Last month we shared with you information about a first trial of an artificial pancreas and this month we share more about another one that has shown excellent results in France. Our headline section will be crammed with information not only about that but about cell transplants and insulin delivering devices as well as infection and type 1 diabetes, and under-treated complications and type 2 and another reason for estrogen replacement. We also bring information in our article abstracts on diabetes control, and risk for developing diabetes and personality types. We then look at a noninvasive glucose monitor being tested and new home tests that can reduce diabetic complications. We end with two articles on diabetic care and complications. So, pull up your monitor and get your reading glasses cleaned because we have a great deal to share.
Our headlines begin with news about tests of two "cures" for diabetes. How many of us as type 1 diabetics were told not to worry, when we were diagnosed, because the cure was just a few years away. I can't tell you how many 5 year periods of time I have counted because very smart researchers would say, "...in 5 years you'll be cured." Our first headline is that Dr. Eric Renard and his colleagues in Montpelier, France with Medtronic MiniMed Corp reported that a new "artificial pancreas" has passed its preliminary testing. The device was tested on 10 people with stable type 1 diabetes for 6 months. The insulin reservoir and the insulin sensor are implanted and allowed for glucose readings 288 times during the day. We'll be reading the journals and papers to see how this progresses. Our second article comes from results of islet cell transplants performed through a research program at U Mass Medical School. Two type 1 diabetics participated in the research, which used the Edmonton Protocol. (See earlier article on this subject) Both patients will have to return later this year for a second transplant of islet cells which they hope will completely remove the need for them to inject insulin. The main challenge appears to be collecting the actual cells that are transplanted, as it takes two pancreases for each islet recipient. In the US, there are one million type 1 diabetics, so researchers are looking into animals such as pigs as a source for islet cells. As of now two more patients have been added to the trials.
Our next headlines have to do with insulin delivering systems. Studies are under way to develop a convenient 24-hour insulin patch, which would deliver a basal dose to patients. In studies under way, patients use a patch with lispro insulin on their forearms. Oral capsules containing an insulin delivery agent (Emisphere) are being studied also both in the US and in Israel. Our third delivery system is inhaled insulin. Oralin is an oral spray that is absorbed through the buccal mucosa. In the single-blind, randomized, crossover study by Modi et al in Toronto, Canada, the spray outperformed injected insulin in rapidity of absorption and elimination, in glucose and C-peptide lowering capacity, and in rise in insulin levels. In a second study the researchers combined Oralin with oral hypoglycemic agents and found that the combination is safe. Overall, Modi's group found that in poorly controlled type 2 diabetics the inhaled insulin either alone or in combination with an oral agent allowed patients to achieve target HbA1c more often than without it.
Three more headlines to consider are as follows: Diabetes 2002;51:1964-1971 has an article which states that newly diagnosed children with type 1 diabetes have enterovirus RNA in their blood cells suggesting that viral infection may contribute to the development of diabetes. Dr. Gun Frisk et al in Sweden studied the occurrence in 24 newly diagnosed type 1 children, 20 of their siblings, and 24 matched age and sex matched controls. The American Journal of Medicine 2002: 112: 603-609, 670-672 has an article which calls for more effective management of cardiovascular risk factors. It is written by Dr Richard Grant from Mass General Hospital. The research compared the proportions of patients who had elevated hemoglobin A1c levels, blood pressure and total blood pressure, but noted treatment for these where often under-medicated or treated. And finally just when you went off of estrogen replacement, Dr. Roberto Civitelli and researchers at Washington University report in the Archives of Internal Medicine report that estrogen replacement can perhaps prevent bone erosion in the jaw. It was found that calcium and vitamin D supplements are not sufficient to restore this loss. However, their research shows that estrogen does appear to restore bone throughout the body. This was published just before the long term women's study was canceled because HRT was found to not stem heart disease and in fact may have detrimental effects on the body.
There are two articles in Clinical Psychiatry News, June 2002 which we know are of interest because of the e-mail we receive on mental health and diabetes. The first by Dr. Richard S. Surwit from Duke University was reported at the annual meeting of the Society of Behavioral Medicine. He reported on a study of 98 relatively young male and female volunteers: 63 African American and 35 white. High hostility levels as measured by a subset of the Cook-Medley Hostility inventory were found to be significantly correlated with elevated fasting blood glucose levels and impaired insulin sensitivity. Hostility was related to high glucose levels in African Americans, but to reduced insulin sensitivity and high fasting insulin levels in whites. High levels of body fat appeared to contribute to this relationship in whites but not in African Americans. Researchers hypothesized that hostility is independently related to fasting glucose in African Americans, but hostility may be part of the constellation of risk behavior in whites. In African Americans the significant relationship between hostility and fasting glucose is thought to have vast implications. Our second article is based on the work of Dr. Paul Ciechanowski and reported at a conference sponsored by the National Institute of Mental Health. It is based on adult attachment theory, which says that the quality of early care giving influences how people perceive others and engage in interpersonal relationships.
