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OBJECTIVE—The Mayo Health System Diabetes Translation Project sought to assess models of community-based diabetes care and use of a diabetes electronic management system (DEMS). Planned care is a redesigned model of chronic disease care that involves guideline implementation, support of self-management, and use of clinical information systems. RESEARCH DESIGN AND METHODS—We studied adult diabetic patients attending three primary care practice sites in Wisconsin and Minnesota. We implemented planned care at all sites and DEMS in the practice of 16 primary care providers. We assessed quality of diabetes care using standard indicators for 200 patients randomly selected from each site at baseline and at 24 months of implementation. We used multivariable analyses to estimate the association between planned care and DEMS and each quality indicator. RESULTS—Planned care was associated with improvements in measurement of HbA1c (odds ratio 7.0 [95% CI 4.2–11.6]), HDL cholesterol (5.6 [4.1–7.5]), and microalbuminuria (5.3 [3.5–8.0]), as well as the provision of tobacco advice (6.9 [4.7–10.1]), among other performance measures. DEMS use was associated with improvements in all indicators, including microalbuminuria (3.2 [1.9–5.2]), retinal examination (2.4 [1.5–3.9]), foot examinations (2.3 [1.2–4.4]), and self-management support (2.6 [1.7–3.8]). Although planned care was associated with improvements in metabolic control, we observed no additional metabolic benefit when providers used DEMS. CONCLUSIONS—Planned care was associated with improved performance and metabolic outcomes in primary care. DEMS use augmented the impact of planned care on performance outcomes but not on metabolic outcomes. Optimal identification of the best translation of evidence to diabetes practice will require longer follow-up or new care-delivery models.

Diabetes electronic management system (DEMS) is a component-based client/server application, written in Visual C++ and Visual Basic, with the database server running Sybase System 11. DEMS is built entirely with a combination of dynamic link libraries (DLLs) and ActiveX components - the only exception is the DEMS.exe. DEMS is a chronic disease management system for patients with diabetes. It is used at the point of care by all members of the diabetes team including physicians, nurses, dieticians, clinical assistants and educators. The system is designed for maximum clinical efficiency and facilitates appropriately supervised delegation of care. Dispersed clinical sites may be supervised from a central location. The system is designed for ease of navigation; immediate provision of many types of automatically generated reports; quality audits; aids to compliance with good care guidelines; and alerts, advisories, prompts, and warnings that guide the care provider. The system now contains data on over 34000 patients and is in daily use at multiple sites.

Gorman C, Looker J, Fisk T, Oelke W, Erickson D, Smith S, Zimmerman B. A clinically useful diabetes electronic medical record. Lessons from the past; pointers toward the future. Eur J Endocrinol 1996;134:31–42. ISSN 0804–4643 We have analysed the deficiencies of paper medical records in facilitating the care of patients with diabetes and have developed an electronic medical record that corrects some of them. The diabetes electronic medical record (DEMR) is designed to facilitate the work of a busy diabetes clinic. Design principles include heavy reliance on graphic displays of laboratory and clinical data, consistent color coding and aggregation of data needed to facilitate the different types of clinical encounter (initial consultation, continuing care visit, insulin adjustment visit, dietitian encounter, nurse educator encounter, obstetric patient, transplant patient, visits for problems unrelated to diabetes). Data input is by autoflow from the institutional laboratories, by desk attendants or on-line by all users. Careful attention has been paid to making data entry a point and click process wherever possible. Opportunity for free text comment is provided on every screen. On completion of the encounter a narrative text summary of the visit is generated by the computer and is annotated by the care giver. Currently there are about 7800 patients in the system. Remaining challenges include the adaptation of the system to accommodate the occasional user, development of portable laptop derivatives that remain compatible with the parent system and improvements in the screen structure and graphic display formats. Colum Gorman, Division of Endocrinology and Metabolism, Mayo Clinic, Rochester. MN. USA

Cardiovascular disease, the main cause of morbidity and mortality in patients with diabetes, justifies an aggressive approach to the reduction of modifiable risk factors. Lipid values are generally normal in patients with insulin-dependent diabetes mellitus, but hypertriglyceridemia and low levels of high-density lipoprotein (HDL) cholesterol are frequently associated with non-insulin-dependent diabetes mellitus (NIDDM). Recommendations for screening and treatment of patients without diabetes do not apply to those with NIDDM. Screening should be done annually and should include fasting total cholesterol, triglycerides, and HDL cholesterol. Therapeutic recommendations based solely on the low-density lipoprotein cholesterol level are inappropriate. Hypertriglyceridemia cannot be ignored in patients with NIDDM. Therapy should first be directed toward improved control of the diabetes through diet, exercise, and insulin or sulfonylureas. Therapeutic goals are selected on the basis of individual risk assessment and are strongly influenced by the presence of preexisting vascular disease. When the goals are not achieved through improved control of diabetes, lipid-lowering drug therapy, based on the specific profile of the lipid abnormalities, should be initiated. (Endocr Pract. 1995; 1:433-439)

