Well-controlled Diabetes Mellitus Research Articles

Serum Adenosine Deaminase in patients with Type-2 Diabetes Mellitus and its Relation with Blood Glucose and Glycated Haemoglobin levels

Background: Diabetes mellitus is a metabolic characterized bydeficiency of insulin and insulin resistance. Adenosine deaminase (ADA) modulates the bioactivity of insulin and Adenosine receptorsstimulate glucogenolysis and gluconeogenesis . but its role in Type 2 diabetes mellitus is not yet characterized. Aim & Objectives : The present study aimed to evaluate the serum Adenosine Deaminase level and to correlate ADA levels with Blood Glucose and Glycated hemoglobin levels in Type-2 Diabetes Mellitus patients. Material and Method: The study population of 120 patients were divided into 3 groups: Group A which consisted of 40 normal healthy individuals without any complication or history of Diabetes. Group B included 40 patients of Type 2 Diabetes Mellitus both with HbA1c 7% (n=40). Fasting blood sugar, HbA1c, ADA, and body mass Index were estimated in all the subjects under study. Results: The study showed that mean Fasting Blood Sugar, Post prandial Blood sugar and HbA1c concentration was significantly higher in Group C & Group B compared to Group A. Compared with the well-controlled Type-2 Diabetes Mellitus patients (HbA1c 7%) showed significantly increased ADA activity (49.79 18.12 U/L vs. 90.10 32.75; P <0.001). The correlation between Adenosine Deaminase and HbA1c was positive and significant in both Group B (r= 0. 389; p= 0.007) and Group C (r = 0.430; p<0.001). Conclusion: Serum ADA levels may have an important role in determining the glycemic status in Diabetics. A positive correlation between ADA level with glycemic control suggest its important role in glucose and lipid metabolic derangements seen in Type 2 Diabetes Mellitus patients.

Elevated micronucleus frequency in patients with type 2 diabetes, dyslipidemia and periodontitis.

The over-production of reactive oxygen species (ROS) can cause oxidative damage to a large number of molecules, including DNA, and has been associated with the pathogenesis of several disorders, such as diabetes mellitus (DM), dyslipidemia and periodontitis (PD). We hypothesise that the presence of these diseases could proportionally increase the DNA damage. The aim of this study was to assess the micronucleus frequency (MNF), as a biomarker for DNA damage, in individuals with type 2 DM, dyslipidemia and PD. One hundred and fifty patients were divided into five groups based upon diabetic, dyslipidemic and periodontal status (Group 1 - poor controlled DM with dyslipidemia and PD; Group 2 - well-controlled DM with dyslipidemia and PD; Group 3 - without DM with dyslipidemia and PD; Group 4 - without DM, without dyslipidemia and with PD; and Group 5 - without DM, dyslipidemia and PD). Blood analyses were carried out for fasting plasma glucose, HbA1c and lipid profile. Periodontal examinations were performed, and venous blood was collected and processed for micronucleus (MN) assay. The frequency of micronuclei was evaluated by cell culture cytokinesis-block MN assay. The general characteristics of each group were described by the mean and standard deviation and the data were submitted to the Mann-Whitney, Kruskal-Wallis, Multiple Logistic Regression and Spearman tests. The Groups 1, 2 and 3 were similarly dyslipidemic presenting increased levels of total cholesterol, low density lipoprotein cholesterol and triglycerides. Periodontal tissue destruction and local inflammation were significantly more severe in diabetics, particularly in Group 1. Frequency of bi-nucleated cells with MN and MNF, as well as nucleoplasmic bridges, were significantly higher for poor controlled diabetics with dyslipidemia and PD in comparison with those systemically healthy, even after adjusting for age, and considering Bonferroni's correction. Elevated frequency of micronuclei was found in patients affected by type 2 diabetes, dyslipidemia and PD. This result suggests that these three pathologies occurring simultaneously promote an additional role to produce DNA impairment. In addition, the micronuclei assay was useful as a biomarker for DNA damage in individuals with chronic degenerative diseases.

