A randomized trial of the efficacy and acceptability of a pen injector.

A controlled trial of pen injection of insulin was performed in 78 patients, with assessment of metabolic control and lifestyle. After a 6-week run-in period, during which control was optimized, the patients were randomized, either to stay on a twice daily insulin regimen (n = 37), or to change to a three times daily pen regimen with human ultralente at night (n = 41). Over the 20 weeks, there was no significant change in mean glycosylated haemoglobin (syringe, mean +/- SD, 11.1 +/- 2.5% to 10.9 +/- 2.0%; pen, 11.3 +/- 2.6% to 11.2 +/- 2.0%), in blood glucose profiles or in frequency of hypoglycaemic attacks in either group. A self-completed questionnaire demonstrated high patient satisfaction with the pen injector (NovoPen), 78% for effect on lifestyle and 81% for increased flexibility. Ninety-five percent preferred the pen injector regimen to conventional treatment and stayed on it.

Hidradenitis suppurativa. Glucose tolerance, clinical, microbiologic, and immunologic features and HLA frequencies in 27 patients.

Glucose tolerance, lymphocyte populations, and HLA types were studied in 27 patients with untreated hidradenitis suppurativa; 18 of these patients had a negative history for acne vulgaris. Six patients (22%) had an increased incidence of impaired glucose tolerance. We failed to confirm a previous report of high incidence of flat glucose tolerance curves. The frequency of HLA-A and HLA-B antigen loci and the median values of peripheral blood T lymphocytes were similar to the control population. However, seven patients with moderate or severe clinical disease had a marked reduction in T lymphocytes and these patients had an increased frequency of the HLA antigens, A1 and B8. These results suggest that T lymphocytes may play a role in the pathogenesis of hidradenitis suppurativa and that HLA-A1 and HLA-B8 may predispose the patient to more severe disease, but further research is necessary to clarify this.

Esophageal function in diabetes mellitus with special reference to acid studies and relationship to peripheral neuropathy.

Esophageal function in 20 subjects with diabetes mellitus was assessed using esophageal manometry, 24-hr ambulatory esophageal pH monitoring, and esophageal scintigraphy. Seven patients had abnormal esophageal manometric studies, and this abnormality was significantly associated with peripheral neuropathy. Almost half of the subjects studied demonstrated excessive gastroesophageal acid reflux, but there was no correlation between the likelihood of abnormal reflux and the presence of peripheral neuropathy. Esophageal scintigraphy was relatively insensitive in the detection of abnormal esophageal function in diabetics.

Management of the pregnant diabetic patient--are the pundits right?

Many authorities are currently suggesting specific strategies for optimal obstetrical management of pregnant diabetic patients which involve early admission, frequent monitoring and a high Caesarean section rate. The author suggests that a more conservative approach may be indicated. In support of this contention, he cites from his personal experience of managing over 1,000 diabetic pregnancies during the past 34 years. As there were no therapeutic abortions, the series is consecutive and unmodified. There were no maternal deaths, and the perinatal loss during the 34-year period was 7.4%. In the years 1979-1984 the perinatal loss in 285 viables was 4.5%, and the Caesarean section rate was 25.9%. In 87 primigravidae, the Caesarean rate was 31%.

Cholesterol ester storage disease in an adult presenting with sea-blue histiocytosis.

An adult patient is described with hepatomegaly and sea-blue histiocytes in the bone marrow. A diagnosis of cholesterol ester storage disease was established following enzyme and lipid analyses on liver biopsy and cultured skin fibroblasts. Acid esterase activity was deficient (approx. 5% of controls) in liver and fibroblasts using [14C]-triolein or 4-methylumbelliferyl palmitate as substrates. Cholesterol ester levels were raised about 70-fold in liver, whereas triglyceride levels were only marginally raised. Marked accumulation of cholesterol esters was also demonstrated in cultured fibroblasts. Clinically, the patient responded favourably to phenobarbitone treatment. However, this was not reflected in liver acid esterase or lipid levels.

A review of thyroid disease in pregnancy.

Goitre is common and alterations in biochemical indices of thyroid function are invariable during pregnancy , but thyroid disease, of which hyperthyroidism is the most frequent (0,05% of 72,257 pregnancies at three Dublin Maternity Hospitals, 1979-81) is rare. Good results in terms of perinatal loss (4/112, 3.57%) has been achieved by one of us (MID) in 109 pregnancies using antithyroid drugs alone. Neonatal thyrotoxicosis occurs in one to two percent of babies born to mothers with thyroid disease. The condition is usually transient but a prolonged course may occur in up to 20 percent. Successful pregnancy is possible despite maternal hypothyroidism; three such pregnancies have been managed by one of us (MID). Clinical hyperthyroidism due to trophoblastic disease is very rare and is cured by evacuation of molar tissue. The course of thyroid cancer is not affected by pregnancy.

Pregnancy in the diabetic patient: timing and mode of delivery.

The clinical outcome of 141 consecutive diabetic pregnancies managed in the National Maternity Hospital between January 1, 1979, and October 31, 1982, is described. Patients with gestational diabetes were excluded. There were 12 spontaneous abortions, and the perinatal mortality in 129 viable pregnancies was 31/1000. The malformation rate was 6.4%. Significant perinatal morbidity occurred in 20% of infants. The incidence of cesarean section was 20%. Spontaneous labor after 38 weeks occurred in 30% because there was a deliberate policy to allow all uncomplicated pregnancies to continue to term. This policy had benefits for the infant as well as the mother because there was a notable reduction in neonatal morbidity. Possible explanations of high cesarean section rates in other centers are discussed.