Prevalence of Chronic Kidney Disease among Patients Attending a Specialist Diabetes Clinic in Jamaica.

OBJECTIVE: To estimate the prevalence of chronic kidney disease (CKD) among patients attending the University Hospital of the West Indies (UHWI) Diabetes Clinic and to determine the proportion of patients at high risk for adverse outcomes. METHODS: We conducted a cross-sectional study among patients attending the UHWI Diabetes Clinic between 2009 and 2010. Trained nurses administered a questionnaire, reviewed dockets, and performed urinalyses. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Albuminuria was assessed using urine test strips for protein and microalbumin. Chronic kidney disease was defined as an eGFR < 60 ml/min/1.73m2 or albuminuria ≥ 30 mg/g creatinine. Risk of adverse outcome (all-cause mortality, cardiovascular disease and kidney failure) was determined using the Kidney Disease: Improving Global Outcome (KDIGO) 2012 prognosis grid. RESULTS: Participants included 100 women and 32 men (mean age, 55.4 ± 12.9 years, mean duration of diabetes, 16.7 ± 11.7 years). Twenty-two per cent of participants had eGFR < 60 ml/min/1.73m2. Moderate albuminuria (30-300 mg/g) was present in 20.5% of participants and severe albuminuria (> 300 mg/g) in 62.1%. Overall prevalence of CKD was 86.3% (95%CI 80.4%, 92.2%). Based on KDIGO risk categories, 50.8% were at high risk and 17.4% at very high risk of adverse outcomes. CONCLUSION: Most patients at the UHWI Diabetes Clinic had CKD and were at high or very high risk of adverse outcomes. Further studies to determine the burden of CKD in other clinical settings and to identify the best strategies for preventing adverse outcomes in developing countries need to be conducted.

Diabetic foot complications among patients attending a specialist diabetes clinic in Jamaica: prevalence and associated factors.

OBJECTIVES: To estimate the prevalence of diabetic foot complications among patients at a specialist diabetes clinic in Jamaica and identify factors associated with foot complications. METHODS: A stratified random sample of 188 patients were interviewed and examined between 2009 and 2010. Trained nurses obtained demographic and clinical data, measured anthropometrics and performedfoot examinations including inspection for amputations, ulcers or infection and assessment of pain, vibration and pressure perception. RESULTS: Participants included 143 women and 45 men (mean age 56years; mean diabetes duration 16 years). The prevalence of amputations was 8.5% (95% CI 4.5, 12.5%) and was higher among men (22.2%) compared to women (4.2%, p < 0.05). Prevalence of current ulcers and current foot infections was 4.3% and 3.7%, respectively. Overall, 12% ofpatients had at least one of these foot complications. Foot complications were more prevalent among men, patients with high blood pressure (BP > or = 130/80 mmHg) or peripheral neuropathy In multivariable logistic regression models, factors associated with foot complications were: neuropathy (OR 9.3 [95% CI 2.8, 30.3]), high BP (OR 7.9 [1.3, 49.7]) and diabetes duration (OR 1.32 [1.02, 1.72]). CONCLUSION: Approximately one of every eight patients in this specialist clinic had a major foot complication. Associated factors were neuropathy, high blood pressure and longer duration of diabetes.

The effect of antenatal factors and postnatal growth on serum adiponectin levels in children.