Association of glycemic control with mortality in patients with diabetes mellitus undergoing percutaneous coronary intervention.

Diabetes mellitus adversely affects outcomes in patients undergoing percutaneous coronary intervention. The association of baseline hemoglobin A1c (HbA1c) at the time of percutaneous coronary intervention with long-term mortality is unknown. Consecutive patients with diabetes mellitus undergoing percutaneous coronary intervention between 1998 and 2008 were identified from our institutional database. Characteristics and outcomes of patients were compared based on HbA1c categories (≤7%, 7.1%-8.0%, 8.1%-9.0%, 9.1%-10.0%, and >10.0%). Among 3008 patients, 1321 had HbA1c ≤7%, 782 with HbA1c 7.1% to 8.0%, 401 with HbA1c 8.1% to 9.0%, 229 with HbA1c 9.1% to 10.0%, and 275 with HbA1c >10%. Compared with low HbA1c (≤7%), those with highest HbA1c (>10%) were younger (56.5 versus 67.5 years), had higher total cholesterol (188 versus 157 mg/dL), more insulin use (54% versus 26%), and presented more often with ST-segment-elevation myocardial infarction (10.9% versus 5.6%). Those with lower HbA1c (≤7%) more often had other comorbidities (more hypertension [90.4% versus 82.5%] and chronic renal failure [14.4% versus 7.6%]). On multivariable Cox proportional hazards modeling, survival analysis demonstrated a trend toward higher mortality with higher HbA1c. Compared with the reference group of patients with HbA1c ≤7%, patients with HbA1c >10% had a significantly higher mortality on follow-up (hazard ratio [95% confidence interval], 1.52 [1.17-1.99]; P=0.002). This difference was primarily seen among noninsulin users; however, insulin users had no significant differences in mortality among HbA1c categories. Patients with diabetes mellitus who were not on insulin and had poor glycemic control (HbA1c >10%) had significantly higher long-term mortality after percutaneous coronary intervention as compared with those with well-controlled diabetes mellitus, evidenced by HbA1c ≤7%. Insulin users, however, had similar rates of mortality among different HbA1c categories.

Application of a Modified Entropy Computational Method in Assessing the Complexity of Pulse Wave Velocity Signals in Healthy and Diabetic Subjects

Using 1000 successive points of a pulse wave velocity (PWV) series, we previously distinguished healthy from diabetic subjects with multi-scale entropy (MSE) using a scale factor of 10. One major limitation is the long time for data acquisition (i.e., 20 min). This study aimed at validating the sensitivity of a novel method, short time MSE (sMSE) that utilized a substantially smaller sample size (i.e., 600 consecutive points), in differentiating the complexity of PWV signals both in simulation and in human subjects that were divided into four groups: healthy young (Group 1; n = 24) and middle-aged (Group 2; n = 30) subjects without known cardiovascular disease and middle-aged individuals with well-controlled (Group 3; n = 18) and poorly-controlled (Group 4; n = 22) diabetes mellitus type 2. The results demonstrated that although conventional MSE could differentiate the subjects using 1000 consecutive PWV series points, sensitivity was lost using only 600 points. Simulation study revealed consistent results. By contrast, the novel sMSE method produced significant differences in entropy in both simulation and testing subjects. In conclusion, this study demonstrated that using a novel sMSE approach for PWV analysis, the time for data acquisition can be substantially reduced to that required for 600 cardiac cycles (~10 min) with remarkable preservation of sensitivity in differentiating among healthy, aged, and diabetic populations.

