A young woman with metabolic acidosis and recently discovered IDDM without ketonuria. A rare autoimmune (?) combination of hypothyroidism, diabetes mellitus and distal renal tubular acidosis

A case of a 29-year-old woman with a multiple autoimmune disorder is reported. She had a history of hypothyroidism since the age of 18. She was admitted to hospital due to hyperglycaemia. At admission she had hyperglycaemia, metabolic acidosis, but no urinary ketone bodies. Further laboratory studies revealed that the acidosis was due to distal renal tubular acidosis rather than diabetic ketoacidosis (although the patient had type 1 diabetes mellitus). Blood tests revealed antibodies to glutamic acid decarboxylase (GAD-65; associated with type 1 diabetes mellitus), thyroid and adrenal tissue, and gastric parietal cells. The patient had not developed pernicious anaemia or Addison's disease. The multiple positive antibody titres in this patient indicate that the diabetes, hypothyroidism and distal renal tubular acidosis are part of an autoimmune syndrome.     

Effects of glucagon-like peptide 1 on the kinetics of glycogen synthase a in hepatocytes from normal and diabetic rats

Glucagon-like peptide 1(7-36)amide (GLP-1) is currently under investigation as a possible tool in the treatment of non-insulin-dependent diabetes mellitus. In addition to enhancing nutrient-stimulated insulin release, the peptide also favors glycogen synthesis and glucose use in liver, muscle, and adipose tissue. GLP-1 also activates glycogen synthase a in hepatocytes from both normal and diabetic rats. In the present study, the kinetic aspects of such an activation were investigated in hepatocytes from normal rats and from animals rendered diabetic induced by injection of streptozotocin, either in the adult age (insulin-dependent diabetes mellitus model) or in days 1 or 5 after birth (non-insulin-dependent diabetes mellitus models). GLP-1 increased, in a dose-dependent manner, glycogen synthase a activity in the hepatocytes from all groups studied. The activation of the enzyme reached a steady state within 1 min exposure to GLP-1, which, at 10(-12) M, caused a half-maximal activation. When comparing fed vs. overnight-starved normal rats, a somewhat lower basal activity of glycogen synthase a in fasted animals (P < 0.05) coincided with a greater relative increment in reaction velocity in response to GLP-1. The basal activity of glycogen synthase a and the relative extent of its inhibition by glucagon or activation by insulin and GLP-1 were modulated by the extracellular concentration of D-glucose. The activation of glycogen synthase a by either insulin or GLP-1 resulted not solely in an increase in maximal velocity but also in a decrease in affinity of the enzyme for uridine diphosphate-glucose; in diabetic animals, the capacity of insulin or GLP-1 to increase the maximal velocity and Michaelis-Menten constant were less marked than in normal rats. In conclusion, this study indicates that the GLP-1-induced activation of glycogen synthase a displays attributes of rapidity, sensitivity, and nutritional dependency that are well suited for both participation in the physiological regulation of enzyme activity and therapeutic purpose.     

Contents of glycogen in neutrophils in patients with diabetes]

Glycogen neutrophils level was evaluated in 54 patients with non-insulin dependent diabetes mellitus (NIDDM) and 10 patients with insulin dependent diabetes mellitus (IDDM). Glycogen concentration estimated by histochemical method was lower in diabetics than in control group. Patients with NIDDM were divided in the groups according to: sex, duration of disease, a kind of complications and a way of treatment. The glycogen contents in neutrophils, defined in "score"-unit was not different in isolated groups. There was found significant correlation between glycogen contents in neutrophils and the metabolic control in patients with IDDM (r = 0.72) and less significant in patients with NIDDM (r = 0.29).     

Extracellular matrix changes in human corneas after radial keratotomy

It has been shown that an adenine (A) to guanine (G) transition at position 3243 of the mitochondrial transfer RNA(tRNA)leu(UUR) gene is associated with a subgroup of diabetes mellitus. Therefore, we screened for this transition in 86 patients with non-insulin-dependent diabetes mellitus (NIDDM) in which two or three generations were affected with diabetes, in 14 patients with insulin-dependent diabetes mellitus, and in 9 families with diabetes mellitus and/or associated disorders suggesting mitochondrial gene abnormalities. We failed to identify the mutation in 100 diabetic patients, 86 NIDDM and 14 insulin-dependent diabetes mellitus (IDDM). Out of the latter 9 families, we identified an A to G transition in 14 individuals in 5 families. Diabetes mellitus was shown to be maternally inherited in one family. In 9 of 14 patients with the mutation, insulin was required to treat diabetes mellitus, indicating impaired insulin secretion. A hyperglycemic clamp test performed in one subject revealed significant impairment of insulin secretion, whereas euglycemic clamp test showed normal insulin sensitivity in this patient. The heteroplasmy of the mutant mitochondrial DNA (mtDNA) in leukocytes does not appear to correlate with the severity of diabetes in terms of the insulin therapy required. Body mass index of the affected individuals was less than 23.3. In one family, in addition to diabetes mellitus and hearing loss, hypoparathyroidism was associated with the mutation, suggesting that hypoparathyroidism is caused by the impaired processing and/or secretion of proparathyroid hormone due to the mutation. In addition, the affected subjects presented with proteinuria at the time of diagnosis of diabetes mellitus which appeared not to be related with diabetic nephropathy.     

