Vinegar With Meals

OBSERVATIONS

Plasma Interleukin-18 ConcentrationsAre Elevated in Type2 Diabetes

W e read with interest the article byAso et al. (1) showing greaterplasma concentrations of inter-

leukin-18 (IL-18) in type 2 diabetic pa-tients compared with matched controlsubjects. While the authors found no sig-nificant associations between fasting lev-els of IL-18 and homeostasis modelassessment, a measure of insulin resis-tance, they found associations betweenIL-18 and C-reactive protein concentra-tions. Moreover, carotid intima-mediathickness, a validated surrogate measureof atherosclerosis, was greater in diabeticpatients with high IL-18 than in thosewith normal IL-18. As a whole, these dataadd to the mounting evidence that diabe-tes may be regarded as a chronic low-grade inflammatory state.

However, we disagree with the au-thors’ conclusions that “the present studydemonstrated for the first time thatplasma IL-18 concentrations were signif-icantly higher in type 2 diabetic patientsthan in age-matched control subjects”because we have reported similar find-ings in Diabetes Care (2). In that study,we demonstrated that 30 newly diag-nosed, slightly overweight (BMI 26.9 �1.2 kg/m2, means � SD) type 2 diabeticpatients without clinical or instrumental ev-idence of micro- and macrovascular com-plications presented higher circulatingconcentrations of IL-18 compared withnondiabetic subjects matched for sex, age,and body weight (205 � 39 vs. 120 � 25pg/ml, P � 0.01). It is reassuring to see thatthe fasting values of IL-18 in the Japanesediabetic patients studied by Aso et al. (1)were quite similar (203 � 153 pg/ml) tothose of our Caucasian diabetic patients andthat the relation between fasting plasma glu-cose and IL-18 concentrations was presentin both studies (r � 0.31, P � 0.05; r �0.24, P � 0.02, respectively). These resultssuggest that ethnicity does not to play a ma-jor role in these associations.

IL-18 is a potent proinflammatory cy-

tokine reported to play a role in plaquedestabilization (3) and predict cardiovas-cular death in patients with coronary ar-tery disease (4). Although IL-18 isproduced mainly by monocyte/macro-phages, a contribution from adipose tis-sue has recently been suggested (5). In thelight of the evidence that IL-18 circulatinglevels are higher in type 2 diabetic pa-tients than matched nondiabetic subjectsand correlate with fasting glucose levels, itdoes not seem hazardous to hypothesizethat IL-18 may play a role in acute coro-nary syndromes through plaque destabi-lization (6). This working hypothesis,which deserves further investigation, alsofinds support in the observation thatacute hyperglycemia may increase circu-lation levels of IL-18 in both normal sub-jects and patients with impaired glucosetolerance (7).

KATHERINE ESPOSITO, MD

RAFFAELE MARFELLA, MD, PHD

DARIO GIUGLIANO, MD, PHD

From the Department of Geriatrics and MetabolicDiseases, Second University of Naples, Naples, Italy.

Address correspondence to Katherine Esposito,MD, Dipartimento di Geriatria e Malattie del Me-tabolismo, Policlinico Universitario, Piazza L. Mira-glia, 80138 Napoli, Italy. E-mail: [email protected].

© 2004 by the American Diabetes Association.

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References1. Aso Y, Okumura K-I, Takebayashi K,

Wakabayashi S, Inukai T: Relationships ofplasma interleukin-18 concentrations tohyperhomocysteinemia and carotid inti-ma-media wall thickness in patients withtype 2 diabetes. Diabetes Care 26:2622–2627, 2003

2. Esposito K, Nappo F, Giugliano F, Di PaloC, Ciotola M, Barbieri M, Paolisso G, Gi-ugliano D: Cytokine milieu tends towardinflammation in type 2 diabetes (Letter).Diabetes Care 26:1647, 2003

3. Mallat Z, Corbaz A, Scoazec A, Besnard S,Leseche G, Chvatchko Y, Tedgui A: Ex-pression of interleukin-18 in human ath-erosclerotic plaques and relation toplaque instability. Circulation 104:1598–1603, 2001

4. Blankenberg S, Tiret L, Bickel C, Peetz D,Cambien F, Meyer J, Rupprecht HJ: Inter-leukin 18 is a strong predictor of cardio-vascular death in stable and unstableangina. Circulation 106:24–30, 2002

5. Esposito K, Pontillo A, Ciotola M, Di PaloC, Grella E, Nicoletti G, Giugliano D:Weight loss reduces interleukin-18 levelsin obese women. J Clin Endocrinol Metab

87:3864–3866, 20026. Capes SE, Hunt D, Malberg K, Gerstein

HC: Stress hyperglycemia and increasedrisk of death after myocardial infarction inpatients with and without diabetes: a sys-temic overview. Lancet 355:773–778,2000

7. Esposito K, Nappo F, Marfella R, Giugli-ano G, Giugliano F, Ciotola M, QuagliaroL, Ceriello A, Giugliano D: Inflammatorycytokine concentrations are acutely in-creased by hyperglycemia in humans: roleof oxidative stress. Circulation 106:2067–2072, 2002

Similar A1COutcomes in Type 1Diabetic PatientsUndergoingIntensive DiabetesManagement WithPreprandial Rapid-Acting Insulin andEither CSII orGlargine

T he importance of achieving andmaintaining tight glycemic controlin patients with type 1 diabetes is

well known (1). Continuous insulin infu-sion therapy (CSII) has been available formany years, but only recently have re-ports of efficacy with rapid-acting insulinanalogues been published. Similarly,multiple daily injection (MDI) therapy us-ing glargine insulin in conjunction withpremeal rapid-acting insulin is relativelynew (2).

In our diabetes center, all patientswith type 1 diabetes receive the same di-abetes education, including instruction incarbohydrate counting. All patients aregiven the option of either CSII or MDItherapy and are encouraged to use which-ever treatment maintains their blood glu-cose levels as close to normal as possible.

To assess our quality of care, we per-formed a random chart audit of 150 pa-tients. To be included in the analysis,patients had to have type 1 diabetes andbe treated for at least 6 months with either

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272 DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY 2004

CSII using rapid-acting insulin (lispro oraspart) or MDI with insulin glargine withpremeal rapid-acting insulin. Patientswho were pregnant, �15 years of age, orreferred for treatment of severe recurrenthypoglycemia were excluded.

There were 103 patients who met ourcriteria; 58 were on CSII and 45 were onMDI therapy. Glargine was given in themorning in 11%, in the evening in 60%,and twice a day in 29% of patients. Age,duration of diabetes, and incidence ofcomplications were similar in bothgroups. Duration of therapy was 16.0 �5.8 (means � SD) (CSII) vs. 11.6 � 3.8months (MDI) (P � 0.0001). Most recentA1C levels were the same in bothgroups—6.79 � 1.07 (CSII) vs. 6.84 �0.90% (MDI) (P � 0.82). One patient inthe CSII group and two patients in theMDI group had an episode of severe hy-poglycemia. One patient in the CSIIgroup had two episodes of diabeticketoacidosis.

Therefore, both CSII and MDI ther-apy can be used to treat patients with type1 diabetes to target. Prospective data areneeded to confirm the findings of thiscross-sectional analysis.

ANNE PETERS HARMEL, MD

RUCHI MATHUR, MD

From the Department of Endocrinology, Universityof Southern California, Los Angeles, California.

Address correspondence to Dr. Anne Harmel,Endocrinology, University of Southern California,2905 Alma Ave., Manhattan Beach, CA 90266. E-mail: [email protected].

A.P.H. has received honoraria from and served onadvisory boards for NovoNordisk, Aventis, and Lillyand has received research support from Minimedand Aventis. R.M. is a member of the Aventisspeaker bureau.


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References1. The Diabetes Control and Complications

Trial Research Group: The effect of inten-sive treatment of diabetes on the develop-ment and progression of long-termcomplications in insulin dependent dia-betes mellitus. N Engl J Med 329:977–986,1993

2. DeWitt DE, Hirsch IB: Outpatient insulintherapy in type 1 and type 2 diabetes mel-litus: scientific review. JAMA 289:2254–2264, 2003

MatrixMetalloproteinase 2May Be a Marker ofMicroangiopathy inChildren andAdolescents WithType 1 Diabetes

P atients with type 1 diabetes developmicroangiopathic complicationssuch as retinopathy, peripheral neu-

ropathy, and nephropathy (1), which areresponsible for morbidity in adulthood.These complications usually have a pro-longed asymptomatic phase, sometimesstarting in adolescence, characterized byearly subclinical functional and structuralabnormalities (2).

Since matrix metalloproteinases(MMPs) represent a serum marker of vas-cular disease (4), the aim of our study wasto detect MMP-2 and -9 levels and activityin type 1 diabetic children and adolescents.

Twenty-five children and adolescents(13 boys and 12 girls), median age 10.6years (7.9�11.7), were longitudinallyevaluated at clinical diagnosis and duringa 5-year follow-up period.

Peripheral neuropathy, assessed byperoneal motor nerve conduction veloc-ity, developed in 12 patients (6 boys and 6girls) 5.7 years (3.7�6.5) from disease di-agnosis. Background diabetic retinopathy(microaneurisms), assessed by fundusphotography, developed in three patients(two boys and one girl) 6.6, 5.8, and 6.0years from disease diagnosis, respectively.

For control subjects, we randomlychose 19 nondiabetic subjects (9 boys and10 girls), median age 12.0 years(11.0�13.0), from among those report-ing for their first hepatitis B virus vaccina-tion and for the 5-year follow-up visit.

Informed consent was obtained fromall parents. The study was approved bythe local ethics committee. MMP-2 and -9levels and activity were detected by ELISA(Amersham, Pharmacia Biotech); GADantibody, IA-2 antigen, and insulin auto-antibody levels were detected by radioim-munoassay (CIS Bio International).HbA1c levels were evaluated by high-performance liquid chromatography(BioRad). All samples were stored at�80°C until analysis was performed.

No significant correlation was ob-

served among MMP results (both levelsand activity) and chronologic age, auto-antibody, and HbA1c levels.

At baseline, MMP-2 levels were sig-nificantly higher in type 1 diabetic pa-tients and type 1 diabetic patients withcomplications than in nondiabetic sub-jects (1,100 [915–1,326], 1,742 [1,426–1,908], and 907 ng/ml [735–970],respectively), as was MMP-2 activity (31[30–37], 152 [127–176], and 97% [88–101], respectively) (P � 0.0001). No sig-nificant differences were observed forMMP-9 level and activity.

Patients who developed microangio-pathic complications during the follow-upperiod had significantly higher MMP-2activity (P � 0.001) and levels (P � 0.009)than patients without complications.

At 5-year follow-up, MMP-2 levelswere significantly higher in patients withmicroangiopathic complications com-pared with control subjects (1,782[1,741–2,089] and 1,022 ng/ml [897–1,125], respectively; P � 0.0001), as wasMMP-2 activity (116 [104–151] and 46%[37–68], respectively; P � 0.0005) andcompared with patients without compli-cations (1,371 ng/ml [1,197–1,479] and31% [30–34] for levels and activity, re-spectively; P � 0.0001).

MMP-9 levels were significantlylower in patients with microangiopathiccomplications (44 ng/ml [30–63]) com-pared with control subjects (95 ng/ml[58–126]; P � 0.024) and patients with-out complications (82 ng/ml [46 –99];P � 0.0013), but no difference was foundbetween control subjects and patientswithout complications. No difference wasobserved for MMP-9 activity among thethree groups.

The three groups did not differ interms of percentage change of MMP-2 lev-els and MMP-9 activity, but did differ interms of percentage change of MMP-2 ac-tivity (P � 0.0036) and MMP-9 levels(P � 0.009).

Our results allow us to postulate thatMMP-2 may be a good index of severityand stability of microangiopathy, and theliterature reports MMP-9 as a marker ofmacroangiopathy (4).

The relationship between MMPs andthe presence of diabetic complicationsneeds to be elucidated; further studies arenecessary to clarify their possible involve-ment in the onset or progression of dia-betic complications.

Letters

DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY 2004 273

GIUSEPPE DEROSA, MD, PHD1

MARIA ANTONIETTA AVANZINI, BD, PHD2

DIEGO GEROLDI, MD1

ROBERTO FOGARI, MD1

RENATA LORINI, MD3

ANNALISA DE SILVESTRI, BD4

CARMINE TINELLI, MD4

GIORGIO RONDINI, MD5

GIUSEPPE D’ANNUNZIO, MD5

From the 1Department of Internal Medicine andTherapeutics, University of Pavia, Pavia, Italy; the2Research Laboratories for Pediatric Oncohematol-ogy and Immunology, IRCCS Policlinico S. Matteo,Pavia, Italy; the 3Department of Pediatrics, Univer-sity of Genova, G. Gaslini Institute, Genova, Italy;the 4Biometric Unit, IRCCS Policlinico S. Matteo,Pavia, Italy; and the 5Department of Pediatrics,IRCCS Policlinico S. Matteo, Pavia, Italy.