Effects of uncomplicated vaginal delivery and epidural analgesia on fetal arterial acid–base parameters at birth in gestational diabetes

AimTo investigate the effects of uncomplicated vaginal delivery and epidural analgesia on fetal acid–base parameters in women with gestational diabetes (GDM) compared with controls. MethodsA retrospective case–control study of 142 women with gestational diabetes and 284 controls. To evaluate the effect of diabetes and analgesia on acid–base status correcting for potential confounders we used ordered logistic equations including quartiles of fetal arterial acid–base parameters collected at birth as outcomes and categories of diabetes and epidural analgesia as explanatory variables. ResultsIn the GDM group cord base deficit (−2.63mmol/l, interquartile range [IQR]=4.2 to −0.65mmol/l vs. −1.9mmol/l, IQR=−3.3 to −0.2 mmol/l, p=0.009, odds ratio (OR)=1.51, 95% confidence interval (CI)=1.04–2.18) was lower and concentration of calcium higher (1.49mmol/l, IQR=1.42–1.56mmol/l vs. 1.47mmol/l, IQR=1.41–1.51mmol/l, p=0.009, OR=1.69, 95% CI=1.12–2.56) compared with controls. Epidural analgesia in the GDM group was associated with reduced cord concentration of glucose (84.0mg/dl [4.7mmol/l], IQR=70–103.3mg/dl vs. 92.5mg/dl [5.1mmol/l], IQR=76.5–121.8mg/dl, p=0.004), lactate (2.65mmol/l (IQR=1.80–4.20) vs. 3.70mmol/l (IQR=2.90–5.55mmol/l), p=0.002) and less pronounced base deficit (−2.05mmol/l, IQR=−3.90 to −0.17mmol/l vs. −2.8, IQR=−5.57 to −1.05mmol/l, p=0.01, OR=0.7, 95% CI=0.49–0.99). ConclusionsIn uncomplicated pregnancies and deliveries, well-controlled gestational diabetes mellitus has potentially significant detrimental effects on fetal acid–base status at birth. Epidural analgesia reduces cord arterial glucose and lactates.

Insulin infusion on postoperative complications of coronary artery bypass graft in patients with diabetes mellitus.

Background:Cardiovascular events are common in patients with diabetes mellitus (DM), which make coronary artery bypass graft (CABG) a highly demanded surgery in this population. Tight control of blood glucose in patients with DM is beneficial in reducing postoperative complications; however, the adequate range has not been determined yet.Objectives:This study aimed to investigate the effect of semi-tight (moderate) control of DM on complications and serum glucose levels during and after CABG.Patients and Methods:In this prospective clinical trial, 18 and 31 patients with and without DM, respectively, who were referred to Shahid Chamran Hospital, Isfahan, Iran, for elective CABG surgery, were enrolled. For DM group, patients with controlled DM (i.e. glycosylated hemoglobin levels [HgA1C] ≤ 7%) were recruited. Blood glucose level (blood sugar, BS) was measured after anesthesia, during pumping, warming, off pumping, six and 12 hours after Intensive Care Unit (ICU) admission, and at discharging from the hospital. The hemodynamic state of the patients, bleeding, need of blood transfusion, infection, and duration of hospitalization were also monitored and recorded.Results:None of the BS measurements (FBS, after anesthesia, on-pump, warming, off pump, six and 12 hours after ICU admission, and at discharge) were significantly different between study groups (P > 0.05). Frequency of surgery site bleeding and blood transfusion need were not significantly different between these groups (P > 0.05).Conclusions:Semi-tight control of DM with insulin infusion during operation did not led to any difference in the type and rate of CABG complications between patients with well-controlled and those without DM; however, BS levels in patients with well-controlled DM could be more easily controlled.

