Diabetes information management systems. General practitioner and population reach.

AIM: To assess the extent to which Australian divisions of general practice are facilitating structured management of diabetes. METHOD: The study was conducted over a 12 month period (1998/1999) and involved two postal surveys of Australia's 123 divisions. RESULTS: In both surveys 53% of divisions were implementing a diabetes program, the main components being continuing education of general practitioners (GPs), establishment of information systems, use of guidelines and shared care. In the 30 divisions operating a program for more than 12 months there was a significant increase in the proportion of GPs registering patients (p = 0.03) and the population who were registered with diabetes (p < 0.001). In 43% of divisions, GP reach was greater than 50%. Population reach of more than 50% was achieved by only 17% of divisions. The larger the division, the lower the GP participation rate (p = 0.001) and the lower the population reach (p < 0.001). CONCLUSION: Strategies to facilitate adequate reach of programs in divisions with large populations warrant consideration. This may include the formation of subgroups and support for practices and divisions to implement structured evidence based care systems for the management of chronic diseases in general practice.

Angiotensin converting enzyme inhibition and arterial endothelial function in adults with Type 1 diabetes mellitus.

AIMS: Arterial endothelial dysfunction is a key early event in atherogenesis, and occurs in asymptomatic adults with Type 1 diabetes mellitus (DM). As angiotensin converting enzyme (ACE) inhibitors have been reported to reverse microvascular endothelial dysfunction acutely, we assessed the longer term effect of ACE inhibition on large vessel endothelial physiology in a randomized, crossover double-blind controlled clinical trial. METHODS: Flow-mediated arterial dilatation (FMD), which is largely due to endothelial release of nitric oxide, was assessed by vascular ultrasound in 20 Type 1 DM subjects with known endothelial dysfunction. These subjects, aged 28+/-5 years, were studied before and after 12 weeks oral therapy with either the ACE inhibitor perindopril 4 mg daily or the diuretic hydrene (triamterene 50 mg with hydrochlorothiazide 25 mg) daily. RESULTS: Although perindopril lowered both systolic and diastolic blood pressure by 2.7/3.2 mmHg, respectively (F3,78 = 4.7, P= 0.006; F3,78 = 3.2, P = 0.03), there was no significant effect of either perindopril or hydrene on FMD (baseline FMD before perindopril 4.6+/-2.5%, after 4.1+/-3.4%, baseline FMD before hydrene 5.4+/-3.6%, after 6.0+/-3.3%; F3,78= 1.9, P=0.1). Glycaemic control deteriorated slightly on hydrene whilst lipid levels, heart rate, resting blood flow and the arterial responses to nitroglycerine, a smooth muscle dilator, were unaffected by the treatment given. CONCLUSION: ACE inhibitor therapy for 3 months did not improve arterial endothelial function in Type 1 DM subjects.

Vascular responses by transcutaneous oximetry in adolescents with and without diabetes.

The vascular response of the skin was evaluated by transcutaneous oximetry (TcPO2) in the forearm in 119 adolescents with type I diabetes aged 10.4-19.8 (median 15.3) years, with a duration of diabetes 0.7 to 18.3 (median 7.8) years, and 49 nondiabetic adolescents aged 11.3-18.8 (median 15.5) years. Two different vascular stimuli were used: heating of the probe to 43 degrees C and 5 min of ischemia. Baseline TcPO2 after 13 min of equilibration at a probe temperature of 43 degrees C, postischemic maximum TcPO2, and the postischemic TcPO2 increase were significantly lower in the diabetic group compared to the control group (p = 0.0001, p < 0.0001, and p = 0.0001, respectively). In both the diabetic and the control groups, gender differences were found for baseline TcPO2 (p = 0.0001 and p = 0.0009, respectively) and postischemic maximum TcPO2 (p = 0.0001 and p = 0.005, respectively), the girls having consistently higher values. After controlling for gender by multiple linear regression analysis, duration of diabetes showed a significant effect on postischemic maximum TcPO2 (R2 = 22%, p = 0.02). The postischemic TcPO2 increase was not affected by gender. Lower values for the postischemic TcPO2 increase were related to higher GHb values (R2 = 4%, p = 0.03). Abnormal values for oximetry were associated only with some autonomic nerve function abnormalities. Differences in the vascular response to heat and ischemia as measured by transcutaneous oximetry can be demonstrated between adolescents with type I diabetes and nondiabetic controls, as well as between girls and boys. Lower values in diabetic subjects are weakly associated with diabetes duration and metabolic control, independent of gender.

