Mimi M Belmonte

Case-Control Study of IDDM

Insulin-dependent diabetes mellitus (IDDM) may be caused by a combination of genetic predisposition and environmental insults. However, there are few solid leads concerning human diabetogenic environmental agents. A case-control study was carried out to investigate the possible relationships between IDDM and various biological, chemical, and psychological factors. All 161 cases of IDDM among children aged 0–17 yr occurring in Montreal from 1983 to 1986 were included. The parent of each newly diagnosed diabetic subject was asked to provide the names of two of the childs friends or neighbors who would be age and sex matched to serve as controls. For those unable to do so, matched controls were selected from a hospital emergency room. Parents of cases and controls were interviewed concerning many factors. There was little or no difference between cases and controls with regard to parental smoking habits, exposure to pets, and consumption of meat products high in nitrosamines. In univariate analyses, there was some indication of elevated risk for children who had not been breast-fed, who attended day care or nursery before age 5 yr, who lived in a crowded household at age 3 yr, or who had a history of asthma or eczema, although in multivariate analyses the only variables that had any effect were crowding and day-care attendance. In univariate and multivariate analyses, there was high risk of IDDM among children who had experienced selected stressful life events during the 12 mo preceding onset of IDDM or who had exhibited symptoms of social or psychological dysfunction during that time. Some of these apparent effects may have been due, in part, to biases induced by the method of selecting controls and to the interview process.

Incidence of IDDM in Montreal by Ethnic Group and by Social Class and Comparisons With Ethnic Groups Living Elsewhere

We examined the incidence of insulin-dependent diabetes mellitus (IDDM) among children aged 0–14 yr in Montreal by social class and by ethnic group from 1971 to 1985. There was a slightly higher risk in wealthier as opposed to poorer classes. This income gradient was more marked in younger than in older children. Children of French extraction had about two-thirds the risk of IDDM of children of other origins, mainly British and other European. This mimics the patterns of risk in Europe, where France is reported to have lower rates than does Britain and Scandinavia. The absolute levels of risks among French Canadian and Jewish Canadian children were about double those reported from France and Israel, respectively. These various results are compatible with the hypothesis that both genetic and environmental factors influence IDDM risk.

Juvenile diabetes mellitus, optic atrophy, sensory nerve deafness, and diabetes insipidus—a syndrome

Four patients with diabetes mellitus, optic atrophy, and high-frequency neurosensory hearing loss, two of whom also had diabetes insipidus, are described. The frequency of this syndrome among patients with juvenile diabetes appears to be between 1/148 and 1/175. Because of the progressive nature of the disabilities and the autosomal recessive mode of inheritance, careful monitoring of all juvenile diabetic patients for other signs of the syndrome is warranted.

Intensified Insulin Therapy in the Type I Diabetic Adolescent: A Controlled Trial

The effects of continuous subcutaneous insulin infusion (CSII), intensified conventional therapy (ICT), and a combination of CSII and ICT (CSII-ICT) on metabolic control were compared in a group of twenty type I diabetic adolescents who had previously failed to respond to twice-daily injections and home glucose monitoring. A marked improvement in control was observed when mean glycemia and glycosylated hemoglobin A1 (HbA1) were compared with conventional therapy (CT). In the course of CSII, a lower HbA1 (P < 0.05) and mean capillary blood glucose (CBG) (P < 0.04) were observed than during ICT and CSII-ICT. Acceptability of CSII was greater that of ICT and CSII-ICT, with 50% of the patients opting for this therapy at the end of the 1-yr trial. The marked improvement of control observed under CSII for the group as a whole was maintained after 6 mo of completion of the study. Thus, it appears that in type I diabetic adolescents CSII is more effective and acceptable than ICT and CSII-ICT.

Evaluation of Two Methods of Self Blood Glucose Monitoring by Trained Insulin-dependent Diabetic Adolescents Outside the Hospital

We studied the accuracy of the Chemstrip bG and Glucometer systems in the self-monitoring of blood glucose by trained adolescents. The determinations were done at home with simultaneous collection of whole blood into capillary tubes (Sarstedt) which were later analyzed by a glucose-Oxidase analyzer (Beckman Instruments). In both cases, there was an excellent correlation between laboratory concen-trations and Chemstrip bG (r = 0.96, P < 0.001) and Glucometer (r = 0.96, P < 0.001). Comparisonsmade at 8 mo remained with the same degree of accuracy. There was a trend toward greater deviation with higher plasma glucose values. Well-trained patients can achieve sufficientaccuracy to permit the use of either of the methods tested with similar results.