Low levels of serum adiponectin (i.e. hypoadiponectinaemia) are a marker of cardiometabolic risk in overweight children. It is not clear whether early-life factors may play a role in the development of hypoadiponectinaemia. We investigated whether antenatal factors and postnatal growth are associated with childhood adiponectin levels. This was an observational study in a birth cohort (Vulnerable Windows Cohort Study). Anthropometry was measured at birth, at 6 weeks, every 3 months up to 2 years and then every 6 months. Fasting glucose, insulin, lipids and adiponectin were measured at a mean age 11.5 years. Data on 323 children were analysed with age- and sex-adjusted multivariate analyses. The sizes of mother, placenta, fetus and newborn were not significantly associated with adiponectin levels. Current weight, body mass index (BMI), fat mass, waist circumference, glucose, insulin resistance [homeostasis model assessment of insulin resistance (HOMA-IR)], triglycerides and systolic blood pressure were inversely related to adiponectin (P < 0.05). Faster growth in BMI during late infancy and childhood was associated with lower adiponectin levels (P < 0.05). After adjusting for current waist circumference, faster growth in BMI during early infancy was positively associated with adiponectin (P < 0.01). Faster growth in BMI during childhood was inversely associated (P < 0.001). These associations were similar after adjusting for HOMA-IR. We concluded that antenatal factors are not determinants of childhood adiponectin levels. Faster growth in BMI during infancy is associated with higher levels, whereas faster rates during childhood are associated with hypoadiponectinaemia. Hypoadiponectinaemia is a marker of a more adverse cardiometabolic profile in Afro-Caribbean children.

The predictive value of urinary vanillylmandelic acid testing in the diagnosis of phaeochromocytoma at the University Hospital of the West Indies.

OBJECTIVE: To investigate the positive predictive value (PPV) of urinary vanillylmandelic acid (VMA) testing in the diagnosis of phaeochromocytoma and to describe the features associated with phaeochromocytoma at the University Hospital of the West Indies (UHWI). SUBJECTS AND METHODS: There were 551 VMA tests performed from January 2003 to June 2009 and 122 tests in 85 patients were elevated (ie > or = 35 micromol/24 hr). The study patients were categorized as: (i) 'surgical' (5 patients who underwent surgery) or (ii) 'non-surgical' (remaining 80 patients). Forty medical charts (out of 85) were reviewed using a standardized data extraction form. RESULTS: The median age for patients in the non-surgical group (with charts reviewed, n = 35) was 36 years (range 9-70) and the median VMA was 43 micromol/24 hr (IQR 38-51). Of these patients, 83% had one or no symptom typical of phaeochromocytoma. In the surgical group the median VMA was 58 micromol/24 hr (IQR 44-101); phaeochromocytoma was confirmed histologically in 3 patients, all of whom had several symptoms typical of catecholamine excess. VMA testing had a PPV of 8%, specificity of 79% and sensitivity of 100%. CONCLUSIONS: VMA testing at UHWI has poor specificity and high sensitivity. These results contrast with international data showing that VMA testing is poorly sensitive but highly specific. The use of assays with higher specificity (eg plasma or urinary metanephrines) may represent a more cost-effective approach to biochemical screening at UHWI.

The effect of feto-maternal size and childhood growth on left ventricular mass and arterial stiffness in Afro-Caribbean children.

We hypothesized that maternal size, fetal size and childhood growth are associated with childhood blood pressure, left ventricular mass (LVM) and arterial stiffness. The Vulnerable Windows Cohort is a longitudinal study of 569 mothers and their offspring. Anthropometry was measured on each child at birth, at 6 weeks, once in 3 months upto 2 years and then every 6 months. Blood pressure and body composition were assessed in 185 children (age 11.5 years) and echocardiography performed. LVM was not associated with maternal size after adjustment for child's weight. LVM was significantly associated with faster growth in childhood and with current weight, fat mass and lean mass. Systolic blood pressure was not related to maternal, fetal or newborn anthropometry, but was positively associated with infant and childhood growth, as well as current body size and fat mass. The pulse pressure/stroke volume ratio (an index of arterial stiffness) was inversely associated with maternal size, placental volume at 20 weeks, fetal size at 35 weeks and childhood growth even after adjustment for current weight. In conclusion, LVM in childhood is positively associated with maternal height, child's current size and rate of growth. Arterial stiffness is inversely related to maternal, fetal and placental size as well as growth throughout childhood.

Predictors of physical activity energy expenditure in Afro-Caribbean children.

