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Many people with diabetes in the U.S. will seek or currently hold a license to drive. For many, a driver's license is essential for everyday life. Considerable discussion has focused on whether, and the extent to which, diabetes may be a relevant factor in determining driver ability and eligibility for a license. This statement addresses such issues in relation to current scientific and medical evidence. A diagnosis of diabetes on its own is not sufficient to make judgments about an individual driver's ability or safety. This statement provides an overview of existing licensing rules for people with diabetes in the U.S., addresses the factors that affect driving ability, identifies general guidelines for assessing driver fitness and determining appropriately tailored licensing restrictions, and provides practical guidance for health care professionals regarding clinical interventions and education for people with diabetes., (© 2024 by the American Diabetes Association.)

Aims: To collect and analyse representative data of structural and process quality in the management of diabetic emergencies in Germany in 2020., Methods: A standardised questionnaire comprising detailed items concerning clinically relevant parameters on the structural and process quality of out-of-hospital management of diabetic emergencies was sent nationwide to medical directors of emergency medical service districts (EMSDs). Results were compared with those from a similar study conducted in 2001., Results: The return rate of the questionnaires represented 126 EMSDs, serving a total population of > 40.1 million. Only 4% of ambulances carried glucagon (6% in 2001). In 2020, blood glucose determination increased significantly to 71% of all emergency interventions and to 29% of suspected cardiac emergencies (24% and 15%, respectively, in 2001). In 100% of EMSDs severe hypoglycaemia (SH) was treated by paramedics by administering intravenous dextrose before the arrival of a doctor compared to 63% in 2001. The potential value of nasal glucagon was acknowledged by 43% of responders. In selected patients, treatment of SH was conducted without hospital admission in 78% of EMDs (60% in 2001). Fifty-three percent of medical directors acknowledged the need for further training in diabetic emergencies (47% in 2001). Cooperation for medical education between emergency teams and a diabetes centre was reported by 14% (41% in 2001)., Conclusion: Structural and process quality of the management of diabetic emergencies in Germany has improved considerably since 2001. Persisting deficiencies could be improved by providing better medical equipment in ambulances and ongoing education to the entire emergency teams., Competing Interests: A. Holstein has received personal fees from Eli Lilly and Company and Novo Nordisk. B.M. Frier has received honoraria for lectures from Novo Nordisk, Eli Lilly, Sanofi, Roche, MSD, and Abbott, and for advisory board membership for Zucara Pharmaceuticals. The remaining authors have no competing interests to declare., (Thieme. All rights reserved.)

Objective: The risk of hypoglycemia in people with insulin-treated diabetes has debarred them from certain "safety-critical" occupations, including flying commercial aircraft. This report evaluates the effectiveness of a protocol enabling a large cohort of insulin-treated pilots to fly commercially., Research Design and Methods: This was an observational study of pilots with insulin-treated diabetes who were granted medical certification to fly commercial and noncommercial aircraft. Clinical details, pre- and in-flight (hourly and 30 min before landing) blood glucose values were correlated against the protocol-specified ranges: green (5-15 mmol/L), amber (low, 4-4.9 mmol/L; high, 15.1-20 mmol/L), and red (low, <4 mmol/L; high, >20 mmol/L)., Results: A total of 49 pilots with type 1 (84%) or type 2 (16%) diabetes who had been issued class 1 or class 2 certificates were studied. Median diabetes duration was 10.9 years. Mean HbA 1c was 7.2% (55.0 mmol/mol) before certification and 7.2% (55.1 mmol/mol) after certification ( P = 0.97). Blood glucose values ( n = 38,621) were recorded during 22,078 flying hours. Overall, 97.69% of measurements were within the green range, 1.42% within the low amber range, and 0.75% within the high amber range. Only 0.12% of readings were within the low red range and 0.02% within the high red range. Out-of-range readings declined from 5.7% in 2013 to 1.2% in 2019. No episodes of pilot incapacitation occurred, and glycemic control did not deteriorate., Conclusions: The protocol is practical to implement, and no events compromising safety were reported. This study represents what is, to our knowledge, the most extensive data set from people with insulin-treated diabetes working in a "safety-critical" occupation, which may be relevant when estimating risk in other safety-critical occupations., (© 2020 by the American Diabetes Association.)