Feasibility of strict diabetes control ininsulin-dependent diabetic adolescents

Nineteen insulin-dependent diabetic adolescents who had poor control on twice daily injections and home glucose monitoring participated in a study assessing the feasibility of improved control. Using a randomized crossover protocol, we examined the relative efficacy of continuous subcutaneous insulin infusion and of intensive conventional therapy with three or four daily injections of insulin. Both therapies were regulated with home glucose monitoring. A marked improvement in control with both therapies was observed when mean blood glucose and glycosylated hemoglobin A1 were compared with conventional therapy. However, pump therapy resulted in significantly lower HbA1 than intensive therapy (P less than 0.05), despite a significantly lower total insulin dose (P less than 0.01). We conclude that in adolescents with type I diabetes, continuous subcutaneous insulin infusion is more effective in achieving improvement of diabetes control than is intensive conventional therapy in the outpatient setting.

Impact of SMBG on control of diabetes as measured by HbA1. 3-yr survey of a juvenile IDDM clinic.

Three hundred twelve diabetic children and adolescents were seen in our diabetic clinic and instructed to test their capillary blood glucose (CBG) twice daily and to use an algorithm to adjust their short-acting insulin. Of this group, 219 youngsters had a full 3-yr period of observation. At each clinic visit, blood was obtained for fasting blood glucose and HbA, and, once a year, cholesterol and triglycerides were also measured. Patient and parent accuracy in measuring CBG was found to be adequate. The changes over time in HbA, were nondifferential across age and sex, and there was no difference in the level of HbA, between age and sex groups, the number of tests reported to have been done by the patients, the number of injections of insulin per day, or the serum cholesterol. There was a significant relationship between the HbA1 and the fasting blood glucose (P < .001) measured by the laboratory as well as with the serum triglyceride (P < .01). The failure to improve diabetic control, despite measures that would have been expected to do so, was believed to relate more to a lack of compliance than to a flaw in the therapeutic approach. It was interesting to note that the adolescent patients in the study were in no worse control than the younger children in the group. Although better technical skills are available today to manage diabetes, the psychosocial approach to patient motivation requires improvement.

Urine Sugar Determination by the Two-drop Clinitest Method

Erroneous urine tests for sugar can result from many causes. The Clinitest method carried out in the usual recommended way (five drops of urine) is accurate in the 0 to 2 per cent sugar concentration range. Over 4 per cent, there is a reversal of color which can be mistaken for 0.75 or 1 per cent and which is referred to as “pass through.” When two drops of urine are used instead of five, the range of Clinitest change is extended from 0 to 5 per cent and the “pass through” delayed until a concentration over 10 per cent sugar is reached. In 191 urines from diabetic children, the confusing “pass through” was found to occur seventy times when the urine was tested by the “five-drop method.” It did not occur in testing the same urines using the “two-drop method.” Quantitative chemical analysis established the range of these two methods. It is recommended that the “two-drop method” should replace the “five-drop method.”

Combined Continuous Subcutaneous Insulin Infusion and Multiple Subcutaneous Injections in Type I Diabetic Patients

Seven insulin-dependent diabetic patients (aged 16–34 yr) were treated for 10 mo with a combination of continuous subcutaneous insulin infusion (CSII) during the night and premeal boluses of insulin during the day. The technology and strategy of the system are discussed. Three of these patients had been on CSII for 1 yr before the start of this study. Mean fasting (126 ± 44 mg/dl), mean preprandial blood glucose (131 ± 54 mg/dl), and mean postprandial blood glucose (216 ± 73 mg/dl) before starting this treatment fell to 86 ± 12 mg/dl, 83 ± 19 mg/dl, and 132 ± 1 7 mg/dl, respectively, after 1 mo of treatment. Glycosylated hemoglobin (10,8 ± 2.9% before the study) reached normal values (7.8 ± 0.6%) after 2 mo of treatment. Improvement of glycemic control may be achieved with this form of insulin administration, which is of immediate practical application, until an ideal system of insulin delivery becomes available. This technique provides the conditions for testing the hypothesis that near normalization of glycemic control prevents or minimizes the degenerative complications associated with diabetes mellitus.

Staphylococcus aureus empyema in cystic fibrosis

We wish to acknowledge the assistance of Dr. M. Michael Cohen, Jr., for his insight into the nature of this syndrome, Dr. David M. Bray for necropsy studies, Mr. Bradley Gong for the illustration, and Mrs. Christine Hansen for secretarial assistance. REFERENCES 1. Bailer, F.: Radiusaplasie und Inzueht, Z. Menschl. Vereb. Konstit. Lehre 29: 782, 1950. 2. Gerold, M.: Frakturheilung bei einem seltenen Fal l kongenitaler Anomalie der oberen Gliedmassen, Zentralbl. Chir. 84: 831, 1959. 3. Cohen, M. M.: An etiologic and nosologic overview of craniosynostosis syndromes, Birth defects (in press). 4. Omen, G. S., Figley, M. M., Graham, C. B., and Heinrichs, W. L.: Prospects for radiographic intrauterine diagnosis-The syndrome of thrombocytopenia with absent radii, N. Engl. J. Med. 288: 777, 1973.