Improvements in the provision of hospital diabetes services in an English region 1988-98.

AIMS: To investigate the changes in provision of hospital-based services for patients with diabetes in an English region over a 10-year period. METHODS: Questionnaires were completed by lead clinicians in hospitals in the Northern region of England in 1988 and repeated in 1998. Information was sought on diabetes service provision including the staff and their working practices. Data are presented to demonstrate changes during the 10 years. RESULTS: During a 10-year period the number of consultants providing specialized diabetes services increased from 16 to 25 (to become one per 126 240 population). Their outpatient sessions changed from 34 to 55.5 per week, with a decrease in nonspecialists providing diabetes services. Reductions occurred in registrar numbers providing sessions from 23 to 15 and senior house officers from 16 to 14. Increases occurred in other health care professionals: diabetes specialist nurses from 19 to 30.3 whole time equivalents (WTEs); dieticians from 16 to 32.3 WTEs and chiropodists from 8 to 23 WTEs. The numbers of specialized clinics and units providing services from diabetes care centres increased. Improved facilities in clinics and access to laboratory tests were available to all units. Diabetes registers came into use in 12 of 16 units, but there have been difficulties in providing funding. 'Out-of-hours' advice has moved towards advising their patients to see their general practitioners or the accident and emergency department of the hospitals. CONCLUSIONS: The number of diabetes professional staff and the provision of specialized diabetes services have increased during a 10-year period in the Northern region of England. However, they still fall far short of recommended staffing levels and services are far from comprehensive in most districts.

The effect of thyroid disease on proinsulin and C-peptide levels.

C-peptide and proinsulin levels were studied in hyper and hypothyroidism both pre and post-treatment and in comparison to matched normals. Fasting C-peptide was reduced in untreated hyperthyroidism (0.4 +/- 0.2 (mean +/- SEM) vs 0.7 +/- 0.2 nmol/l, P less than 0.05) but returned to normal levels following treatment. Fasting proinsulin was elevated in untreated hyperthyroidism (3.6 +/- 0.7 vs 2.4 +/- 0.5 pmol/l, P less than 0.05) also returning to normal after treatment. A similar pattern was seen after oral glucose. The increased proinsulin and reduced C-peptide suggest there may be a defect of proinsulin processing in hyperthyroidism. Fasting C-peptide was reduced in untreated hypothyroidism (0.4 +/- 0.1 vs 0.7 +/- 0.1 nmol/l, P less than 0.05) and also returned to normal after treatment. Fasting proinsulin did not differ significantly from controls. However, proinsulin was reduced after oral glucose (4.7 +/- 0.7 vs. 7.9 +/- 2.0 pmol/l, P less than 0.05) as was C-peptide (0.9 +/- 0.2 vs 2.6 +/- 0.3 nmol/l, P less than 0.05). Both returned to normal after treatment. These findings suggest there are abnormalities of proinsulin and C-peptide levels in both hyper and hypothyroidism.

The treatment of a hyperandrogenic and virilizing state in an elderly female with a synthetic LHRH agonist.

A case of hyperandrogenism and virilization is described in an elderly female. She had elevated testosterone levels, but normal DHEAS and 24-h urinary 17-oxosteroid excretion, suggesting an ovarian tumor. Stimulation and suppression tests, and radioisotopic and radiological scans proved unhelpful in the diagnosis although hyperthecosis of the ovary was later suggested by ultrasound. Testosterone and gonadotropin levels fell during therapy with cyproterone acetate and subsequently ethinyl estradiol. Because of side effects encountered on these drugs, she was treated with a synthetic, slow-release preparation of an LHRH agonist, D-TRP-6-LHRH (Decapeptyl), with symptomatic and biochemical improvement. Long term LHRH agonists might be a valuable treatment for hyperandrogenic states in elderly patients.

Effect of preoperative iodine in patients with Graves' disease controlled with antithyroid drugs and thyroxine.

Thirty-four patients with Graves' disease, first rendered euthyroid with antithyroid drugs (ATD) then given supplementary thyroxine (T4), were randomly allocated to three treatment groups. In Group I ATD and T4 were stopped 10 days before partial thyroidectomy and the patients were treated with Lugol's iodine alone. In Group II the patients were treated up to the time of operation with ATD and T4 alone. In Group III ATD and T4 were continued until the day of operation, but the patients also received 10 days' treatment with Lugol's iodine. Analysis of the results showed that pre-operative iodine therapy in patients with Graves' disease, already rendered euthyroid with ATD and T4, made no difference to the vascularity of the gland, operative blood loss or thyroid follicular size. Over a third of patients in Group I, treated with Lugol's iodine alone for 10 days pre-operatively, had subnormal levels of thyroid hormones at the time of operation and this was also the Group in which the complications of partial thyroidectomy tended to occur. It is concluded that the addition of iodine preoperatively is unnecessary in the patient who is already euthyroid on ATD and T4.