Index of Suspicion in the Nursery: Persistent Tachypnea

At 2 days of age, a term female newborn infant is evaluated for tachypnea. She was born at 40 weeks’ gestation, with birthweight 4.6 kg, to a 34-year-old G2P2 woman via normal spontaneous vaginal delivery. Maternal history is pertinent for well-controlled gestational diabetes mellitus and hypothyroidism treated with levothyroxine. Prenatal laboratories are significant for group B Streptococcus positivity for which the mother was adequately treated. All other prenatal laboratories are unremarkable. The delivery was complicated by a nuchal cord and apnea requiring positive pressure ventilation for 10 seconds. Apgar scores were 6 at 1 minute and 9 at 5 minutes. A review of her vital signs from the newborn nursery reveal the following: heart rate, 128 beats per minute; respiratory rate, 52 breaths per minute; and oxygen saturation, 89% in room air that had improved without supplemental oxygen. Her respiratory rate is 82 breaths per minute, and pre- and postductal oxygen saturations are 97% in room air. On physical examination, she is consistently tachypneic, as noted by multiple caregivers, with minimal subcostal retractions but without grunting or flaring. The remainder of her examination is within normal limits. Basic metabolic panel, capillary blood gas, and complete blood count are all normal. A chest radiograph is read as unremarkable (Fig 1A). Blood cultures are drawn, but given a low risk for sepsis, antibiotics are not started. A cardiologist is consulted for sustained tachypnea and a new grade I/VI systolic murmur in the left lower sternal border. An echocardiogram …

Response to Comment on: Au et al. Body Composition Is Normal in Term Infants Born to Mothers With Well-Controlled Gestational Diabetes Mellitus. Diabetes Care 2013;36:562–564

The comment letter by McElduff (1) acknowledges that our study (2) is an excellent example of the research needed to determine optimal glycemic targets for mothers with gestational diabetes mellitus (GDM). The primary objective of our study was to describe the body composition at birth of infants born to mothers with GDM compared with infants born to mothers with normal glucose tolerance using air-displacement plethysomography (2). Body composition at birth, measured accurately by air-displacement plethysomography, is a more sensitive marker of the intrauterine environment than weight alone, and includes estimates of fat mass and fat-free mass. To our knowledge, this is the first study to show that infant body composition …

Body Composition Is Normal in Term Infants Born to Mothers With Well-Controlled Gestational Diabetes Mellitus

Body Composition Is Normal in Term Infants Born to Mothers With Well-Controlled Gestational Diabetes Mellitus

Body Composition Is Normal in Term Infants Born to Mothers With Well-Controlled Gestational Diabetes Mellitus

OBJECTIVEThis study aims to describe body composition in term infants of mothers with gestational diabetes mellitus (GDM) compared with infants of mothers with normal glucose tolerance (NGT).RESEARCH DESIGN AND METHODSThis cross-sectional study included 599 term babies born at Royal Prince Alfred Hospital, Sydney, Australia. Neonatal body fat percentage (BF%) was measured within 48 h of birth using air-displacement plethysmography. Glycemic control data were based on third-trimester HbA1c levels and self-monitoring blood glucose levels. Associations between GDM status and BF% were investigated using linear regression adjusted for relevant maternal and neonatal variables.RESULTSOf 599 babies, 67 (11%) were born to mothers with GDM. Mean ± SD neonatal BF% was 7.9 ± 4.5% in infants with GDM and 9.3 ± 4.3% in infants with NGT, and this difference was not statistically significant after adjustment. Good glycemic control was achieved in 90% of mothers with GDM.CONCLUSIONSIn this study, neonatal BF% did not differ by maternal GDM status, and this may be attributed to good maternal glycemic control.

Associations Between Elevated Homocysteine, Cognitive Impairment, and Reduced White Matter Volume in Healthy Old Adults