Quantitative evaluation of flow in the portal vein. Comparison of bolus tracking magnetic resonance and Doppler color ultrasound]

We have attempted to identify any characteristics which could be used to predict the development of cerebral edema in four children under 5 years of age with new onset insulin-dependent diabetes mellitus and diabetic ketoacidosis. We retrospectively analysed and compared the concentration of serum sodium (corrected for serum glucose value) and effective serum osmolality of these 4 children with values of 10 age-matched controls with new onset insulin-dependent diabetes mellitus who did not develop cerebral edema during treatment of diabetic ketoacidosis. The initial serum sodium values of the two groups were not statistically different. Patients who developed cerebral edema had lower initial serum glucose values and effective serum osmolality. During treatment, patients who developed cerebral edema had consistently lower mean serum sodium and osmolality than controls at each 4-h interval after the first 4 h of therapy. Serum sodium and osmolality declined progressively after the initiation of therapy in cerebral edema patients, while remaining stable in controls. These data suggest that children who develop cerebral edema during treatment for diabetic ketoacidosis initially may have a relatively normal serum osmolality and subsequently develop progressive hyponatremia and/or a trend of declining serum sodium before developing cerebral edema.     

Diabetics with coronary disease have a prevalence of asymptomatic ischemia during exercise treadmill testing and ambulatory ischemia monitoring similar to that of nondiabetic patients. An ACIP database study. ACIP Investigators. Asymptomatic Cardiac Ischemia Pilot Investigators

BACKGROUND: There are conflicting data as to whether diabetics have a higher prevalence of asymptomatic ST-segment depression during exercise treadmill testing (ETT) and ambulatory ECG (AECG) monitoring. This study was conducted to determine whether diabetic patients with coronary disease enrolled in the Asymptomatic Cardiac Ischemia Pilot (ACIP) have more episodes of asymptomatic ischemia during ETT and 48-hour AECG monitoring than nondiabetic patients and to compare differences in angiographic variables and the magnitude of ischemia as measured by standard ETT and AECG criteria. METHODS AND RESULTS: Angiographic variables and the prevalence and magnitude of ischemia during the qualifying ETT and 48-hour AECG were compared by the presence and absence of diabetes mellitus in 558 randomized ACIP patients. Seventy-seven patients had a history of diabetes and were taking oral hypoglycemics or insulin (diabetic group); 481 patients did not meet these criteria (nondiabetic group). Multivessel disease (87% versus 74%, P = .01) was more frequent in the diabetic group. The percentages of patients without angina during the ETT were similar in the diabetic and nondiabetic groups (36% and 39%, respectively). Time to onset of > or = 1-mm ST-segment depression and time to onset of angina were similar in both groups. The percentages of patients with only asymptomatic ST-segment depression during the 48-hour AECG were similar in the diabetic and nondiabetic groups (94% versus 88%, respectively). However, total ischemic time per 24 hours (15.0 +/- 21.4 versus 23.6 +/- 31.1 minutes, P = .02), ischemic time per episode (6.3 +/- 4.6 versus 9.0 +/- 8.7 minutes, P < .01), and the maximum depth of ST-segment depression tended to be less in the diabetic group. CONCLUSIONS: Patients enrolled in ACIP were selected on the basis of an abnormal ETT and 48-hour AECG and ability to undergo coronary revascularization. When patients with diabetes mellitus were compared with those without diabetes, there was a similar prevalence of asymptomatic ischemia during ETT and 48-hour AECG monitoring. Despite more extensive and diffuse coronary disease, diabetic ACIP patients tended to have less measurable ischemia during the 48-hour AECG.     

