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PubMed2003

The direct medical cost of type 2 diabetes.

OBJECTIVE: To describe the direct medical costs associated with type 2 diabetes, as well as its treatments, complications, and comorbidities. RESEARCH DESIGN AND METHODS: We studied a random sample of 1,364 subjects with type 2 diabetes who were members of a Michigan health maintenance organization. Demographic characteristics, duration of diabetes, diabetes treatments, glycemic control, complications, and comorbidities were assessed by surveys and medical chart reviews. Annual resource utilization and costs were assessed using health insurance claims. The log-transformed annual direct medical costs were fitted by multiple linear regression to indicator variables for demographics, treatments, glycemic control, complications, and comorbidities. RESULTS: The median annual direct medical costs for subjects with diet-controlled type 2 diabetes, BMI 30 kg/m(2), and no microvascular, neuropathic, or cardiovascular complications were 1,700 dollars for white men and 2,100 dollars for white women. A 10-kg/m(2) increase in BMI, treatment with oral antidiabetic or antihypertensive agents, diabetic kidney disease, cerebrovascular disease, and peripheral vascular disease were each associated with 10-30% increases in cost. Insulin treatment, angina, and MI were each associated with 60-90% increases in cost. Dialysis was associated with an 11-fold increase in cost. CONCLUSIONS: Insulin treatment and diabetes complications have a substantial impact on the direct medical costs of type 2 diabetes. The estimates presented in this model may be used to analyze the cost-effectiveness of interventions for type 2 diabetes.

Aged↗
PubMed1998

Effect of meal dilution on the postprandial glycemic response. Implications for glycemic testing.

OBJECTIVE: To investigate the effect of varying the volume of sugar meals on the post-prandial glycemic response (PGR). RESEARCH DESIGN AND METHODS: On six separate occasions, after an overnight fast, blood glucose concentrations were measured in eight healthy subjects (34 +/- 4 years of age, BMI 22.9 +/- 0.9 kg/m2) after the consumption of 25 g glucose, sucrose, or fructose dissolved in either 200 or 600 ml of water. Blood was obtained at fasting and then at times 15, 30, 45, 60, and 90 min after the start of the test meal. RESULTS: PGR was found to be influenced by carbohydrate type (P < 0.001). Mean response areas (min.mmol.l-1) to the three sugars were statistically different (P < 0.05). Glucose had the highest response area (90.0 +/- 8.1), followed by sucrose (61.3 +/- 5.0) and then fructose (14.7 +/- 2.8). Independent of this effect, PGR was also found to be influenced by volume dose (P < 0.01). By tripling meal volume from 200 to 600 ml, PGR areas were significantly increased for all three sugars, glucose (79.3 +/- 10.3 vs. 100.8 +/- 12.0, P = 0.035), sucrose (52.6 +/- 5.5 vs. 70 +/- 7.4, P = 0.0094), and fructose (11.0 +/- 3.8 vs. 18.4 +/- 3.9, P = 0.012). Where the effects of time (P < 0.05) and dose (P < 0.05) were determined to be independent (interaction nonsignificant) for all three sugars, this increase in volume also significantly increased glycemic concentrations at 15 min, for glucose (P = 0.033) and sucrose (P = 0.026), suggesting that changes in gastric emptying time may be a mechanism of action. CONCLUSIONS: Varying the volume of liquid sugar meals alters PGR. Understanding this concept may help to reduce variability both in the glycemic testing of foods and oral glucose tolerance testing.

Administration, Oral↗
PubMed2001

Glycemic index and serum high-density lipoprotein cholesterol concentration among us adults.

