Marios C. Balodimos

Ruby-laser photocoagulation of early diabetic neovascular retinopathy: preliminary report of a long-term controlled study.

Between February 1967 and April 1969, 329 patients with various degrees of diabetic proliferating retinopathy have been treated by a circumferential ruby laser photocoagulation technique. Of these, 178 patients represent controls in which both eyes have equal degree of neovascular retinal disease in each eye on the basis of funduscopy, photography, and fluorescein angiography. One eye is treated, the opposite serving as a control. Seventy-two of these control patients had early neovascular retinopathy, have one or more years of follow-up, and are presented herein as a preliminary report of a detailed ongoing control study. Eighty percent of treated eyes have shown a definite improvement to a lesser stage of neovascular retinopathy. Fifty-four percent have had complete disappearance of neovascularization. All untreated controls have remained unchanged or have worsened.

Personality patterns in patients with diabetes mellitus of long duration.

One hundred and twelve patients with diabetes for twenty-five to forty-eight years were studied with the Minnesota Multiphasic Personality Inventory. Of these, sixty-seven had been awarded the Quarter Century Victory Medal, having been found free of vascular complications after twenty-five or more years of diabetes. The personality inventory disclosed statistically significant differences between medal and nonmedal patients in three of the thirteen scales, and three other scales approached significance. When divided as to sex, different personality patterns characterized the groups but in both sexes nonmedal patients had significantly higher hypochondriasis scores. When depression, a frequently elevated score, was excluded, significantly more nonmedal patients had other abnormal scale scores (above 2 standard deviations). The differences in scores between medal and nonmedal patients warrant early personality screening and appropriate therapy to help the adaptation process of the person with diabetes.

Nine years' experience with tolbutamide in the treatment of diabetes☆

Abstract Experience with tolbutamide in the treatment of 3,387 selected patients for periods up to 9 years has been presented. These included 526 with “primary” failures and 202 with “indeterminate” failures; 104 other patients received tolbutamide in combination with other hypoglycemic agents. The remaining 2,555 patients achieved satisfactory (good or fair) control for at least 1 month. Of these, 2,056 had continuously satisfactory control throughout the period of observation, whereas secondary failures occurred in 499 patients at an average rate of 25 per cent/year. Men had fewer secondary failures than women. A significantly larger proportion of persons with satisfactory control had a duration of known diabetes of under 1 year as compared to those with primary or secondary failures. The age at onset of diabetes of 60 years and over was significantly more frequent among those with continuously satisfactory control than in the groups with primary or secondary failures. A total of 1,266 patients had been treated with insulin prior to tolbutamide therapy. The proportion of those with continuously satisfactory response on tolbutamide who had received small insulin doses prior to the oral therapy was significantly greater than in those with primary or secondary failures. Continuously satisfactory control with tolbutamide was attained more often among the patients whose diabetes had been controlled satisfactorily also with insulin. Forty-eight per cent of the patients who returned to insulin after a variable period of tolbutamide therapy, showed a higher insulin requirement than before the oral therapy. No other significant differences were found between those patients with continuously satisfactory control and those with secondary failure in this selected population. Four hundred thirty patients had received tolbutamide for 6 to 9 years. The secondary failures in this group amounted to 113 (26 per cent). In this highly selected population, no differences were discernible that would help predict those likely to have a long-term satisfactory control with tolbutimide. The overall attrition rate of patients treated with tolbutamide was high. Only about 10 per cent of patients started on tolbutamide were known to be taking the drug 6 to 9 years later. Reduction in numbers was due chiefly to death (not related to tolbutamide administration), secondary failure, or loss to follow-up. Side effects to tolbutamide were remarkably few and benign. Three patients developed blood dyscrasia (one each with thrombocytopenic purpura, nonthrombocytopenic purpura and neutropenia) documented by tests for circulating antibodies, and in each instance discontinuance of the drug resulted in recovery.

Pathological findings after long-term sulfonylurea therapy.