Human sperm beta-glucuronidase is poorly extractable by Triton X-100

OBJECTIVE: To evaluate the prevalence of silent myocardial ischemia in patients with non-insulin dependent diabetes mellitus with no symptoms of cardiac disease. SETTING: Tertiary care center. PATIENTS: 60 patients with non-insulin dependent diabetes mellitus; mean age 58 +/- 12 years, who had no symptoms of angina or any other clinical evidence of coronary artery disease and normal resting electrocardiogram. A control group of 57 healthy volunteers, matched for age and sex were included. MEASUREMENTS: All patients underwent a 24 hour electrocardiographic Holter monitoring test. An ischemic episode was defined as depression of the ST segment > or = 1 mm for > or = 1 min. RESULTS: 10 of the 60 diabetic (17%) were found to have silent myocardial ischemia and only 3/57 (5%) was detected in the controls. In a two years follow up, four diabetics developed symptomatic angina pectoris. CONCLUSIONS: Silent myocardial ischemia in asymptomatic diabetics occurs frequently; a lack of symptoms does not discard a myocardial ischemia, and the Holter recordings may help in its detection.     

Glycogen storage diseases and the liver

Carbohydrate metabolism in the liver is responsible for plasma glucose homeostasis. Liver glycogen storage diseases are metabolic disorders which result in abnormal storage amounts and/or forms of glycogen, and often (but not always) have hepatomegaly and hypoglycaemia as presenting features. To understand the clinical complexity of the glycogen storage diseases, it is necessary to understand the properties and regulation of the proteins involved in glycogen metabolism. Advances in treatment have greatly improved metabolic control and hence the quality of life and survival. However, the lack of understanding of the molecular basis of some of the clinical features of glycogen storage diseases makes it difficult logically to devise optimal treatment regimens to prevent some of the long-term complications. Recently, molecular biology has greatly advanced our understanding of the proteins and genes involved in liver glycogen metabolism and has led to better and less invasive methods of diagnosis of these disorders.     

Feto-placentary pathology in human parvovirus B19 infection

Non-insulin-dependent diabetes mellitus is associated with obesity in 80 to 90%. The presence of obesity enhances insulin resistance, which increases the demands on insulin secretion and causes deterioration of glucose tolerance. Hyperinsulinism has some metabolic sequelae which increase the risk of the development and progression of atherosclerosis. Reduction of body weight is a basic therapeutic provision in obese diabetics. It results not only in better compensation of diabetes but also other metabolic parameters and blood pressure as it leads to a higher tissue sensitivity for insulin. This can delay the development of long-term complications of diabetes mellitus.     

The nature and use of purified insulins

The limited availability of highly purified insulin preparations for the treatment of diabetes mellitus in australia since 1975, has prompted a review of their history, clinical use and potential in the treatment of diabetics receiving insulin.     

Spontaneous diabetes mellitus in young cattle: histologic, immunohistochemical, and electron microscopic studies of the islets of Langerhans

Pathomorphologic studies were carried out on three cases of bovine diabetes mellitus with clinical signs of polydipsia, polyuria, severe emaciation, glycosuria, persistent hyperglycemia, and decreased glucose tolerance. At necropsy, two animals had atrophy of the pancreas, whereas other visceral organs, including the endocrine organs, showed no significant changes. Microscopically, there was atrophy and reduced numbers of pancreatic islets accompanied by interlobular and interacinar fibrosis and compensatory enlargement of some remaining islets. Lymphocytes were observed commonly around and within atrophic islets and occasionally around and within enlarged islets. Vacuolar degeneration with occasional accumulation of glycogen granules was observed in the beta-cells of these enlarged islets. Immunohistochemical studies of atrophic islets demonstrated complete loss of beta-cells or only a few small beta-cells. There also was a corresponding decrease in the number of cells that stained with anti-glucagon (alpha-cells) or anti-somatostatin (delta-cells) antibodies. The vacuolated cells in the enlarged islets stained strongly with anti-insulin antibody (beta-cells). Ultrastructurally, the majority of cells in the atrophic islets had reduced cytoplasmic volume and few secretory granules, features consistent with alpha-cells. In contrast, enlarged islets that had prominent immunohistochemical staining for insulin (beta-cells) consisted of beta-cells with cytosolic edema, mitochondrial swelling, dilated smooth endoplasmic reticulum, and reduced numbers of or degranulated secretory granules. These pathomorphologic features found in cattle are similar to those found in juvenile-onset insulin-dependent diabetes mellitus in human beings and suggest autoimmune involvement in diabetes.     