BACKGROUND: Dietary glycemic index, an indicator of the ability of the carbohydrate to raise blood glucose levels, and glycemic load, the product of glycemic index and carbohydrate intake, have been positively related to risk of coronary heart disease. However, the relationships between glycemic index and glycemic load and high-density lipoprotein cholesterol (HDL-C) concentration in the US population are unknown. METHODS: Using data from 13 907 participants aged 20 years and older in the Third National Health and Nutrition Examination Survey (1988-1994), we examined the relationships between glycemic index and glycemic load, which were determined from a food frequency questionnaire and HDL-C concentration. RESULTS: The age-adjusted mean HDL-C concentrations for increasing quintiles of glycemic index distribution were 1.38, 1.32, 1.30, 1.26, and 1.27 mmol/L (P<.001 for trend). (To convert millimoles per liter to milligrams per deciliter, divide by 0.0259.) After additional adjustment for sex, ethnicity, education, smoking status, body mass index, alcohol intake, physical activity, energy fraction from carbohydrates and fat, and total energy intake, the mean HDL-C concentrations for ascending quintiles of glycemic index were 1.36, 1.31, 1.30, 1.27, and 1.28 mmol/L (P<.001 for trend). Adjusting for the same covariates and considering glycemic index as a continuous variable, we found a change in HDL-C concentration of -0.06 mmol/L per 15-unit increase in glycemic index (P<.001). The multiple R(2) for the model was 0.23. Similarly, the multivariate-adjusted mean HDL-C concentrations for ascending quintiles of glycemic load distribution were 1.35, 1.31, 1.31, 1.30, and 1.26 mmol/L (P<.001 for linear trend). The inverse relationships between glycemic index and glycemic load and HDL-C persisted across all subgroups of participants categorized by sex or body mass index. CONCLUSIONS: These findings from a nationally representative sample of US adults suggest that high dietary glycemic index and high glycemic load are associated with a lower concentration of plasma HDL-C.

Adult↗
PubMed2003

Glucose sensor evaluation of glycemic instability in pediatric type 1 diabetes mellitus.

Maintaining blood glucose (BG) levels within the target range can be an elusive goal in children with type 1 diabetes mellitus (DM). To identify factor(s) that may contribute to glycemic instability, we analyzed the Continuous Glucose Monitoring System (CGMS) (Medtronic MiniMed, Northridge, CA) profiles of a group of children with type 1 DM and a history of frequent BG fluctuations and hypoglycemia. A total of 30 (17 girls, 13 boys) pediatric patients with a history of frequent BG fluctuations and hypoglycemia (mean age, 10.5 +/- 0.7 years; duration, 5.0 +/- 0.6 years), on three to four injections of insulin daily or insulin pump therapy, were evaluated by the CGMS. The mean BG (MBG), absolute means of daily differences (MODD), mean amplitude of glycemic excursion (MAGE), and number of hypoglycemic events (BG <60 mg/dL) for 48 h were calculated in each patient. There was a significant correlation between MBG and glycosylated hemoglobin (HbA1c) (r(2) = 0.22, p < 0.009). There was also a significant correlation between severity of lipohypertrophy and glycemic control (HbA1c) (r(2) = 0.20, p < 0.01). The MODD values had a positive correlation with the severity of injection site lipohypertrophy (r(2) = 0.37, p < 0.0003). The MAGE values had a positive correlation with bolus:basal insulin ratio (r(2) = 0.22, p < 0.009) and number of hypoglycemic events (r(2) = 0.21, p < 0.008), independent of age, MBG, and glycemic control. The 48-h CGMS profile can help characterize day-to-day and within-day BG variability and identify factors influencing glycemic instability in pediatric type 1 DM.

Adolescent↗
PubMed2001

Lipids and psychosocial status in aboriginal persons with and at risk for Type 2 diabetes: implications for tertiary prevention.

This study assessed psychosocial correlates of dyslipidemia, towards enabling improved tertiary prevention of macrovascular complications of diabetes mellitus (DM). We tested the hypothesis that psychosocial measures are related to high-density lipoprotein cholesterol (HDL-C) and triglyceride concentrations in a rural aboriginal population in British Columbia, Canada. Persons sampled were on-reserve registered Indians (n=198) with and at risk for Type 2 DM. Relationships between HDL-C and psychosocial variables were associated with glycemic status. For persons with diabetes and impaired glucose tolerance (n=44), quality of life and mastery were positively related (P<0.001), and depression inversely related (P<0.001), to HDL-C. An apparent lack of effect of behavior suggests the influence of emotional pathways involving autonomic-neuroendocrine axes. We recommend assessing mental health, and promoting mastery and diabetes quality of life through empowerment oriented diabetes management strategies, in negotiating culturally acceptable treatment of diabetic dyslipidemia for aboriginal people.

Adaptation, Psychological↗
PubMed1992

Oscillatory potentials, retinopathy, and long-term glucose control in insulin-dependent diabetes.

