Biomedical subjects
Publications and source records attributed to S Hoops.
Knowledge of the physiologic changes, conditions, and therapies of pregnancy that increase the risk of pulmonary edema enables nurses to influence the outcome of their patients who develop medical complications while undergoing tocolytic therapy. Cooperation between perinatal and critical care nurses ensures optimal care of both the mother and the fetus.
Microangiopathy characterizes both diabetic retinopathy and nephropathy. It is currently unclear which diabetic subjects should be treated with angiotensin-converting enzyme (ACE) inhibitors. A double-blind, placebo-controlled protocol was implemented using captopril to treat subjects with Type I diabetes, early diabetic nephropathy (albumin excretion rates, 20-200 micrograms/min), and normal blood pressures. After two years, the final eye grades were improved in two treated subjects but not in any of the controls. Three control and one treated subject showed worsening of their eye grade after two years (P < .001, by chi-square test). Significant differences in renal albumin excretion were not seen between the two groups. The distribution of changes in retinal grades in the treatment group compared with the placebo group was improved after two years. Studies of larger numbers of patients will be necessary to determine if ACE inhibitors should be used routinely in subjects with diabetic retinopathy and to determine which subjects are most likely to respond.
Three hundred and fifty seven subjects (178 males and 179 females) with insulin dependent diabetes mellitus were evaluated for the presence of limited joint mobility of the interphalangeal joints. Sixty six subjects (19%) had stage 1 and 26 subjects (7%) had stage 2 involvement of their interphalangeal joints. The presence of contractures was significantly related to mean longitudinal glycated haemoglobin (HbA1) concentrations, duration of diabetes, age of onset, mean longitudinal cholesterol concentrations and blood pressure. Limited joint mobility was also significantly associated with early diabetic retinopathy and raised albumin excretion rates. Limited joint mobility remained a significant factor in the logistic regression model for albuminuria and grade of retinopathy when controlled for smoking, cholesterol concentrations, duration of diabetes, age, gender, and blood pressure. However, limited joint mobility was only significantly associated with diabetic retinopathy when the effect of HbA1 concentrations was included in the multivariate model.
The association of retinal changes with exercise microalbuminuria and with changes in systolic and diastolic blood pressure (BP) were evaluated in 162 young subjects with insulin-dependent (type 1) diabetes mellitus. Higher systolic and diastolic BPs at rest or after 10 or 20 min of exercise were significantly associated with more severe retinal changes in the subjects with diabetes compared to controls (P less than 0.02; global ANOVA). The mean (+/- SEM) exercise albumin excretion rate (AER) was 17.6 +/- 3.1 if there was no evidence of retinopathy compared to 81.5 +/- 23.5 when only microaneurysms were detected and 467.1 +/- 133.3 when more severe retinopathy was present. The percentage of subjects with abnormal AERs for these three retinal groups was 13, 30 and 60, respectively. (P less than 0.0001, chi-square test). It is clear that retinal changes relate to early renal changes, as monitored by exercise AERs and changes in resting and exercise BPs. It is concluded that the renal and retinal microvascular changes occur concurrently in young subjects with type 1 diabetes.
Vitreous fluorophotometry was performed on 240 eyes of 120 young subjects who had insulin-dependent diabetes mellitus (type I) and various grades of retinopathy. The concentration of fluorescein was measured in the anterior chamber and posterior vitreous 1 hour after intravenous injection of fluorescein. There was a significant association (P less than .001) between the grade of retinopathy and the level of posterior vitreous leakage. The amount of posterior vitreous leakage in each eye also had a significant association with borderline elevation of diastolic blood pressure. Subjects with excessive posterior vitreous leakage had significantly higher levels of urinary microalbumin excretion. In a multiple linear regression analysis for posterior vitreous leakage, retinal grade consistently entered the model at a significant level (P less than or equal to .00001 to .003). Blood pressure also entered the model for posterior vitreous leakage at a significant level for retinal grades of the right and left eyes and of the worst eye. These results demonstrate an association between leakage of retinal and renal vessels, possibly linked at least in part to elevation in diastolic blood pressure.
Islet cell antibodies were found in 71 of 1169 first-degree relatives (6.1%) from 448 families who had a proband with type I diabetes. Seven children have since become insulin dependent. All had islet cell antibodies and were followed up prospectively with measurement of first-phase insulin production during intravenous glucose tolerance testing. In this group the statistical probability of developing type I diabetes within 12 months with 95% confidence was found to be 59% to 100% when the first-phase insulin secretion was less than 25 microU/mL. The identification of the prediabetes time period should allow an opportunity for intervention in the underlying disease process to determine if the onset of type I diabetes can be altered.
There is a need for better and earlier markers of clinical renal damage in subjects with Type I diabetes. In this prospective study, exercise albumin excretion rates (AERs) were studied longitudinally for a 4-year period in 187 young subjects with Type I diabetes. For this time period, 54% of subjects continued to have normal overnight and exercise AERs, 11% had continuously elevated exercise and overnight AERs, 11% developed an elevated exercise AER with the overnight AER remaining normal, and 12% had a normal overnight AER throughout the study, with initially elevated exercise levels later decreasing to normal. This improvement in exercise AER was associated with improved glycosylated hemoglobin (HbA1) values for 64% of the subjects (p = 0.0004, paired t test). Five percent of subjects, who initially had only an elevated exercise AER, developed a consistently elevated overnight AER. Seven of these nine subjects showed either worsening (greater than 10%) or no improvement in their HbA1 values from the initial to the final study periods. Five percent of subjects continued to have an elevated exercise and normal overnight AER throughout the study. These results show that the elevated exercise AER represents a definite transitional stage between a normal and an abnormal (greater than 30 micrograms/min) overnight AER. In addition, a "window" exists during which an elevated exercise AER may be reversed by improved glucose control, but if this improvement does not occur, progression to an increased overnight AER is likely to result.
The etiology of diabetic nephropathy is currently unknown, but blood pressure is believed an important risk factor. A total of 173 subjects with type I diabetes who participated in two or more exercise tests with simultaneous measurements of blood pressure (BP) and heart rate were studied. Subjects with diabetes had significantly elevated resting and exercise diastolic and systolic BPs when compared with controls. This was not related to the presence of albuminuria. During exercise, elevation of diastolic BP was present in 65 (38%) of the 173 test subjects. Elevated exercise diastolic BPs among the subjects with diabetes (excluding controls) was present only for subjects with elevated exercise and overnight albuminuria. It is concluded that factors other than early diabetic nephropathy are likely related to elevated resting and exercise BPs in subjects with diabetes compared with controls. Early renal damage, however, is related to further elevations in resting and exercise diastolic BPs within the group of subjects with diabetes.
Over the past decade much has been learned about the relationship between good glycemic control and the alteration or prevention of long-term renal and retinal complications of insulin-dependent diabetes mellitus. The challenge for diabetes health professionals is to translate knowledge into improved patient care. A model program, using a multidisciplinary team approach, is presented to show how the art of changing the outcome can be incorporated into each patient encounter through screening, education, and counseling.
Intervention for poor glucose control was attempted in 38 children and adolescents with a mean follow-up time of 3 years. Changing the quantity of insulin or changing the number of injections per day resulted in improvement in 10 of the 21 patients who responded to intervention. Six others responded to a family conference and four responded to a parent temporarily taking over the diabetes management. The presence of a supportive family member living in the home was a major factor in the likelihood of intervention being successful.