Non-insulin Dependent Patients Research Articles

Efficiency of vibration exercise for glycemic control in type 2 diabetes patients

Although it is well documented that persons suffering from diabetes type 2 profit from muscular activities, just a negligible amount of patients take advantage of physical exercises. During the last decade, vibration exercise (VE) could be established as an effective measure to prevent muscular atrophy and osteoporosis with low expenditure of overall exercise-time. Unfortunately, little is known about the metabolic effects of VE. In the present study we compared VE with the influence of strength training and a control group (flexibility training) on glycemic control in type 2 diabetes patients. Forty adult non-insulin dependent patients participated in the intervention. Fasting glucose concentration, an oral glucose tolerance test (OGTT), haemoglobin A1c (HbA1c), the isometric maximal torque of quadriceps muscles, and endurance capacity were evaluated at baseline and after 12 weeks of training with three training sessions per week. The main findings are: Fasting glucose concentrations remind unchanged after training. The area under curve and maximal glucose concentration of OGTT were reduced in the vibration and strength training group. HbA1c values tended to decrease below baseline date in the vibration training group while it increased in the two other intervention groups. Theses findings suggest that vibration exercise may be an effective and low time consuming tool to enhance glycemic control in type 2 diabetes patients.

Rationale for glycemic control in cardiac surgical patients: The portland diabetic project

Since 1987, the Portland Diabetic Project has enrolled >5000 patients with diabetes mellitus (DM)—including patients with noninsulin-dependent DM and patients with insulin-dependent DM—in a prospective nonrandomized study of the effects of perioperative insulin administration on morbidity and mortality after open-heart surgical procedures. In the early stages of the study, patients received SC insulin. In 1991, we instituted a continuous intravenous insulin (CII) protocol, which has been refined several times since its introduction. Our principal measure of glycemic control is the mean blood glucose value obtained by measuring glucose every 0.5 to 2 hours during the initial 3-day postoperative period (3-BG). There is a strong relationship between postoperative mortality and 3-BG value, even after adjusting for other clinical variables that influence mortality. The postoperative mortality rate was significantly lower among patients who received CII rather than SC insulin after coronary artery bypass grafting (CABG) or cardiac surgery of any type. We have also found that 3-BG is strongly associated with the risk of postoperative deep sternal wound infection (DSWI), and that treatment with CII significantly reduces the risk of infection. Our CII glucose protocol is slightly more expensive to administer than conventional SC insulin. However, when cost savings associated with a reduced rate of serious infection and reduced length of hospital stay are considered, CII results in total savings of >$4500 per patient. Widespread use of our CII protocol to manage perioperative hyperglycemia in patients with diabetes who undergo open-heart surgical procedures would result in substantial reductions in morbidity, mortality, and overall costs to the health care system.

'Urine testing is a waste of time': newly diagnosed Type 2 diabetes patients' perceptions of self-monitoring.

To date, there is no convincing evidence that non-insulin treated patients who undertake self-blood glucose monitoring (SBGM) have better glycaemic control than those who test their urine. This has led to a recommendation that non-insulin dependent patients undertake urine testing, which is the cheaper option. This recommendation does not take account of patients' experiences and views. This study explores the respective merits of urine testing and SBGM from the perspectives of newly diagnosed patients with Type 2 diabetes. Qualitative study using repeat in-depth interviews with 40 patients. Patients were interviewed three times at 6-monthly intervals over 1 year. Patients were recruited from hospital clinics and general practices in Lothian, Scotland. The study was informed by grounded theory, which involves concurrent data collection and analysis. Patients reported strongly negative views of urine testing, particularly when they compared it with SBGM. Patients perceived urine testing as less convenient, less hygienic and less accurate than SBGM. Most patients assumed that blood glucose meters were given to those with a more advanced or serious form of diabetes. This could have implications for how they thought about their own disease. Patients often interpreted negative urine results as indicating that they could not have diabetes. Professionals should be aware of the meanings and understandings patients attach to the receipt and use of different types of self-monitoring equipment. Guidelines that promote the use of consistent criteria for equipment allocation are required. The manner in which negative urine results are conveyed needs to be reconsidered.

Postural hypotension and postural dizziness in patients with non-insulin-dependent diabetes.