Address correspondence to Giuseppe Derosa,MD, PhD, Department of Internal Medicine andTherapeutics, University of Pavia, P.le C. Golgi,2-27100 PAVIA, Italy. E-mail: [email protected].


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References1. Law GR, McKinney PA, Staines A, Wil-

liams R, Kelly M, Alexander F, Gilman E,Bodansky HJ: Clustering of childhoodIDDM: links with age and place of resi-dence. Diabetes Care 20:753–756, 1997

2. Pomilio MP, Mohn A, Verrotti A, ChiarelliF: Endothelial dysfunction in childrenwith type 1 diabetes mellitus. J Pediatr En-docrinol Metab 15:343–361, 2002

3. Dollery CM, McEwan JR, Henney AM:Matrix metalloproteinases and cardiovas-cular disease. Circ Res 77:863–868, 1995

4. Maxwell PR, Timms PM, Chandran S, andGordon D: Peripheral blood level alter-ations of TIMP-1, MMP-2 and MMP-9 inpatients with type 1 diabetes. Diabet Med18:777–780, 2001

Plasma Adiponectinand Pregnancy-Induced InsulinResistance

L indsay et al. (1) recently publishedan article in Diabetes Care that claimsadiponectin is present in the cord

blood of the offspring of diabetic and non-diabetic pregnant mothers and that itslevel does not correlate with their birthweight and skinfold thickness. Our data,obtained from a case-control study ofnondiabetic women and women with ges-tational diabetes mellitus (GDM), further

support the role of adiponectin in insulinresistance.

We observed significantly decreasedplasma adiponectin levels (7.55 � 2.04�g/ml [means � SD]) using radioimmu-noassay (Linco Research, St. Charles,MO) (intra-assay precision coefficient ofvariation [CV] 3.86%, interassay CV8.47%) in 30 women with GDM, all ofwhom were treated with insulin (aged28.12 � 2.71 years, gestational age27.35 � 6.15 weeks), compared with 40nondiabetic pregnant women tested withoral glucose tolerance test (OGTT) (totalgroup 9.91 � 3.32, P � 0.01, Mann-Whitney, aged 26.91 � 2.65 years, gesta-tional age 23.17 � 10.91 weeks, 15 in thefirst, 12 in the second, and 13 in the thirdtrimester) and 30 age-matched nonpreg-nant nondiabetic women (12.54 � 3.76,P � 0.01, aged 28.42 � 3.48 years). GDMwas diagnosed with a 75-g OGTT accord-ing to the World Health Organization rec-ommendations. In the nondiabeticpregnant group, plasma adiponectin lev-els were significantly lower in the second(9.30 � 2.78) and third (8.06 � 2.44)trimesters compared with women in thefirst trimester (12.30 � 3.20, P � 0.01).After correction for gestational age andBMI, the differences still remained signif-icant. No difference was found in plasmaadiponectin levels before and after insulintreatment in the GDM patients.

In the GDM group, plasma adiponec-tin levels were in a significant negativelinear correlation with serum tumor ne-crosis factor-� (TNF-�) (r � �0.65, P �0.0001, Spearman’s rank correlationtest), leptin (r � �0.75, P � 0.0004),fasting C-peptide concentrations (r ��0.83, P � 0.0001), BMI (r � �0.67,P � 0.0001), and, as an indirect parame-ter of insulin resistance, fasting C-peptide/blood glucose ratio (r � �046,P � 0.0109). The same was found in thetotal group of nondiabetic pregnantwomen (TNF-�: r � �0.56, P � 0.0002;leptin: r � �0.45, P � 0.003; fasting C-peptide: r � �0.70, P � 0.0001; BMI:r � �0.51, P � 0.0007; C-peptide–to–blood glucose ratio: r � �0.43, P �0.0046). In the nonpregnant nondiabeticcontrol subjects, negative correlationswith serum leptin (r � �0.44, P �0.0134), fasting C-peptide concentra-tions (r � �0.46, P � 0.01), and BMIs(r � �0.57, P � 0.0008) were found.

Maternal plasma adiponectin levelscorrelated positively with the body weight

of the neonates, in both the GDM (new-borns, n � 30, 13 boys and 17 girls, ma-ternal gestational age at delivery 38.22 �0.51 weeks, 14 Cesarean sections, bodyweight 3,151 � 672 g, centile 55.87 �30.29%, r � 0.4345 Spearman’s rankcorrelation test, P � 0.0164) and the non-diabetic pregnant group (n � 20, 9 boysand 11 girls, gestational age at delivery38.92 � 0.32 weeks, 6 Cesarean sections,body weight 3,562 � 359 g, centile63.46 � 15.80%, r � 0.6124, P �0.0041) after the correction for gesta-tional age.

There is an association between adi-ponectin concentrations and insulin sen-sitivity. The protein is exclusivelyproduced in adipocytes. Its inverse rela-tionship with the increasing BMI, fastingC-peptide concentrations, and C-peptide–to–blood glucose ratio of nondi-abetic pregnant women and patients withGDM underlines the importance of adi-pose tissue and its secreted products,such as adiponectin, in pregnancy-induced insulin resistance. The negativecorrelation between TNF-�, leptin, andadiponectin may suggest a negative regu-latory role of these cytokines in the ex-pression and secretion of adiponectin.The peroxisome proliferator–activated re-ceptor system in adipocytes is a knownregulator of fat cell differentiation and theproduction of TNF-�, leptin, and adi-ponectin (2). On the other hand, TNF-�may inhibit peroxisome proliferator–activated receptor function in adipocytes.Through this mechanism, the TNF sys-tem may have a suppressive effect on adi-ponectin production during the course ofpregnancy (3).

Maternal insulin resistance and adi-pocytokines may influence different an-thropometric parameters (body weight,body length, and head circumference) ofthe neonates. TNF-� and leptin were in anegative correlation with these parame-ters in neonates of mothers with GDM (4).However, analyzing the relationship be-tween these parameters and maternalplasma adiponectin levels, the significantpositive linear correlation between adi-ponectin, and the neonatal body weight,both in GDM and nondiabetic pregnantwomen, suggests a regulatory role of theprotein in neonatal development.

KAROLY CSEH, MD, DSC1

EVA BARANYI, MD, PHD2

ZSOLT MELCZER, MD3

Letters


EDIT KASZAS, MD1

EVA PALIK, MD4

GABOR WINKLER, MD, DSC5

From the from 11st Department of Internal Medi-cine, Karolyi Hospital, Budapest, Hungary; the 2Na-tional Health Center Diabetes Outpatient Unit,Budapest, Hungary; the 32nd Department of Obstet-rics and Gynecology, Budapest, Hungary; the 43rdDepartment of Internal Medicine, Semmelweis Uni-versity, Budapest, Hungary; and the 5Department ofInternal Medicine II, St. John’s Hospital, Budapest,Hungary.

Address correspondence to Gabor Winkler, MD,DSc, Head of the Department of Internal MedicineII, St. John’s Hospital, Budapest, Dios arok 1-3,Hungary. E-mail: [email protected].


Acknowledgments— This work was sup-ported by grants ETT 03/2000 and ETT 015/2003 from the Ministry of Health.

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References1. Lindsay RS, Walker JD, Havel PJ, Hamil-

ton BA, Calder AA, Johnstone FD, on be-half of the Scottish Multicentre Study ofDiabetes in Pregnancy: Adiponectin ispresent in cord blood but is unrelated tobirth weight. Diabetes Care 26:2244–2249, 2003

2. Chandran M, Phillips SA, Ciaraldi T,Henry RR: Adiponectin: more than justanother fat cell hormone? Diabetes Care26:2442–2450, 2003

3. Winkler G, Cseh K, Baranyi E, Melczer Z,Speer G, Hajos P, Salamon F, Tury Z, Ko-vacs M, Vargha P, Karady I: Tumor necro-sis factor system in insulin resistance ingestational diabetes. Diabetes Res ClinPract 56:93–99, 2002

4. Cseh K, Baranyi E, Melczer Z, CsakanyGM, Speer G, Kovacs M, Gero G, Karady I,Winkler G: The pathophysiological influ-ence of leptin and tumor necrosis factorsystem on maternal insulin resistance:negative correlations with anthropomet-ric parameters of neonates in gestationaldiabetes. Gynecol Endocrinol 16:453–460,2002

Vitiligo AssociatedWith SubcutaneousInsulin LisproInfusion in Type 1Diabetes

V itiligo vulgaris, the loss of skin pig-mentation, is known to occur withincreased frequency in patients

with type 1 diabetes and, based on a pre-ponderance of circumstantial evidence(1), presumed to be of autoimmune etiol-ogy. For example, 20% of 39 patientswith vitiligo were found to have diabetesin a Romanian community study (2), and

9% of 457 consecutive Italian patientswith diabetes had vitiligo in another study(including 54% of the type 1 patients) (3).However, the factors that can specificallyprecipitate vitiligo in type 1 diabetes arenot known. Here, we present a case offocal vitiligo vulgaris precipitated and ex-acerbated by the subcutaneous infusionof the human insulin analog, insulinlispro.

A 32-year-old female with a 19-yearhistory of type 1 diabetes began continu-ous subcutaneous insulin infusion (CSII)therapy 3.5 years before presentation. Shehad previously noted stable vitiligo vul-garis of the elbows and knees for �10years. After initiating CSII therapy withinsulin lispro, she developed two sym-metrical patches of depigmentation onher abdomen �6 cm in diameter sur-rounding the insulin infusion sites bilat-erally (Fig. 1). There was no knownantecedent inflammatory skin disease.

The antibody response to rapid-acting human insulin analogs has beenshown to be similar in magnitude to thattriggered by human insulin (4,5). Mostcutaneous allergies to insulin, however,manifest as IgE-mediated wheal and flareresponses (6). In this case, the focal vitil-igo was apparently induced by insulin in-fusion, raising questions about itspathogenesis. Possible mechanisms in-

Figure 1—Vitiligo vulgaris on the abdominal skin of a young woman associated with the subcutaneous infusion of insulin lispro.

Letters


clude a postinflammatory, Koebner-typeresponse in which depigmentation occursin areas of mild injury or inflammation,but no evidence of skin damage or inflam-mation was present in the lesions. Morelikely, a local allergic reaction to the con-stituents of the insulin (or possibly theinfusion catheter) may have precipitatedan inflammatory response culminating indepigmentation. Other scenarios includemolecular mimicry between the insulinlispro molecule and various melanocytesurface antigens, resulting in melanocytedestruction.

This case represents the first report oflispro insulin analog infusion as an etio-logic factor in the development of focalvitiligo in diabetes. Aside from the stan-dard treatment options for vitiligo, otheroptions in this case include changing thetype of insulin used, changing the type ofinfusion catheter used, and/or changingthe site of insulin infusion. The patientwas changed to insulin aspart and told toplace her infusion catheter into an entirelynew area of abdominal skin. Upon fol-low-up 6 months later, however, the orig-inal vitiligo lesions remained unchangedand new lesions were forming around thenew infusion sites.

MARK R. BURGE, MD1

J. DAVID CAREY, MD2

From the 1Department of Medicine, University ofNew Mexico Health Science Center, Albuquerque,New Mexico; and the 2Albuquerque DermatologyAssociates, Albuquerque, New Mexico.

Address correspondence to Mark R. Burge, MD,Associate Professor of Medicine, University of NewMexico School of Medicine, Department of Medi-cine/Endocrinology—5ACC, Albuquerque, NM87131. E-mail: [email protected].


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References1. Kemp EH, Waterman EA, Weetman AP:

Autoimmune aspects of vitiligo. Autoim-munity 34:65–77, 2001

2. Birlea S, Pop A, Haller M, Maier N, DasPK: PP-31 A clinical and epidemiologicalstudy on a small community with a prev-alence of vitiligo (Abstract). Pigment CellRes 16:603, 2003

3. Romano G, Moretti G, Di Benedetto A,Giofre C, Di Cesare E, Russo G, CalifanoL, Cucinotta D: Skin lesions in diabetesmellitus: prevalence and clinical correla-tions. Diabetes Res Clin Pract 39:101–106,1998

4. Fineberg NS, Fineberg SE, Anderson JH,Birkett MA, Gibson RG, Hufferd S: Immu-

nologic effects of insulin lispro [Lys (B28),Pro (B29) human insulin] in IDDM andNIDDM patients previously treated withinsulin. Diabetes 45:1750–1754, 1996

5. Lindholm A, Jensen LB, Home PD, RaskinP, Boehm BO, Rastam J: Immune re-sponses to insulin aspart and biphasic in-sulin aspart in people with type 1 and type2 diabetes. Diabetes Care 25:876–882,2002

6. Gonzalo MA, De Argila D, Revenga F,Garcia JM, Diaz J, Morales F: Cutaneousallergy to human (recombinant DNA) in-sulin. Allergy 53:106–107, 1998

Aseptic PeritonitisRevealed ThroughRecurrent CatheterObstructions in Type1 Diabetic PatientsTreated withContinuousPeritoneal InsulinInfusion

R eiterated catheter obstructionsthwart improved diabetes controlwith continuous peritoneal insulin

infusion (CPII) from implantable pumps(1). Occlusions, from either fibrin clots oromental encapsulations, are promoted byCPII and diabetes duration and insulininstability (2,3). Pathological analysis ofencapsulation tissues disclosed, amongpredominant collagen fibrosis, inflamma-tory reactions, including lymphocytesand amyloid-like deposits reacting to an-ti-insulin antibodies, surrounded by his-tiocytes or giant cells (2). However,catheter obstructions were not related tohigh plasma anti-insulin antibody levels(4,5). Enhanced migration toward insulinand the chemotactic peptide formyl-methionyl-leucyl-phenylalanine ofmonocyte-issued macrophages fromthree patients with previous catheter en-capsulations suggested that higher mac-rophage chemotaxis might promote theseevents (5). We report two unique obser-vations of aseptic peritonitis with pre-dominant macrophagic reactions thatoccurred in patients using implantablepumps with recurrent catheter obstruc-tions, supporting this hypothesis.

