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Objective: Cystic Fibrosis Foundation guidelines recommend annual diabetes screening by oral glucose tolerance test (OGTT) in pediatric patients with cystic fibrosis (CF) starting at the age of 10 years. Adherence to these guidelines proves to be challenging, and the nationwide screening rates are still considered suboptimal. The aim of this study was to assess and improve the screening rates at our large pediatric center., Methods: A 4-year retrospective audit of OGTT completion among pediatric patients with CF of age ≥10 years who are not yet diagnosed with diabetes was conducted. A collaborative working group was formed to identify the barriers to screening and formulate a quality improvement plan, which was monitored and evaluated for a 9-month period., Results: Diabetes screening rates determined by OGTT completion at our center showed a gradual decline during the COVID-19 pandemic from 2019 to 2022. Following the implementation of the quality improvement plan during the summer of 2023, there was a marked increase in OGTT ordering compliance by providers as well as test completion by patients. Notably, the fractional OGTT completion rate rose from 45% during the preintervention phase (January-April 2023) to 70% during the postintervention phase (May-September 2023)., Conclusion: Diabetes screening in pediatric patients with CF can be effectively improved by refining practices related to patient experience, care coordination, and laboratory testing strategies., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Purpose: This study aimed to determine the threshold for defining abnormal retinal sensitivity (RS) that correlates with structural changes in diabetic macular ischemia (DMI) patients with stable treated proliferative diabetic retinopathy (PDR)., Design: Prospective cross-sectional study., Methods: In a single center, we recruited 85 eyes (67 patients) with stable treated PDR with best-corrected visual acuity (BCVA) ≥54 Early Treatment Diabetic Retinopathy Study (ETDRS) letters (Snellen equivalent 20/80) and optical coherence tomography angiography evidence of DMI. The function-function and function-structure correlation were assessed. Two preselected thresholds in overall RS (oRS), 25 decibels (dB) and age-matched normative data (AMND), were tested on their ability to reflect abnormal anatomy in DMI. Finally, a multivariable regression model was established to depict the relationship between the oRS and various parameters., Results: The oRS showed only a modest correlation with BCVA and low-luminance visual acuity (LLVA). The whole-image deep vessel density (wiDVD) was the most reliable vascular metric correlated with RS. For every 1% decline in the wiDVD, the oRS decreased by 0.37 dB (P < .001) after multivariable adjustment. Furthermore, both a reduction of oRS to <25 dB or below AMND could differentiate eyes with FAZ ≥0.5 mm 2 , whole image superficial vessel density (wiSVD) <37.7%, wiDVD <41.9%, and the presence of disorganization of the retinal inner layers (DRIL) from their counterparts., Conclusions: The absolute value of 25 dB in oRS is worth considering as a trial endpoint, because it does not require complex calculation and closely reflects the structural abnormalities in DMI., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

A library of 22 derivatives of 1,3,4-oxadiazole-2-thiol was synthesized, structurally characterized, and assessed for its potential to inhibit α-amylase, α-glucosidase, acetylcholinesterase (AChE), butyrylcholinesterase (BChE), and antioxidant activities. Most of the tested compounds demonstrated good to moderate inhibition potential; however, their activity was lower than that of the standard acarbose. Significantly, compound 3f exhibited the highest inhibition potential against α-glucosidase and α-amylase enzymes, with IC 50 values of 18.52 ± 0.09 and 20.25 ± 1.05 µM, respectively, in comparison to the standard acarbose (12.29 ± 0.26; 15.98 ± 0.14 µM). Compounds also demonstrated varying degrees of inhibitory potential against AChE (IC 50  = 9.25 ± 0.19 to 36.15 ± 0.12 µM) and BChE (IC 50  = 10.06 ± 0.43 to 35.13 ± 0.12 µM) enzymes compared to the standard donepezil (IC 50  = 2.01 ± 0.12; 3.12 ± 0.06 µM), as well as DPPH (IC 50  = 20.98 ± 0.06 to 52.83 ± 0.12 µM) and ABTS radical scavenging activities (IC 50  = 22.29 ± 0.18 to 47.98 ± 0.03 µM) in comparison to the standard ascorbic acid (IC 50  = 18.12 ± 0.15; 19.19 ± 0.72). The kinetic investigations have demonstrated that the compounds exhibit competitive-type inhibition for α-amylase, noncompetitive-type inhibition for α-glucosidase and AChE, and mixed-type inhibition for BChE. Additionally, a molecular docking study was performed on all synthetic oxadiazoles to explore the interaction details of these compounds with the active sites of the enzymes., (© 2023 Deutsche Pharmazeutische Gesellschaft.)