Elevated homocysteine has emerged as a risk factor for cognitive impairment even in healthy elderly persons. Reduced brain volume and white matter hyperintensities also occur in healthy elderly as well, but the interrelationships between these have not been well studied. We report these interrelationships in non demented, relatively healthy, community-dwelling older adults from a single East Asian population. Two hundred twenty-eight right-handed participants age 55 years and above were evaluated. Persons with medical conditions or neurological diseases other than well-controlled diabetes mellitus and hypertension were excluded. Participants underwent quantitative magnetic resonance imaging of the brain using a standardized protocol and neuropsychological evaluation. Plasma homocysteine, folate, vitamin B(12), and markers for cardiovascular risk: blood pressure, body mass index, fasting blood glucose, and lipid profile were measured. Elevated homocysteine was associated with reduced global cerebral volume, larger ventricles, reduced cerebral white matter volume, and lower cognitive performance in several domains. Elevated homocysteine was associated with reduced white matter volume (β=-20.80, t=-2.9, df= 223, p= 0.004) and lower speed of processing (β=-0.38, t=-2.1, df= 223, p= 0.03), even after controlling for age, gender, and education. However, the association between homocysteine and lower speed of processing disappeared after controlling for white matter volume. Elevated homocysteine was not associated with white matter hyperintensity volume or with hippocampal volume. Although homocysteine and folate levels were correlated, their effects on white matter volume were dissociated. In non demented, relatively healthy adults, elevated homocysteine is associated with lower cognitive scores and reduced cerebral white matter volume. These effects can be dissociated from those related to white matter hyperintensities or reduced folate level.

Effects of Interleukin-1β Inhibition With Canakinumab on Hemoglobin A1c, Lipids, C-Reactive Protein, Interleukin-6, and Fibrinogen

Background— To test formally the inflammatory hypothesis of atherothrombosis, an agent is needed that reduces inflammatory biomarkers such as C-reactive protein, interleukin-6, and fibrinogen but that does not have major effects on lipid pathways associated with disease progression. Methods and Results— We conducted a double-blind, multinational phase IIb trial of 556 men and women with well-controlled diabetes mellitus and high cardiovascular risk who were randomly allocated to subcutaneous placebo or to subcutaneous canakinumab at doses of 5, 15, 50, or 150 mg monthly and followed over 4 months. Compared with placebo, canakinumab had modest but nonsignificant effects on the change in hemoglobin A1c, glucose, and insulin levels. No effects were seen for low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, or non–high-density lipoprotein cholesterol, although triglyceride levels increased ≈10% in the 50-mg ( P =0.02) and 150-mg ( P =0.03) groups. By contrast, the median reductions in C-reactive protein at 4 months were 36.4%, 53.0%, 64.6%, and 58.7% for the 5-, 15-, 50-, and 150-mg canakinumab doses, respectively, compared with 4.7% for placebo (all P values ≤0.02). Similarly, the median reductions in interleukin-6 at 4 months across the canakinumab dose range tested were 23.9%, 32.5%, 47.9%, and 44.5%, respectively, compared with 2.9% for placebo (all P ≤0.008), and the median reductions in fibrinogen at 4 months were 4.9%, 11.7%, 18.5%, and 14.8%, respectively, compared with 0.4% for placebo (all P values ≤0.0001). Effects were observed in women and men. Clinical adverse events were similar in the canakinumab and placebo groups. Conclusions— Canakinumab, a human monoclonal antibody that neutralizes interleukin-1β, significantly reduces inflammation without major effect on low-density lipoprotein cholesterol or high-density lipoprotein cholesterol. These phase II trial data support the use of canakinumab as a potential therapeutic method to test directly the inflammatory hypothesis of atherosclerosis. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00900146.

54-Year-Old Man With Severe Prostatism, Palatal Mass, and History of Pancreatitis