Case 1 is a 54-year-old woman, type 1diabetes duration 42 years. After 2 years

of CPII, she received an implantablepump (model MIP 2007; MiniMed, Syl-mar, CA) in July 2000. In December2000, a fibrin clot occluding catheter tipwas removed using laparoscopy. Ashorter replacement catheter was im-planted when obstruction recurred inMay 2001. Following surgery, CPII wasineffective and ketosis required intrave-nous insulin delivery. Computerized to-mography scanning identified peritonealfluid accumulation and diffuse thickeningof mesenteric fat, suggesting possible neo-plasic peritonitis. Laparoscopy revealeddiffuse peritoneal inflammation but nocancer node. Neither bacterial infectionnor cancer cells were found in peritonealfluid, but a high content of fibrin, mono-cytes, lymphocytes, and macrophageswere found. The catheter tip stuck to theperitoneum and was surrounded by pre-dominant macrophages among an inflam-matory cell reaction. CPII becameeffective again only after high doses of oralprednisone (1 mg � kg�1 � day�1). Pred-nisone (15 mg/day) remained necessaryto keep CPII effective, with each steroidinterruption resulting in recurrent hyper-glycemia. No catheter obstruction re-curred thereafter.

Case 2 is a 62-year-old man, type 1diabetes duration 30 years, using CPIIsince 1981 with previous implantablepump catheter encapsulations from1990. He received a new implantablepump in December 2000. In June 2002,the catheter encapsulation needed peel-ing by laparoscopy. Removed tissueshowed a predominantly macrophagic in-flammatory reaction, including somelymphocytes, giant cells, and pseudo-amyloid material among collagen fibrosis.Catheter obstruction recurred in January2003. Laparoscopy revealed diffuse peri-toneal inflammation with whitish urticar-ia-like plaques. Pathological analysisidentified granulomatous peritoneal le-sions with histiocytes, fibrosis, and pseu-do-amyloid material unlabeled by anti-insulin antibodies. Similar histiocyticreaction was found in collagen fibrosissurrounding the catheter tip. Prednisone(20 mg/day) was prescribed to treat peri-toneal reaction until pump replacementin July 2003 because an unexpectedpump failure precluded assessment of ste-roid effect on CPII efficacy. CPII was ef-fect ive with the new pump, andprednisone could be stopped 2 weeks af-ter surgery.

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In our experience with 87 patients us-ing an implantable pump since 1990,such generalized peritoneal reactionshave not been seen previously or reportedelsewhere. In both cases, a predominantmacrophagic reaction was disclosed, aspreviously described in encapsulation tis-sues (2,5). Long-term CPII or diabeteslikely promoted these events in patientswho appear to be specifically reactive toperitoneal infusion. Because pseudo-amyloid material in Case 2 could not belabeled by anti-insulin antibodies, contri-bution of insulin in peritoneal macroph-agic reaction cannot be argued. Werecommend that recurrent implantablepump catheter obstructions should be ex-plored by laparoscopy for peritoneal ex-amination. Although steroid treatmentappeared to be effective on peritonitis andrestored CPII efficacy, continuation ofCPII in such cases must be debated.

ERIC RENARD, MD, PHD

ISABELLE RAINGEARD, MD

GUY COSTALAT, MD

DOMINIQUE APOSTOL, MD

DOMINIQUE LAUTON, MD

FRANCOISE BOULET, MD

JACQUES BRINGER, MD

From the Endocrinology Department, LapeyronieHospital, Montpellier, France.

Address correspondence to Eric Renard, MD,PHD, Endocrinology Department, Lapeyronie Hos-pital, F 34295 Montpellier cedex 5, France. E-mail:[email protected].


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References1. Broussolle C, Jeandidier N, Hanaire-

Broutin H, the Evadiac Study Group:French multicentre experience with im-plantable insulin pumps. Lancet 343:514–515, 1994

2. Renard E, Baldet P, Picot MC, Jacques-Apostol D, Lauton D, Costalat G, BringerJ, Jaffiol C: Catheter complications withimplantable systems for peritoneal insulindelivery: an analysis of frequency, predis-posing factors, and obstructing materials.Diabetes Care 18:300–306, 1995

3. Renard E, Bouteleau S, Jacques-ApostolD, Lauton D, Boulet-Gibert F, Costalat G,Bringer J, Jaffiol C: Insulin underdeliveryfrom implanted pumps using peritonealroute: determinant role of insulin-pumpcompatibility. Diabetes Care 19:812–817,1996

4. Olsen CL, Chan E, Turner DS, Iravani M,Nagy M, Selam JL, Wong ND, Waxman K,Charles MA: Insulin antibody responses

after long-term intraperitoneal insulin ad-ministration via implantable programma-ble insulin delivery systems. Diabetes Care17:169–176, 1994

5. Kessler L, Tritschler S, Bohbot A, Sigrist S,Karsten V, Boivin S, Dufour P, Belcourt A,Pinget M: Macrophage activation in type 1diabetic patients with catheter obstruc-tion during peritoneal insulin deliverywith an implantable pump. Diabetes Care24:302–307, 2001

Comparative Studyof Prognostic Valuefor Coronary DiseaseRisk Between theU.K. ProspectiveDiabetes Study andFramingham Models

A ccording to epidemiological andangiographic studies (1,2), diabeticpatients present a two to four times

greater risk for coronary artery disease(CAD) than nondiabetic individuals.

The Framingham model (3) estimates10-year CAD risk based on the traditionalrisk factors, including age, sex, HDL andLDL cholesterol, hypertension, andsmoking. In addition to these risk factors,the U.K. Prospective Diabetes Study(UKPDS) model, designed for peoplewith type 2 diabetes (4), incorporatesmore specific variables, such as HbA1c,age at diabetes diagnosis, and diabetesduration.

The aim of this analysis was to com-pare the accuracy of these models in theprediction of 10-year risk for CAD in di-abetic patients.

Clinical information related to theabove factors was retrieved from our dia-betic outpatient database with 10-yearclinical follow-up. Of the 339 participants(53% women and 47% men), 108 (32%)presented with CAD. We did not observeany statistically significant differences intheir demographic characteristics. The di-agnosis of CAD was established by coro-nary angiography. Diabetic patientswithout a history of CAD were not con-sidered to have CAD; however, if they hadpresented symptoms of CAD, they wouldundergo a treadmill test and myocardiumscanning with Th 201 (single photonemission computerized tomography).

Receiver operating characteristic

curves were constructed for both modelsto evaluate their accuracy in the predic-tion of 10-year CAD risk (measured bythe area under the receiver operatingcharacteristic curve, range 0.5–1).

Areas under the curves were 0.61(P � 0.01) and 0.65 (P � 0.01) forUKPDS and Framingham, respectively.The comparative analysis showed similarsensitivity (56 vs. 55%) between thesemodels. A higher specificity in the Fram-ingham model (65 vs. 56%) was noted.We also noted higher positive and nega-tive predictive values of Framingham, 43and 75%, respectively, compared with 37and 73% in the UKPDS.

According to the results of this analy-sis, the Framingham model seems to bemore appropriate for the prediction ofCAD risk in diabetic patients. An expla-nation for this could be the small contri-bution of UKPDS variables (HbA1c, age atdiabetes diagnosis, and diabetes dura-tion) to the 10-year risk for CAD.

Regarding the relation of HbA1c to thedevelopment of CAD, data from theUKPDS 23 (5) indicated that for each 1%increment in HbA1c there was a 1.11-foldincreased risk of CAD, whereas for each1-mmol/l increment in LDL concentra-tion there was a 1.57-fold increased risk.It should also be noted that an HbA1c in-crement from 6.5 to 11% (6) just doublesthe risk of myocardial infarctions,whereas an HbA1c increment of 1% mul-tiplies the risk of microangiopathic inci-dents by 10. Additionally, recent studies(7,8) have confirmed the significant roleof traditional risk factors in the predictionof CAD in contrast to the poor prognosticvalue of blood glucose concentration. Inconclusion, comparing the above data,the association of HbA1c with the risk forCAD is considered rather weak.

Regarding the contribution of age atdiabetes diagnosis and diabetes durationto the 10-year risk, it is well known that inthe early stages of the disease, when thesymptoms are not apparent, diabetes isfrequently underdiagnosed. Moreover, insome cases, although diabetes complica-tions (micro- and/or macrovascular) havealready presented, the existence of diabe-tes is still ignored by the patient. How-ever, it is difficult to determine the exactage of diabetes onset and duration. There-fore, the evaluation of the exact durationof diabetes is potentially inaccurate,which may result in underestimation ofCAD risk.

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Future efforts should focus on the ul-timate estimation and evaluation of theprognostic value of both models usingrandomized, prospective, comparativestudies.

IOANNIS D. PROTOPSALTIS, MD, PHD

PANAYIOTIS A. KONSTANTINOPOULOS, MD

ALEXANDROS V. KAMARATOS, MD, PHD

ANDREAS I. MELIDONIS, MD, PHD

From the Diabetes Center, Tzaneio General Hospitalof Piraeus, Piraeus, Greece.

Address correspondence to Dr. Ioannis D. Pro-topsaltis, Tzaneio General Hospital of Piraeus, Dia-betes Center, Zanni & Afentouli 1, Piraeus, 185 36,Greece. E-mail: [email protected].


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References1. Melidonis A, Dimopoulos V, Lampidakis

E, Hatzisassavas J, Kouvaras G, Stefanidis,Foussas S: Angiographic study of coro-nary artery disease in diabetic patients incomparison with nondiabetic patients.Angiology 12:997–1006, 1999

2. Kannel WB, McGee DL: Diabetes and car-diovascular disease: the Framinghamstudy. JAMA 241:2035–2038

3. Wilson PWF, D’Agostino RB, Levy D, Be-langer AM, Silbershatz H, Kannel WB:Prediction of coronary heart disease riskusing risk factor categories. Circulation97:1837–1847, 1998

4. Stevens RJ, Kothari V, Adler AI, StrattonIM, United Kingdom Prospective Diabe-tes Study (UKPDS) Group: The UKPDSrisk engine: a model for the risk of coro-nary heart disease in type II diabetes (UK-PDS 56). Clin Sci (Lond) 101:671–679,2001

5. Turner RC, Millns H, Neil HAW, StrattonIM, Manley SE, Matthews DR, HolmanRR: Risk factors for coronary artery dis-ease in non-insulin dependent diabetesmellitus: United Kingdom Prospective Di-abetes Study (UKPDS 23). BMJ 316:823–828, 1998

6. Stratton IM, Adler AI, Neil HA, MathewsDR, Manley SE, Cull CA, Hadden D,Turner RC, Holman RR: Association ofglycaemia with macrovascular and micro-vascular complications of type 2 diabetes(UKPDS 35): prospective observationalstudy. BMJ 321:405–412, 2000

7. Stern MP, Fatehi P, Williams K, HaffnerSM: Predicting future cardiovascular dis-ease: do we need the oral glucose toler-ance test? Diabetes Care 25:1851–1856,2002

8. Meigs JB, Nathan DM, D’ Agostino RB,Wilson PWF: Fasting and postchallengeglycemia and cardiovascular risk: the Fra-mingham Offspring Study. Diabetes Care25:1845–1850, 2002

The BiologicalVariation of SexHormone–BindingGlobulin in Type 2Diabetes

Implications for sex hormone–binding globulin as a surrogatemarker of insulin resistance

Quantitative determination of insulinresistance is technically demandingand expensive. We have recently

shown (1) that insulin resistance deter-mined using the homeostasis model as-sessment of insulin resistance (HOMA-IR) has a significantly greater biologicalvariability in individuals with type 2 dia-betes than in healthy ones. A surrogatemarker of insulin resistance that was re-producible, stable, and easily measuredwould be invaluable for both research andclinical practice, particularly for followinginsulin-sensitizing therapy, such as met-formin and the thiazolidinediones. A lowsex hormone–binding globulin (SHBG)concentration reflects hyperinsulinemicinsulin resistance and has been proposedas such a surrogate measure (2–4). Thisstudy aimed to compare the biologicalvariation of SHBG and insulin resistancein type 2 diabetes to determine the poten-tial for SHBG as a surrogate marker of in-sulin resistance in type 2 diabetes.