BACKGROUND/OBJECTIVES: We hypothesized that maternal size during pregnancy and birth size are determinants of childhood physical activity energy expenditure (PAEE). Also, childhood PAEE is inversely related to adiposity and levels of cardiovascular risk factors. SUBJECTS/METHODS: The Vulnerable Windows Cohort Study is a longitudinal observational study of 569 Afro-Jamaican mothers recruited from the first trimester and their offspring. Anthropometry, bioelectrical impedance, PAEE (using the Actical monitor) and cardiovascular risk factors (blood pressure, fasting glucose, insulin and lipids) were measured in 124 boys and 160 girls at a mean age of 13.2 years. RESULTS: Boys had more fat-free mass (FFM) and expended more energy than girls (12.3±3.3 vs 9.6±2.8 kcal/kg/day; P<0.001). Maternal weight was associated with child's PAEE (r=0.29; P<0.001). PAEE was not significantly associated with birth weight. Maternal weight, after adjusting for child's age and sex, was positively associated with the child's FFM, fat mass and %fat (P-values 0.01). Age- and sex-adjusted PAEE was positively associated with FFM, fat mass and % fat (P-values <0.001), but not after adjusting for current weight. Age- and sex-adjusted PAEE was positively associated with triglycerides, insulin and systolic blood pressure (P-values <0.05), but not after adjusting for weight and height. PAEE was associated with fasting glucose after controlling for age, sex, weight and height (r=-0.12; P=0.02). CONCLUSIONS: Maternal size, but not birth weight, is a determinant of childhood PAEE. PAEE is not strongly associated with childhood body composition, but is inversely related to fasting glucose concentration.

Clinical and laboratory features of youth onset type 2 diabetes in Jamaica.

OBJECTIVES: To assess the frequency of youth onset Type 2 diabetes mellitus (T2D) in Jamaica and the characteristics of youth with this form of diabetes. METHODS: Patients from two major referral hospitals, diagnosed with diabetes before age 25 years and < 6 years prior to the study, were evaluated. Classification was based on the presence of GAD-65 and IA-2 diabetes autoantibodies (AB), fasting (FCP) and stimulated C-peptide (SCP) measurements, serum leptin and clinical phenotype as follows: (i) Type IA diabetes--AB+, (ii) Type lB diabetes--AB- and FCP < 230 pmol/l and/or SCP < 660pmol/l, (iii) Type 2 diabetes - AB- and FCP > 500 pmol/L and or SCP 2 1160 pmol/l (iv) Untypeable diabetes--AB- and FCP 230-500 pmol/l and or SCP 660-1160 pmol/l and (v) Lipoatrophic diabetes--clinical phenotype and serum leptin. RESULTS: Fifty-eight participants (21M, 37F, age 20-8 years, duration of diabetes 2.6-2 years) were enrolled in the study. Using the classification criteria, Type 1 diabetes was the most common form of diabetes: 18 (31%) Type 1A, 18 (31%) Type IB. Overall 22% (13 patients) had T2D. Patients with T2D were more likely to be female, older at diagnosis, obese and have a higher blood pressure when compared to those with Type 1 diabetes. In logistic regression analysis, age of diabetes onset, gender BMI, systolic and diastolic blood pressure were significantly associated with T2D. Obesity measured by BMI was the strongest predictor of T2D. CONCLUSIONS: While Type 1 diabetes was the predominant form of diabetes in this study, a significant proportion of Jamaicans with youth onset diabetes may have T2D. Obesity is the strongest clinical predictor of Type 2 diabetes in the young diabetic patient.

Cardiovascular risk profile in Caribbean youth with diabetes mellitus.