Postural hypotension with a decline of 20 mm Hg or more in systolic blood pressure on standing is considered a potentially dangerous hypotensive response. Postural dizziness is often strongly associated with postural hypotension. However, there is conflicting evidence, and previous studies have been confined to the elderly, not specifically to patients with diabetes. Thus, we evaluated the association between postural hypotension and postural dizziness, and determined the factors most likely related to postural hypotension in patients with diabetes. The subjects were 204 consecutive noninsulin-dependent patients with diabetes and 408 age- and sex-matched control subjects. Postural hypotension was defined as a decline of 20 mm Hg or more in systolic blood pressure 1 minute after standing. Postural dizziness was any feelings of dizziness, lightheadedness, or faintness that occurred while standing during the examination. The prevalence of postural hypotension and postural dizziness in patients with diabetes was higher than in control subjects. Those patients with both diabetes and postural hypotension were older and had higher supine systolic blood pressures and higher plasma glycosylated hemoglobin and fasting glucose levels. They had higher prevalence of postural dizziness, hypertension, and cerebrovascular disease, and lower standing systolic blood pressures than those without postural hypotension. They also were more often being treated with antihypertensive agents. Only 32.8% of patients with diabetes with postural hypotension suffered from postural dizziness. Postural dizziness, hypertension, cerebrovascular disease, and plasma glycosylated hemoglobin levels were independently associated with postural hypotension in patients with diabetes. Postural dizziness, glycemic control, hypertension, and cerebrovascular disease were important determinants of postural hypotension in patients with diabetes. Postural hypotension was associated with postural dizziness, but it cannot be determined clinically just from the presence of postural dizziness because the sensitivity for diagnosis of postural hypotension is low.

Renal Protection in Diabetes-An Emerging Role for Calcium Antagonists

The combination of diabetes and hypertension increases the changes of progressive renal disorder and ultimately renal failure. Roughly 40% of all diabetics, whether insulin dependent or not, develop diabetic nephropathy. Diabetic nephropathy is the single most important cause of end-stage renal disease in the western world and accounts for more than a quarter of all end-stage renal diseases. It is also a major cause of increased morbidity and mortality in diabetic patients. Increased arterial blood pressure is an early and common phenomenon in incipient and overt diabetic nephropathy. The relationship between arterial blood pressure and diabetic nephropathy is a complex one, diabetic nephropathy increasing blood pressure and blood pressure accelerating the course of nephropathy. Calcium antagonists antagonize preglomerular vasoconstriction. Furthermore, additional putative mechanisms include the ability to retard renal growth and possibly to attenuate mesangial entrapment of macromolecules and to attenuate the mitogenic effects of diverse growth factors. Calcium antagonists (except the old short-acting dihydropyridine drugs) reduce microalbuminuria and preserve kidney function in diabetic patients with incipient diabetic nephropathy. Long-term trials using the new long-acting dihydropyridine calcium antagonists for the treatment of patients with incipient nephropathy are still lacking. A recent 1-year randomized double-blind study in hypertensive insulin-dependent diabetic patients with diabetic nephropathy showed a more beneficial effect on the decline rate in the glomerular filtration rate of nisoldipine (long-acting dihydropyridine) than angiotensin-converting-enzyme (ACE) inhibition. The mean arterial blood pressure during the study based on 24-hour recordings was nearly identical, 103 (SD 9) and 101 (SD 11) mm Hg in the two groups. Furthermore, a recent 5-year randomized open study in hypertensive noninsulin-dependent patients with diabetic nephropathy has revealed the same beneficial effect of a calcium antagonist and ACE inhibition on the progression of nephropathy. In a third group treated with sympatholytic drugs, more than 50% of the subjects had a doubling of their creatinine as compared to less than 10% in the two other groups mentioned above. However, long-term studies are needed to consolidate these findings and expand them to insulin-dependent diabetic patients with diabetic kidney disease.