Background: Indian Diabetic Risk Score (IDRS) and Community Based Assessment Checklist (CBAC) are easy, inexpensive, and non-invasive tools that can be used to screen people for Metabolic Syndrome (Met S). The study aimed to explore the prediction abilities of IDRS and CBAC tools for Met S., Methods: All the people of age ≥30 years attending the selected rural health centers were screened for Met S. We used the International Diabetes Federation (IDF) criteria to diagnose the Met S. ROC curves were plotted by taking Met S as dependent variables, and IDRS and CBAC scores as independent/prediction variables. Sensitivity (SN), specificity (SP), Positive and Negative Predictive Value (PPV and NPV), Likelihood Ratio for positive and negative tests (LR+ and LR-), Accuracy, and Youden's index were calculated for different IDRS and CBAC scores cut-offs. Data were analyzed using SPSS v.23 and MedCalc v.20.111., Results: A total of 942 participants underwent the screening process. Out of them, 59 (6.4%, 95% CI: 4.90-8.12) were found to have Met S. Area Under the Curve (AUC) for IDRS in predicting Met S was 0.73 (95%CI: 0.67-0.79), with 76.3% (64.0%-85.3%) sensitivity and 54.6% (51.2%-57.8%) specificity at the cut-off of ≥60. For the CBAC score, AUC was 0.73 (95%CI: 0.66-0.79), with 84.7% (73.5%-91.7%) sensitivity and 48.8% (45.5%-52.1%) specificity at the cut-off of ≥4 (Youden's Index, 2.1). The AUCs of both parameters (IDRS and CBAC scores) were statistically significant. There was no significant difference (p = 0.833) in the AUCs of IDRS and CBAC [Difference between AUC = 0.00571]., Conclusion: The current study provides scientific evidence that both IDRS and CBAC have almost 73% prediction ability for Met S. Though CBAC holds relatively greater sensitivity (84.7%) than IDRS (76.3%), the difference in prediction abilities is not statistically significant. The prediction abilities of IDRS and CBAC found in this study are inadequate to qualify as Met S screening tools., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Gupta et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aim: To synthesize pyrrolopyridine-based thiazolotriazoles as a novel class of α-amylase and α-glucosidase inhibitors and to determine their enzymatic kinetics. Methodology: Pyrrolopyridine-based thiazolotriazole analogs ( 1-24 ) were synthesized and characterized through proton nuclear magnetic resonance, carbon-13 nuclear magnetic resonance and high-resolution electron ionization mass spectrometry. Results: All synthesized analogs displayed good inhibitory potential of α-amylase and α-glucosidase ranging 17.65-70.7 μM and 18.15-71.97 μM, respectively, compared with the reference drug, acarbose (11.98 μM and 12.79 μM). Analog 3 was the most potent among the synthesized analogs, having α-amylase and α-glucosidase inhibitory activity at 17.65 and 18.15 μM, respectively. The structure-activity relationship and binding modes of interactions between selected analogs were confirmed via docking and enzymatic kinetics studies. The compounds ( 1-24 ) were tested for cytotoxicity against the 3T3 mouse fibroblast cell line and were observed to be nontoxic.