Hypoglycaemia is a frequent adverse effect of treatment of diabetes mellitus with insulin and sulphonylureas. Fear of hypoglycaemia alters self-management of diabetes mellitus and prevents optimal glycaemic control. Mild (self-treated) and severe (requiring help) hypoglycaemia episodes are more common in type 1 diabetes mellitus but people with insulin-treated type 2 diabetes mellitus are also exposed to frequent hypoglycaemic events, many of which occur during sleep. Hypoglycaemia can disrupt many everyday activities such as driving, work performance and leisure pursuits. In addition to accidents and physical injury, the morbidity of hypoglycaemia involves the cardiovascular and central nervous systems. Whereas coma and seizures are well-recognized neurological sequelae of hypoglycaemia, much interest is currently focused on the potential for hypoglycaemia to cause dangerous and life-threatening cardiac complications, such as arrhythmias and myocardial ischaemia, and whether recurrent severe hypoglycaemia can cause permanent cognitive impairment or promote cognitive decline and accelerate the onset of dementia in middle-aged and elderly people with diabetes mellitus. Prevention of hypoglycaemia is an important part of diabetes mellitus management and strategies include patient education, glucose monitoring, appropriate adjustment of diet and medications in relation to everyday circumstances including physical exercise, and the application of new technologies such as real-time continuous glucose monitoring, modified insulin pumps and the artificial pancreas.

Objective: Hypoglycemia is associated with increased heat production and, despite of this, hypothermia. Heat production is likely to be mediated by sympathetic innervation. Brown adipose tissue is activated by cold exposure and stimulated by the sympathetic nervous system. We therefore examined the effect of hypoglycemia on uptake of the labeled glucose analogue (18)F-fluorodeoxyglucose in brown adipose tissue using positron emission tomography and computer tomography., Methods: In nine healthy adults (18)F-fluorodeoxyglucose uptake as measure of brown adipose tissue activity was assessed in a cold environment (17 °C) during euglycemia (blood glucose 4.5 mmol/L) and hypoglycemia (2.5 mmol/L) using a hyperinsulinemic glucose clamp., Results: Brown adipose tissue activity was observed in all participants. No difference was observed in the median (range) maximal standardized uptake values of (18)F-fluorodeoxyglucose in brown adipose tissue between euglycemia and hypoglycemia: 4.2 (1.0-7.7) versus 3.1 (2.2-12.5) g/mL (p=0.7). Similarly there were no differences in mean standardized (18)F-fluorodeoxyglucose uptake values or total brown adipose tissue volume between euglycemia and hypoglycemia. Body temperature dropped by 0.6 °C from baseline during the hypoglycemic condition and remained unchanged during the euglycemic condition. There was no correlation between the maximal standardized uptake values of (18)F-fluorodeoxyglucose in brown adipose tissue and levels of counterregulatory hormones., Conclusions: This study shows that there is a similar amount of (18)F-fluorodeoxyglucose uptake in brown adipose tissue during hypoglycemia when compared to euglycemia, which makes a role for systemic catecholamines in brown adipose tissue activation and a role for brown adipose tissue thermogenesis in hypoglycemia associated hypothermia unlikely. Future studies in humans should determine whether hypoglycemia indeed increases energy expenditure, and if so which alternative source can explain this increase., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The aim of the present study was to examine symptoms of hypoglycemia, to develop a method to quantify individual differences in the consistency of symptom reporting, and to investigate which factors affect these differences., Methods: Participants recorded their symptoms with every episode of hypoglycemia over a 9-12-month period. A novel logistic-type latent variable model was developed to quantify the consistency of each individual's symptom complex and was used to analyze data from 59 subjects (median age, 57.5 years [range, 22-74 years], 65% male, 77% type 1 diabetes) who had experienced 19 or more hypoglycemic episodes. The association between the calculated consistency parameter and age, sex, type and duration of diabetes, and C-peptide and serum angiotensin converting enzyme concentration was examined using a generalized linear model. Analyses were performed under a Bayesian framework, using Markov chain Monte-Carlo methodology., Results: Individuals exhibited substantial differences in between-episode consistency of their symptom reports, with only a small number of individuals exhibiting high levels of consistency. Men were more consistent than women. No other factors affected consistency in patients with normal hypoglycemia awareness., Conclusions: By using a novel stochastic model as a quantitative tool to compare the consistency of hypoglycemic symptom reporting, much greater intra-individual variability in symptom reporting was identified than has been recognized previously. This is relevant when instructing patients on identification of hypoglycemic symptoms and in interpreting symptomatic responses during experimentally induced hypoglycemia.