The main objective of the study was to assess effects of long-term lowering of glucosylated hemoglobin (HbA1%) on neurosensory function in insulin-dependent diabetes. Individual (OP-1, OP-2, OP-3) and summed (OP-sum) amplitudes of oscillatory potentials (OPs) of electroretinography were recorded at study start and 7-years later in 45 patients (the Oslo study). As an overall 7-year change, amplitudes of OP-2, OP-3 and OP-sum were reduced (p < 0.0001-0.01), retinopathy worsened (p = 0.005), intraocular pressure decreased (p < 0.001), systolic blood pressure increased (p < 0.0002), and glycemic control improved from HbA1 of 11.2 +/- 2.2% at study start to a 7-year cumulative mean of 9.5 +/- 1.5% (p < 0.0001). Multiple regression analysis did not identify any independent relations between change in OP-1, OP-2, OP-3, OP-sum and change in glycemic control or background variables, including change in age and duration of diabetes. However, cross-sectional observations at 7 years showed negative correlations between all OPs and age (p < 0.0001-0.003), and between OP-3 and duration (p = 0.003) and counts of microaneurysms (p = 0.02). The data suggest that various clinical background variables may influence individual and summed amplitudes of OPs differently. Reduced neurosensory retinal function (OPs) seemed to appear after 7-years, independently of vascular defects of retinopathy and long-term improvement in glucose control.

Adolescent↗
PubMedDate not supplied

Anemia associated with new-onset diabetes: improvement with blood glucose control.

OBJECTIVE: To evaluate the mild normochromic normocytic anemia associated with new-onset diabetes in young, otherwise healthy patients. METHODS: We undertook a retrospective review of medical records of patients with new-onset diabetes and unexplained anemia. Anemia was defined as a hemoglobin concentration of less than 12.5 g/dL in women and less than 14 g/dL in men. Patients with obvious causes of anemia, such as renal insufficiency, infection, pancreatitis, deficiency of glucose-6-phosphate dehydrogenase, hemolysis, or acute or chronic blood loss, were excluded from the study. RESULTS: In 16 otherwise seemingly healthy patients with new-onset diabetes, a normochromic normocytic anemia (mean corpuscular volume, 86.4 +/- 4 fL) was diagnosed at initial assessment. These 16 patients (8 men and 8 women) had a mean age of 33 +/- 10 years. At diagnosis, the mean glycated hemoglobin (HbA1c) was 15.5 +/- 3.4%, the mean hemoglobin concentration was 12.5 +/- 0.6 g/dL, and the mean hematocrit was 36.2 +/- 2%. All patients were treated with insulin. After a mean follow-up of 10.8 +/- 17 months, insulin treatment resulted in a decline in HbA1c to 7.7 +/- 1.7% (P<0.001; confidence interval [CI], 5.7 to 9.8). The hemoglobin concentration increased to 14.3 +/- 0.9 g/dL (P<0.001; CI, 1.22 to 2.38), and the hematocrit increased to 42.1 +/- 1.9% (P<0.001; CI, 3.59 to 7.04). All patients had hemoglobin AA and normal levels of hemoglobin A2. Men and women had equal improvement in hematologic variables after improvement in glycemic control. CONCLUSION: Some patients with new-onset diabetes have a mild normochromic normocytic anemia that is not attributable to usual causes, such as infection, pancreatitis, or blood loss. Improvement in glycemic control tends to be associated with normalization of hemoglobin levels. The cause of such cases of anemia may be either direct "glucose toxicity" to erythrocyte precursors in the bone marrow or perhaps oxidative stress to mature erythrocytes.

Adult↗
PubMed2000

Diabetic retinopathy in pregnancy during tight metabolic control.