54-year-old man with a history of benign prostatic hypertrophy, hypothyroidism, and well-controlled insulin-dependent diabetes mellitus secondary to idiopathic pancreatitis presented to our internal medicine consultation clinic. He complained of a lump in the hard palate, dry mouth present for 2 years, and bilateral submandibular gland swelling for which he had been evaluated by an otolaryngologist. A previous biopsy of the hard palate mass had demonstrated florid reactive lymphoid hyperplasia with fibrosis, polyclonal plasmacytosis and increased IgG4-positive plasma cells. He also complained of obstructive urinary symptoms and was found to have a very large and nodular prostate on digital rectal examination. The prostate-specific antigen level was 0.13 ng/mL (reference range, 0-3.2 ng/ mL), and results of urinalysis were unremarkable. A computed tomographic scan of the chest from an outside facility showed a mass in the right middle lobe in addition to bilateral renal lesions. Suspicion for a common link among his current symptoms and previous diagnoses was raised. 1. Which of the following is the most likely unifying diagnosis? a. Multiple myeloma b. Amyloidosis c. Metastatic prostate cancer d. IgG4-related sclerosing disease (IgG4RSD)

Diabetic cardiac autonomic neuropathy in well-controlled diabetics within 1 year of diagnosis

Sir, Diabetic Cardiac Autonomic Neuropathy (DCAN) is associated with high risk of cardiovascular morbidity and mortality.[1] Several methods have been devised to assess cardiac autonomic neuropathy such as measurement of resting heart rate (HR), HR variability, etc. Reduced HR variability has been associated with increased cardiac events in diabetic subjects.[2] Portable ANSiscope is a device that noninvasively measures the parasympathetic/sympathetic nervous system imbalance in an office setting. The ANSiscope computes a percentage of dysautonomia from a recording of 571 RR intervals termed ANS index. Based on scoring described by Bellavere et al.,[3] five risk categories have been identified using the computed ANS Index. Subjects with ANS index <11%, 11–20%, 21–50%, 51–60% and 61-100% were classified into healthy, early, late, advanced, and most-advanced diabetic cardiac autonomic neuropathy (DCAN) groups, respectively. We investigated prevalence of DCAN amongst well-controlled type-2 diabetes mellitus (T2DM) subjects within 1 year of diagnosis. After obtaining informed consent, all T2DM subjects diagnosed within the past 12-months and hemoglobin A1C (A1C) ≤7 were included in the study. Eighteen of 29 subjects recruited were female, with a mean diabetes duration of 9-months and a mean A1C of 6.3% (5.3-7.0) [Table 1]. 10/29 subjects had no DCAN, whereas 4, 11, 1, and 3 subjects had early, late, advanced, and most-advanced DCAN, respectively. Table 1 Diabetic cardiac autonomic neuropathy profile of 29 subjects with type 2 diabetes mellitus within one year of diagnosis and an A1C of <7.0 Our study clearly indicates that despite good glycemic control, almost two-third of recently diagnosed T2DM subjects in Pakistan have some level of DCAN. A similar study conducted in India demonstrated an even higher prevalence of DCAN, albeit using different diagnostic criteria.[4] It is a well-known fact that newly diagnosed T2DM subjects have the disease for at least 5-10 years before they are diagnosed. It is quite possible that if we diagnose diabetes earlier followed by aggressive treatment, we can prevent or reduce the morbidity associated with DCAN. All our subjects had their diabetes under good control for at-least 3 months as indicated by an A1C<7.0. It seems that short-term good glycemic control does not reverse cardiac dysautonomia. Previous studies have shown that intensive diabetes control in type-1 diabetic subjects is associated with partial reversibility of DCAN.[5] Therefore, it would be interesting to compare the DCAN profile before and after good glycemic control. American Diabetes Association recommends yearly screening for autonomic neuropathy in T2DM from the time of diagnosis. This cannot be accomplished efficiently unless there is a device available that is accurate and easy to use in a doctor's office setting. Portable ANSiscope seems to be a device that has the potential to meet all these needs of a busy diabetologist.