The Diabetes Control and Complications Trial and the Stockholm Study have conclusively demonstrated that improving the blood glucose control in patients with insulin-dependent diabetes mellitus (IDDM) reduces the risk of developing retinopathy, nephropathy and neuropathy. Each patient with IDDM should be carefully evaluated for the appropriateness of institution of an intensive insulin treatment programme. In particular, the risk of severe hypoglycaemia must be considered and the goals modified if necessary to reduce the risk. Successful implementation of an intensive treatment programme requires an experienced healthcare team and a knowledgeable and well motivated cooperative patient. Several variations of intensive treatment programmes can be used, with no definite superiority of one treatment method over the others. Individualization is the key to success. Each programme has the same general principles. Regular insulin is used to control the postprandial glucose excursion and a slow infusion of regular insulin by a pump or injected intermediate or long-acting insulin is used to balance fasting glucose utilisation and production. The treatment will not be successful without self-monitoring of blood glucose by the patient and frequent adjustment of the insulin doses to compensate for variations in blood glucose levels, diet and activity. The treatment should be followed with quarterly glycated haemoglobin determinations and a regular follow-up plan. During follow-up the main challenge for the healthcare team will be to maintain motivation in the patient and to assist with behaviour modification. A detailed understanding of intensive treatment programmes may be beyond the skill of the average primary care physician, but any physician caring for patients with diabetes will benefit from an understanding of the general treatment principles outlined in this article.

In this study, our aim was to develop a practical strategy to facilitate the management of patients with diabetes mellitus and chronic diarrhea in a tertiary referral practice. We reviewed the pertinent English-language literature of the past 30 years that described the pathophysiologic mechanisms and treatment of patients with diabetic diarrhea and retrospectively reviewed the medical records of all patients with diabetic diarrhea examined at the Mayo Clinic during 1990. Three typical case studies are described to illustrate the diverse mechanisms that lead to chronic diarrhea in patients with diabetes. No report in the literature has systematically evaluated all the putative mechanisms of chronic diarrhea in any group of patients with diabetes. In our tertiary referral practice, diabetic diarrhea was frequently due to celiac sprue, bacterial overgrowth in the small bowel, or fecal incontinence in conjunction with anorectal dysfunction; however, in almost 50% of the patients, these causes were excluded, and abnormal intestinal motility or secretion was postulated to be one of the likely causes of the diarrhea. These data suggest a practical algorithm based on three sequential assessments: first, tests of blood and stool specimens and flexible sigmoidoscopy to detect evidence of malabsorption or disease in the distal colon; second, small bowel aspirate and biopsy if the results of initial blood or stool tests are abnormal or anorectal function tests if those test results are normal; and, finally, measurement of gastrointestinal transit or therapeutic trials with opioids, clonidine hydrochloride, and, rarely, cholestyramine resin or octreotide acetate (or both methods). The mechanisms whereby abnormal neural function due to diabetes results in altered digestive, secretory, absorptive, or motor function necessitate further elucidation. The management of chronic diarrhea in patients in a tertiary referral practice, however, can be based on a practical algorithm to determine the cause and to adopt specific treatment to correct it.

Long term complications continue to be the major source of morbidity and mortality in patients with diabetes. Acarbose could potentially help to reduce diabetic complications if it improved glucose control, reduced lipid levels and hyperinsulinaemia. Acarbose has been shown to effectively reduce postprandial hyperglycaemia and haemoglobin A1c. This effect might be helpful in patients with insulin-dependent diabetes mellitus, as insulin injections do not provide complete control of rises in postprandial glucose levels, and in patients with non-insulin-dependent diabetes mellitus, because it simplifies the treatment programme. If improved control is shown to reduce complications, acarbose may be helpful. Although acarbose does not reduce hyperinsulinaemia, it reduces lipid levels and thus could reduce the risk of atherosclerosis.