The emerging role of ACE inhibitors in diabetes: From theory to therapeutic management

M icroalbuminuria was identified more than a decade ago as predicting diabetic nephropathy both in patients with insulin-dependent and non-insulin-dependent diabetes. More surprisingly, however, reports from the early 1980s described an association between microalbuminuria and atherothrombotic vascular disease. ~,2 The figure for this risk differ from between a twofold and an eightfold increase in non-insulindependent patients with microalbuminuria. A more recent study from London, UK, has shown that microalbuminuria is able to predict cardiovascular mortality over a 23-year follow-up in insulin-dependent diabetic patients. 3 These observations are supported by the finding of a substantially increased mortality rate from cardiovascular disease in proteinuric patients with insulin-dependent diabetes, some 8.5 times in excess of nonproteinuric patients. 4 Several studies have now demonstrated an association between microalbuminuria and cardiovascular disease in nondiabetic subjects. We have shown that around 10°/, of the population aged over 40 years have an increase in albumin excretion rate, and these subjects have a substantially increased risk of death, predominantly from cardiovascular disease. 5 Thus, any mechanism invoked to explain the connection between microalbuminuria and cardiovascular disease must be independent of the existence of glucose intolerance.

Peripheral microvascular disease in diabetes

In recent years a variety of techniques have been developed for studying peripheral microvascular function in man, which have provided important information regarding the functional breakdown of the microcirculation in diabetes mellitus. In insulin dependent diabetes a sequence of physiological changes have been described which support the so-called haemodynamic hypothesis: control-dependent increases in capillary pressure result in microvascular sclerosis leading to limitation of hyperaemia and loss of autoregulation. Furthermore, capillary pressure appears to be especially raised in patients with incipient nephropathy who are at particular risk of microangiopathy. The limitation of maximum hyperaemia is duration related, may be observed in early childhood, and is correlated with the degree of basement membrane thickening. In contrast in normotensive non-insulin dependent patients a different array of functional disturbances are described: Capillary pressure and capillary filtration coefficient are normal whereas maximum hyperaemia is profoundly depressed even at diagnosis. This differential pattern of abnormalities arguably reflects the impact of a prediabetic insulin resistant phase on the subsequent expression of microangiopathy. An understanding of the physiological breakdown of the microcirculation in diabetes permits the generation of plausible candidate cellular and molecular mechanisms, knowledge of which will accelerate the development of protective therapy.

The development of the diabetes integration scale: A psychometric study of the ATT39

In this paper we report a factor analytic study on the ATT39, a measure of psychological adjustment to diabetes. The ATT39 was developed in response to the need for more specific measurement tools for the assessment of psychosocial issues in diabetes. The factor analyses in this study were conducted separately for insulin-dependent and non-insulin dependent patient groups to acknowledge the known clinical differences between these two subclasses of diabetes. The results showed a core of 19 items in a single subscale to be common to both IDD (Insulin-Dependent Diabetes) and NIDD (Non Insulin-Dependent Diabetes) patient groups based on rigorous factor analytic criteria involving the use of a factor matching technique (FACTOREP) and replication samples. Coefficient alpha values were in the range of 0.82 to 0.84, showing it to have acceptable internal reliability. Future research on the measure should focus on its clinical-usefulness to detect change in patient psychological functioning and to predict diabetes self-care behaviours and metabolic control.

Is community chiropodial/podiatric care appropriately targeted at the ‘at-risk’ diabetic foot?

The concept of the ‘at-risk’ diabetic foot is well developed in hospital-based practice but much care of the elderly non-insulin dependent diabetic patient, particularly prone to foot ulceration, occurs in the community. Therefore, a community survey of 570 diabetic patients was undertaken to establish the prevalence of foot ulceration, presence of established risk factors and frequency of chiropody. 1.9% of patients had active foot ulcers; 6.3% a history of ulceration. 50.8% of ‘ulcerated’ patients and those deemed ‘at risk’ were receiving chiropody, compared to 33.3% of those at relatively low risk ( P < 0.001). This survey demonstrated a similar prevalence of active foot ulceration to previous reports, confirming the vulnerability of older non-insulin dependent patients in this respect. Half of the ‘at-risk’ patients were not receiving chiropody, whereas a relatively high proportion of ‘not at-risk’ patients were. The reasons for this apparent misappropriation of conservative chiropodial podiatric care require further investigation.