An evaluation was made of postmortem findings in a group of fifty-five diabetic patients who were treated with sulfonylurea compounds, primarily tolbutamide, from twenty-four to 112 months, for a total of over 2,500 patientmonths and an average of 45.7 months per patient. The results were compared in “blind” fashion to the postmortem findings in two control groups: (a) fifty-five patients, closely matched to the former as to sex, age at death, and known duration of diabetes, who had been treated with insulin and had never received oral hypoglycemic agents; and (b) nineteen patients who had been treated exclusively by dietary restriction. The frequencies of myocardial infarcts, cerebral vascular accidents, diabetic retinopathy and nephropathy, as well as neoplasms, thyroid disease, and ulcers of the stomach and duodenum were not statistically different in the three groups. Peripheral vascular disease (gangrene and/or amputations) occurred more frequently in the insulin-treatedgroup, probably because of the customary use of insulin in patients with these conditions. The findings do not provide evidence that the sulfonylureas influence the pattern ofdiseases or specific complications of diabetes when compared to suitable controls. Islet cell tumors occurred more frequently in sulfonylurea treated patients when compared to the over-all experience of this hospital. The importance of such a finding has to be further substantiated.

Human Growth Hormone Secretion after Double Stimulation with Arginine in Normal and Insulin-dependent Diabetic Women

The standard intravenous arginine test was modified by infusing two equal doses of arginine eighty minutes apart. The serum growth hormone, blood glucose and plasma free fatty acid responses were studied in fifteen young juvenileonset diabetic women and in seven healthy women of comparable age and weight. The biphasic growth hormone response to the two arginine infusions observed in normals did not occur in the diabetics. In addition, the diabetics differed from the normals in several qualitative aspects of growth hormone secretion. A derangement in the diabetic is postulated with impaired sensitivity or defective mechanism of growth hormone secretion. Diabetics with chronically elevated blood glucose levels had a blunted growth hormone response to arginine. In five patients with diabetic retinopathy, growth hormone response was somewhat blunted, probably due to higher blood glucose levels, as compared with findings in five patients without this complication.

Diabetic Glomerulosclerosis in Children

A boy died in diabetic acidosis at the age of nine, after seven years of known diabetes. At necropsy there was diffuse glomerulosclerosis by light microscopy, evidenced by diffuse mesangial thickening of the peripheral glomeru-lar loops and irregular thickening of the capillary basement membrane of the glomeruli. Glomerulosclerosis is a rare finding in a person of this age as revealed in a review of the literature.

Lipemia retinalis: Microcirculatory changes and lipid studies in a family☆

Abstract A 13-year-old girl with diabetic acidosis had lipemia retinalis and massive hyperchylomicronemia ( 19.5 Gm. 100 ml. total lipids) corrected by insulin administration. Fat uptake by embryonic cells in tissue culture using the patients lipemic serum was very marked and was maximal after heparin administration. Red-cell aggregation could be induced in the retinal vessels at the height of her hypertriglyceridemia while conjunctival red-cell aggregation persisted at lower levels of hyperlipemia. Whole-blood viscosity was actually subnormal during the stage of lipemia. With clearing of the hyperchylomicronemia a pre-β band appeared in the lipoprotein electrophoretic pattern of the plasma, which persisted when blood lipid levels returned to normal. The patients father, mother and brother had pre-β bands despite normal blood lipid and insulin levels and normal glucose tolerance. The pre-β band disappeared on heparin administration. This pattern may represent a prototype of carbohydrate-induced lipemia.

Bragg peak proton beam irradiation of the pituitary gland for proliferative diabetic retinopathy.

Abstract Bragg peak proton beam irradiation of the pituitary gland for proliferative diabetic retinopathy was carried out in 56 patients. Most of them had been considered unsuitable for surgical hy...

Acetohexamide in the therapy of diabetes mellitus

Abstract The experience of the Joslin Clinic with acetohexamide in the therapy of 290 diabetic patients has been presented. Seventy per cent achieved good or fair (satisfactory) control, and six per cent had poor control. Twenty-one per cent experienced primary, and 3 per cent secondary, failures. A satisfactory response was obtained more frequently in persons with diabetes of recent onset and/or previously untreated. The mean daily dose of those who achieved satisfactory control was 500 to 700 mg. of acetohexamide. Side effects observed were neither frequent nor severe, attesting to the relative safety of acetohexamide in the patients studied. A review of the literature regarding acetohexamide showed a similar success rate in selected diabetic patients. The reported side-effects were tabulated and discussed. Hypoglycemia presents a certain hazard in some types of diabetic patients during sulfonylurea therapy.