BACKGROUND: The relation between retinopathy and the parameters: 24-h blood pressure, glucose control, albuminuria, and outcome of pregnancy was studied before, during, and after pregnancy in women with insulin-dependent diabetes mellitus on tight metabolic control during pregnancy. METHODS: Prospective study of 112 pregnant women with insulin-dependent diabetes mellitus followed with fundus photography at the Department of Ophthalmology, Arhus University Hospital. Changes in retinopathy were related to 24-h blood pressure, blood glucose, albuminuria, and adverse perinatal outcome. RESULTS: There was an association between grade of retinopathy and HbAlc before (Spearman's rho=0.49, p<0.04) and after pregnancy (Spearman's rho=0.42, p<0.02), but no such correlation was found at any examination during pregnancy where glycemia was kept tight. Those women who had progression of retinopathy during or after pregnancy had significantly earlier onset of diabetes mellitus (14+/-8 years, range 1-27) than those women with improvement or no progression of retinopathy (19+/-8 years, range 1-36, p<0.04). No association was found between progression of retinopathy and HbA1c, blood pressure, adverse perinatal outcome or any of the other variables studied. CONCLUSIONS: Tight glycemic control during pregnancy is recommendable to avoid progression of retinopathy. Attention should be given to the period after delivery where the tight regulation may be difficult to achieve. IDDM women should be encouraged to plan pregnancies early in life.

Adolescent↗
PubMed2006

Long hydrocarbon chain diols and diacids with central ether or ketone moieties that favorably alter lipid disorders.

Long hydrocarbon chain derivatives with bis-terminal hydroxyl or carboxyl groups and various central moieties (ketone, ether, ester, amide, carbamate, etc.) have been synthesized and evaluated for their effects on the de novo incorporation of radiolabeled acetate into lipids in primary cultures of rat hepatocytes as well as for their effects on lipid, glycemic and body weight variables in female obese Zucker fatty rats following one and two weeks of oral administration. The most active compounds were found to be symmetrical with four to five methylene groups separating the ether or ketone central functionality from the gem dimethyl, cycloalkyl or methyl/aryl substituents. Cycloalkyl substitution alpha to the carboxyl group in keto-acids lowered the in vitro activity to micromolar values. Furthermore, in vivo biological activity was found to be greatest for cyclopropyl-substituted ketone derivatives, particularly the ketodiacid with five methylene groups on each side of the central ketone functionality, which was identified as an HDL elevator and was also found to reduce insulin and glucose.

Aging↗
PubMed1998

Bone turnover and insulin-like growth factor I levels increase after improved glycemic control in noninsulin-dependent diabetes mellitus.

It is unclear whether both bone resorption and formation are affected by glycemic control, and contribute to diabetic osteopenia. In this study, 20 patients with noninsulin-dependent diabetes mellitus (12 men and 8 postmenopausal women) and 20 healthy control subjects (10 men and 10 postmenopausal women) were examined at baseline and 2 months. The diabetic patients showed an improvement of glycemic control (decreased HbA1c) at the second measurement. Analysis of variance showed that there was no effect of gender on the variables that increased with improved glycemic control, and therefore results are presented for both male and female subjects. Baseline values of serum osteocalcin, a marker of formation, were significantly lower in diabetic patients compared with healthy subjects (2.5 +/- 1.3 versus 4.4 +/- 1.4 ng/ml; P = 0.0006), but markers of bone resorption [urinary pyridinoline (PYD), deoxypyridinoline (DPD)] did not differ. Improved glycemic control in diabetic patients resulted in increased values of PYD (P = 0.012), DPD (P = 0.049), serum osteocalcin (P = 0.001), and serum insulin-like growth factor I (IGF-I, P = 0.003), but no change in serum parathyroid hormone or 25-hydroxyvitamin D. In diabetic patients there were inverse correlations for the percent change from baseline to improved glycemic control for osteocalcin and HbA1c (r = -0.53; P = 0.016) and glucose (r = -0.46; P = 0.050). These data suggest that improved glycemic control is accompanied by an increase in bone turnover for male and female diabetic patients, possibly mediated by increased levels of circulating IGF-I.

Adult↗
PubMed1995

A new bioassay for insulin in conscious rabbits by continuous measurement of glycemic responses.