OBJECTIVE—The aims of this study were to provide estimates of 1) the risk of mortality for individuals with both diabetes and peripheral arterial disease (PAD) relative to that for individuals with either condition alone and 2) the association between PAD progression and mortality for individuals with diabetes, PAD, and both conditions. RESEARCH DESIGN AND METHODS—This longitudinal cohort study was conducted in Rochester, Minnesota. Local residents age 50–70 years with a prior diagnosis of PAD and/or diabetes were identified from the Mayo Clinic diagnostic registry and invited to a baseline examination (1977–1978). Those who met inclusion criteria were assessed for PAD progression at 2 and 4 years and followed for vital status through 31 December 1999. RESULTS—The numbers who met criteria for PAD, diabetes, and both conditions at baseline were 149, 238, and 186, respectively. Within each group, observed survival was less than expected (P < 0.001). The adjusted risk of death for both conditions was 2.2 times that for PAD alone. Among the 449 who returned at 4 years, the risk of subsequent death was greater for those whose PAD had progressed; among individuals with diabetes alone at baseline, 100% (17 of 17) who met criteria for PAD progression were dead by 31 December 1999 compared with 62% (111 of 178) of those who had not met criteria (adjusted relative hazard 2.29 [95% CI 1.30–4.02], P = 0.004). The increased mortality associated with PAD progression was significant only for individuals with diabetes (alone or with PAD). CONCLUSIONS—Diabetes is a risk factor for both PAD and PAD-associated mortality, emphasizing the critical need to detect and monitor PAD in diabetic patients.

The Mayo Health System Diabetes Translation Project sought to assess models of community-based diabetes care and use of a diabetes electronic management system (DEMS). Planned care is a redesigned model of chronic disease care that involves guideline implementation, support of self-management, and use of clinical information systems.We studied adult diabetic patients attending three primary care practice sites in Wisconsin and Minnesota. We implemented planned care at all sites and DEMS in the practice of 16 primary care providers. We assessed quality of diabetes care using standard indicators for 200 patients randomly selected from each site at baseline and at 24 months of implementation. We used multivariable analyses to estimate the association between planned care and DEMS and each quality indicator.Planned care was associated with improvements in measurement of HbA(1c) (odds ratio 7.0 [95% CI 4.2-11.6]), HDL cholesterol (5.6 [4.1-7.5]), and microalbuminuria (5.3 [3.5-8.0]), as well as the provision of tobacco advice (6.9 [4.7-10.1]), among other performance measures. DEMS use was associated with improvements in all indicators, including microalbuminuria (3.2 [1.9-5.2]), retinal examination (2.4 [1.5-3.9]), foot examinations (2.3 [1.2-4.4]), and self-management support (2.6 [1.7-3.8]). Although planned care was associated with improvements in metabolic control, we observed no additional metabolic benefit when providers used DEMS.Planned care was associated with improved performance and metabolic outcomes in primary care. DEMS use augmented the impact of planned care on performance outcomes but not on metabolic outcomes. Optimal identification of the best translation of evidence to diabetes practice will require longer follow-up or new care-delivery models.

Despite the growing consensus that postprandial glucose levels provide a more accurate and valuable early marker of diabetes symptoms than fasting plasma glucose, the ability to forestall diabetic complications by managing postprandial hyperglycemia has not been proved. Patients who are not considered to have diabetes mellitus may have impaired glucose tolerance (and increased risk for developing cardiovascular disease), and targeting nonfasting glucose can reduce insulin requirements for patients with insulin-dependent diabetes mellitus (type 1 diabetes mellitus). The challenge now is to determine what fasting glucose levels merit intervention, when and how they should be determined, and who should measure them. After outlining the discrepancies and lack of consensus between measurement guidelines developed by different professional organizations, the author then reviews options for treating postprandial hyperglycemia, including prepackaged meals, alpha-glucosidase inhibitors, acarbose therapy, and fast-acting insulin preparations.

The objective of the Mayo Health System Diabetes Translation Project is to assess the impact of three different models of care on the overall quality of diabetes care in the community. The unit of study is the primary care practice with a different model of care implemented at each of three sites. The design incorporates a comparison of a diabetes guideline implementation team initiative (Practice model A), a guideline initiative combined with clinical use of a Diabetes Electronic Management System (DEMS) by primary care providers (Practice model B) and a guideline initiative combined with DEMS utilization combined with electronic review of DEMS patient encounters by an endocrinologist (Practice model C). Administrative data sets were used to define the patient population at each practice. Patients were designated as new, attending or non-attending based on their pattern of visits over the preceding 12 months. A random sample of 200 charts from attending patients at each site was audited at baseline for diabetes-related process and outcome measures. This audit will be repeated yearly during the 2 years of the project. Baseline data revealed significant differences across sites in adherence to certain key indicators of the quality of diabetes care including: frequency of documentation of eye examinations (19, 39 and 37% for sites A, B and C, respectively), haemoglobin A1c monitoring (64, 89 and 77%) and microalbumin monitoring (3, 15 and 6%). The interventions being assessed in this study include traditional (diabetes education; guideline implementation) and modern (DEMS; telemedicine specialist review) methods for improving the quality of diabetes care. In spite of variation in baseline quality indicators, the setting and design should lead to broad applicability of the results and help determine an optimal model of diabetes care in the community.