Objective: To investigate the relative effect of disorganization of the retinal inner layers (DRIL) and ellipsoid zone (EZ) loss on visual function in diabetic macular ischemia (DMI)., Design: Prospective cross-sectional observational study., Participants: Patients with stable treated proliferative diabetic retinopathy (PDR) without center-involved diabetic macular edema were recruited at the Moorfields Eye Hospital from December 2019 to November 2021. The main inclusion criteria were best-corrected visual acuity (BCVA) of ≥ 40 ETDRS letters (Snellen equivalent 20/160) with OCT angiography (OCTA) evidence of DMI in ≥ 1 eye., Methods: Each eligible eye of the recruited patients was assessed for BCVA, OCT, and OCTA metrics. The prespecified OCT parameters were DRIL and subfoveal EZ loss. Generalized estimating equations were used., Main Outcomes Measures: The frequency of DRIL and EZ loss, their relative contributions to vision loss, and their associations with microvascular alterations were evaluated., Results: A total of 125 eyes of 86 patients with PDR were enrolled; 104 (83%) eyes had a BCVA of ≥ 70 letters. Disorganization of the retinal inner layers was more prevalent than EZ loss (46% [58 eyes] vs. 19% [24 eyes]). On average, the presence of DRIL had a more pronounced impact on vision, retinal thickness, and microvascular parameters than EZ loss. After multivariable adjustment, the odds of coexisting DRIL increased by 12% with every letter decrease in BCVA; however, there was no statistically significant association of subfoveal EZ loss with BCVA. In eyes with DRIL in the absence of EZ loss, the BCVA declined significantly by 6.67 letters compared with eyes with no DRIL nor EZ loss (95% confidence interval [CI], -9.92 to -3.41; P < 0.001). However, if DRIL and EZ loss coexisted, the resultant BCVA was 13.22 letters less than eyes without these structural abnormalities (95% CI, -18.85 to -7.59; P < 0.001)., Conclusions: In patients with DMI with a Snellen visual acuity of 20/160 or better, eyes with DRIL were associated with more visual function loss and retinal blood circulation alterations than those with subfoveal EZ loss only., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Identification of molecules having dual capabilities to reduce postprandial hyperglycemia and oxidative stress is one of the therapeutic approaches to treat diabetes mellitus. In this connection, a library of benzofuran-linked chalcone derivatives were evaluated for their dual action. Methods: A series of substituted benzofuran-linked chalcones ( 2-33 ) were synthesized and tested for α-amylase inhibitory as well as 2,2-diphenylpicrylhydrazyl (DPPH) and 2,2'-azino- bis (3-ethylbenzothiazoline-6-sulfonic acid) (ABTS) radical scavenging activities. Results: All compounds showed α-amylase inhibitory activity ranging from IC 50  = 12.81 ± 0.03 to 87.17 ± 0.15 μM, compared with the standard acarbose (IC 50  = 13.98 ± 0.03 μM). Compounds also demonstrated radical scavenging potential against DPPH and ABTS radicals. Conclusion: The identified compounds may serve as potential leads for further advanced research.

Background: To discover novel lead molecules against diabetes, Alzheimer's disease and oxidative stress, a library of arylated pyrazole-fused pyran derivatives, 1-20 , were synthesized in a one-pot reaction. Materials & methods: 1 H-NMR spectroscopic and electron ionization mass spectrometry techniques were used to characterize the synthetic hybrid molecules 1-20 . Analogs were screened against four indispensable therapeutic targets, including α -amylase, α -glucosidase, acetylcholinesterase and butyrylcholinesterase enzymes. Results: Except for derivatives 17 and 18 , all other compounds exhibited varying degrees of inhibitory activities against target enzymes. The kinetic studies revealed that the synthetic molecules followed a competitive-type mode of inhibition for α -glucosidase and butyrylcholinesterase enzymes. In addition, molecular docking studies identified crucial binding interactions of ligands with the enzyme's active site. α These molecules may serve as a potential drug candidate to cure diabetes, Alzheimer's disease and oxidative stress in the future.Conclusion: These molecules may serve as a potential drug candidate to cure diabetes, Alzheimer's disease and oxidative stress in the future.

Background: In previous landmark studies on central retinal vein occlusion, retinal nonperfusion assessments were obtained using 7-field (7F) angiography. The widespread current use of widefield imaging allows better visualization of the peripheral retina and more comprehensive estimation of the total area of nonperfusion. The relationship between nonperfusion measurement of 7F and widefield angiography (WFA) in central retinal vein occlusion has not been studied. We aim to identify the correlation of retinal nonperfusion measured within the 7F and on WFA in eyes with central retinal vein occlusion., Methods: Retinal nonperfusion in participants with central retinal vein occlusion was determined using a 7F Early Treatment Diabetic Retinopathy Study template and the concentric rings method., Results: A total of 153 eyes were included. Pearson correlation test showed a near-perfect positive, linear correlation between the nonperfusion found in the 7F and total retinal nonperfusion on WFA (0.985 95% CI [0.793, 0.999]) The regression line equation for nonperfusion on 7F and WFA was y = 37 + 3.2x. Eyes with 0 disk areas (DA), >0 DA to 10 DA and >10 DA of nonperfusion on 7-fields had on average 23 DA 95% CI (19.20, 27.06), 45 DA 95% CI (35.75, 55.18), and 115 DA 95% CI (88.89, 142.05) on widefield respectively., Conclusion: There is a positive and linear relationship between nonperfusion measured by 7F and WFA in central retinal vein occlusion with more than 3-times the amount of nonperfusion identified on WFA. Despite <10 DA no areas of nonperfusion on 7F, there is typically at least 35 DA of nonperfusion on WFA whereas eyes with >10 DA of nonperfusion on 7F had at least 88 DA on WFA.