Identifying the G protein, Gz alpha, and its associated proteins in nervous tissue using mass spectrometry and microsequencing techniques

The current case describes a young woman with diabetes mellitus who developed end-stage renal disease (ESRD) and many other devastating complications related to her primary illness. Her experience illustrates many ways in which complicated illness can interrupt life's plans, dashing any dreams that she or her family might have for the future. Yet her story also illustrates the important role that a trained Peer Resource Consultant (PRC) can play in helping to better understand chronic illness, face and grieve losses, and even design new plans and create new dreams for the future. The discussion that follows includes several perspectives that offer poignant insight into the difficult situations characterized by the young diabetic with ESRD.     

Zinc and diabetes mellitus

In patients with type 1 and 2 diabetes was frequently found: low blood zinc levels, high zincuria, severe and ubiquitous cellular depletion of zinc, increased basal and after loading blood mineral clearance, and hyperglycaemia due to the reduction of pancreatic insulin secretion and to the reduced biological action of the hormone on liver, as a consequence of chronic zinc deficit. Strong endocellular zinc depletion in diabetics; low insulin secretion; insulin biological action decrease for zinc deficit; IG-I concentration decrease, that happens in this condition; insulin and IGF-I resistance; insulin and IGF-I receptors depletion in diabetics: are strong arguments for zinc pharmacological supplementation, in gastric protective formulation, to avoid gastroenteric problems.     

Fatal rhino-orbital-cerebral zygomycosis

Rhinocerebral zygomycosis is usually an aggressive, fulminant and, at times, fatal disease most often affecting poorly controlled diabetics of all ages. We report the case of a 13-month-old white boy, a previously undiagnosed diabetic. He came to our hospital with recurrent epistaxis, decreasing consciousness, and a small visible infection at the inner canthus of the left eye. Initial evaluation revealed that the patient was in diabetic ketoacidosis. Despite aggressive medical and surgical treatment, his condition deteriorated rapidly, including the development of diabetes insipidus, and he died 4 days after admission. At autopsy, he was found to have fungal cerebritis (Rhizopus) with multiple areas of infarction and massive cerebral edema.     

Moyamoya disease associated with pulmonary sarcoidosis--case report

A 61-year-old female presented with a unique case of moyamoya disease associated with pulmonary sarcoidosis. She was admitted for sudden onset of left temporalgia with episode of numbness on face, tongue, and upper extremity on the right side. The next morning, she had symptoms of Gerstmann syndrome and her ability to speak was disturbed. Her medical history included radical resection of lung cancer on the right side. She had no symptoms of pulmonary sarcoidosis. Neuroimaging showed an infarction in the left occipital lobe. Angiography showed occlusions of the bilateral internal carotid arteries at the supraclinoid portions. Subsequently, a left superficial temporal artery-middle cerebral artery anastomosis with encephalo-myo-synangiosis was performed. Ninety-three days after admission, she suddenly developed dyspnea which resulted in death 3 hours later. Autopsy findings showed typical epithelioid granulomas of sarcoid type in the lymph nodes of the peribronchus, lung, and liver. Thrombotic emboli were found in the bilateral pulmonary arteries, and marked fibrous intimal thickening in the bilateral internal carotid arteries. Immunological reaction with inflammatory events may cause pathological changes in patients with moyamoya disease or sarcoidosis. The co-incidence in this case suggests that some common inflammatory events may be involved in the pathogenesis of these diseases.     

Enhanced insulin-stimulated activation of phosphatidylinositol 3-kinase in the liver of high-fat-fed rats

Insulin receptor substrate (IRS)-1 and IRS-2, which mediate phosphatidylinositol (PI) 3-kinase activation, play essential roles in insulin-induced translocation of GLUT4 and in glycogen synthesis. In this study, we investigated the process of PI 3-kinase activation via binding with IRS-1 and -2 in liver, muscle, and fat of high-fat-fed rats, a model of insulin-resistant diabetes. In the liver of high-fat-fed rats, insulin increased the PI 3-kinase regulatory subunit p85alpha and the PI 3-kinase activities associated with IRS-1 3.6- and 2.4-fold, and with IRS-2, 4.7- and 3.0-fold, respectively, compared with those in control rats. The tyrosine phosphorylation levels of IRS-1 and IRS-2 were not significantly altered, however. In contrast with the liver, tyrosine phosphorylation levels and associated PI 3-kinase proteins and activities were decreased in the muscle and adipose tissue of high-fat-fed rats. Thus, high-fat feeding appears to cause insulin resistance in the liver by a mechanism different from the impaired PI 3-kinase activation observed in muscle and adipose tissue. Taking into consideration that hepatic PI 3-kinase activation is severely impaired in obese diabetic models such as Zucker fatty rats, it is possible that the mechanism by which a high-fat diet causes insulin resistance is quite different from that associated with obesity and overeating due to abnormality in the leptin system. This is the first report to show increased PI 3-kinase activation by insulin in an insulin-resistant diabetic animal model. These findings may be important for understanding the mechanism of insulin resistance in human NIDDM, since a high-fat diet is considered to be one of the major factors exacerbating insulin insensitivity in humans.     