Hypoglycaemia is a frequent side-effect of treatment with insulin and sulfonylureas for people with diabetes, threatening potentially serious morbidity and preventing optimal glycaemic control. Fear of hypoglycaemia and development of syndromes such as impaired awareness and counterregulatory deficiency provide additional hazards for intensification of treatment. Rapid lowering of HbA1c may be potentially dangerous in type 2 diabetes because of the adverse cardiovascular effects induced by hypoglycaemia. Hypoglycaemia can disrupt many everyday activities such as driving, work performance and recreational pursuits. Measures to reduce the risk of hypoglycaemia are labour-intensive and require substantial resources.

Human diabetes is associated with cognitive impairment and structural abnormalities in the brain such as cerebral atrophy. The aetiology of these abnormalities is not known. The BB/E rat is a well-established model of type 1 (insulin dependent) diabetes. A cohort of 34 BB/E rats with diabetes was divided into three sub-groups according to age (and duration of diabetes). Basal ganglia calcification (BGC) was present in the brains of more than 50% of diabetic animals, but not in any of 37 non-diabetic BB/E rats. BGC occurred more commonly in those animals which had the longest duration of diabetes (p=0.001), such that BGC was present in only 8% of animals with diabetes for 20 weeks, but in 100% of animals with diabetes for 60 weeks. There were no other significant light microscopic neuropathologic changes in diabetic animals. It will be important to investigate the mechanism of brain calcification, whether a similar process occurs in humans with diabetes, and its possible relationship to cognitive decline.

Aims: To assess prospectively the activity and effectiveness of a diabetes specialist on-call service., Methods: All requests for specialist advice received by the doctor on-call for diabetes in a large teaching hospital were recorded and analysed over a period of 3 weeks., Results: The total number of calls was 135 (mean 45 per week) of which 48.1% were outside normal working hours. Requests for advice from surgical and medical ward staff accounted for 43% of calls, the remainder were from staff in the maternity ward (12.6%), staff in other hospitals in the city (3.7%), general practitioners (13.3%) and patients (27.4%). The time spent by the on-call doctor for diabetes responding to calls was a mean of 8.6 h per week. The number of acute admissions prevented by this service was estimated to be 11 (3.6 per week)., Conclusions: Open access to specialist advice provided by a doctor with expertise in diabetes is an effective adjunct to the delivery of diabetes care in the setting of a large teaching hospital.

A survey of patients' waiting times was performed in the follow-up clinics of a large hospital outpatient diabetic department (approximately 6500 patients). Over a period of 1 week, 138 patients attended 5 review outpatient clinics. The overall patient:doctor ratio was 11.1:1. Only 18.8% of patients were seen by the doctor, and 86% by the nurse within 30 min of their appointment time. A policy of strict adherence to the formal appointment times was implemented but had no effect on the waiting time (20% of patients were seen by the doctor, and 82.2% by the nurse within 30 min of their appointment time). The combined effects of adherence to actual appointment times and increasing the number of doctors (lowering the patient:doctor ratio to 7.7:1), reduced the total waiting times, and increased the proportion of patients seen by the doctor or nurse within 30 min of their appointment time, to 31% and 100%, respectively. Strict adherence to appointment times was difficult to implement and ineffective but the patient:doctor ratio was important in determining waiting times in the diabetic clinic. Inadequate medical staffing of diabetic outpatient clinics is a major cause of prolonged waiting time for patients. This approach may be useful in assessing and improving the organizational efficiency of a diabetes service.

Hospital in-patient statistics are an important outcome measurement in the assessment of the morbidity associated with diabetes mellitus. A prospective study of 157 consecutive admissions over a 28-day period compared diagnoses obtained from the clinical records with the ICD9 coding of the same admissions recorded at the Information and Statistics Division of the Scottish Health Service. Sixty-one percent of all discharge summaries omitted the diagnosis of diabetes. Even when admission was principally related to diabetes complications, 47% of medical and 88% of surgical discharge summaries omitted diabetes as a diagnostic category. ICD9 coding underestimated the percentage of admissions accounted for by diabetic patients by 100% (2.8 vs 5.6%) and as a result underestimated bed occupancy by over 200% (4.3 vs 13.7%), and is thus failing to fulfil its potential as a demographic and epidemiological record of resource use by disease classification.