Predictors of Clinical Remission in Cats with Diabetes Mellitus

Clinical remission is frequent in cats with well-controlled diabetes mellitus, but few studies explored predictors of this phenomenon. Data retrieved from medical records at admission might be valuable to identify likelihood of remission and its duration in diabetic cats. Ninety cats with newly diagnosed diabetes, followed-up until death or remission. Retrospective cohort study. Data were collected from records at admission, including history, signalment, physical examination, haematology, and biochemical profile, and the occurrence and duration of remission, defined as normoglycemia without insulin for ≥4 weeks. Predictors of remission were studied with univariate and multivariate logistic regression. Factors associated with remission duration were analyzed with Kaplan-Meier and Cox proportional hazard models. Forty-five (50%) cats achieved remission, after a median time of 48 days (range: 8-216). By study end, median remission duration was 114 days (range: 30-3,370) in cats that died and 151 days (range: 28-1,180) in alive cats. Remission was more likely with higher age (OR: 1.23, 95% CI: 1.04-1.46; P=.01) and less likely with increased serum cholesterol (OR: 0.36, 95% CI: 0.11-0.87; P=.04). Remission was longer with higher body weight (HR: 0.65, 95% CI: 0.42-0.99; P=.04) and shorter with higher blood glucose (HR: 1.01, 95% CI: 1.00-1.02; P=.02). Age, body weight, cholesterol, and glucose levels are suggested for prediction of remission or its duration in diabetic cats. Older cats developing diabetes may have a better outcome, possibly suggesting a slower disease progression.

Dental caries and adolescents with type 1 diabetes

The aim of this study was to determine the prevalence of dental caries in adolescents with type 1 diabetes mellitus (DM). A clinical examination was carried out on 259 adolescents with type 1 DM as compared with 259 age- and sex-matched metabolically healthy controls. The DM cases were characterised by postprandial blood glucose and HBA1c levels, duration of the diseases, age at onset and level of control. Dental caries was assessed using the DMFT index. Data were analysed by Shapiro-Wilk's W, ANOVA, Student's t and Tukey's posthoc test. An intact dentition was found in none of the DM patients. DM adolescents had a higher mean DMFT score (p <0.001), fewer decayed (p <0.0001), and more filled (p <0.001) teeth than in the controls. In the well-controlled DM adolescents, the mean number of decayed (D) teeth was lower (p <0.0001) and the number of filled(F) teeth was higher than in patients with poorer glycaemic control. Early onset of DM was related to fewer decayed and filled teeth, but only if the oral hygiene was adequate (p <0.0001). Poor glycaemic control and the early onset of DM may increase the risk of dental caries, but appropriate oral hygiene together with satisfactory metabolic control may prevent the development of dental caries in adolescents with type 1 DM.

Prevalence of previously unknown elevation of glycosylated hemoglobin in spine surgery patients and impact on length of stay and total cost

Elevated levels of glycosylated hemoglobin (HbA1c) among spine surgery patients may have an impact on length of stay (LOS) and healthcare cost. We retrospectively reviewed the charts of 556 spine surgery patients who underwent 1 of 3 types of surgery: lumbar microdiscectomy (LMD), anterior cervical decompression and fusion (ACDF), and lumbar decompression and fusion (LDF). Information was collected about their diabetes mellitus (DM) history and HbA1c levels. We used HbA1c 6.1% as the screening cutpoint. Percentages of nondiabetic patients, those with subclinical elevation of HbA1c and those with already known DM were calculated and statistical analysis was applied. After excluding the small group of well-controlled DM (n = 14), 72.4% of patients were nondiabetic, 14.3% were subclinical patients with previously unknown HbA1c elevation, and 13.3% were already known, confirmed DM patients. There were significant differences in the LDF group between the "No DM" and "Subclinical" groups (P < 0.05) in terms of cost and LOS (P < 0.05). Age and body mass index (BMI) were very significant predictors of total cost in spine surgery patients (P <or= 0.001), in addition to the type of surgery. Univariate analysis with age, BMI, or both as covariates deprived DM-HbA1c status of statistical significance (P > 0.05) in determining cost. There is a significant segment of spine surgery patients who were unaware of their elevated HbA1c status before their preoperative visit. These patients seem to utilize more healthcare resources, which is especially evident in the LDF group. We believe that HbA1c should be considered in the routine preoperative workup of spine surgery patients.