The increased risk of coronary artery disease in subjects with diabetes mellitus can be partially explained by the lipoprotein abnormalities associated with diabetes mellitus. Hypertriglyceridemia and low levels of high-density lipoprotein are the most common lipid abnormalities. In type 1 diabetes mellitus, these abnormalities can usually be reversed with glycemic control. In contrast, in type 2 diabetes mellitus, although lipid values improve, abnormalities commonly persist even after optimal glycemic control has been achieved. Screening for dyslipidemia is recommended in subjects with diabetes mellitus. A goal of low-density lipoprotein cholesterol of less than 130 mg/dL and triglycerides lower than 200 mg/dL should be sought. Several secondary prevention trials, which included subjects with diabetes, have demonstrated the effectiveness of lowering low-density lipoprotein cholesterol in preventing death from coronary artery disease. The benefit of lowering triglycerides is less clear. Initial approaches to lowering the levels of lipids in subjects with diabetes mellitus should include glycemic control, diet, weight loss, and exercise. When goals are not met, the most common drugs used are hydroxymethylglutaryl coenzyme A reductase inhibitors or fibrates.

OBJECTIVE To compare the compliance with diabetes care performance indicators by diabetes specialists using a diabetes electronic management system (DEMS) and by those using the traditional paper medical record. RESEARCH DESIGN AND METHODS A DEMS has been gradually introduced into our subspecialty practice for diabetes care. To assess the value of this DEMS as a disease management tool, we completed a retrospective review of the medical records of 82 randomly selected patients attending a subspecialty diabetes clinic (DC) during the first quarter of 1996. Eligible patients were defined by the suggested criteria from the American Diabetes Association Provider Recognition Program. During the first quarter of 1996, ∼ one half of the providers began using the DEMS for some but not all of their patient encounters. Neither abstractors nor providers were aware of the intent to examine performance in relationship to use of the DEMS. RESULTS Several measures were positively influenced when providers used the DEMS. The number of foot examinations, the number of blood pressure readings, and a weighted criterion score were greater (P < 0.01) for providers using the DEMS. There was evidence, although not statistically significant, for lower mean diastolic blood pressures (P = 0.043) in patients and for number of glycated hemoglobins documented (P = 0.018) by users of the DEMS. CONCLUSIONS Performance and documentation of the process of care for patients with diabetes in a subspecialty clinic are greater with the use of a DEMS than with the traditional paper record.

Sulfonylureas have been available for the treatment of non-insulin-dependent diabetes mellitus (NIDDM) since the 1950s. With the introduction of new oral agents, there is a tendency to discount the value of sulfonylurea therapy. Sulfonylureas have the advantage of multiple formulations, low costs, minimal side effects, and demonstrated efficacy in controlling hyperglycemia. The major disadvantage of sulfonylureas is secondary failure, which may occur with all oral agents as part of the progression of NIDDM. Sulfonylureas should continue to play an important role in the treatment of NIDDM.

OBJECTIVE To evaluate both the concordance in the classification of diabetes by clinical and C-peptide criteria and, prospectively, the consistency of the classification by C-peptide. RESEARCH DESIGN AND METHODS Individuals with diabetes who were enlisted in the prospective epidemiological study of diabetic neuropathy (Rochester Diabetic Neuropathy Study [RDNS]) were classified clinically by National Diabetes Data Group (NDDG) criteria to IDDM and NIDDM at entry to the study. In addition, C-peptide response to 1 mg glucagon was measured at entry for the classification to IDDM (basal C-peptide, < 0.17 pmol/ml; increment above basal, < 0.07 pmol/ml) and NIDDM (all other responses) and for concordance with the clinical classification made. The consistency of the C-peptide response was assessed every 2 years for up to 8 years. RESULTS Among 346 individuals with diabetes, 84 were classified as IDDM and 262 as NIDDM by clinical algorithm. COncordance with the C-peptide response occurred in 89% of the patients and remained consistent during 8 years of follow-up. Among the 37 patients with discordant clinical and C-peptide classification, those considered clinically to have NIDDM had a consistent IDDM C-peptide response during follow-up, and most of those considered to have IDDM clinically eventually showed an IDDM C-peptide response during follow-up. CONCLUSIONS Clinical criteria for the classification of diabetes are highly correlated with the assessment of insulin secretory reserve. A small number of individuals considered to have NIDDM clinically or by C-peptide have or develop an IDDM peptide response.