Because of the substantial variability often observed in the determination of insulin potency by the United States Pharmacopeia (USP) bioassay method, a large number of rabbits are required in order to attain an accuracy of +/- 6% and each bioassay needs 2-3 weeks to be completed. In this report, an improved bioassay method has been developed. This bioassay was conducted in conscious healthy rabbits. The decline in blood glucose levels, following intravenous injection of an insulin preparation, was monitored (in uninterrupted manner) by the continuous glucose monitoring system developed. A glucose response curve was generated, and from this response curve, various pharmacodynamic parameters were easily determined. The whole procedure could be completed in 1 day and also achieved an accuracy where upon only one rabbit is needed to determine accurately the insulin potency. To validate the method, a total of nine healthy rabbits were studied to determine the inter- and intra-animal reproducibility. The values of insulin potency determined from four pharmacodynamic parameters were compared, and the potency calculated from the ABGC (area of the blood glucose response curve under baseline) was found to be the most accurate: a mean (+/- SEM) value of 102.3(+/- 1.2)% was determined by inter-animal study (n = 9) and a value of 100.6(+/- 1.3)% by intra-animal study (n = 4). The inter-bioassay variability among the random-dose bioassays was 1.2% for inter-animal and 1.3% for intra-animal studies. The insulin potency in an insulin sample determined by this bioassay had attained an overall mean (+/- SEM) value of 101.6(+/- 0.8)% (n = 17).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2001

A controlled study of oral self-care and self-perceived oral health in type 2 diabetic patients.

A controlled study was carried out in mid-Sweden with the aim of comparing oral self-care and self-perceived oral health in 102 randomly sampled type 2 diabetic patients with that of 102 age-and-gender-matched non-diabetic controls. Oral health variables were also related to glycemic control (HbA1c), duration, anti-diabetic treatment, and late complications. Questionnaires were used to collect data on oral self-care and self-perceived oral health. Diabetes-related variables were extracted from medical records. Eighty-five percent of the diabetic subjects had never received information about the relation between diabetes and oral health, and 83% were unaware of the link. Forty-eight percent believed that the dentist/ dental hygienist did not know of their having diabetes. Most individuals, but fewer in the diabetic group, were regular visitors to dental care and the majority felt unaffected when confronted with dental services. More than 90% in both groups brushed their teeth daily and more than half of those with natural teeth did proximal cleaning. Subjects in the diabetic group as well as in the control group were content with their teeth and mouth (83% vs 85%. Those with solely natural teeth and those with complete removable dentures expressed most satisfaction. Sensation of dry mouth was common among diabetic patients (54%) and subjects with hypertension exhibited dry mouth to a greater extent (65%) than those who were normotensive. Our principal conclusion is that efforts should be made to give information about diabetes as a risk factor for oral health from dental services to diabetic patients and diabetes staff.

Adult↗
PubMed1991

The glycemic index: methodology and clinical implications.

There is controversy regarding the clinical utility of classifying foods according to their glycemic responses by using the glycemic index (GI). Part of the controversy is due to methodologic variables that can markedly affect the interpretation of glycemic responses and the GI values obtained. Recent studies support the clinical utility of the GI. Within limits determined by the expected GI difference and by the day-to-day variation of glycemic responses, the GI predicts the ranking of the glycemic potential of different meals in individual subjects. In long-term trials, low-GI diets result in modest improvements in overall blood glucose control in patients with insulin-dependent and non-insulin-dependent diabetes. Of perhaps greater therapeutic importance is the ability of low-GI diets to reduce insulin secretion and lower blood lipid concentrations in patients with hypertriglyceridemia.

Blood Glucose↗
PubMed1994

Intraperitoneal versus subcutaneous insulin in patients on nighttime IPD.

For the diabetic patient on peritoneal dialysis, the intraperitoneal administration of insulin can lead to improvement in glycemic control while eliminating uncomfortable subcutaneous injections. Furthermore, the relatively higher portal vein concentrations of insulin compared to peripheral levels is reminiscent of the physiologic state in which the portal vein carries the insulin secreted by the pancreas. The pharmacokinetics of intraperitoneal insulin depends upon whether the insulin is administered along with the usual volume of dialysis fluid or is given undiluted. This variability has important implications for glycemic control in the patient receiving cycler peritoneal dialysis, particularly if the abdomen is dry for prolonged periods during the day. Recommendations are made based on the known pharmacokinetics of intraperitoneal insulin in both the dry and filled peritoneal cavity.

Diabetes Mellitus↗
PubMed2003

Closing the loop: physician communication with diabetic patients who have low health literacy.