A variety of dihydroquinazolin-4(1H)-one derivatives (1-37) were synthesized via "one-pot" three-component reaction scheme by treating aniline and different aromatic aldehydes with isatoic anhydride in the presence of acetic acid. Chemical structures of compounds were deduced by different spectroscopic techniques including EI-MS, HREI-MS, 1 H-, and 13 C-NMR. Compounds were subjected to α-amylase and α-glucosidase inhibitory activities. A number of derivatives exhibited significant to moderate inhibition potential against α-amylase (IC 50  = 23.33 ± 0.02-88.65 ± 0.23 μM) and α-glucosidase (IC 50  = 25.01 ± 0.12-89.99 ± 0.09 μM) enzymes, respectively. Results were compared with the standard acarbose (IC 50  = 17.08 ± 0.07 μM for α-amylase and IC 50  = 17.67 ± 0.09 μM for α-glucosidase). Structure-activity relationship (SAR) was rationalized by analyzing the substituents effects on inhibitory potential. Kinetic studies were implemented to find the mode of inhibition by compounds which revealed competitive inhibition for α-amylase and non-competitive inhibition for α-glucosidase. However, in silico study identified several important binding interactions of ligands (synthetic analogues) with the active site of both enzymes., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG part of Springer Nature.)

Syndromes of severe insulin resistance can result from mutations in the insulin receptor gene or autoantibodies to the insulin receptor. The type B syndrome of insulin resistance results from autoantibodies to the insulin receptor and occurs predominantly in women under age 50 years. Here we report on a 64 year old African American man with systemic lupus erythematosus (SLE) and acanthosis nigricans who had severe insulin resistance requiring up to 5000 units of insulin per day. He was diagnosed with type B insulin resistance syndrome based on his clinical presentation and demonstration of autoantibodies to the insulin receptor in his serum. This case study underscores the importance of assaying for autoantibodies to the insulin receptors especially in African American patients with severe insulin resistance and diabetes requiring excessive doses of insulin, in the setting of an autoimmune disease like SLE. It also behooves reference laboratories to develop and offer this assay because these patients have a very high mortality., (Published by Oxford University Press on behalf of American Society for Clinical Pathology 2021.)

Vision-threatening diabetic retinopathy (VTDR) is one of the leading causes of impaired vision in the working-age population. Early identification, timely diagnosis, and prompt treatment of VTDR have to be tackled simultaneously to reduce the rate of blindness due to this condition. Considerable emphasis has been placed globally on establishing diabetic retinopathy screening (DRS) programs to enable early identification and referral of VTDR for treatment. However, there is an urgent need to shift from the common practice of opportunistic screening to a systematic DRS pathway to ensure that individuals with diabetes are screened at regular intervals and treated appropriately. While systematic DRS programs have been successfully established in countries such as the United Kingdom (UK), it continues to be a challenge to initiate and sustain such programs in low- and middle-income countries (LMIC), home to approximately 80% of people with diabetes. Telemedicine is widely recognized as an ideal DRS screening program. Although it has resulted in an upsurge of opportunistic screening, systematic recall of screened patients remains a challenge. In addition, the link between referred patients from the telemedicine programs to treatment centers is often not established or has failed to deliver; so, there is minimal impact of these telemedicine programs on VTDR blindness at present. This review covers the various barriers of establishing and sustaining systematic telemedicine DRS programs, especially in resource-constrained settings, and the challenges in aligning telemedicine to VTDR treatment pathways to ensure patients with VTDR are treated promptly and effectively., Competing Interests: None

Objective: Routine monitoring of hemoglobin A1c (HbA1c) is the standard of care in diabetes mellitus (DM), but adhering to regular laboratory appointments may be challenging when access to care is limited, such as during the initial wave of the COVID-19 pandemic in the United States in 2020., Materials: We evaluated trends in patient encounters and laboratory testing for DM in a pediatric healthcare system from March to September 2019 and during the same period in 2020., Results: Evaluation of 17,367 patient encounters illustrated that the pandemic was associated with significantly fewer in-person office visits and point-of-care HbA1c tests for patients with DM in 2020 relative to 2019. A separate analysis of 7,193 HbA1c results measured by point-of-care testing in the general population found a significant increase in the number of measured HbA1c >14 % in May 2020 relative to 2019, but other measured HbA1c values did not differ. As a means to address lapses in the monitoring of HbA1c due to the pandemic, we evaluated the use of the dried blood spot (DBS) matrix for measurement of HbA1c by the Vitros 5600 chemistry analyzer. DBS HbA1c was well correlated to whole blood (r=0.9889) and exhibited intra- and inter-assay precision from 0.5-3.5%., Conclusion: DBS measurement of HbA1c presents a viable alternative to routine in-person laboratory monitoring of DM., (© 2021 by the Association of Clinical Scientists, Inc.)