Fornix damage from solitary subependymal giant cell astrocytoma causing postoperative amnesic syndrome

The amnesic syndrome is characterized by difficulty learning and recalling information, either previously encoded (retro-grade) or newly encountered (anterograde). Various structures within the medial temporal lobe and limbic system of the brain are thought to be important in memory formation and retrieval, as evidenced by the fact that damage to these areas may result in an amnesic syndrome (Papanicolaou, 2006). For example, anterograde amnesia associated with damage to the fornix (Sweet et al, 1959), a fibre bundle connecting the hippocampus to the mamillary bodies within the limbic system, is well described following removal of third ventricle colloid cysts (Hodges and Carpenter, 1991; McMackin et al, 1995; Aggleton et al, 2000), suggesting the importance of the fornix as one of the anatomical substrates of the distributed neural network underpinning memory functions (Mesulam, 1990). This article reports the cognitive impairments associated with left fornix damage which became apparent following surgical removal of a solitary subependymal giant cell astrocytoma.

Spontaneous resolution of diabetic macular oedema after discontinuation of thiazolidenediones

To report a case of spontaneous resolution of diabetic maculopathy with cystoid macular oedema in a diabetic patient after discontinuation of rosiglitazone, documented with serial ocular computed tomography (OCT) images. A 59-year-old male with a 6-year history of well-controlled diabetes mellitus presented with reduced visual acuity (VA) attributed to clinically significant macular oedema (CSMO). The patient had been started on rosiglitazone 8 months previously. Glitazone treatment was stopped and the patient prospectively followed up. The patient demonstrated CSMO on OCT at presentation. Three months after cessation of rosiglitazone, CSMO had completely resolved and VA improved. Resolution of CSMO was confirmed on OCT examination. The patient required no interventional treatment, i.e. no laser or intravitreal therapy, for his CSMO. To the best of our knowledge, this is the first case to document spontaneous resolution of CSMO and improvement in VA on discontinuation of a glitazone. Glitazones have a definitive role in the management of diabetic patients and ophthalmologists and physicians should both be aware that there may be an association with weight gain, peripheral oedema and CSMO. We recommend that ophthalmologists consider discontinuing glitazones in consultation with the diabetologist before embarking on interventional management such as laser or intravitreal injections.

Multimodality imaging approach to complex regional pain syndrome of the hand following herpes zoster

A 75-year-old man with well-controlled diabetes mellitus (type 2) developed a typical zoster rash over his right scapular region. Therapy included systemic valacyclovir and topic acyclovir. During follow-up a second painful herpetic rash appeared over his right hand. Therapy was integrated with codeine/acetaminophen. Both rash and pain improved but did not disappear. Three weeks later the patient complained of a strong pain and edema in his right hand. Pain was described as constant and deep, burning on the third finger. The right hand and the fingers were swollen; skin was warm, taut and glossy. Strength was reduced in the territory of the ulnar nerve. Serum analysis were normal. Ultrasonography (US) and magnetic resonance imaging (MRI) of both hands were requested. US showed diffuse thickening of the subcutaneous layers. MR demonstrated a small amount of fluid in the metacarpophalangeal joint of the thumb, diffuse soft tissue swelling, and intramuscular edema, more evident at the thenar eminence. Findings suggested complex regional pain syndrome (CRPS). The diagnosis was confirmed by patient's follow-up. To the best of our knowledge this is the first time that both MRI and US were performed in a case of CRPS of the hand following herpes zoster. Since CRPS is possible in subjects with herpes zoster affecting the distal extremity and indicates increased risk for development of post-herpetic neuralgia (PHN) a correct diagnosis is mandatory to prevent such complication. Combined MRI and US examination may help clinicians making an early diagnosis especially when the syndrome appears as a relatively limited syndrome in which naturopathic pain/sensory abnormalities predominate.