Subjects were initially recruited for astudy to assess the biological variation ofinsulin resistance in individuals with type2 diabetes (1). Postmenopausal Cauca-sian subjects (n � 12) with type 2 diabe-tes (median age 62 years, range 50–73,and median BMI 31.6 kg/m2, range 25.1–35.7) and 11 age- and weight-matched,healthy, postmenopausal Caucasian con-trol subjects (median age 56 years, range48 –70, and median BMI 32.0 kg/m2,range 26.6–44.4) participated. Fastingblood samples were collected at 4-day in-tervals on 10 consecutive occasions.Plasma glucose was analyzed in singletonwithin 4 h of collection. Duplicate sam-ples (i.e., two per visit) of stored serumwere randomized and then analyzed (in asingle continuous batch using a singlebatch of reagents) for SHBG and insulin(on a DPC Immulite 2000 analyzer; Euro/DPC, Llanberis, U.K.). The coefficient of

variation for serum insulin and SHBG was10.6% and 8.5%, respectively. The ana-lytical sensitivity of the insulin assay was 2�U/ml, and there was no stated cross-reactivity with proinsulin. All subjectswere asked to have an unrestricted dietand instructed not to modify their eatingpatterns during the sampling period. Thesubjects were also advised to refrain fromexcessive physical exercise and alcoholbefore each fasting blood test.

The insulin resistance was calculatedusing the HOMA-IR method (HOMA-IR � [insulin � glucose]/22.5). Biovari-ability data were analyzed by calculatinganalytical, within-subject, and between-subject variances (5,6). The critical differ-ence (i.e., the smallest percentage changeunlikely to be due to biological variabil-ity) between two consecutive SHBG sam-ples in an individual subject with type 2diabetes was calculated using the formula2.77(CVI) (5), where CVI is the within-subject biological coefficient of variation.

Figure 1 shows the mean and range ofHOMA-IR and SHBG for the individualsin the two groups. In the type 2 diabeticgroup, SHBG concentrations were lowerthan those in the control subjects(mean � SD; 38.8 � 18.2 vs. 42.2 � 17.1nmol/l, P � 0.001), the insulin levelswere higher (13.1 � 5.4 vs. 9.42 � 3.4�IU/ml, P � 0.0001), and the HOMA-IRgreater (4.33 � 2.3 vs. 2.11 � 0.79 units,P � 0.0001).

An inverse relationship was demon-strated between SHBG concentration andHOMA-IR in the group with type 2 dia-betes (r � �0.32, P � 0.001) and in con-trol subjects (r � �0.28, P � 0.003). Theintraindividual variance of SHBG rose lin-early with increasing SHBG concentra-tions (r � 0.82, P � 0.0001), and afteraccounting for analytical variation, theintraindividual variation of SHBG for thegroup with type 2 diabetes was similar tothat seen in the control group (mean 2.35vs. 2.44 nmol/l, P � 0.93). In contrast,the mean intraindividual variation of se-rum insulin (mean 2.38 vs. 1.45 �U/ml,P � 0.016) and HOMA-IR (mean 1.05 vs.0.15 units, P � 0.001) was significantlygreater in the group with type 2 diabetesthan in the control subjects.

The critical difference between twoconsecutive SHBG samples in an individ-ual patient with type 2 diabetes was14.5% at any initial level of SHBG, indi-cating that a subsequent sample must rise

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Figure 1— Means (range) of insulin resistance and SHBG (unadjusted for analytical variation) in control subjects and type 2 diabetic subjects.

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or fall by 14.5% to be considered signif-icantly different from the first.

The subjects with type 2 diabeteswere hyperinsulinemic, insulin resistant,and demonstrated lower SHBG levelsthan control subjects. However, the morevariable fasting insulin/insulin resistancein the subjects with type 2 diabetes wasnot reflected by similarly more variableSHBG readings compared with those ofthe control subjects. This suggests that alow SHBG concentration is a stable inte-grated marker of insulin resistance andtherefore has the characteristics to be po-tentially used as a surrogate measure ofinsulin resistance, perhaps in monitoringthe response of an individual to insulinsensitizers. However, although SHBG lev-els differed significantly between thosewith and without diabetes, the absolutemean difference was small, indicating thatmeasurement of SHBG cannot be used asa simple test for insulin resistance in dia-betes. A much larger study is required toinvestigate whether diagnostic cutoff val-ues for low SHBG concentrations and in-sulin resistance in type 2 diabetes can beestablished. Without these parameters,the utility of a low SHBG concentration asa reflection of insulin resistance in type 2diabetes will be for the serial monitoringof insulin resistance in individuals ontreatment after the presence of insulin re-sistance has been established by conven-tional means. The low variation of SHBGcompared with insulin resistance is likelydue to the inherent temporal volatility ofinsulin and glucose levels as comparedwith SHBG. In conclusion, in the evalua-tion of serial measurements of SHBG con-centration for an insulin-resistantindividual with type 2 diabetes, such asbefore and after therapeutic intervention,the critical difference value of 14.5% re-ported here will identify whether anychange is beyond that of natural biologi-cal variation and therefore a trueresponse.

VIJAY JAYAGOPAL, MRCP1

ERIC S. KILPATRICK, MRCPATH2

PAUL E. JENNINGS, FRCP3

STEVE HOLDING, PHD2

DAVID A. HEPBURN, FRCP1

STEPHEN L. ATKIN, FRCP1

From the 1Department of Medicine, University ofHull, Hull, U.K.; the 2Department of Clinical Bio-chemistry, Hull Royal Infirmary, Hull, U.K.; and the3Department of Medicine, York Hospital, York, U.K.

Address correspondence to Dr. V. Jayagopal, Mi-

chael White Centre for Diabetes and Endocrinology,Brocklehurst Building, Hull Royal Infirmary, 220-236 Anlaby Road, Hull, HU3 2RW, U.K. E-mail:[email protected].


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References1. Jayagopal V, Kilpatrick ES, Jennings PE,

Hepburn DA, Atkin SL: Biological varia-tion of homeostasis model assessment–derived insulin resistance in type 2diabetes. Diabetes Care 25:2022–2025,2002

2. Nestler JE: Sex hormone-binding globu-lin: a marker for hyperinsulinemia and/orinsulin resistance? (Editorial). J Clin Endo-crinol Metab 76:273–274, 1993

3. Pugeat M, Crave JC, Tourniaire J, ForestMG: Clinical utility of sex hormone-bind-ing globulin measurement. Horm Res 45:148–155, 1996

4. Jayagopal V, Kilpatrick ES, Jennings PE,Hepburn DA, Atkin SL: The biologicalvariation of testosterone and sex hor-mone-binding globulin (SHBG) in poly-cystic ovarian syndrome: implications forSHBG as a surrogate marker of insulin re-sistance. J Clin Endocrinol Metab 88:1528–1533, 2003

5. Fraser CG, Harris EK: Generation and ap-plication of data on biological variation inclinical chemistry. Crit Rev Clin Lab Sci 27:409–437, 1989

6. Gowans EM, Fraser CG: Biological varia-tion of serum and urine creatinine andcreatinine clearance: ramifications for in-terpretation of results and patient care.Ann Clin Biochem 25:259–263, 1988

Development of anAssessment Tool forScreening Childrenfor GlucoseIntolerance by OralGlucose ToleranceTest

The American Diabetes Association(ADA) has recommended screeningfor type 2 diabetes by fasting plasma

glucose (FPG) in children who are over-weight (BMI 85th percentile) who havetwo of the following risk factors: at-riskethnic minority origin, family history ofdiabetes in a first- or second-degree rela-tive, or insulin resistance (acanthosis nig-ricans, polycystic ovarian syndrome,hypertension, or dyslipidemia) (1).

The case for refining the criteria forscreening has been made previously (2).

In that study, the sensitivity of the criteriawas 24%, with a positive predictive valueof 3%, i.e., 40 children needed to betested to yield one abnormal result. In aresponse to this, Rosenbloom (3) high-lighted the need to test the ADA criteria inhigh-risk populations to establish thestrength and risk level of different factorsthat are influential in the development oftype 2 diabetes.

Our institution covers a populationwhere type 2 diabetes in childhood hasemerged (4). We describe our experienceof applying the ADA criteria and proposea clinical assessment tool to refine the se-lection of children for screening by theoral glucose tolerance test (OGTT).

In the last 4 years, 66 children havehad OGTTs for suspected glucose intoler-ance. The characteristics of this popula-tion were mean age of 12.7 years (range4.8–17.3), mean BMI standard deviationscore 3.0 (0.0–4.6), 71% female, 83%ethnic minority origin (of whom 73%were South Asian and 9% African Carib-bean), 88% had acanthosis nigricans, and67% had a first- or second-degree familyhistory of diabetes. Of these, 13 childrenhad abnormal glucose tolerance (4 diabe-tes, 8 impaired glucose tolerance [IGT],and 1 impaired fasting glycemia).

Applying the ADA criteria, 11 of the13 children with abnormal results wouldhave qualified for screening, missing 1child with diabetes and 1 with IGT.Screening these 11 with FPG as per therecommendations would have missed afurther 7 children, 1 with diabetes and 6with IGT, as only 1 of the children withIGT had impaired fasting glycemia. Over-all, the sensitivity of the ADA criteria us-ing FPG as a screening test in ourpopulation was 31%. Use of the ADA cri-teria to screen by OGTT would have iden-tified 11 of the 13 abnormal results in thiscohort, giving a sensitivity of 85% for thecriteria and a specificity of 26%, with apositive predictive value of 22%, i.e., fivechildren would need to be tested to yieldan abnormal result.

Using the clinical characteristics ofour cohort, we calculated the positive pre-dictive value for each parameter singlyand in combination. We used this data toweight each parameter and calculate a cu-mulative risk score, dividing children intolow and high risk of abnormal glucosetolerance when tested by OGTT (Fig. 1).We then applied this risk score to our co-

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hort: 36 children scored as high risk,which included all 13 children with ab-normal glucose tolerance. The sensitivityof this scoring system in our cohort is100%, specificity 57%, and positive pre-dictive value 36%, i.e., three childrenneed to be tested to identify one abnormalresult. Prospective validation of this as-sessment tool is now underway in ourclinic. We suggest that other units de-velop risk assessment tools for their pop-ulations so that screening at-risk childrenfor glucose intolerance becomes more fea-sible and is not “a lost battle.”

SARAH EHTISHAM, MBBCHIR

NICK SHAW, MBCHB

JEREMY KIRK, MD

TIMOTHY BARRETT, PHD

From the Department of Diabetes and Endocrinol-ogy, Birmingham Children’s Hospital, Birmingham,U.K.

Address correspondence to Dr. Sarah Ehtisham,Diabetes Homecare Unit, Birmingham Children’sHospital, Steelhouse Lane, Birmingham B4 6NH,U.K. E-mail: [email protected].


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References1. American Diabetes Association: Type 2

diabetes in children and adolescents(Consensus Statement). Diabetes Care 23:381–389, 2000

2. Fagot-Campagna A, Saaddine JB, Engel-gau MM: Is testing children for type 2 di-abetes a lost battle? (Letter). Diabetes Care23:1442–1443, 2000

3. Rosenbloom AL: Is testing children fortype 2 diabetes a lost battle? Response toFagot-Campagna et al. (Letter) DiabetesCare 23:1443, 2000

4. Ehtisham S, Barrett TG, Shaw NJ: Type 2diabetes mellitus in UK children: anemerging problem. Diabet Med 17:867–871, 2000

5. Williams CL, Hayman LL, Daniels SR,Robinson TN, Steinberger J, Paridon S,Bazzarre T: Cardiovascular health inchildhood: a statement for health profes-sionals from the Committee on Athero-sclerosis, Hypertension and Obesity inthe Young (AHOY) of the Council on Car-diovascular Disease in the Young, Ameri-

can Heart Association. Circulation 106:143–160, 2002

Vinegar ImprovesInsulin Sensitivity toa High-CarbohydrateMeal in SubjectsWith InsulinResistance or Type 2Diabetes

The number of Americans with type 2diabetes is expected to increase by50% in the next 25 years; hence, the

prevention of type 2 diabetes is an impor-tant objective. Recent large-scale trials(the Diabetes Prevention Program andSTOP-NIDDM) have demonstrated thattherapeutic agents used to improve insu-lin sensitivity in diabetes, metformin andacarbose, may also delay or prevent theonset of type 2 diabetes in high-risk pop-

Figure 1—Assessment tool for the selection of children at risk of abnormal glucose tolerance. The assessment tool does not apply to children referredwith raised fasting blood glucose values or with suspected glucose intolerance posttransplantation or secondary to other diagnoses. Children arescored on the clinical characteristics as shown. The scores for family history and insulin resistance are cumulative, giving a maximum score of 24.*Definite diagnosis on scan or irregular menses and hirsutism; †systolic or diastolic blood pressure 95th percentile for age (5). Scores: 0–11, lowrisk; 12–24, high risk (these children should be screened by OGTT).

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ulations. Interestingly, an early reportshowed that vinegar attenuated the glu-cose and insulin responses to a sucrose orstarch load (1). In the present report, weassessed the effectiveness of vinegar in re-ducing postprandial glycemia and insu-linemia in subjects with varying degreesof insulin sensitivity.