Background: Diabetes and its complications are increasing in frequency worldwide. Lower-extremity complications carry a high risk for morbidity and mortality, yet are largely preventable through education and self-monitoring. In India, rural areas lack access to education, care, and treatment. Despite existing evidence-based programs to reduce diabetes-related lower-extremity complications in areas with limited resources, uptake and sustainability may be hampered by the lack of translation to the local cultural context., Aims: To address this gap, this study used the Culturally Informed Healthy Aging nursing process to develop a lower extremity complication prevention program in a rural village. The paper describes the results of a community health needs assessment conducted annually from 2009 to 2014, and subsequent pilot test of an intervention incorporating these results., Methods: The Culturally Informed Healthy Aging process is a naturalistic, inductive method used to identify and address health needs. Components include community partnership, community assessment, program planning, selection of health priorities, workgroup formation and translation of evidence, and program outcome evaluation. The programming is assessed using process evaluation, which allows for continuous monitoring and program modification., Results: Community assessment revealed a number of values, beliefs, and practices related to foot care and assessment in rural south India. These were incorporated into culturally informed programming and evidence-based protocols were adapted for use in the local context. Programming resulted in increased community capacity for lower extremity complication prevention, accessible population screening, and culturally informed foot care education., Discussion: Strengths, limitations and implications for care in rural India and other areas are discussed.

Purpose of Review: Obesity and diabetes are worldwide epidemics. There is also a growing body of evidence relating the gut microbiome composition to insulin resistance. The purpose of this review is to delineate the studies linking gut microbiota to obesity, metabolic syndrome, and diabetes., Recent Findings: Animal studies as well as proof of concept studies using fecal transplantation demonstrate the pivotal role of the gut microbiota in regulating insulin resistance states and inflammation. While we still need to standardize methodologies to study the microbiome, there is an abundance of evidence pointing to the link between gut microbiome, inflammation, and insulin resistance, and future studies should be aimed at identifying unifying mechanisms.

Older adults' health is sensitive to variations in neighborhood environment, yet few studies have examined how neighborhood factors influence their health care access. This study examined whether neighborhood environmental factors help to explain racial and socioeconomic disparities in health care access and outcomes among urban older adults with diabetes. Data from 123 233 diabetic Medicare beneficiaries aged 65 years and older in New York City were geocoded to measures of neighborhood walkability, public transit access, and primary care supply. In 2008, 6.4% had no office-based "evaluation and management" (E&M) visits. Multilevel logistic regression indicated that this group had greater odds of preventable hospitalization in 2009 (odds ratio = 1.31; 95% confidence interval: 1.22-1.40). Nonwhites and low-income individuals had greater odds of a lapse in E&M visits and of preventable hospitalization. Neighborhood factors did not help to explain these disparities. Further research is needed on the mechanisms underlying these disparities and older adults' ability to navigate health care. Even in an insured population living in a provider-dense city, targeted interventions may be needed to overcome barriers to chronic illness care for older adults in the community.

Background: Obesity, metabolic syndrome, and type 2 diabetes are major public health challenges. Recently, interest has surged regarding the possible role of the intestinal microbiota as potential novel contributors to the increased prevalence of these 3 disorders., Content: Recent advances in microbial DNA sequencing technologies have resulted in the widespread application of whole-genome sequencing technologies for metagenomic DNA analysis of complex ecosystems such as the human gut. Current evidence suggests that the gut microbiota affect nutrient acquisition, energy harvest, and a myriad of host metabolic pathways., Conclusion: Advances in the Human Microbiome Project and human metagenomics research will lead the way toward a greater understanding of the importance and role of the gut microbiome in metabolic disorders such as obesity, metabolic syndrome, and diabetes., (© 2013 American Association for Clinical Chemistry)

The Klotho gene has been identified as an aging suppressor gene that encodes a transmembrane protein, which is expressed primarily in renal tubules. There are 2 forms of Klotho, membrane and secreted. However, there is a paucity of data on levels of soluble Klotho in diseases like diabetes and kidney disease. We validated an enzyme-linked immunosorbent assay for Klotho and quantitated Klotho levels separately in patients with diabetes and also in patients with chronic kidney disease (CKD). The Klotho assay showed good precision and was linear down to 19 ng/mL. There were no significant effects on Klotho levels with the addition of common interferents such as ascorbate, triglycerides, or hemolysis; only bilirubin (250 mg/L) significantly reduced Klotho levels (P < .05). There was a significant reduction in Klotho levels in samples with glycated hemoglobin (HbA(1c)) levels of 6.5% or more compared with control samples (HbA(1c) < 6.5%; P < .001). We also documented significantly higher levels of Klotho with CKD. Thus, we validated an assay for Klotho and made the novel observation that levels are decreased in diabetes and increased in CKD.

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.