Determinants of vibration perception thresholds in IDDM and NIDDM patients

The relative influence of diabetes mellitus-related and physiological factors on vibration perception thresholds was assessed in 353 patients in a hospital-based setting (173 insulin-dependent and 180 non-insulin dependent patients, aged 51.1 ± 15.9 years) and 80 healthy controls (aged 43.3 ± 15.2 years) employing a Biothesiometer. Vibration perception thresholds were bilaterally measured at the thumbs, medial malleoli and halluces. Sixty (17.0%) older patients had offscale thresholds (> 50 V). As no systematic side differences were found, values of contralateral sites were averaged. Considering the effects of age, height, gender and skin temperature in controls, age accounted for 46.7 and 52.2% threshold variance at the ankles and halluces, respectively, while height explained 5.1 and 5.1%, respectively. At the thumbs, only age was of relevance. Age relationships with vibration thresholds in health did not differ from published reports at any site. In the patient group, influences of age, height, gender, skin temperature, years from diagnosis, HbA 1c, serum creatinine, drop in systolic blood pressure on standing, and ankle/arm blood pressure indices were assessed for each type of diabetes. For both types, age and height again had relevant effects at the lower extremities as did age and gender at the thumbs. Skin temperature was only marginally significant at the halluces of NIDDM patients. Of the disease-related factors, HbA 1c had the strongest effect: for both IDDM and NIDDM higher levels were associated with lower vibration sensitivity. Increasing disease duration led to significantly higher thresholds in IDDM patients. The Biothesiometer, although consistent in results when compared between control groups, is not the most suitable instrument to measure vibration sensitivity in older patients due to the vast deterioration of vibration sense with age. After correcting for confounding effects of age at all sites and height at the lower extremities, HbA 1c and duration of IDDM proved to be significant and relevant factors in the explanation of interindividual variance in vibration sensitivity.

Fluorophotometric study of lens autofluorescence and the blood-retinal barrier in 56 diabetic patients.

We examined lens autofluorescence and the permeability of the blood-retinal barrier in 56 diabetic patients (34 insulin-dependent and 22 non-insulin-dependent), using the Fluorotron Master (R), a commercially available fluorophotometer. Significant relationships were found between age and lens autofluorescence (p < 0.01), between duration of diabetes and lens autofluorescence in insulin-dependent diabetics (p < 0.01), and between duration of diabetes and blood-retinal barrier permeability in all diabetics (p < 0.05). The relationships between lens autofluorescence and duration of diabetes in non-insulin dependent patients (p > 0.05), and between lens autofluorescence or the penetration ratio and HBA Ic during the five preceding years (p > 0.05) were not significant. Fluorophotometry provides an objective and reproducible method for in vivo investigation of the ocular complications of diabetes and of the factors influencing them.

Beta 2-glycoprotein-1 (apolipoprotein H) excretion and renal tubular malfunction in diabetic patients without clinical proteinuria.

To compare the urinary excretion of beta 2-glycoprotein-1 with that of two other markers of early tubular disorder in diabetic patients without clinical proteinuria. The urinary excretion of retinol binding protein, beta 2-glycoprotein-1, and N-acetyl-beta-D-glucosaminidase was measured in 90 known diabetic patients who had a negative reagent strip test for proteinuria. Among 43 patients with urinary albumin excretion within the reference range, 23 (53%) had raised urinary N-acetyl-beta-D-glucosaminidase activity, five (12%) increased excretion of beta 2-glycoprotein-1, and five (12%) increased loss of retinol binding protein. Among 47 patients with an albumin excretion of 0.9-7.9 mg/mmol creatinine, 42 (89%) had increased urinary N-acetyl-beta-D-glucosaminidase, 23 (49%) an increased output of beta 2-glycoprotein-1, and 16 (34%) a raised excretion of retinol binding protein. The excretion of these markers of tubular defects seldom exceeded two and a half times the upper reference limit and the differences between the findings in the insulin dependent and non-insulin dependent patients with similar albumin excretion were small and insignificant. In diabetic patients with a negative dipstick test for proteinuria: (a) assay of urinary beta 2-glycoprotein-1 may be a more sensitive test for the detection of impaired tubular reabsorption of protein than measurement of retinol-binding protein; (b) assay of N-acetyl-beta-D-glucosaminidase can detect tubular injury at a time when protein reabsorption remains normal; and (c) impaired renal tubular function may be present in the absence of evidence of glomerular malfunction.

Diabetes care: who are the experts?