OBJECTIVE: To assess the effect of diabetes mellitus type on conventional and novel cardiovascular risk factors in patients, diagnosed with diabetes from two major referral hospitals in Jamaica, before age 25 years and with diabetes duration < 6 years. METHODS: Participants were classified based on the presence of GAD-65 and IA-2 autoantibodies, C-peptide, leptin and clinical phenotype. Trained observers obtained anthropometric measurements and sitting blood pressure. Fasting blood was taken for glucose, A1c, lipids, high sensitivity C-reactive protein and lipoprotein profile. RESULTS: Fifty-eight participants (21M; 37F age 20 +/- 8 [Mean +/- SD] years, diabetes duration 2.6 +/- 2 years) were enrolled. Thirty-six had Type 1 diabetes (T1D), thirteen Type 2 diabetes (T2D), six were not typed and three had lipoatrophic diabetes. Patients with Type 2 diabetes (T2D) were more obese with a higher systolic blood pressure but a lower A1c than those with Type 1 diabetes (T1D). Total cholesterol, LDL-cholesterol, triglycerides, VLDL, LDL and HDL particle numbers were similar in patients with T1D and T2D. HDL-cholesterol and LDL and HDL particle sizes were lower in patients with T2D but differences were no longer significant after adjusting for BMI. CONCLUSIONS: Risk factors for cardiovascular disease are common in patients with all forms of youth onset diabetes. Clinicians should therefore investigate these risk factors in their patients regardless of diabetes type.

Autoantibodies in Caribbean youth with diabetes mellitus.

The prevalence of diabetes and other autoantibodies in patients with recently diagnosed youth onset diabetes was evaluated. Fifty-seven patients (95% black, age 19 +/- 5 years, 36% male, diabetes duration 2.6 +/- 2.2 years) were clinically diagnosed as having type 1 (n = 35), type 2 (n = 13) and lipoatrophic diabetes (n = 3) while 6 remained untyped. GAD65 was the most common diabetes-associated autoantibody in patients with type 1A diabetes (12/17; 71%). The prevalence of any diabetes-associated autoantibodies decreased with diabetes duration (OR[95%CI]/yr after diagnosis 0.50[0.31,0.82]) and was not associated with age of onset, duration or gender. Rheumatoid factor (13/57; 23%), smooth muscle (6/57; 11%), gastric-parietal cell (5/57; 9%) and thyroid microsomal antibodies (5/57; 9%) were the most frequent non-diabetes associated autoantibodies and were more common in patients with type 1A diabetes. Only one patient had clinical autoimmune disease (hypothyroidism). Type 1A diabetes may constitute up to half the cases of newly diagnosed type 1 diabetes in Jamaican youth and is associated with a higher prevalence of other organ-specific autoantibodies.

Prospective evaluation and characteristics of patients with suspected primary hyperaldosteronism.

Primary hyperaldosteronism (PH), resulting in hypokalaemic hypertension, may be due to an aldosterone-producing adenoma (APA) or bilateral zona glomerulosa hyperplasia. Six patients with suspected PH were identified at the University Hospital of the West Indies and standardized screening was carried out. Plasma renin activity (PRA) and serum aldosterone concentrations (SAC) were measured, followed by confirmatory intravenous saline suppression test. The patients were all women, of median age 48 years (interquartile range, IQR: 41-51.7 years). They tended to be overweight with suboptimal blood pressure control. Median serum potassium was 3.1 mmol/L (IQR 2.7 - 3.3 mmol/l) and kaliuresis was elevated or inappropriately normal. All individuals had suppressed PRA (< 0.6 ng/ml/hr) and elevated SAC (> 30 ng/dl), with SAC/PRA ratios > 50. Five patients had confirmed PH (ie post-saline SAC > 10 ng/dl); PH could not be definitely excluded in the sixth patient (ie post-saline SAC 5 - 10 ng/dl). Imaging studies revealed normal adrenal glands in one patient, unilateral adrenal enlargement in three patients, and unilateral adrenal masses in two patients. Only one of these latter two patients was shown to have an adrenal adenoma on histological examination. In this series, there appears to be fewer cases of the APA subtype of PH than expected. It remains to be seen whether the distribution of PH subtypes in Jamaica is actually different from elsewhere. This, and the cost-effectiveness of different approaches to screening, identification and management of patients suspected of having PH in Jamaica are areas for further study.

Insulinoma induced hypoglycaemia in a Jamaican patient.

