Maja Radman

Assessing glycemia in type 1 diabetic patients using a microdialysis system for continuous glucose monitoring

BACKGROUND Continuous glucose monitoring systems can monitor moment-to-moment changes in blood glucose concentration, which cannot be detected by intermittent self-monitoring. Continuing monitoring systems may lead to improved glycemic control. We evaluated a microdialysis technique for improving glycemic control in type 1 diabetes patients treated by different means of basal insulin substitution. PATIENTS AND METHODS Fifty-two type 1 diabetic patients on twice daily NPH and pre-meal aspart insulin were randomized in two groups: the continuation of NPH (n=26) (group 1) or once daily glargine (n=26) (group 2). 48-hour GlucoDay registrations were started at the beginning and after 4 months. RESULTS At baseline, time spent in the euglycemic range (glucose between 3.9 and 8.0 mmol/L) was 37.96±6.81% for the NPH group and 35.83±6.24% for the glargine group. At endpoint, time in the euglycemic range increased in both groups (51.02±7.22% and 57.29±10.27%, P<0.001 vs. before treatment for both groups). Time spent in the hypoglycemic range (glucose <3.9 mmol/L) was 9.98±2.57% for the first group and 10.24±3.55% for the second group at baseline. At endpoint, time in the hypoglycemic range decreased in both groups (8.00±2.13% and 6.59±2.04%, P<0.001 vs. before treatment for both groups). CONCLUSION The analysis of the GlucoDay data gave us information about glycemia other than HbA1c and self-monitoring of blood glucose, such us a peakless activity profile and the lower percentage of time spent in the hypoglycemic range in the glargine-treated group.

Influence of hypertension and type 2 diabetes mellitus on cerebrovascular reactivity in diabetics with retinopathy.

BACKGROUND AND OBJECTIVES Cerebrovascular reactivity (CVR) provides information on the intracerebral arterioles capacity to react to vasodilatory stimuli. The current study aimed to investigate the influence of hypertension and type 2 diabetes mellitus on CVR in diabetics with retinopathy. DESIGN AND SETTING Retrospective analysis of data prospectively collected over a 1-year period. SUBJECTS AND METHODS Subjects were classified into four groups each comprised of 30 participants: diabetic retinopathy with hypertension (DRH), diabetic retinopathy without hypertension (DR), hypertension without diabetes mellitus (H), and healthy controls without diabetes and hypertension (C). CVR was estimated in relation to the increase in the mean flow velocity compared with the basal velocity in both middle cerebral arteries during hypercapnia. RESULTS In the DRH group, the mean (SD) increase in CVR was 8.8 (2.49) cm/s, in the H group 14.4 (2.59) cm/s and in the DR group 9.7 (2.97) cm/s. The analysis of variance showed significant differences among the groups in blood flow velocity after a breath-holding test (F=89.83; df=3.116; P<.001). CONCLUSIONS Diabetes mellitus influences CVR more than hypertension.

Reactive macrophage activation syndrome in a patient with parvovirus B19 infection, lymphocytic lichenoid vasculitis, urticaria and angioedema

47-year-old woman had a history of episodic acute intermittent angioedema and urticaria with moderate pruritus for one month. She was on 10 mg of loratadine daily. She had a fever of 39oC, arthralgia, fatigue, and angioedema of the upper respiratory tract. Laboratory results are shown in [Table 1]. She had elevated IgE (206 kU/L). The immunoassay for C1-esterase inhibitor was normal. She was treated with H1- and H2-blocking antihistamines, and methylprednisolone intravenously (1 mg/kg/day). Culture results and viral titers were negative except for a high positive titer of specific IgG antibody to parvovirus B19 of 11.1 (positive titer >1). On the third week of hospitalization, she deteriorated rapidly and developed a macular rash on the trunk and extremities with generalised lymphadenpathy, liver dysfunction and disseminated intravascular coagulopathy (DIC) [Figure 1]. A skin biopsy specimen was compatible with lymphocytic lichenoid vasculitis. An inflammatory pattern centered on the basal layer of the epidermis and upper dermis in a dense band-like distribution. Direct immunofluorescence showed no IgG, IgA, IgM, C3, C1q and fibrinogen deposits. A bone marrow aspirate showed hemophagocytosis [Figure 2]. Parvovirus B19 DNA was detected by the polymerase chain reaction (PCR) in bone marrow [Figure 3]. Macrophage activation syndrome was confirmed. The patient was treated with methylprednisolone 250 mg/day intravenously and intravenous immunoglobulin (IVIG) 0.55 g/kg BW/day for five consecutive days, followed by methylprednisolone 1 mg/kg daily. Fresh frozen plasma and enoxaparin were administered. Two days after treatment, she improved. Monthly infusions of IVIG were continued for 6 months. Corticosteroids were tapered gradually to 8 mg of methylprednisolone daily. On periodic follow-up, the patient was quite well without episodes of angioedema and no new skin lesions were seen. Our patient met all criteria for reactive macrophage activation syndrome (rMAS) outlined by Imashuku. [1] Acute parvovirus B19 infection can be diagnosed by demonstrating a four-fold rise in serum B19-specific IgG antibody titers, as in our case. B19 specific DNA or antigens can be detected for months or even years after infection. [2], [3] We speculate that the presence of acute parvovirus B19 infection was a trigger for rMAS. [4] Lymphocytic vasculitis is a reactive process. [5], [6] Purpura pigmentosa chronica, fixed drug eruption, urticarial vasculitis, allergic vasculitis, and the vasculitis of Sjogren syndrome are known to have lymphocytic vasculitis. We conclude that rMAS might represent a subgroup of patients with systemic inflammatory response amenable to IVIG treatment. Given early, IVIG may interrupt the processes that lead to macrophage overactivation.