Our study included nondiabetic sub-jects who were either insulin sensitive(control subjects, n � 8) or insulin resis-tant (n � 11) and 10 subjects with type 2diabetes. Subjects provided written in-formed consent and were not taking dia-betes medications. Fasting subjects wererandomly assigned to consume the vine-gar (20 g apple cider vinegar, 40 g water,and 1 tsp saccharine) or placebo drinkand, after a 2-min delay, the test meal,which was composed of a white bagel,butter, and orange juice (87 g total carbo-hydrates). The cross-over trial was con-ducted 1 week later. Blood samples werecollected at fasting and 30 and 60 minpostmeal for glucose and insulin analyses.Whole-body insulin sensitivity during the60-min postmeal interval was estimatedusing a composite score (2).

Fasting glucose concentrations wereelevated �55% in subjects with diabetescompared with the other subject groups(P � 0.01, Tukey’s post hoc test), andfasting insulin concentrations were ele-vated 95–115% in subjects with insulinresistance or type 2 diabetes comparedwith control subjects (P � 0.01). Com-

pared with placebo, vinegar ingestionraised whole-body insulin sensitivity dur-ing the 60-min postmeal interval in insu-lin-resistant subjects (34%, P � 0.01,paired t test) and slightly improved thisparameter in subjects with type 2 diabetes(19%, P � 0.07). Postprandial fluxes ininsulin were significantly reduced by vin-egar in control subjects, and postprandialfluxes in both glucose and insulin weresignificantly reduced in insulin-resistantsubjects (Fig. 1).

These data indicate that vinegar cansignificantly improve postprandial insu-lin sensitivity in insulin-resistant subjects.Acetic acid has been shown to suppressdisaccharidase activity (3) and to raiseglucose-6-phosphate concentrations inskeletal muscle (4); thus, vinegar maypossess physiological effects similar toacarbose or metformin. Further investiga-tions to examine the efficacy of vinegar asan antidiabetic therapy are warranted.

CAROL S. JOHNSTON, PHD

CINDY M. KIM, MS

AMANDA J. BULLER, MS

From the Department of Nutrition, Arizona StateUniversity, Mesa, Arizona.

Address correspondence to Carol S. Johnston,Department of Nutrition, Arizona State University,East Campus, 7001 E. Williams Field Rd, Mesa, AZ85212. E-mail: [email protected].


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References1. Ebihara K, Nakajima A: Effect of acetic

acid and vinegar on blood glucose andinsulin responses to orally administeredsucrose and starch. Agric Biol Chem 52:1311–1312, 1988

2. Matsuda M, DeFronzo RA: Insulin sensi-tivity indices obtained from oral glucosetolerance testing. Diabetes Care 22:1462–1470, 1999

3. Ogawa N, Satsu H, Watanabe H, FukayaM, Tsukamoto Y, Miyamoto Y, ShimizuM: Acetic acid suppresses the increase indisaccharidase activity that occurs duringculture of Caco-2 cells. J Nutr 130:507–513, 2000

4. Fushimi T, Tayama K, Fukaya M, Kitako-shi K, Nakai N, Tsukamoto Y, Sato Y: Ace-tic acid feeding enhances glycogenrepletion in liver and skeletal muscle ofrats. J Nutr 131:1973–1977, 2001

Sleep Disturbanceand Onset of Type 2Diabetes

S leep disturbance, which is often ob-served among patients with diabetes(1), is possibly caused by impaired

glucose metabolism or physical and psy-chological discomfort due to the disorder.In addition, a recent prospective study ofwomen has indicated an interesting asso-ciation between sleep patterns and later-onset type 2 diabetes, with a greaterincidence among both short-term (�6 h)and long-term (8 h) sleepers (2). Dis-turbance in sleep quality may also affectthe later onset of overt diagnosis of type 2diabetes. We investigated the associationbetween sleep disturbance and the subse-quent onset of type 2 diabetes in a groupof Japanese male employees.

We analyzed the database of an 8-yearprospective study of male employees of anelectrical company in Japan (3). We fol-lowed 2,649 male employees with nomedical history of diabetes or otherchronic illnesses at baseline for 8 yearsfrom 1984 to 1992. Data from 2,265(86%) male respondents, who were thor-oughly followed, were analyzed. All sub-jects received a medical checkup once ayear during the follow-up to identifythose with type 2 diabetes according toWorld Health Organization criteria (4). Amailed questionnaire was used to assesssleep disturbance in the previous monthat baseline. Two single-item questions

Figure 1—Effects of vinegar (�) and placebo (}) on plasma glucose (A– C) and insulin (D– F)responses after a standard meal in control subjects, insulin-resistant subjects, and subjects withtype 2 diabetes. Values are means � SE. The P values represent a significant effect of treatment(multivariate ANOVA repeated-measures test).

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were asked concerning difficulty initiat-ing sleep (“Did you have trouble fallingasleep?”) and difficulty maintaining sleep(“Did you often wake up in the middle ofthe night?”). The subjects were classifiedinto one of two categories: low for thosewho indicated “seldom” or “sometimes”and high for those who indicated “often”or “almost everyday” in response to thequestions.

During the 18,006 person-year ob-servation, 38 incidents of type 2 diabeteswere identified (an incidence rate of 1.68per 1,000 person-years). Those who ex-perienced a high frequency of difficultyinitiating sleep had a significantly higherage-adjusted hazard ratio (2.98, 95% CI1.36–6.53) for type 2 diabetes comparedwith those who experienced low-frequency difficulty initiating sleep. Asimilar hazard ratio was observed for dif-ficulty maintaining sleep (2.23, 1.08 –4.61). These hazard ratios were almostidentical and were statistically significantafter controlling for other factors relevantto type 2 diabetes (i.e., age, education,occupation, shift work, BMI, leisure-timephysical activity, smoking, alcohol con-sumption, and family history of diabetes).

Our analysis demonstrated that thosewho had sleep disturbances showed atwo- to threefold higher risk of later onsettype 2 diabetes. The association was inde-pendent of known risk factors for type 2diabetes and was not attributable to treat-ment for sleep disturbance. Sleep distur-bance at baseline was unlikely due tocomplications or disability from the treat-ment of diabetes because we excludedsubjects with known diabetes at baseline.A possible explanation is that an in-creased sympathetic nervous activity as-sociated with sleep disturbance (5) causesglucose intolerance (6) and increases therisk of type 2 diabetes. Physicians mayneed to pay more attention to patientswith sleep disturbance because it may in-dicate a higher risk for type 2 diabetes.

NORITO KAWAKAMI, MD1

NAOYOSHI TAKATSUKA, MD2

HIROYUKI SHIMIZU, MD2

From the 1Department of Hygiene and PreventiveMedicine, Okayama University Graduate School ofMedicine and Dentistry, Okayama, Japan; and the2Department of Epidemiology and Preventive Med-icine, Gifu University School of Medicine, Gifu,Japan.

Address correspondence to Prof. NoritoKawakami, Hygiene and Preventive Medicine,

Okayama University Graduate School of Medicineand Dentistry, 2-5-1 Shikata-cho, Okayama 700-8558, Japan. E-mail: [email protected].


Acknowledgments— This study was sup-ported in part by a grant-in-aid from the Jap-anese Ministry of Education, Science, andCulture.● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

References1. Resnick HE, Redline S, Shahar E, Gilpin

A, Newman A, Walter R, Ewy GA,Howard BV, Punjabi NM: Diabetes andsleep disturbances: findings from theSleep Heart Health Study. Diabetes Care26:702–709, 2003

2. Ayas NT, White DP, Al-Delaimy WK,Manson JE, Stampfer MJ, Speizer FE, Pa-tel S, Hu FB: A prospective study of self-reported sleep duration and incidentdiabetes in women. Diabetes Care26:380–384, 2003

3. Kawakami N, Takatsuka N, Shimizu H,Ishibashi H: Depressive symptoms andoccurrence of type 2 diabetes among Jap-anese men. Diabetes Care 22:1071–1076,1999

4. World Health Organization: WHO ExpertCommittee on Diabetes Mellitus, Second Re-port. Geneva, World Health Org., 1981(Tech. Rep. Ser., no. 646)

5. Bonnet MH, Arand DL: Heart rate vari-ability in insomniacs and matched normalsleepers. Psychosom Med 60:610–615,1998

6. Gonzalez-Ortiz M, Martinez-Abundis E,Balcazar-Munoz BR, Pascoe-Gonzalez S:Effect of sleep deprivation on insulin sen-sitivity and cortisol concentration inhealthy subjects. Diabetes Nutr Metab 13:80–83, 2000

Non-HDL CholesterolContributes to the“HypertriglyceridemicWaist” as aCardiovascular RiskFactorThe Hoorn Study

L emieux et al. (1) described the “hy-pertriglyceridemic waist” as amarker of the atherogenic metabolic

triad (hyperinsulinemia, hyperapoli-poprotein B, and small, dense LDL) inmen. In 287 men, those with a waist cir-cumference �90 cm and with triglyceridelevels �2 mmol/l had an odds ratio of 3.6(95% CI 1.17–10.93) for having angio-

graphically diagnosed coronary arterydisease compared with those with smallerwaists and lower triglyceride concentra-tions. We recently reported (2) the pre-dictive value of non-HDL cholesterol andtriglyceride concentrations for 10-yearcardiovascular disease incidence in theHoorn Study, a population-based cohortstudy of glucose tolerance. In people withabnormal glucose metabolism, high tri-glyceride concentration was associatedwith the risk of cardiovascular disease,particularly in people with high non-HDLcholesterol, but not in those with normalglucose metabolism (3).

We used the Hoorn Study data to pro-spectively investigate whether the risk as-sociated with the hypertriglyceridemicwaist differs between subjects with nor-mal and abnormal glucose metabolism.Additionally, we studied whether non-HDL cholesterol adds to the predictivepower of the hypertriglyceridemic waistin predicting cardiovascular disease. TheHoorn Study is a cohort study among2,484 subjects in the Netherlands thatstarted in 1989. Cardiovascular diseasewas defined as first new cardiovascularfatal or nonfatal event (3). Because thecutoff points for waist girth in men usedby Lemieux et al. (1) are not applicable forwomen, we used waist �94 cm in menand �80 cm in women, according to theEuropean Group of Insulin Resistancedefinition (4). The results show that inparticular the combination of a large waistand a high triglyceride level (�2 mmol/l)was associated with cardiovascular dis-ease in subjects with both normal and ab-normal glucose metabolism (hazard ratio1.82 [95% CI 1.27–2.62] and 2.68[1.89 –3.81], respectively). These find-ings concur with those of Lemieux et al.(1). In addition, we observed that afterstratification for non-HDL cholesterol,defined as the difference between totalcholesterol and HDL cholesterol concen-tration, the risk associated with the hyper-triglyceridemic waist was furtherincreased by 50% in the presence of highnon-HDL cholesterol concentrations(above the median, i.e., 5.2 mmol/l formen and 5.3 mmol/l for women) (Fig. 1).The hazard ratio for subjects with a com-bination of large waist, high triglycerides,and high non-HDL cholesterol concentra-tions was 2.94 (2.06–4.19).

Non-HDL cholesterol is closelylinked to visceral obesity (5). Non-HDLcholesterol includes all cholesterol in po-

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tentially atherogenic triglyceride-rich li-poproteins and may be a better predictorfor the “bad” triglycerides, which are as-sociated with increased risk of cardiovas-cular disease (6).

In conclusion, in the Hoorn Study,non-HDL cholesterol contributes consid-erably to the risk associated with the hy-pertriglyceridemic waist. Further studiesare clearly required to evaluate the clinicalrelevance of monitoring these particularvariables for the assessment of cardiovas-cular risk.

GRIET BOS, MSC1

JACQUELINE M. DEKKER, PHD1

ROBERT J. HEINE, PHD1,2

From the 1Institute for Research in Extramural Med-icine, VU University Medical Center, Amsterdam,the Netherlands; and the 2Department of Endocri-nology, Diabetes Center, VU University MedicalCenter, Amsterdam, the Netherlands.

Address correspondence to G. Bos, MSc, Institutefor Research in Extramural Medicine, VU UniversityMedical Center Van der Boechorststraat 7, 1081 BTAmsterdam, Netherlands. E-mail: [email protected].