Herein reported is the case of a young woman who had hyperinsulinaemic hypoglycaemia which was biochemically consistent with an insulinoma. Initial imaging was negative and definitive treatment was delayed until repeat imaging localized the tumour several years later. This case demonstrates the importance of clinical judgment and biochemical testing in the diagnosis of insulinoma despite negative imaging.

Prospective evaluation and characteristics of patients with suspected primary hyperaldosteronism / Evaluación prospectiva y características de los pacientes con sospecha de hiperaldosteronismo primario

Primary hyperaldosteronism (PH), resulting in hypokalaemic hypertension, may be due to an aldosterone-producing adenoma (APA) or bilateral zona glomerulosa hyperplasia. Six patients with suspected PH were identified at the University Hospital of the West Indies and standardized screening was carried out. Plasma renin activity (PRA) and serum aldosterone concentrations (SAC) were measured, followed by confirmatory intravenous saline suppression test. The patients were all women, of median age 48 years (interquartile range, IQR: 41-51.7 years). They tended to be overweight with suboptimal blood pressure control. Median serum potassium was 3.1 mmol/L (IQR 2.7 - 3.3 mmol/l) and kaliuresis was elevated or inappropriately normal. All individuals had suppressed PRA (< 0.6 ng/ml/hr) and elevated SAC (> 30 ng/dl), with SAC/PRA ratios > 50. Five patients had confirmed PH (ie post-saline SAC > 10 ng/dl); PH could not be definitely excluded in the sixth patient (ie post-saline SAC 5 - 10 ng/dl). Imaging studies revealed normal adrenal glands in one patient, unilateral adrenal enlargement in three patients, and unilateral adrenal masses in two patients. Only one of these latter two patients was shown to have an adrenal adenoma on histological examination. In this series, there appears to be fewer cases of the APA subtype of PH than expected. It remains to be seen whether the distribution of PH subtypes in Jamaica is actually different from elsewhere. This, and the cost-effectiveness of different approaches to screening, identification and management of patients suspected of having PH in Jamaica are areas for further study.

El hiperaldosteronismo primario (HP), que trae como resultado hipertensión hipocalémica, puede tener por causa un adenoma productor de aldosterona (APA) o una hiperplasia bilateral de la zona glomerulosa. Seis pacientes con sospecha de HP fueron identificados en el Hospital Universitario de West Indies, y se llevó a cabo un tamizaje estandarizado. Se realizaron mediciones de la actividad de renina plasmática (ARP) y las concentraciones de aldosterona en suero (CAS), seguidas de una prueba confirmatoria de supresión con salina por vía intravenosa. Los pacientes fueron en su totalidad mujeres, con una edad mediana de 48 años (rango intercuartil, IQR: 41­51.7 años). Tenían tendencia al sobrepreso y un control subóptimo de la presión sanguínea. La mediana de potasio sérico fue 3.1 mmol/L (IQR 2.7­3.3 mmol/l) y la caliuresis fue elevada o inadecuadamente normal. Todos los indi-viduos presentaron ARP suprimida (< 0.6 ng/ml/hr) y CAS elevada (> 30 ng/dl), coproporciones CAS/ARP> 50. A cinco pacientes les fue confirmado HP (ie CAS post-salina > 10 ng/dl); el HP no pudo ser definitivamente excluido en el sexto paciente (ie CAS post-salina 5 ­ 10 ng/dl). Estudios de imagen revelaron glándulas suprarrenales normales en un paciente, agrandamiento suprarrenal unilateral en tres pacientes, y masas suprarrenales unilaterales en dos pacientes. Solamente uno de estos dos últimos pacientes mostró tener un adenoma adrenal al realizarse el examen histológico. En esta serie, parece haber menos casos del subtipo APA de HP que lo esperado. Queda por ver si la distribución de los subtipos de HP en Jamaica es en realidad diferente de la de otras partes. Esto, al igual que el costo-efectividad de los diferentes métodos de tamizaje, identificación y tratamiento de pacientes con sospecha de HP en Jamaica, son áreas que requieren ulterior investigación.