To identify issues that patients and professionals consider important in diabetes care and differences in their priorities for care and to determine patients' and professionals' judgements of the relative importance of their chosen priorities. Structured group interviews using the nominal group technique. Five district health authorities on Tyneside. Five nominal groups: expert (seven), non-expert (seven) health care professionals; insulin dependent (four), non-insulin dependent patients (eight); and carers of diabetic patients (eight). Items important in diabetes care to each nominal group (themes of care), ranked into a series of "top 10" items for each group, and allocated a score according to relative importance to individual members; scores were standardised by individual weighting and group weighting for comparison within and between groups. Patients and professionals agreed that information given to patients, interaction between professionals and patients, patient autonomy, and access were important for good diabetes care, but the importance assigned to each differed. Thus the professionals emphasised empathy and aspects of good communication and patients the desire to know enough to live a "normal" life. Differences were also found within the patient groups; these related to changes in patients' needs at specific points in the development of their illness and in their orientations to care. Patients differ from professionals in their orientation to diabetes care, and they can, and should, be involved in setting priorities for care. Since these priorities are dynamic further work is needed to explore the nature of patient satisfaction with diabetes care.

Predisposition to essential hypertension and the development of diabetic nephropathy.

Only a subset of insulin-dependent diabetic patients are at risk of developing nephropathy. Prospective studies of uncomplicated insulin-dependent diabetic cohorts have shown that a rise in systemic arterial pressure is a concomitant feature of the progression to early nephropathy. The development of hypertension is an integral feature of established nephropathy in diabetes, and its amelioration retards the progression of disease and may improve overall mortality. Family studies have suggested that nondiabetic parents of insulin-dependent diabetic patients with nephropathy have a greater prevalence of hypertension, and in certain groups of non-insulin dependent patients, it has been found that the blood pressure before the onset of diabetes correlates with the development of nephropathy after the onset of diabetes. These results indicate that a propensity to hypertension may be part of the genetic predisposition to nephropathy. This contention is further supported by the finding that a raised erythrocyte sodium-lithium countertransport, a biochemical marker of hypertension and cardiovascular disease whose activity is largely genetically determined, occurs with greater frequency in proteinuric diabetic patients and their nondiabetic parents than in those diabetic patients without nephropathy and their parents. Recent family studies have also shown that a family history of cardiovascular disease significantly increases the risk of nephropathy by up to three-fold in insulin-dependent diabetes. It is suggested that the cardiorenal complications of diabetes mellitus may be linked to reduced insulin sensitivity, which itself is associated with hypertension, raised sodium-lithium countertransport rates, and cardiovascular disease.

Perioperative Management of the Diabetic Patient

The diabetic patient has major surgery more frequently than nondiabetic patients. Although many of these operations are done on an elective basis, desirable perioperative control of blood glucose (ranging from 120-180 mg/dL) remains a therapeutic challenge. In planning the management, the type of diabetes, current treatment, the degree of recent control, the presence of complications, and the type of surgical procedure must all be considered. All insulin-dependent patients and many non-insulin-dependent patients need insulin therapy perioperatively. The variable stress associated with major procedures makes a flexible insulin regimen desirable. This can be provided using a continuous insulin (regular) infusion system and frequent bedside blood glucose monitoring.

Effect of morphological abnormalities on blood retinal barrier permeability in diabetic retinopathy.

The morphological base for the impaired function of the blood retinal barrier was studied in 50 eyes of 10 insulin dependent and 21 non-insulin dependent patients with various levels of diabetic retinopathy. The permeability of the blood retinal barrier (PBRB) was determined by vitreous fluorophotometry with correction for autofluorescence, lens transmission and non-protein bound plasma fluorescein concentration. Morphological abnormalities of diabetic retinopathy assessed by fundus photography and fluorescein angiography were individually scored on a decimal scale and related to the PBRB by multiple regression analysis. The PBRB was not correlated to morphological abnormalities of non-proliferative retinopathy [(1) microaneurysms, (2) hard exudates, (3) soft exudates, (4) intraretinal hemorrhages, (5) fluorescein leakage, and (6) capillary closure, p greater than 0.3]. The PBRB was correlated to morphological abnormalities of (pre)proliferative retinopathy [(1) intraretinal microvascular abnormalities (SIRMA) and (2) new vessels (Sneo): PBRB = A+B.SIRMA + C.Sneo with PBRB in nm/sec, A = 1.5 +/- 0.5, B = 0.9 +/- 0.2 and C = 1.7 +/- 0.4, R2 = 0.65, p less than 0.0001]. It can be concluded that the increased blood retinal barrier permeability in diabetic patients is mainly due to (pre)proliferative abnormalities and not to non-proliferative abnormalities.

C-peptide response to oral glucose and its clinical role in elderly people.