Prevalence and risk factors for retinopathy in adolescents with type 1 diabetes.

OBJECTIVES: To establish the prevalence of, and risk factors associated with, diabetic retinopathy in an Australian adolescent diabetes clinic population. DESIGN: A prospective longitudinal study; baseline findings. PATIENTS: Two hundred and fifty-five patients with Type 1 (insulin-dependent) diabetes mellitus assessed by our service were studied. Entry criteria were: age 11.0-19.9 years; diabetes duration of at least two years; and gradable fundus photographs of at least one eye. MAIN OUTCOME MEASURES: The presence and severity of retinopathy, as assessed by the grading of stereoscopic fundus photographs. Possible risk factors assessed were age, sex, diabetes duration, pubertal stage, blood pressure, glycaemic control and total cholesterol level. RESULTS: The prevalence of retinopathy was 42%; all of those affected had mild background retinopathy. Highly significant associations were found with glycaemic control and both total and prepubertal duration of diabetes. No associations were found with age, sex, pubertal stage, blood pressure or total cholesterol level. CONCLUSIONS: The high prevalence of early diabetic retinopathy in this group of Australian adolescents is comparable to recent reports from other centres. The significant associations with glycaemic control and duration of diabetes provide further strong evidence for the benefit of optimal glycaemic control during adolescence. Our finding that the prepubertal years of diabetes contribute to the development of retinopathy suggests that glycaemic control before puberty should also be optimised. The planned follow-up of this cohort will establish the risk of progression to vision-threatening retinopathy and allow risk factors to be further evaluated.

Pupillary abnormalities in type I diabetes occurring during adolescence. Comparisons with cardiovascular reflexes.

OBJECTIVE: To evaluate computerized infrared pupillometry for the assessment of autonomic neuropathy in adolescents with type I diabetes. RESEARCH DESIGN AND METHODS: We measured resting pupil diameters and pupillary light reflexes in 142 adolescents with type I diabetes (72 boys and 70 girls, 10.4-19.8 yr of age, duration of diabetes 0.7-18.3 yr) and in 75 nondiabetic control subjects (29 boys, 46 girls, 11.3-19.8 yr of age). All study participants were assessed using four standard cardiovascular tests: maximum-minimum heart rate during deep breathing (mean of three cycles); heart-rate change during a Valsalva maneuver (Valsalva ratio, mean of three maneuvers); lying-to-standing heart-rate change (30:15 ratio); and lying-to-standing BP change. RESULTS: Mean resting pupil diameters were significantly smaller in the diabetic group: 6.28 +/- 0.06 vs. 6.77 +/- 0.11 mm, P < 0.0001); and significantly smaller with greater duration of diabetes (r = -0.29, P = 0.0006) and higher levels of GHb (r = -0.24, P = 0.004). Patients with retinopathy grade 30 or more (Wisconsin 191 grading) had significantly smaller resting pupil diameters: 5.9 +/- 0.16 vs. 6.4 +/- 0.12 mm, P = 0.008). The phasic light reflex as determined by reflex amplitude and maximum constriction velocity was significantly reduced in the diabetic group: 2.27 +/- 0.03 vs. 2.44 +/- 0.04 mm, P = 0.0009; and 6.68 +/- 0.12 vs. 7.24 +/- 0.16 mm/s, P = 0.007). Reduced reflex amplitude was related to a longer postpubertal duration of diabetes (r = -0.18, P = 0.04). We found no association between pupillary and cardiovascular tests. CONCLUSIONS: Infrared computerized pupillometry demonstrates subclinical diabetic autonomic neuropathy as early as adolescence. Its presence seems to be related to longer duration of diabetes and unfavorable metabolic control.