Insulinoma induced hypoglycaemia in a Jamaican patient / Hipoglicemia inducida por insulinoma en un paciente de Jamaica

Herein reported is the case of a young woman who had hyperinsulinaemic hypoglycaemia which was biochemically consistent with an insulinoma. Initial imaging was negative and definitive treatment was delayed until repeat imaging localized the tumour several years later. This case demonstrates the importance of clinical judgment and biochemical testing in the diagnosis of insulinoma despite negative imaging.

Aquí se reporta el caso de una joven que presentó hipoglicemia hiperinsulinémica, bioquímicamente concordante con un insulinoma. La imagen inicial fue negativa y el tratamiento fue retardado hasta que mediante la repetición de la técnica de imaginología años más tarde localizó el tumor. Este caso demuestra la importancia de juicio clínico y las pruebas bioquímicas en el diagnóstico del insulinoma, especialmente frente a la obtención de una imagen negativa.

Cold-induced elevation of forearm vascular resistance is inversely related to birth weight.

Fetal growth retardation has been linked to elevated blood pressure in adult life. This association between birth weight and blood pressure is present in childhood and is amplified with age. However, the mechanisms that underlie this association are largely unknown. We examined the relationship between birth weight and forearm vascular resistance and forearm blood flow in children aged 9-12.7 years. A total of 58 children were randomly selected from a cohort of 1610 born at the University Hospital of the West Indies in Jamaica where adequate antenatal and delivery records were available. Blood pressure, heart rate and forearm blood flow (by venous occlusion plethysmography) were measured at rest and after cold pressor and mental arithmetic tests. There was a significant inverse correlation between birth weight and the change in the vascular resistance for the cold pressor test (r=-0.47; P<0.001) and the mental arithmetic stress test (r=-0.26; P=0.05). The log ratio of vascular resistance under stress to resting decreased by 0.289 units per kg of birth weight (95% CI: 0.145-0.434; P=0.0002). Lower birth weight is associated with increased vascular responsiveness. Increased vascular resistance might be one mechanism linking fetal growth to subsequent elevated blood pressure.

Energetic determinants of glucose tolerance status in Jamaican adults.

As type 2 diabetes mellitus (DM2), obesity and sedentary lifestyles are increasing in developing countries, this observational study investigated the role of physical activity on DM2 in Jamaica. Anthropometry, body composition (by bioelectrical impedance analysis) and glucose tolerance status was assessed in 722 adults in 1993 and 1997. Energy expenditure was estimated in a subset using measured resting energy expenditure in combination with self-reported activity recalls. The rates of impaired glucose tolerance (IGT) were 23.7 and 27.3%, and DM2 were 16.3 and 23.7% among men and women, respectively. After adjusting for body composition, a one-unit increase in physical activity significantly reduced the odds of having diabetes (OR = 0.05; 95% CI: 0.004, 0.66), but not IGT. Hence, decreased physical activity is a significant independent contributor to the high rates of glucose intolerance in Jamaica. Efforts must be directed at minimizing obesity and increasing physical activity in developing countries.

Features of isolated post-challenge hyperglycaemia in Jamaican adults.