The effect of chlorpropamide on blood glucose, plasma insulin, C-peptide and glucagon levels was studied in 21 patients with insulin-independent diabetes. A metabolic profile of these parameters was obtained throughout a normal day in seven newly-diagnosed diabetic patients (group A), before, and 3 to 8 weeks after treatment with chlorpropamide was established, and in 14 patients on longterm therapy with chlorpropamide (seven taking less than 250 mg. chlorpropamide--group B; seven taking 250-375 mg.--group C), before, and two weeks after withdrawal of the drug. In group A, correction of hyperglycaemia was not accompanied by a significant rise in the mean plasma insulin and C-peptide levels but a fall was observed in the mean plasma pancreatic glucagon concentrations. In groups B and C, withdrawal of chlorpropamide produced no significant change in plasma insulin, C-peptide or glucagon levels, although the mean blood glucose increased. This study supports an extrapancreatic effect of chlorpropamide to lower blood glucose after prolonged administration. In the short-term, it is possible that chlorpropamide may influence the secretion of pancreatic glucagon.

A survey of 250 patients with insulin-dependent diabetes (IDD) holding a full motor vehicle driving licence revealed that 107 (42.8%) had not declared IDD on their application for a driving licence. 70 of these (28% of entire group) claimed that they were unaware of the statutory requirements. There was no difference in the declaration-rate between men and women. 159 patients (66%) declared IDD for their motor insurance. 86 patients (34.4%) had had severe or frequent hypoglycaemia in the preceding six months, during which they had been driving regularly. 34 patients (13.6%) admitted involvement in a driving accident since commencing treatment with insulin, and 13 of these patients were aware that hypoglycaemia had been an important causal factor. The prevalence of diabetic retinopathy and cataracts was considerable, but few patients (2.4%) had severe impairment of vision in both eyes.

A retrospective survey of symptomatic awareness of hypoglycaemia was performed in 189 randomly selected patients with insulin-treated diabetes who had been transferred from highly purified animal insulins to human insulin in the preceding 24 months. Of the 189 patients 44 (23%) complained of chronic hypoglycaemic unawareness, unrelated to ambient blood glucose control, before change of insulin species. Only 12 of the remaining 145 patients reported a reduction in awareness of hypoglycaemia following transfer to human insulin (6% of the whole group), while 6 (3%) reported an increase in awareness following the transfer. The 12 patients reporting reduced awareness had a mean duration of diabetes of 24 +/ 10 years compared to a duration of 15 +/- 10 years in the patients with normal awareness. The mean glycosylated haemoglobin concentrations were similar in all of the groups of patients. Six patients had developed total loss of awareness of the onset of hypoglycaemia, with all but one patient having suffered multiple episodes of severe hypoglycaemia. This reduced hypoglycaemic awareness on human insulin therapy was not associated with any significant improvement in blood glucose control.

To study the possible relationship between the quality of glycaemic control in diabetes mellitus and the carriage of Candida species, the candidal carrier status of 412 diabetic patients was examined using an oral rinse technique and correlated with measurements of random blood glucose and total glycosylated haemoglobin. Candida was isolated in 210 diabetics (51%) with 13 patients (6%) carrying more than one species. The positive isolates were: Candida albicans (89%), Candida krusei (2.8%), Candida glabrata (2.8%), Candida tropicalis (6.2%), Candida stellatoidea (2.8%) and Candida parapsilosis (0.5%). No association was identified between carriage rates and the type of treatment of diabetes, or with the quality of glycaemic control. As in non-diabetic subjects, the carriage rates were higher in diabetic patients wearing dentures. Thus, the oral carriage of Candida in diabetic patients was independent of glycaemic control but in certain sub-groups the carriage rates were higher, and involved uncommon candidal species.

Factitious diabetic instability is described in four patients. In three the predominant problem was recurrent hypoglycaemia. The fourth presented with apparent insulin resistance and episodes of ketoacidosis. The methods used to make the diagnosis are described, and the factors which contribute to this type of diabetic instability are discussed.

The turnover of isotopically labeled squalene formed in plasma from [14C]mevalonate has been used to measure cholesterol synthesis in diabetics over a 7-h period. Five patients were studied while in poor diabetic control (mean daytime glycemia, 349 mg/dl) and at a later date once improved control was established by multiple daily insulin injections (mean glycemia, 175 mg/dl). This degree of diabetic control resulted in an increase in the fractional conversion of [14C]mevalonic acid to [14C]squalene from 55.2 +/- 1% to 67.5 +/- 4% (P less than 0.025). These data together with the area under the squalene specific activity curve yeild an estimated rate of cholesterol synthesis based on the likely assumption that mevalonate pool size did not decrease. Insulinization increased this calculated mean rate of cholesterol synthesis from 961 +/- 151 to 1206 +/- 223 mg/day (P less than 0.025). The use of squalene kinetics to evaluate changes in cholesterol synthesis deserves further study, particularly in metabolically unstable states such as diabetes in which conventional methods for measuring cholesterol synthesis are difficult to apply and to interpret.