BACKGROUND: Patients recall or comprehend as little as half of what physicians convey during an outpatient encounter. To enhance recall, comprehension, and adherence, it is recommended that physicians elicit patients' comprehension of new concepts and tailor subsequent information, particularly for patients with low functional health literacy. It is not known how frequently physicians apply this interactive educational strategy, or whether it is associated with improved health outcomes. METHODS: We used direct observation to measure the extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts during outpatient encounters, using audiotapes of visits between 38 physicians and 74 English-speaking patients with diabetes mellitus and low functional health literacy. We then examined whether there was an association between physicians' application of this interactive communication strategy and patients' glycemic control using information from clinical and administrative databases. RESULTS: Physicians assessed recall and comprehension of any new concept in 12 (20%) of 61 visits and for 15 (12%) of 124 new concepts. Patients whose physicians assessed recall or comprehension were more likely to have hemoglobin A(1c) levels below the mean (< or = 8.6%) vs patients whose physicians did not (odds ratio, 8.96; 95% confidence interval, 1.1-74.9) (P =.02). After multivariate logistic regression, the 2 variables independently associated with good glycemic control were higher health literacy levels (odds ratio, 3.97; 95% confidence interval, 1.09-14.47) (P =.04) and physicians' application of the interactive communication strategy (odds ratio, 15.15; 95% confidence interval, 2.07-110.78) (P<.01). CONCLUSIONS: Primary care physicians caring for patients with diabetes mellitus and low functional health literacy rarely assessed patient recall or comprehension of new concepts. Overlooking this step in communication reflects a missed opportunity that may have important clinical implications.

Adult↗
PubMed1999

Progression of retinopathy after improved metabolic control in type 2 diabetic patients. Relation to IGF-1 and hemostatic variables.

OBJECTIVE: To determine the impact of improved glycemic control on the development and progression of retinopathy after the institution of insulin therapy in patients with type 2 diabetes and to assess the relation to IGF-1 and hemostatic variables. RESEARCH DESIGN AND METHODS: In a prospective observational study, 45 type 2 diabetic patients were examined at baseline and 1, 3, 6, 12, and 24 months after change to insulin therapy. Retinopathy was graded on fundus photographs using the Wisconsin scale; HbA1c, IGF-1, and hemostatic variables were measured. RESULTS: During the observation period of 2 years, 23 patients progressed in the retinopathy scale; 8 progressed > or = 3 levels. After 2 years of insulin treatment, HbA1c and IGF-1 were significantly lower than at baseline, whereas the hemostatic variables had not changed significantly. Progression of retinopathy > or = 3 levels was related to the degree of HbA1c reduction, the duration of diabetes, a higher prothrombin fragment 1 + 2 levels (F1 + 2), but not to other hemostatic variables or IGF-1. The relative risk for progression > or = 3 levels was 2.6 when HbA1c had been reduced > or = 3 percent units (95% CI 1.1-6.1). CONCLUSIONS: The magnitude of improvement of HbA1c by the institution of insulin treatment over a 2-year period may be associated with progression of retinopathy in patients with type 2 diabetes.

Diabetes Mellitus, Type 2↗
PubMed2001

Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot.

OBJECTIVE: To evaluate the effectiveness of a diabetic foot risk classification system by the International Working Group on the Diabetic Foot to predict clinical outcomes. RESEARCH DESIGN AND METHODS: A total of 225 diabetic patients were initially evaluated as part of a prospective case-control study at the University of Texas Health Science Center at San Antonio. Complete records were available for 213 patients for follow-up evaluation after 29 months. Upon enrollment, subjects were stratified into four risk groups based on the presence of risk factors according to the consensus of the International Working Group on the Diabetic Foot. Group 0 consisted of subjects without neuropathy, group 1 consisted of patients with neuropathy but without deformity or peripheral vascular disease (PVD), group 2 consisted of subjects with neuropathy and deformity or PVD, and group 3 consisted of patients with a history of foot ulceration or a lower-extremity amputation. RESULTS: Upon enrollment, patients in higher-risk groups had longer duration of diabetes, worse glycemic control, vascular and neuropathic variables, and more systemic complications of diabetes. During 3 years of follow-up, ulceration occurred in 5.1, 14.3, 18.8, and 55.8% of the patients in groups 0, 1, 2, and 3, respectively (linear-by-linear association, P < 0.001). All amputations were found in Groups 2 and 3 (3.1 and 20.9%, P < 0.001). CONCLUSIONS: The foot risk classification of the International Working Group on the Diabetic Foot predicts ulceration and amputation and can function as a tool to prevent lower-extremity complications of diabetes.

Blood Pressure↗