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References1. Lemieux I, Pascot A, Couillard C,

Lamarche B, Tchernof A, Almeras N,Bergeron J, Gaudet D, Tremblay G,Prud’homme D, Nadeau A, Despres JP:Hypertriglyceridemic waist: a marker ofthe atherogenic metabolic triad (hyperin-sulinemia; hyperapolipoprotein B; small,dense LDL) in men? Circulation 102:179–184, 2000

2. Mooy JM, Grootenhuis PA, de Vries H,Valkenburg HA, Bouter LM, Kostense PJ,Heine RJ: Prevalence and determinants ofglucose intolerance in a Dutch Caucasianpopulation: the Hoorn Study. DiabetesCare 18:1270–1273, 1995

3. Bos G, Dekker JM, Nijpels G, De Vegt F,

Diamant M, Stehouwer CD, Bouter LM,Heine RJ: A combination of high concen-trations of serum triglyceride and non-high-density-lipoprotein-cholesterol is arisk factor for cardiovascular disease insubjects with abnormal glucose metabo-lism: the Hoorn Study. Diabetologia 46:910–916, 2003

4. Balkau B, Charles MA: Comment on theprovisional report from the WHO consul-tation: European Group for the Study ofInsulin Resistance (EGIR). Diabet Med 16:442–443, 1999

5. Bittner V, Hardison R, Kelsey SF, WeinerBH, Jacobs AK, Sopko G: Non-high-density lipoprotein cholesterol levels pre-dict five-year outcome in the BypassAngioplasty Revascularization Investiga-tion (BARI). Circulation 106:2537–2542,2002

6. Brewer HB Jr: Hypertriglyceridemia:changes in the plasma lipoproteins asso-ciated with an increased risk of cardiovas-cular disease. Am J Cardiol 83:3F–12F,1999

Improvement ofTemperature andFlow in Feet ofSubjects withDiabetes With Useof a TransdermalPreparationof L-Arginine

A pilot study

C irculatory impairment and its se-qulae have long been known to bemajor complications of diabetes. It

has been shown that in diabetes, the func-tionality of the endothelial nitric oxide(NO)/nitric oxide synthase (eNOS) sys-

tem is impaired (1–3). NO is generated inthe endothelium through the oxidation ofthe amino acid L-arginine by the enzymeeNOS. NO causes vascular smooth mus-cle to relax, resulting in increased bloodflow. In addition to being a substrate ofeNOS, L-arginine facilitates the dimeriza-tion of two identical subunits, forming ahomodimer. The enzyme is only active inthe dimeric form. Under proper condi-tions, dimerization occurs rapidly, on atimescale of minutes. Once formed, thedimer is stable (4).

Subjects with diabetes have abnor-mally low levels of L-arginine (5) and ele-vated levels of the eNOS inhibitorasymmetric dimethylarginine (ADME)(6) in their plasma. Though the value ofincreasing L-arginine levels in cases of im-paired circulation is now recognized,practical schemes for therapeutic use ofL-arginine have been elusive. In this pilotstudy, we sought to determine whethersupplying L-arginine transdermallywould improve vascular function of thefeet in patients with diabetes as indicatedby flow and temperature.

The study was designed as a double-blind, vehicle-controlled, two-period,crossover protocol with washout periodsof 1 week. Sixteen subjects were enrolled,and 13 completed the study (aged 56 � 8years). After analyzing the data, it wasclear that the effect of L-arginine persistedthroughout the washout periods (Tables1 and 2). Because of this, except for theinitial exposure of L-arginine virgin feet,the analysis was altered to determine theeffect from cumulative exposure toL-arginine throughout the protocol. Flowwas measured at the metatarsal and Achil-les area using a Doppler flow meter (7),and temperature was measured at themetatarsal and big toe areas using an in-frared thermometer. The active creamwas a water-based moisturizing vehiclecontaining 12.5% L-arginine hydrochlo-ride in a hostile biophysical environmentcomprised of high concentrations of cho-line chloride, sodium chloride, and mag-nesium chloride. The vehicle control wasidentical except that the L-arginine wasomitted.

At the first visit, after baseline mea-surements were made each subjectrubbed active cream (4 mg L-arginine/cm2) into one foot and vehicle into theother. After 30 min, measurements weremade again. A 1-week washout periodfollowed. Patients returned after the

Figure 1—Hazard ratios(HRs) of cardiovascular dis-ease for combined categoriesof triglycerides and waistcircumference, stratified fornon-HDL cholesterol. �,waist �94/80 cm; f, waist�94/80 cm.

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washout period and flow and tempera-ture measurements were made. Theywere then randomly given either active orplacebo cream and told to rub it into theirfeet in the morning and evening every dayfor 2 weeks. At the end of 2 weeks, sub-jects returned and again measurementswere made. A second 1-week washoutperiod followed that third visit. At the endof that period subjects returned and mea-surements were made. They were giventhe crossover product and told again torub it into their feet morning and eveningfor 2 weeks. The subjects returned for fi-nal flow and temperature measurementsat the end of that period.

At the first visit, flow was increased atthe Achilles area in the foot with activecream from 8.1 � 3.3 to 11.5 � 5.5 AU(P � 0.05) 30 min after application. In thefoot that received placebo cream, flowfailed to increase (8.1 � 1.4 vs. 8.3 � 2.2AU). Furthermore, at the last visit thetemperature at the metatarsal area hadrisen from the initial value of 82.0 � 2.3to 86.9 � 2.4°F (P � 0.0001), and thetemperature of the big toe had risen fromthe initial visit value of 74.4 � 4.2 to82.4 � 4.8°F (P � 0.0001). And at thelast visit the flow at the metatarsal areahad risen from 8.7 � 4.3 to 11.6 � 5.5AU (P � 0.0001), and flow at the Achillesarea had risen from 8.4 � 2.5 to 11.4 �5.5 AU (P � 0.02). While the failure ofthe L-arginine effect to wash out removedthe opportunity for placebo control, theimprovement in temperature and flowwere substantial and highly statistically

significant. Though puzzling, one expla-nation of the persistence of the L-arginineeffect is that the local tissue concentrationof L-arginine becomes high enough tocause inactive monomers of eNOS to formactive dimers.

We conclude that in the patients westudied with diabetes, treatment of theirfeet with a transdermal preparation ofL-arginine improved both flow and tem-perature, and this effect was surprisinglylong lasting. Such improvement of com-promised local blood flow should bebeneficial and could reduce the complica-tions of the disease.

ERIC T. FOSSEL, PHD

From Strategic Science and Technologies, Welles-ley, Massachusetts.

Address correspondence to Eric T. Fossel, Strate-gic Science and Technologies, 892 Worcester Rd.,Wellesley, MA 02481. E-mail: [email protected].


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References1. Cooke JP, Dzau V: Nitric oxide synthase:

role in the genesis of vascular disease.Annu Rev Med 28:489–501, 1997

2. Calles-Escandon J, Cipolla M: Diabetesand endothelial dysfunction: a clinicalprospective. Endocr Rev 22:36–52, 2001

3. Kin KY, Ito A, Asagami T, Tsai PSS, Adi-moolan S, Kimoto M, Hideaki T, ReavenGM, Cooke JP: Impaired nitric oxide syn-thase pathway in diabetes mellitus: role ofasymmetric dimethylarginine and dim-ethylarginine dimethyoaminohydrolase.

Circulation 106:987–992, 20024. Panda K, Rosenfeld RF, Ghosh S, Meade

AL, Getzoff ED, Stuehr DJ: Distinct dimerinteraction and regulation in nitric oxidesynthase types I, II, and III. J Biol Chem277:31020–31030, 2002

5. Pieper GM, Siebeneich W, DondlingerLA: Short-term oral administration ofL-arginine reverses defective endotheli-um-dependent relaxation and cGMP gen-eration in diabetes. Eur J Pharmacol 317:317–320, 1996

6. Abbasi F, Asagmi T, Cooke JP, LamendolaC, McLaughlin T, Reaven GM, Stueh-linger M, Tsao PS: Plasma concentrationsof asymmetric dimethylarginine are in-creased in patients with type 2 diabetesmellitus. Am J Cardiol 88:1201–1203,2001

7. Vongsavan N, Matthews B: Some aspectsof the use of laser doppler flow meters forrecording tissue blood flow. Exper Physiol78:1–14, 1993

IncreasedPrevalence ofEnteroviral RNA inBlood Spots FromNewborn ChildrenWho LaterDeveloped Type 1DiabetesA population-based case-controlstudy

V irus infections during fetal life maylead to persistent infections due tounresponsiveness of the immature

immune system and by different mecha-nisms inducing autoimmunity in the-cell (1). In a previous study, we foundgroup-reacting antibodies to enterovirusmore frequently increased in serum at de-livery in a cohort of mothers whose chil-dren later developed diabetes than incontrol subjects (2). It has been arguedthat mothers of later diabetic childrenmight have increased immune responsesto certain viruses (3). Therefore, detectionof the virus nucleic acid would be impor-tant to confirm.

Enteroviral infections typically occuras epidemics with a short viremic phase;therefore, they are detectable for only ashort time in peripheral blood (4). Con-sequently, large series of blood or serumsamples would be necessary. Since 1973,blood spots routinely taken on days 2–4

Table 1—Effect of transdermal L-arginine cream on temperature

Metatarsal (°F) P vs. visit 1 Big toe (°F) P vs. visit 1

Visit 1 82.0 � 2.3 74.4 � 4.2Visit 2 84.1 � 3.4 0.004 77.7 � 5.3 0.01Visit 3 87.0 � 2.4 �0.0001 83.6 � 4.9 �0.0001Visit 4 86.1 � 2.4 �0.0001 80.6 � 5.4 �0.0001Visit 5 86.9 � 2.4 �0.0001 82.4 � 4.8 �0.0001

Data are means � SD.

Table 2—Effect of transdermal L-arginine cream on flow

Metatarsal (AU) P vs. visit 1 Achilles (AU) P vs. visit 1

Visit 1 8.7 � 4.3 8.4 � 2.5Visit 2 10.8 � 5.9 NS 8.5 � 3.9 NSVisit 3 10.8 � 4.8 0.05 9.2 � 3.9 NSVisit 4 11.6 � 8.3 NS 10.0 � 4.2 0.06Visit 5 11.6 � 5.5 �0.0001 11.4 � 5.5 0.02

Data are means � SD.

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of life for analysis of inherited metabolicdiseases in all newborns in Sweden arestored in a biobank. From this biobank,we collected blood spots from 600 chil-dren in the Swedish childhood diabetesregister who were born during the years1986–1995 and who had diabetes onsetbefore 1996. For each case, a control sam-ple was included from a child born on thesame date and not found in the Swedishchildhood diabetes register, and the con-trol sample was stored adjacent to the casefilter.

Nested enterovirus PCR was per-formed essentially according to Puig et al.(5). To exclude the possibility of false-positivity due to contamination, we ex-cluded all case-control pairs with doublepositivity and each step of RNA extractionand analysis included positive and nega-tive controls. All case-control pairs wereanalyzed in the same run. As references,representatives of the most common con-genital viral infections were chosen foranalysis: CMV (6) and parvo B19 virus(7). A total of 542 pairs of samples werevalid and analyzed for enterovirus RNA.

Twenty-seven diabetic cases wereRNA positive, as compared with 14 con-trol subjects (odds ratio 1.98 [95% CI1.04�3.77], two-tailed P � 0.04). Due tolimited material, typing of enteroviralRNA by sequencing was not possible . ForCMV and parvo B19 viruses, no differ-ences were shown between cases and ref-erences in samples of 208 and 180 pairs,respectively.

The findings support the hypothesisthat early enteroviral infections may playa role in the pathogenesis of type 1 diabe-tes. In our previous study of maternalsera, the etiological fraction of enteroviralinfection in pregnancy (4) was calculatedat 27%. Thus, early fetal or neonatal in-fections may explain a fraction of child-hood diabetes cases.

GISELA G. DAHLQUIST, MD, PHD1

JENNY FORSBERG, MS1

LARS HAGENFELDT, MD, PHD2†

JENS BOMAN, MD3

PER JUTO, MD, PHD3

From the 1Department of Clinical Sciences–Paediatrics, Umeå University, Umeå, Sweden; the2Centre of Inherited Metabolic Diseases, HuddingeUniversity Hospital, Karolinska Institute, Stock-holm, Sweden; and the 3Department of Virology,Umeå University, Umeå, Sweden.

Address correspondence to Professor GiselaDahlquist, Umeå University, Department of Clinical

Sciences–Paediatrics, SE-901 87 Umeå, Sweden. E-mail: [email protected].

†Deceased, summer 2003.© 2004 by the American Diabetes Association.

Acknowledgements— This study was sup-ported by grants from the Swedish ResearchCouncil (Medicine) (project no. 07531), theSwedish Diabetes Association, and the Vaster-botten County Council.● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

References1. Jun HS, Yoon JW: The role of viruses in

type I diabetes: two distinct cellular andmolecular pathogenic mechanisms of vi-rus-induced diabetes in animals. Diabeto-logia 44:271–285, 2001

2. Dahlquist GG, Ivarsson S, Lindberg B,Forsgren M: Maternal enteroviral infec-tion during pregnancy as a risk factor forchildhood IDDM: a population-basedcase-control study. Diabetes 44:408–413,1995

3. Graves PM, Norris JM, Pallansch MA,Gerling IC, Rewers M: The role of entero-viral infections in the development ofIDDM. Diabetes 46:161–168, 1997

4. Cherry JP: Enteroviruses: polioviruses,coxsackieviruses, echoviruses and entero-viruses. In Textbook of Pediatric InfectiousDiseases. Vol. 2, 3rd ed. Feigin RD, CherryJD, Eds. Philadelphia, PA, WB Saunders,1992, p. 1705–1753

5. Puig M, Jofre J, Lucena F, Alland A,Wadell G, Girones R: Detection of adeno-viruses and enteroviruses in polluted wa-ters by nested PCR amplification. ApplEnvironment Microbiol 60:2963–2970,1994

6. Brytting M, Sundqvist VA, Stålhandske P,Linde A, Wahren B: CytomegalovirusDNA detection of an immediate early pro-tein gene with nested primer oligonucle-otides. J Virol Methods 32:127–138, 1991

7. Lundqvist A, Tolfvenstam T, Bostic J,Soderlund M, Broliden K: Clinical andlaboratory findings in immunocompetentpatients with persistent parvovirus B 19DNA in bone marrow. Scand J Infect Dis31:11–16, 1999

Physician AttitudesToward Foot CareEducation and FootExamination andTheir CorrelationWith Patient Practice

F oot complications are one of themost serious causes of morbidity,disability, poor quality of life, and

resource use among diabetic people (1).