The prevalence of raised serum liver-associated enzyme activity in stabilised, treated diabetic outpatients without concurrent hepatobiliary disease was investigated using a retrospective computer search of biochemical data. The frequency of raised alanine aminotransferase, aspartate aminotransferase, or gamma glutamyl transferase activity found among diabetic, general medical and respiratory outpatients was compared with that found in apparently healthy controls. It was established that a raised activity of any of the three enzymes occurred with a similar frequency in each outpatient group. However, only with alanine aminotransferase did the frequency of elevation (7.1%) in the patients with previously diagnosed hepatobiliary disease exceed that of healthy controls. A raised alanine aminotransferase activity in diabetic outpatients was associated with good glycemic control (hemoglobin A1 less than 8%, p less than 0.02) and treatment with oral hypoglycaemic agents (p less than 0.001).

The medical fitness of drivers who have diabetes is assessed primarily by general practitioners. A survey was made of the knowledge of driving and diabetes of 105 general practitioners in Glasgow. Ninety four (90%) knew that people who were insulin dependent were required by law to declare their condition to the Driver and Vehicle Licensing Centre in Swansea, but most were unaware that people with diabetes should not hold a "till 70" driving licence. Seventy one doctors (69%) claimed that patients were recalled individually for fitness to drive. The minimum visual acuity for driving was stated correctly by 37 (35%). Only eight respondents knew that a hypoglycaemic diabetic driver can be charged with driving under the influence of a drug (Road Traffic Act 1972), and the practical advice that was given to patients about hypoglycaemia and driving was unsatisfactory. As a group the general practitioners showed deficiencies in knowledge regarding diabetes and driving, suggesting a need for further postgraduate education.

One hundred and nine patients with diabetes mellitus and 100 age-, sex- and denture-status-matched, non-diabetic individuals were investigated prospectively. Comparison was made of oral candidal carriage, clinical infection and inherited ability to secrete blood group antigens in saliva. Diabetic patients had a significantly higher prevalence of oral candidal carriage and infection (P less than 0.001) than non-diabetic individuals, but the candidal load between the 2 groups, was not significant. A comparable proportion of insulin-dependent, non-insulin dependent and control groups were secretors of blood group antigens, and there was no difference in the oral candidal carriage and infection rates between secretors and non-secretors.

The adaptation of an immunoturbidimetric assay to quantitatively measure urinary albumin is described and this was used to evaluate a commercial latex agglutination slide test, Albuscreen, with a sensitivity of 25 mg/l. Excellent agreement was observed between the two methods, and in clinical studies an acceptable classification of patients was made using Albuscreen, an albumin: creatinine ratio of less than or equal to 2.5 being used to indicate possible microalbuminuria. A small number of false negative and false positive results occurred in some dilute and concentrated urine samples, respectively.

A survey of 186 diabetic patients examined their collective experience of life and motor insurance. Some form of life insurance policy had been obtained by 150 patients, with a combined total of 204 policies, 107 of which had been agreed before the diagnosis of diabetes. Most patients had declared diabetes to the insurer but 12 patients had been refused acceptance. Only 15 patients sought alternative quotations. The premium had been loaded by 10-40% for 36 patients because of diabetes, and 48 required a medical report. Of 147 diabetic drivers, 95 (65%) had declared diabetes either to the Licensing authority, or to the motor insurer, but only 62 (42%) had informed both. Fourteen patients had been refused motor insurance cover by individual companies, and 36 patients were aware of having had their premium increased, but only 16 patients had sought alternative quotations. Major differences in attitude with regard to diabetes as a risk factor for insurance are evident, and patients should be advised to approach several companies when seeking insurance cover.

Fasting serum trypsin concentration and pancreatic trypsin output, stimulated by secretin and cholecystokinin-pancreozymin, were measured in 18 patients with insulin-dependent diabetes, to assess a possible correlation between these two indices of exocrine pancreatic function. Serum trypsin concentration was subnormal in 13, and pancreatic trypsin output was decreased in 14 patients, but there was no significant correlation between the two measurements. There was no correlation between serum trypsin and residual beta cell function measured by plasma C-peptide immunoreactivity (CPR). After an interval of four years serum trypsin measurements were repeated in 11 subjects. All individual trypsin levels were lower than the previous results, the difference being highly significant (t = 9.0; p < 0.001). Serum trypsin concentration therefore represents a qualitative index of reduced exocrine pancreatic function in diabetes, but has no value in quantitating the degree of deficiency.