and vascular adhesion molecule-1 declined by 20% on L-AGE (P < 0.01) and increased by 4% on H-AGE. Serum AGEs were increased by 28.2% on H-AGE (P = 0.06) and reduced by 40% on L-AGE (P = 0.02), whereas AGE low density lipoprotein was increased by 32% on H-AGE and reduced by 33% on L-AGE diet (P < 0.05). Thus in diabetes, environmental (dietary) AGEs promote inflammatory mediators, leading to tissue injury. Restriction of dietary AGEs suppresses these effects.

Patterns of foot examination in a diabetes clinic

Peripheral vascular disease is a well-known source of morbidity and potential mortality in diabetic patients. Sixty-five subjects with diabetes were studied in order to describe the contributions of the patient, the physician, and the health care system to the performance of a preventive foot examination. The incidences of foot examination on the day of study (12.3 percent) and during the previous year (49.2 percent) were similar to those found by other investigators. The feet of patients at higher risk for limb amputation were not examined with greater frequency at the clinic, although such patients were more often referred to a podiatrist. The most significant determinants of physician foot examination were patient recall of foot-related education received at the clinic and inter-physician variability. These data suggest that the patient, physician, and clinic routine all play an important role in the success of a foot screening program for patients with diabetes.

Disopyramide (Norpace®)-induced hypoglycemia

Disopyramide (Norpace) is a recently released antiarrhythmic agent with quinidine-like actions, but structurally unique. We describe a patient in whom impressive hypoglycemia developed following treatment with this agent. Blood glucose levels returned to normal after cessation of therapy, but dropped again following rechallenge with the drug. The pathogenesis of the hypoglycemia was investigated by assessment of serum insulin, plasma glucagon and serum alanine levels during disopyramide rechallenge. Clinicians should be aware of fasting hypoglycemia as an unusual but potentially serious complication of disopyramide therapy.

Diabetes mellitus and male sexual function: a controlled study.

SummaryThere is an extensive clinical literature on the erectile disorders of diabetic men but a paucity of controlled studies that have taken into account the effects of age, concurrent illnesses and medication on sexual function. This investigation was carried out on 40 diabetic men free from other illness or drugs that could affect sexual capacity and 40 age-matched healthy control subjects. Each subject and his female partner underwent semistructured interviews and the men had comprehensive medical evaluations and polygraphic assessment of sleep and nocturnal penile tumescence in the sleep laboratory during three nights. In comparison to control subjects, diabetic patients reported significant decreases in sexual desire, subjective arousal, erectile capacity, coital frequency and sexual satisfaction. The diabetic group also had significant decrements in duration of rapid eye movement sleep and in frequency, duration and degree of nocturnal penile tumescent episodes. There were no differences between Type 1 (insulin-dependent) and Type 2 (non-insulin dependent) diabetic patients in prevalence of sexual problems or in nocturnal tumescent measures. Significant relations were observed between lack of metabolic control, diabetic complications and impaired nocturnal tumescence. Sexually non-dysfunctional diabetic men had significant nocturnal penile tumescence abnormalities. Diabetic men without coital failures may have a subclinical impairment in erectile function which, although of not significant magnitude to interfere with penetration, is reflected in nocturnal penile tumescent measures. This result raises a note of caution in the interpretation of the nocturnal penile tumescence test for the differential diagnosis of diabetic erectile impotence.

The benefits of tight glycemic control in type 2 diabetes mellitus.

Type 2 diabetes mellitus (DM) is associated with significantly increased risk of microvascular and macrovascular disease. Although most studies have focused on the microvascular complications of diabetes (eg, nephropathy, neuropathy, retinopathy), most patients with type 2 DM die from causes that are related to macrovascular disease (eg, myocardial infarction). Poor glycemic control increases the risk of future cardiovascular events, and prospective studies of patients with type 1 and type 2 DM have demonstrated that the incidence of vascular complications is reduced by lifestyle modifications or medications that reduce blood glucose concentrations.

Diabetes, sleep disorders, and male sexual function

The prevalence and role of sleep disorders in the sexual problems of diabetic patients remain unexplored. This study was conducted on 40 diabetic men carefully screened to exclude the confounding effects of other medical illnesses or drugs likely to impair sexual function and 40 age-matched healthy volunteers. They underwent an extensive psychosexual interview, medical and psychiatric evaluations, and three recorded nights in a sleep laboratory. Electroencephalogram, eye movements, muscle tone, and nocturnal penile tumescence were monitored continuously. Respiratory airflow and bilateral anterior tibialis recordings were obtained during the first sleep session. Diabetic men had significantly higher prevalences of respiratory and periodic leg movement disturbances during sleep. There was clinical, although not nocturnal penile tumescence, evidence suggesting that respiratory abnormalities during sleep are associated with erectile difficulties in diabetic men. Future studies should include blood oxygenation and respiratory effort measures to clarify the significance of sleep-related airflow disturbances in diabetic patients.

An Analysis of the HumaPen® Luxura™ HD Pen: What is the Role of 0.5-Unit Insulin Dosing?

The HumaPen® Luxura™ HD is an insulin pen device that has the ability to deliver insulin in half-unit increments. This study demonstrates the precision of this pen device using a computer-controlled dose accuracy glide force system. Although one other half-unit pen device is currently on the market, we are not aware of any studies using a similar methodology to verify its precision and accuracy. Clinical experience in treating a select group of adults with diabetes demonstrates the need for such a device. Although there are no outcome studies, this device should help to improve glycemic control and reduce hypoglycemia in such patients. We believe a half-unit insulin pen device is beneficial to more than just the pediatric population, and therefore, this device represents an improvement in present technology.