The adoption of preventive strategies toreduce the rate of foot problems thus rep-resents an important priority. In fact, astrategy that includes prevention, patientand staff education, multidisciplinarytreatment of foot complications, and closemonitoring has been demonstrated to bevery effective in reducing amputation rate(2).

In the context of a nationwide out-comes research program (the QuEDproject), we investigated several aspectsrelated to foot care in 3,564 patients withtype 2 diabetes enrolled by 125 diabetesoutpatient clinics and 103 generalpractitioners.

Details on study design have been re-ported elsewhere (3). Briefly, all patientswith type 2 diabetes were considered eligi-ble, irrespective of age, duration of diabetes,and treatment. Foot complications in-cluded ulcers, gangrene, nontraumatic am-putations, and claudicatio intermittens.

Patients filled out a questionnaire in-vestigating whether they had received in-formation about foot care, how often theyhad had their feet examined in the lastyear, and how often they usually checkedtheir feet. Analyses were adjusted for pa-tient case mix and physician-level cluster-ing using multivariate multilevel logisticregression models (4).

The prevalence of lower limb compli-cations was 6.8%. Seventy-two percent ofthe patients declared that they had re-ceived foot education, but only 49% re-ported that they had had their feetexamined in the last year. Patients with�5 years of school education (odds ratio[OR] 1.3, 95% CI 1.1–1.6) and those withlow income (�$12,000) (1.2, 1.0–1.4)were more likely not to receive foot edu-cation. The presence of foot complica-tions, peripheral vascular disease,cardiac-cerebrovascular disease, and dia-betic neuropathy were not independentlyassociated with a greater chance of receiv-ing foot education. Foot examination wasmore likely to be performed in low-income patients (1.3, 1.1–1.6) and inthose with foot complications (1.5, 1.1–2.1) but not in those with diabetic neu-ropathy, peripheral vascular disease, orcardiac-cerebrovascular disease. Foot ex-amination tended to be performed lessfrequently by general practitioners andother specialists in diabetes outpatientclinics as opposed to diabetologists, eventhough the statistical significance wasreached only for the comparison between

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general practitioners and diabetologists(0.6, 0.4–1.0).

Overall, 33% of the patients declaredthat they never checked their feet. Pa-tients who had received foot education(OR � 2.5, 95% CI 2.0–3.0) and thosewho had had their feet examined by theirphysician (1.7, 1.4–2.0) were more likelyto check their feet regularly. Similarly, pa-tients with foot complications (2.2, 1.5–3.2), but not those with peripheralvascular disease, cardiac-cerebrovasculardisease, or diabetic neuropathy, weremore likely to check their feet.

In conclusion, the attention to footcomplications is generally poor, and asubstantial proportion of type 2 diabeticpatients is not offered foot education andexamination, even in those subgroupsshowing a significant increase in the riskof foot complications. Even in the pres-ence of foot complications or major riskfactors, one-quarter of the patients didnot pay any attention to foot care. Thosepatients who had received foot educationand had had their feet examined were sig-nificantly more likely to regularly checktheir feet. This finding underlines the cru-cial role of physicians in orienting patientpractices.

GIORGIA DE BERARDIS, MSC (CHEM PHARM)1

FABIO PELLEGRINI, MS1

MONICA FRANCIOSI, MSC (BIOL)1

MAURIZIO BELFIGLIO, MD1

BARBARA DI NARDO, HSDIP1

SHELDON GREENFIELD, MD2

SHERRIE H. KAPLAN, PHD, MPH2

MARIA C.E. ROSSI, (CHEM PHARM)1

MICHELE SACCO MD1

GIANNI TOGNONI MD1

MIRIAM VALENTINI MD1

ANTONIO NICOLUCCI MD1

THE QUED STUDY GROUP

From the 1Department of Clinical Pharmacologyand Epidemiology, Istituto di Ricerche Farmaco-logiche Mario Negri, Consorzio Mario Negri Sud,S. Maria Imbaro, Italy; and the 2Center for HealthPolicy Research, University of California Irvine, Ir-vine, California.

Address correspondence to Antonio Nicolucci,MD, Department of Clinical Pharmacology and Ep-idemiology, Consorzio Mario Negri Sud, Via Nazio-nale, 66030 S. Maria Imbaro, Italy. E-mail:[email protected].


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References1. Humphrey AR, Dowse GK, Thoma K,

Zimmet PZ: Diabetes and nontraumatic

lower extremity amputations: incidence,risk factors, and prevention: a 12-year fol-low-up study in Nauru. Diabetes Care 19:710–714, 1996

2. Larsson J, Apelqvist J, Agardh CD, Sten-strom A: Decreasing incidence of majoramputation in diabetic patients: a conse-quence of a multidisciplinary foot careteam approach? Diabet Med 12:770–776,1995

3. Belfiglio M, De Berardis G, Franciosi M,Cavaliere D, Di Nardo B, Greenfield S,Kaplan SH, Pellegrini F, Sacco M, Tog-noni G, Valentini M, Nicolucci A, CaimiV, Capani F, Corsi A, Della Vedova R,Massi Benedetti M, Nicolucci A, TabogaC, Tombesi M, Vespasiani G: The rela-tionship between physicians’ self-re-ported target fasting blood glucose levelsand metabolic control in type 2 diabetes.Diabetes Care 24:423–429, 2001

4. Snijders TAB, Bosker RJ. Multilevel Analy-sis: An Introduction to Basic and AdvancedMultilevel Modeling. London, SAGE Publi-cations, 1999

Hepatocyte GrowthFactor in theVitreous Fluid ofPatients WithProliferativeDiabetic Retinopathy

Its relationship with vascularendothelial growth factor andretinopathy activity

The role of hepatocyte growth factor(HGF) in the etiopathogenesis ofproliferative diabetic retinopathy

(PDR) remains to be elucidated. Othersand we (1–5) have found high intravitre-ous concentrations of HGF in patientswith PDR. However, in these previous re-ports, the main confounding factors thatcould lead to misinterpretation of the re-sults (vitreous hemorraghe, intravitrealprotein concentration, and plasma HGFlevels) have not been fully considered. Inthe present study, we consider all theseconfounding factors in order to evaluatethe vitreous levels of HGF in patients withPDR and to investigate its relationshipwith vascular endothelial growth factor(VEGF) and retinopathy activity.

A total of 28 diabetic patients withPDR, in whom a vitrectomy was per-formed, were included in the study.

Thirty nondiabetic patients with otherconditions requiring vitrectomy but inwhom the retina was not directly affectedby neovascularization served as a controlgroup. Patients in whom intravitreous he-moglobin was detectable by spectopho-tometry were excluded. HGF and VEGFwere determined by enzyme-linked im-munosorbent assay (R&D Systems,Abingdon, U.K.). The results are ex-pressed as the median and range.

Vitreal levels of both VEGF and HGFwere higher in diabetic patients with PDRthan in the control group (1.34 [0.16–6.2] vs. 0.009 ng/ml [0.009–0.003] and19.38 [0.4 – 80] vs. 6.04 mg/ml [1.8 –17.34], respectively, P � 0.0001). Thesedifferences remained highly significant af-ter adjusting for serum levels (P �0.0001). To explore the influence of thebreakdown of the blood-retinal barrierand, in consequence, the increased serumdiffusion that occurs in PDR patients, thelevels of both HGF and VEGF were nor-malized for total vitreal protein concen-tration. After correcting for total vitreousprotein concentration, the ratio of VEGF-to-vitreal proteins remained significantlyhigher in diabetic patients with PDR thanin the control group (0.34 [0.01–2.3] vs.0.01 ng/mg [0.003–0.03], respectively,P � 0.0001). However, the ratio of HGF-to-vitreal proteins was lower in diabeticpatients than in nondiabetic control sub-jects (5.03 [2–20] vs. 7.52 ng/mg [1.9–26], P � 0.02). The lower intravitreouslevels of HGF obtained after correcting forintravitreal proteins in patients with PDRin comparison with nondiabetic controlsubjects suggest that serum diffusionlargely explains the differences detectedin the intravitreous HGF levels betweenthese groups.

The vitreous concentrations of VEGFwere higher in patients with active PDRthan in patients with quiescent PDR (1.89[0.2–6.2] vs. 0.78 ng/ml [0.1–1.7], re-spectively, P � 0.004). By contrast, vitre-ous HGF was not related to PDR activity(active vs. quiescent, 17.1 [7.3–46.6] vs.23 ng/ml [0.4 – 80], respectively, P �NS). Previous studies have found higherHGF concentrations in patients with ac-tive PDR than in those with quiescentPDR (1,2). However, after carefully con-sidering the main confounding factorsthat could lead to a misinterpretation ofthe results, we did not observe any rela-tionship between PDR activity and intra-vitreous HGF concentrations.

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Finally, we did not find a relationshipbetween intravitreous levels of HGF andVEGF. This was true in absolute termsand after normalizing for vitreal proteins.The different response of HGF and VEGFto hyperglycemia (6) and hypoxia (7)could explain the lack of relationship de-tected between these growth factors in thevitreous fluid of patients with PDR.

RAFAEL SIMO, MD1

ALBERT LECUBE, PHD1

JOSE GARCıA-ARUMı, MD2

ESTHER CARRASCO, PHD1

CRISTINA HERNANDEZ, MD1

From the 1Department of Endocrinology, HospitalGeneral Universitari Vall d’Hebron, Barcelona, Spain;and the 2Department of Ophthalmology, HospitalGeneral Universitari Vall d’Hebron, Barcelona, Spain.

Address correspondence to Rafael Simo, MD, Di-abetes Unit, Endocrinology Division, Hospital Uni-vesitari Vall d’Hebron, Pg. Vall d’Hebron 119-129,08035 Barcelona, Spain. E-mai l : rs [email protected].


Acknowledgments— This work was sup-ported by grants from the Ministerio de Cien-cia y Tecnologıa (PM99-0136), InstitutoCarlos III (G03/212, C03/08), and Novonor-disk Pharma (01/0,066)

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References1. Katsura Y, Okano T, Noritake M, Kosano

H, Nishigori H, Kado S, Matsuoka T: He-patocyte growth factor in vitreous fluid ofpatients with proliferative diabetic reti-nopathy and other retinal disorders. Dia-betes Care 21:1759–1763, 1998

2. Nishimura M, Ikeda T, Ushiyama M,Nanbu A, Kinoshita S, Yoshimura M: In-creased vitreous concentrations of humanhepatocyte growth factor in proliferativediabetic retinopathy. J Clin EndocrinolMetab 84:659–662, 1999

3. Canton A, Burgos B, Hernandez C, Mateo C,Segura RM, Mesa J, Simo R: Hepatocytegrowth factor in vitreous and serum frompatients with proliferative diabetic retinop-athy. Br J Ophthalmol 84:732–735, 2000

4. Umeda N, Ozaki H, Hayashi H, Kondo H,Uchida H, Oshima K: Non-paralleled in-crease of hepatocyte growth factor andvascular endothelial growth factor in theeyes with angiogenic and nonangiogenicfibroproliferation. Ophthalmic Res 34:43–47, 2002

5. Mitamura Y, Takeuchi S, Matsuda A, Ta-gawa Y, Mizue Y, Nishihira J: Hepatocytegrowth factor levels in the vitreous of pa-tients with proliferative vitreoretinopa-thy. Am J Ophthalmol 129:678–680, 2000

6. Taniyama Y, Morishita R, Hiraoka K, AokiM, Nakagami H, Yamasaki K, MatsumotoK, Nakamura T, Kaneda Y, Ogihara T:Therapeutic angiogenesis induced by hu-man hepatocyte growth factor gene in ratdiabetic hind limb ischemia model: mo-lecular mechanisms of delayed angiogen-esis in diabetes. Circulation 104:2344–2350, 2001

7. Hayashi S, Morishita R, Nakamura S,Yamamoto K, Moriguchi A, Nagano T, TaijiM, Noguchi H, Matsumoto K, Nakamura T,Higaki J, Ogihara T: Potential role of hepa-tocyte growth factor, a novel angiogenicgrowth factor, in peripheral arterial disease:downregulation of HGF in response to hyp-oxia in vascular cells. Circulation 100(Suppl. 19):II301–II308, 1999

AutoimmuneHypoglycemia in aType 2 DiabeticPatient With Anti-Insulin and InsulinReceptor Antibodies

There are two types of autoimmunehypoglycemia, one due to autoanti-bodies acting against the insulin

receptor and the other due to autoanti-bodies acting against insulin itself in indi-viduals who have or have never receivedexogenous insulin, respectively (1). Bothtypes are rare and can produce fasting andpostprandial reactive hypoglycemia.