C-Peptide response to oral glucose was measured in 45 elderly diabetics, in whom final treatment was established on clinical grounds during a 16-18 months follow-up. The diabetic patients comprised 19 ultimately classified as insulin-dependent (IDD) (group 1) and 26 regarded as non-insulin-dependent (NIDD) (group 2). Fifteen matched controls (group 3) and 15 young controls (group 4) were similarly studied. Fasting C-peptide values were lower in groups 1 and 2 (1.48 +/- 0.39 and 2.14 +/- 0.22 ng/ml; mean +/- SEM, respectively) compared with groups 3 and 4 (2.51 +/- 0.16 and 2.71 +/- 0.20 ng/ml, respectively) (p less than 0.001). Peak C-peptide levels were reached at 30 min in healthy young and at 60 min in healthy elderly. All non-diabetic control subjects showed a peak of at least 6.5 ng/ml and an increment of at least 4 ng/ml. The ratio of C-peptide increment/blood glucose increment (100 delta CP/delta BG) at 60 min derived to assess beta-cell function was at least 90 in all healthy subjects. The ratio was less than 10 in 68% of IDD but in only 27% of NIDD patients (p less than 0.01). The 100 delta CP/delta BG was inversely related to the prevailing fasting blood glucose (FBG) (p less than 0.001). These findings suggest that C-peptide response to oral glucose may be a useful test in certain elderly diabetic patients whose insulin dependence is in question.

Patterns of Insulin Dependence in an African Diabetic Clinic

Analysis of the age of onset of diabetes amongst insulin-treated patients in a large African diabetic clinic revealed a bimodal type of distribution, 23 per cent having an age of onset before 30 years and 77 per cent with onset at greater than or equal to 30 years of age. All 66 of the young insulin-treated group (21.7 +/- 4.8 years (mean +/- 1 SD)), and a random selection of 50 older insulin-treated patients (49.7 +/- 10 years), were studied. The older group were better controlled (HbA1 8.4 +/- 1.7 per cent vs. 10.8 +/- 2.6 per cent, p less than 0.001), on lower doses of insulin (49 +/- 23 vs. 71 +/- 23 u/day, p less than 0.001) and had higher body mass index (26.0 +/- 5.6 vs. 21.8 +/- 3.5, p less than 0.001). Serum C-peptide (0.24 +/- 0.15 vs. 0.07 +/- 0.10 nmol/l, p less than 0.0001), and C-peptide/glucose ratio (2.57 +/- 2.65 vs. 0.56 +/- 0.98 nmol/mmol x 10(2), p less than 0.001) were very significantly higher in older patients. Patients with later onset disease thus had better preservation of pancreatic function, higher body mass index and better glycaemic control on lower doses of insulin. These features suggest that older insulin-treated patients could in fact be 'Type 2' or non-insulin dependent patients, and the condition may be controllable with diet and/or oral hypoglycaemic agents, at least in some.

Morphologic study of the kidney in Japanese non-insulin-dependent patients

The characteristic histologic finding of nephropathy in patients with diabetes mellitus (DM) has been diabetic glomerulosclerosis (DMGS), either of diffuse or nodular type, which was frequently associated with tubulointerstitial and vascular lesions. Primary glomerulonephritis (GN) has been also reported to be superimposed on DMGS. Most patients with DM in Japan have so-called type II diabetes. In the present study, we attempted to clarify the relationship between morphologic findings and clinical features in DMGS and DM-associated GN of non-insulindependent (NIDDM) patients.

Early pharmacotherapy in non-insulin-dependent diabetes mellitus: help or hindrance?

To the Editor.— The recent article by Watts and colleagues 1 sheds important light on the effects of modest weight loss on glycemic control in obese noninsulin-dependent patients with diabetes mellitus. However, we feel that the authors' data do not support their conclusion and recommendation that their more obese, early diet-failure non-insulin-dependent patients with baseline and more persistent and severe hyperglycemia are better treated early with long-term pharmacotherapy. The authors postulate, without insulin or C-peptide levels mented, that those patients are more severely insulin deficient and imply that early replacement therapy would be more cost effective, less ing, and would avoid the possible damaging effects of persistent hyperglycemia. The axiomatic assertion that long-term good glycemic control can be achieved with insulin therapy in these individuals is not substantiated by the authors' data as follow-up blood glucose levels and glycohemoglobin levels were not provided. Indeed, the authors treated only seven of