People with a "dismissing" attachment style were reported to have much poorer glucose control than others who have other adult attachment styles. People with a dismissing attachment style, which makes up about 25% of the general population, may develop a pervasive need for independence and self-sufficiency because of unresponsive or even neglectful care giving as a child. These people become uncomfortable being close or trusting others and appear unaware that people need people. This style of attachment obstructs collaborative working relationships, which are crucial for those with a chronic disease. The researchers studied 276 subjects with type 1 diabetes. It was found that 62% of those with dismissing attachment had a HbA1c of 8% or higher, while only one third of those with secure attachment style had such high scores. We know that a 1% difference in this hemoglobin level translates into nearly a 60% increase in the development of diabetic retinopathy over a ten-year period of time. Once clinicians understand the basis for noncompliance they can deal with the problem with empathy rather than frustration. The researchers found that a business-like but patient-centered relationship works well with these people, but take note, regular phone calls to stop missed or canceled appointments are also important. About now you all want to know the other 4 types of attachment. 50% have a secure attachment, while the other 25% have preoccupied or fearful attachment styles.
A new noninvasive blood glucose monitor was presented on June 15, 2002 at the ADA Annual Meeting. Ohad Cohen and colleagues from Chaim Sheba Medical Center in Tel Hashomer, Israel presented a completely noninvasive monitor, the Roche Reflectron glucometer, which measures arterial blood glucose levels. It does this by increasing the glucose concentration, which reduces the refractive index mismatches, which in turn reduces the scattering coefficient. This phenomenon is utilized in a clinically applicable apparatus to measure blood glucose levels. The authors reflected that large-scale evaluation of the glucometer is warranted because of the reliability of the measuring technique.
Still another report on a meeting of the ADA Annual Meeting on June 15, 2002 shares the news that there are two new tests that may help reduce complications of diabetes. The first monitors skin temperature of feet to reduce complications, including ulcers, fractures, and amputations. The FootScan is used to give an "early warning sign" of inflammation and injury and is used along with a daily foot exam. The second monitor measures blood beta-hydroxybutyrate, reducing the need for hospitalization for ketosis. Failed sick day management leads to hospital visits and missed school/work for more than 100,000 people yearly. This monitor, presented by Lori M.B. Laffel from Joslin Diabetes Center, can detect impending ketoacidosis and allow for timely treatment.
JAMA 2002; 287:2563-2569 has an article titled Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus as reported by the writing team for the diabetes control and complications trial/epidemiology of diabetes interventions and complications research group. The DCCT proved that intensive treatment reduced the risks of retinopathy, neuropathy, and nephropathy by 35% to 90% compared to conventional treatment. Intensive treatment was most effective when begun early, before complications were detectable. These risk reductions were achieved at a HbA1c level difference of 9.1% for conventional treatment vs. 7.3% for intensive treatment, even though the difference between these scores narrowed over a five-year period of time. Of great importance is that the rate of progression of complications from their levels at the end of the DCCT remains less in the intensive treatment group. Thus, the results show that the benefits of 6.5 years of intensive treatment extend well beyond the period of its most intensive implementation. These results strongly suggest that intensive treatment should be started as soon as it is safely possible after the onset of type 1 diabetes and maintained after that point with the goal of a target HbA1c level of 7.0% or less.
Finally, we look at JAMA 2002;287:2519-2527 and Ethnic disparities in diabetic complications in the insured population by Andrew J. Karter, PhD et al. The researchers, noting that higher rates of microvascular complications have been reported in minorities, which in the past has been attributed to quality of medical care, examined a diverse population with uniform health care. The design was a longitudinal observational study conducted at Kaiser Permanente Care Program in northern California. Incidents included myocardial infarction (MI), stroke, congestive heart failure (CHF), and nontraumatic lower extremity (LEA), defined by primary hospitalization discharge diagnosis, procedures, or underlying cause of death; and end-stage renal disease (ESRD), defined as renal insufficiency requiring renal replacement therapy or transplantation for survival, or underlying cause of death. The study results confirm previous reports of elevated incidence of ESRD among ethnic minorities despite uniform medical care coverage, and provides new evidence that rates of other complications are similar or lower relative to those of whites. The persistence of ethnic disparities after adjustment suggests a possible genetic origin, the contribution of unmeasured environmental factors, or a combination of these factors.
BSP