Isolated post-challenge hyperglycaemia (IPH) can be defined as a two-hour plasma glucose concentration > or = 11.1 mmol/L with a fasting plasma glucose concentration < 7.0 mmol/L. The aim of this prospective study was to determine the prevalence of IPH in a cohort of Jamaican individuals, and to determine if simple clinical features may predict the presence and subsequent diagnosis of IPH. A cohort of 1694 adults aged 25-74 years without physician-diagnosed diabetes mellitus was randomly selected. An oral glucose tolerance test (OGTT) was performed. Anthropometry, blood pressure and lipid profiles were measured. The prevalence of undiagnosed diabetes mellitus by the 1999 World Health Organization criteria was 6.4%. IPH accounted for 24% of these cases and 1.4% of the entire population. Individuals with IPH were significantly older, with greater body mass index, waist-hip ratio, systolic blood pressure, fasting blood glucose, total cholesterol and LDL-cholesterol than individuals with normal glucose tolerance. Individuals with IPH were not significantly different from individuals with fasting plasma glucose levels > or = 7 mmol/L (i.e. fasting hyperglycaemia) in anthropometry or blood pressure. However, total cholesterol and LDL-C were significantly elevated in the IPH group. OGTT screening of individuals with impaired fasting glucose (i.e. 6.1-6.9 mmol/l) could reduce the IPH group by 50%. Reducing the threshold for fasting glucose to 5.6 mmol/L would correctly classify 87% of the population. We concluded that individuals with IPH have features of the metabolic syndrome, which can aid in selection for screening. OGTT screening of individuals with fasting glucose values of 5.6-6.9 mmol/l is needed to identify IPH.

Features of isolated post-challenge hyperglycaemia in Jamaican adults

Isolated post-challenge hyperglycaemia (IPH) can be defined as a two-hour plasma glucose concentration > or = 11.1 mmol/L with a fasting plasma glucose concentration < 7.0 mmol/L. The aim of this prospective study was to determine the prevalence of IPH in a cohort of Jamaican individuals, and to determine if simple clinical features may predict the presence and subsequent diagnosis of IPH. A cohort of 1694 adults aged 25-74 years without physician-diagnosed diabetes mellitus was randomly selected. An oral glucose tolerance test (OGTT) was performed. Anthropometry, blood pressure and lipid profiles were measured. The prevalence of undiagnosed diabetes mellitus by the 1999 World Health Organization criteria was 6.4. IPH accounted for 24 of these cases and 1.4 of the entire population. Individuals with IPH were significantly older, with greater body mass index, waist-hip ratio, systolic blood pressure, fasting blood glucose, total cholesterol and LDL-cholesterol than individuals with normal glucose tolerance. Individuals with IPH were not significantly different from individuals with fasting plasma glucose levels > or = 7 mmol/L (i.e. fasting hyperglycaemia) in anthropometry or blood pressure. However, total cholesterol and LDL-C were significantly elevated in the IPH group. OGTT screening of individuals with impaired fasting glucose (i.e. 6.1-6.9 mmol/l) could reduce the IPH group by 50. Reducing the threshold for fasting glucose to 5.6 mmol/L would correctly classify 87 of the population. We concluded that individuals with IPH have features of the metabolic syndrome, which can aid in selection for screening. OGTT screening of individuals with fasting glucose values of 5.6-6.9 mmol/l is needed to identify IPH

Intraperitoneal delivery of insulin via mechanical pump: surgical implications.

Between November 1986 and January 2000, 28 patients with insulin-dependent diabetes mellitus were enrolled in the implanted insulin pump study at Johns Hopkins Hospital. An additional two patients underwent pump implantation under compassionate use guidelines due to apparent resistance to subcutaneously administered insulin uptake. The mean patient age was 44 +/- 10.5 years. Eleven patients (39%) were female and the mean duration of diabetes was 25.7 +/- 8.9 years. Diabetic retinopathy, neuropathy, and nephropathy were present in 43%, 25% and 11 % of patients, respectively. The insulin pumps functioned safely for a total of 189 patient years. Mean pump life was 26 +/- 1.2 months. There was no mortality. Morbidity was limited to pump-site infections [n=y (4%) of all pumps placed], one case of pump migration and skin erosion, and one small bowel obstruction associated with the pump catheter. Mean serum hemoglobin AIC levels before and after pump placement were 9.0 +/- 2.9% and 7.5 +/- 0.7% (P=0.0023), respectively. Correspondingly, the mean daily blood glucose levels decreased from l61 +/- 40 mg/dl before placement to 141 +/- 27 mg/dl after pump placement (P=0.0063). Intraperitoneal delivery of insulin by a mechanical pump appears to be an attractive alternative for the treatment of insulin-dependent diabetes mellitus.