A 72-year-old woman with frequentsevere hypoglycemia was admitted to theemergency room, presenting with loss ofconsciousness. Three weeks before heradmission, she was diagnosed with diabe-tes and received insulin at a local hospital.In the emergency room, her blood glu-cose level was 40 mg/dl. She had been ingood general health, except for hyperten-sion for 30 years and postmenopausal os-teoporosis 10 years before admission. Shehas no evidence of other diseases associ-ated with altered immunity.

Three weeks ago, her biceps tendonruptured when she slipped and fell, andduring treatment, her blood glucose lev-els were 400 mg/dl. She was treatedwith insulin. However, she stopped insu-lin treatment because of frequent hypo-glycemic events. Although she had hadintravenous glucose injections, she hadfrequent hypoglycemic attacks, such asdisorientation, loss of consciousness, pal-

pitation, and diaphoresis. Her blood glu-cose levels had been �40 mg/dl on everyhypoglycemic event, especially duringfasting hypoglycemia.

Physical examination revealed nor-mal vital signs except for a chronically illappearance. Her HbA1c was 6.3% (range3–6%), plasma glucose 40 mg/dl, insulin103.7 �U/ml, C-peptide 4.1 ng/ml, GADautoantibody levels 0.01 units/ml (nor-mal range 0–1.45 units/ml; RSR, Cardiff,U.K. ), and insulinoma-associated protein2 autoantibody 0.01 units/ml (normalrange 0–1.1 units/ml; RSR). Her thyroid,liver, and adrenal function studies werenormal. She was anemic, with a hemoglo-bin level of 9.2 g/dl. Her creatinine levelwas 0.8 mg/dl. Tests for anti-nuclear an-tibody, anti-DNA antibody, anti-smoothantibody, and anti-microsomal antibodywere all negative. Insulin antibody levelswere 58.5% (nonspecific binding, normalrange �7%, measured by radioimmuno-assay [Cobra 5010; Biosource Europe,Nivelles, Belgium]), and she was positivefor insulin receptor antibodies (measuredby radioreceptor assay [LKB 1261; BML,Tokyo, Japan]).

She was prescribed glucocorticoidsand glucose tablets. Treatment with pred-nisone and glucose tablets was accompa-nied by the resolution of hypoglycemicepisodes within 48 h. Six months later,her insulin antibody level was 67%, andshe was negative for insulin receptorantibodies.

Most cases of insulin autoimmune hy-poglycemia described in Asian races (2,3)have shown a strong correlation with cer-tain HLA systems, suggesting the exis-t ence o f a pred i spos ing genet i ccomponent. This subject’s HLA typing re-sult was HLA-DRB1*. Autoimmune hy-poglycemia is associated with certain HLAsystems, such as DR4 and DQw3, and es-pecially DRB1*0406/DQA1*0302/DQB1*0302. There have been 190 casesof insulin autoimmune syndrome re-ported over the past 20 years. It is note-worthy that HLA-DRB1*0406 is quiteprevalent in Japanese patients (2,3). Ourpatient’s HLA typing is predisposed to au-toimmune hypoglycemia.

Several types of insulin antibodieshave been reported and are most fre-quently seen in patients who receive in-sulin injections, but there have also beenreports of them in nondiabetic patientswith such autoimmune disease. Postpran-dial hypoglycemia is more common with

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this syndrome than fasting hypoglycemia(1), and the course of this condition isbenign and self-limited, with remissionusually occurring within 1 year.

The insulin receptor antibody is asso-ciated with the inhibition of insulin bind-ing to insulin receptors, acceleratedreceptor degradation, receptor down-regulation, and extreme insulin resistanceand hyperglycemia (4). Insulin receptorantibodies act as agonists or antagonists tothe insulin receptor. Insulin receptor an-tibodies may also inhibit insulin binding,thereby inhibiting insulin clearance andelevating levels of plasma insulin. Themost important laboratory test in autoim-mune hypoglycemia is a direct assay forthe presence of antibodies directedagainst the insulin receptor or insulin.

Patients with this condition have lowcirculating insulin, C-peptide levels, andrefractory hypoglycemia. Antibody titersgenerally decrease over time and remis-sion eventually occurs in most patients.However, because of the severity of thehypoglycemia, aggressive treatment is in-dicated. High-dose glucocorticoids, plas-mapheresis, and alkylating agents havebeen tried with varying success (5).

CHONG HWA KIM, MD

JI HYUN PARK, MD, PHD

TAE SUN PARK, MD, PHD

HONG SUN BAEK, MD, PHD

From the Division of Endocrinology and Metabo-lism, Department of Internal Medicine, ChonbukNational University Medical School, Chonju, Korea.

Address correspondence to T.S Park, MD, PHD,Division of Endocrinology and Metabolism, Depart-ment of Internal Medicine, Chonbuk National Uni-versity Medical School, Chonju, Korea 634-18,Keum-Am Dong, Dukjin Gu, Chonju, Chonbuk,561-712, Korea. E-mail: [email protected].


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References1. Taylor SI, Barbetti F, Accili D, Roth J, Gor-

den P: Syndromes of autoimmunity andhypoglycemia: autoantibodies directedagainst insulin and its receptor. EndocrinolMetab Clin North Am 18:123–143, 1989

2. Cavaco B, Uchigata Y, Porto T, Amparo-Santos M, Sobrinho L, Leite V: Hypogly-caemia due to insulin autoimmunesyndrome: report of two cases with char-acterisation of HLA alleles and insulin au-toantibodies. Eur J Endocrinol 145:311–316, 2001

3. Uchigata Y, Hirata Y, Omori Y: Hypogly-cemia due to insulin antibody (Letter).Am J Med 94:556–557, 1993

4. Elias D, Cohen IR, Schechter Y, Spirer Z,Golander A: Antibodies to insulin recep-tor followed by anti-idiotype: antibodiesto insulin in child with hypoglycemia. Di-abetes 36:348–354, 1987

6. Dozio N, Scavini M, Beretta A, Sarugeri E,Sartori S, Belloni C, Dosio F, Savi A, FazioF, Sodoyez JC, Pozza G: Imaging of thebuffering effect of insulin antibodies inthe autoimmune hypoglycemia syn-drome. J Clin Endocrinol Metab 83:643–648, 1998

COMMENTS ANDRESPONSES

PhenotypicHeterogeneity andAssociations of TwoAldose ReductaseGene PolymorphismsWith Nephropathyand Retinopathy inType 2 Diabetes

Response to Wang et al.

W ang et al. (1) recently examinedaldose reductase as a susceptibil-ity gene for diabetic nephropa-

thy among type 2 diabetic Chinese inHong Kong. Although there was a smallincrease in the frequencies of the risk al-leles of the (CA)n dinucleotide repeat andC-106T polymorphisms, analysis of thegenotype distribution failed to detect anysignificant association between thesepolymorphisms and diabetic nephropa-thy (1). This negative result persisted de-spite confining the statistical analyses tocontrol subjects who were normoalbu-minuric with at least 5 years of knowndiabetes duration and case subjects withboth diabetic nephropathy and concomi-tant diabetic retinopathy.

By and large, this study does not con-firm earlier findings, which had impli-cated aldose reductase as a genetic riskfactor for diabetic nephropathy amongCaucasians with type 1 diabetes (2). Al-though the two studies were done on pa-tients with different types of diabetes,drawn from separate human populations,which may arguably provide a basis for

the discordant findings, a distinct possi-bility relates to the differential definitionsof diabetic nephropathy. In this Bostonstudy, diabetic nephropathy was definedon the basis of persistent proteinuria, i.e.,�1� on Multistix or albumin-to-creatinine ratio (ACR) �300 mg/g, orend-stage renal disease due to diabetic ne-phropathy (2). In contrast, the definitionused in the current Hong Kong study wasless stringent and included patients withmicroalbuminuria (albumin excretionrate �20 �g/min or ACR �3.5 g/mmol)(1). This latter criterion poses some con-cern in terms of misclassification becauseregression of micro- to normoalbumin-uria is likely to be a common phenome-non, as recently demonstrated in type 1diabetic patients (3). In genetic epidemi-ological studies, such misclassificationcan diminish the power of a study to de-tect an association. Therefore, the studyby Wang et al. does not negate the hy-pothesis that aldose reductase could be asusceptibility gene for advanced diabeticnephropathy in type 2 diabetes. This pos-sibility might be addressed by reanalyzingtheir data using a stricter definition basedon advanced diabetic nephropathy.

DANIEL P.K. NG, PHD

KEE-SENG CHIA, FAMS, MD, FFOM

DAVID KOH, MBBS, MSC, PHD

From the Department of Community, Occupationaland Family Medicine, National University of Singa-pore, Singapore; and the Centre for Molecular Epi-demiology, National University of Singapore,Singapore.

Address correspondence to Daniel P K Ng, PhD,Department of Community, Occupational and Fam-ily Medicine (MD3), Faculty of Medicine, NationalUniversity of Singapore, 16 Medical Dr., Singapore,117597 Singapore. E-mail: [email protected].


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References1. Wang Y, Ng MC, Lee SC, So WY, Tong

PC, Cockram CS, Critchley JA, Chan JC:Phenotypic heterogeneity and associa-tions of two aldose reductase gene poly-morphisms with nephropathy andretinopathy in type 2 diabetes. DiabetesCare 26:2410–2415, 2003

2. Moczulski DK, Scott L, Antonellis A, Ro-gus JJ, Rich SS, Warram JH, Krolewski AS:Aldose reductase gene polymorphismsand susceptibility to diabetic nephropa-thy in type 1 diabetes mellitus. Diabet Med17:111–118, 2000

3. Perkins BA, Ficociello LH, Silva KH,Finkelstein DM, Warram JH, Krolewski

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AS: Regression of microalbuminuria intype 1 diabetes. N Engl J Med 348:2285–2293, 2003

PhenotypicHeterogeneity andAssociations of TwoAldose ReductaseGene PolymorphismsWith Nephropathyand Retinopathy inType 2 Diabetes

Response to Ng et al.

W e thank Ng et al. (1) for their re-sponse to our recent article onthe associations of two aldose re-

ductase gene polymorphisms, a (CA)nmicrosatellite at the 5� region and a pro-moter C/T polymorphism with nephrop-athy and retinopathy in type 2 diabetes(2).

However, we hold the view that Ng etal. have misinterpreted our data and in-advertenly commented that our “nega-tive” results were related to our less

stringent definitions of nephropathy,when in fact, we have provided clear evi-dence to show that both the z-2 and Tallele of the aldose reductase gene poly-morphisms were risk factors for diabeticnephropathy in Chinese type 2 diabeticpatients.

In the consecutive cohort analysis in-volving all 738 type 2 diabetic patients,those with the T allele had higher albu-minuria than noncarriers (30.2 vs. 21.9�g/min) (2). This difference remainedsignificant after adjustment for age, dura-tion of disease, blood pressure, andHbA1c.

We then excluded patients with ashort duration of disease (�5 years) andused a case-control study design to fur-ther test the hypothesis. We defined casesubjects as diabetic patients with both di-abetic retinopathy and nephropathy,whereas patients who had no complica-tions were selected as control subjects.Using this design, we found that both z-2(odds ratio 2.64) and T alleles (odds ratio2.48) were independent risk factors forthe coexistence of diabetic nephropathyand retinopathy. The other predictorswere age, blood pressure, HbA1c, triglyc-eride, and male sex (2).

Hence, contrary to the commentsmade by Ng et al. that we failed to confirm

results from previous studies on aldosereductase as risk genotypes for diabeticnephropathy in type 1 diabetes, our studyhas indeed provided corroborative evi-dence to support these findings.

JULIANA CHAN, MD, FRCP

YING WANG, PHD

From the Department of Medicine and Therapeu-tics, the Chinese University of Hong Kong, thePrince of Wales Hospital, Shatin, Hong Kong.

Address correspondence to Juliana Chan, MD,FRCP, The Chinese University of Hong Kong, De-partment of Medicine & Therapeutics, Prince ofWales Hospital, Shatin, N.T., Hong Kong. E-mail:[email protected].


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References1. Ng DPK, Chia K-S, Koh D: Phenotypic

heterogeneity and associations of two al-dose reductase gene polymorphisms withnephropathy and retinopathy in type 2diabetes (Letter). Diabetes Care 27:289–290, 2004

2. Wang Y, Ng MCY, Lee SC, So WY, TongCY, Cockram CS, Critchley JAJH, ChanJCN: Phenotypic heterogeneity and asso-ciations of two aldose reductase genepolymorphisms with nephropathy andretinopathy in type 2 diabetes. DiabetesCare 26:2410–2415, 2003

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