The management of diabetes in pregnancy

The aim of the diabetes specialist is to provide a service to the pregnant diabetic woman so that she will present to her obstetrician with such well-controlled plasma glucose levels that her pregnancy will proceed without any diabetes-related problem, and she will be delivered of a normal baby, of normal size, at the normal full-term gestation, by the normal route. There are some problems in achieving this aim. The exact definition of hyperglycaemia in pregnancy is still a matter of dispute. Screening methods to identify the problem differ widely. Many centres have developed joint diabetes/antenatal clinics, but there are practical problems with such an approach. Pre-pregnancy counselling, and discussion of contraceptive measures is an important task for the diabetologist and requires up-to-date knowledge. Control of plasma glucose requires alteration of insulin doses as pregnancy proceeds. Mothers with retinal, renal or cardiac problems will need special care. The medical problems which develop, and the management of blood glucose during labour and delivery, mean that the diabetes team must be very adjacent to the obstetric service, and a centralised approach offers many advantages. The postpartum state, and the long-term outcome for both mother and baby, remain both an interest and a responsibility for the obstetric physician.     

Pharmacological profiles of a novel oral antidiabetic agent, JTT-501, an isoxazolidinedione derivative

JTT-501, 4-[4-[2-(5-methyl-2-phenyl-4-oxazolyl)ethoxy]benzyl]-3,5-isoxaz olidinedione, is an isoxazolidinedione derivative which is structurally distinct from thiazolidinediones such as pioglitazone and troglitazone. We investigated the effects of JTT-501 on insulin-sensitizing activity and in rodent diabetic models. JTT-501 enhanced insulin-stimulated cell differentiation of 3T3-L1 fibroblasts with an EC50 value of 110 nM. Furthermore, JTT-501 activated peroxisome proliferator-activated (PPA) gamma and alpha receptors with the EC5-fold values of 0.28 and 5.4 microM, respectively. In the non-insulin-dependent diabetes mellitus model KK-Ay mice, JTT-501 improved hyperglycemia, hyperinsulinemia and hypertriglyceridemia, and enhanced insulin-stimulated glucose oxidation in adipose tissues. JTT-501 was also effective in the non-insulin-dependent diabetes mellitus model Zucker diabetic fatty (ZDF) rats but not in the insulin-dependent diabetes mellitus model streptozotocin-induced diabetic mice. These observations suggest that JTT-501 enhances insulin sensitivity in peripheral tissues and improves hyperglycemia, hyperinsulinemia, and hypertriglyceridemia in non-insulin dependent diabetes mellitus models. In particular, the triglyceride-lowering activity of JTT-501 is a unique characteristic compared to the thiazolidinediones. Therefore, JTT-501 may be a promising antidiabetic agent for treating non-insulin-dependent diabetes mellitus patients with insulin resistance.     

BRCA2 mutation in Icelandic prostate cancer patients

OBJECTIVE: To investigate the effect of the exercise on glucose transporter 4 (GLUT4) gene expression in skeletal muscles of rats with streptozotocin-induced diabetes. METHODS: Three experiment groups of rats were investigated: diabetic non-exercise group; diabetic exercise group; and normal controls. Diabetic exercise rats were swim-trained for 6 weeks. The GULT4 mRNA of skeletal muscle cells was determined with dot blot. RESULTS: There was weak gene expression of GULT4 in diabetic rats, and dot blot revealed that the GLUT4 mRNA decrease 54.9% in skeletal muscle cells compared with the normal control. After 6 weeks exercise training, the hyperglycemia of diabetic exercise rats decreased significantly (from 18.5 +/- 1.9 mmol/L to 14.0 +/- 3.3 mmol/L, t = 4.64 P < 0.01). In muscle cells of diabetic exercise rats, the GLUT4 mRNA increased 56% as compared with the diabetic rats (t = 15.56, P < 0.01). CONCLUSION: Chronic hyperglycemia may inhibit the gene expression of GLUT4 in diabetic rats, which caused the post-receptor insulin resistance in peripheral tissue. Exercise training can improve the impaired GLUT4 expression in diabetic rats, which may contribute to the mechanisms of enhanced insulin sensitivity and decreased hyperglycemia in diabetics mellitus.