Lipoprotein analyses in varying degrees of glucose tolerance. Comparison between non-insulin-dependent diabetic, impaired glucose tolerant, and control populations.

Atherosclerosis is the major cause of death in diabetic patients. Lipoproteins and lipids are frequently altered in non-insulin-dependent diabetes. These lipoprotein alterations are of interest because of their possible role in the origin of the accelerated atherosclerosis found in diabetes. Because of the link between lipoproteins and diabetes, serum lipids and lipoproteins were measured in 215 middle-aged patients (107 female, 108 male) with varying degrees of glucose tolerance: control subjects, subjects with impaired glucose tolerance (IGT), and patients with non-insulin-dependent diabetes mellitus (NIDDM). In male subjects, levels of fasting total triglycerides were significantly greater in those with NIDDM compared with control subjects. In female subjects, fasting total cholesterol levels were significantly greater in NIDDM compared with IGT. Both high-density lipoprotein (HDL) cholesterol and HDL2 cholesterol values were significantly lower in both sexes with NIDDM compared with control subjects. Low-density lipoprotein (LDL) cholesterol levels were elevated in the male subjects with IGT. No differences in HDL cholesterol or its subfractions were seen in both sexes with IGT compared with control subjects. Bivariate analyses showed that the reduced HDL cholesterol and HDL subfraction levels were most closely associated with both total triglycerides and weight. This study shows that reduced HDL cholesterol and HDL2 cholesterol levels occur in NIDDM, whereas persons with "impaired glucose tolerance" do not have the dramatic alterations in HDL levels.

The effect of long-term metabolic control on free thyroid hormone levels in diabetics during insulin treatment.

Serum concentration of free T3 and, in female patients, FT4, were found to be lower in 20 asymptomatic, moderately-poor or well controlled, diabetics treated with insulin than in a group of non-diabetic subjects. Over a mean 3-month period of the study a significant fall occurred in HbA1 concentration in both groups of diabetics without change in free thyroid hormone levels. The mean capillary blood glucose, fasting free insulin and fasting lipid concentrations, other than high density lipoprotein (HDL) cholesterol, did not change. No correlations were found between the changes in HbA1 and free thyroid hormone concentrations. Improvement in long term metabolic control did not influence free thyroid hormone levels in well controlled and moderately-poor controlled diabetics, taking insulin.

The effects of reverse sequential anti-androgen therapy (cyproterone acetate and ethinyl estradiol) on hematological parameters.

Hematological parameters were studied in female patients receiving reverse-sequential anti-androgen therapy for hirsutism and acne. A significant fall in hemoglobin, total red cell count and packed cell volume occurred after 3-month treatment in 30 patients during the 10-day cyproterone acetate and ethinyl estradiol phase; this change was sustained in 14 patients studied to 12 months. A fall in hemoglobin and packed cell volume alone occurred after 3 months in 31 patients in the ethinyl estradiol phase. Reverse-sequential therapy may influence hemopoiesis by its anti-androgenic action on erythropoiesis, although we found no relationship between changes in hematological parameters and total testosterone levels.

Glucagonoma without cutaneous manifestations.

A 63 year old man presented with features of the glucagonoma syndrome, that is thromboembolic disease, weight loss, raised sedimentation rate, diabetes mellitus, hypoproteinaemia and reduced plasma amino acid levels, but without necrolytic migratory erythema. The plasma glucagon level was raised and the tumour was demonstrated by abdominal CT scan. Immunofluorescent studies of the resected tumour confirmed the diagnosis. The normal tissue zinc status supports the view that necrolytic migratory erythema is related to zinc deficiency.

The use of ultrasound in the localisation of parathyroid glands in parathyroid disorders.

Eleven patients with clinical and biochemical evidence of primary hyperparathyroidism were studied with ultrasonography. In nine patients who were treated surgically, four had predictive ultrasound scans (44% consistency). There was no correlation between the transverse diameters of the glands, as measured from the scans, and either the pathologist's measurements or the mean protein-corrected serum calcium and parathormone (PTH) levels. The investigation failed to identify the only patient with parathyroid hyperplasia. The difficulties encountered and the reasons for the high number of both false positive and false negative scans are discussed. Five patients with parathyroid disorders associated with hyperplasia were also studied and in four patients the enlarged glands were identified. A variation in size between the glands in each patient was noted. No correlation between the total of the transverse diameters and either the protein-corrected serum calcium or PTH levels was found. Reduction in size of the glands in one patient occurred over a 12-month period on treatment and a role for ultrasonography in the follow-up of patients with secondary hyperparathyroidism is discussed.