From October 1987 to December 1988, 59 patients underwent assessment for combined kidney and pancreas transplantation or pancreas transplantation after receiving a kidney allograft. We report our criteria for accepting candidates for transplantation, the results of the selection process, and the clinical and laboratory profile of those patients who underwent transplantation. Of the overall group, 22 patients (37%) were approved medically, 3 of whom were awaiting financial approval. Of the 59 patients, 15 (25%) were not approved for the transplantation program for medical reasons; in addition, 16 patients declined participation and 3 were not accepted because of lack of financial resources. Medical reasons for exclusion from pancreas transplantation were coronary artery disease in six patients, severe peripheral vascular disease in six patients, other medical problems in two patients, and noncompliance in one patient. Thus, many patients who underwent assessment for pancreas transplantation did not enter the program because of medical, financial, or personal preference reasons. In most cases, the medical reason for exclusion from pancreas transplantation was a cardiovascular disorder.

To determine comparative rates of development and progression of peripheral occlusive arterial disease, 110 healthy nondiabetic control subjects, 112 patients with peripheral occlusive arterial disease (POAD), 240 patients with diabetes mellitus (DM), and 100 patientswith diabetes mellitus and peripheral occlusive arterialdisease (DM + POAD) were studied over 4 yr with noninvasive techniques. The presence of peripheral occlusive arterial disease was determined by postexercise ankle-brachial index (ABI) values; progression of peripheral occlusive arterial disease was determined by the rate of change in postexercise ABI. Patients who underwent peripheral arterial reconstructive surgery or amputation were also classified as having progression of their peripheral occlusive arterial disease. On this basis, follow-up revealed that peripheral occlusive arterial disease developed and therefore progressed in 1 (1%) of the control group and 22 (9%) of the DM. Peripheral occlusive arterial disease progressed in 31 (28%) of the POAD and 26 (26%) of the DM + POAD. The presence of peripheral occlusive arterial disease predisposes to progression of disease, and peripheral occlusive arterial disease is more likely to develop in diabetic patients who do not have peripheral occlusive arterial disease than in nondiabetic control subjects. However, the presence of diabetes mellitus in patients with peripheral occlusive arterial disease does not seem to increase the risk of progression.

Non-insulin-dependent diabetes mellitus (NIDDM) frequently is diagnosed in the asymptomatic patient, and therapy is often a weight reduction diet alone or oral hypoglycemic medication without other instructions. In the past, patients were often told they had borderline diabetes and their physicians exhibited little interest in careful follow-up or vigorous treatment. Unfortunately, even asymptomatic patients with moderate hyperglycemia are subject to severe complications of diabetes. Appropriate therapy for NIDDM no longer permits a passive approach to the treatment program. Active involvement with efforts to modify the patient’ s dietary habits, behavior patterns, medication program, glucose monitoring, and medical follow-up is necessary. These efforts may create behavioral and neuropsychological problems which are as complex as the more commonly studied problems in patients with insulin-dependent diabetes mellitus (IDDM). This chapter will briefly review the medical aspects of NIDDM which must be understood if the behavioral issues are to be addressed.

The clinical, biochemical, and vascular laboratory measurements potentially associated with the development and/or progression of peripheral occlusive arterial disease (POAD) were assessed during a 4-year period in 110 normal control subjects, 112 patients with POAD without diabetes mellitus, 240 patients with diabetes mellitus without POAD, and 100 patients with diabetes mellitus and POAD. Age, history of hypertension or coronary heart disease, history of cigarette smoking, presence of POAD, systolic blood pressure, and β-thromboglobulin level were associated with progression of POAD. A multivariate logistic regression model indicated that the presence of diabetes mellitus or POAD or both at baseline, decreased postexercise ankle-brachial index, increased arm systolic blood pressure, and current smoking were independently associated with progression of POAD. This study suggests that cessation of smoking and control of hypertension are essential treatment modifications to decrease the risk of progression of peripheral vascular disease in diabetic patients. (Arch Intern Med.1991;151:717-721)

Management of the patient with NIDDM requires the skill and patience of the physician and the input of a health team, including the dietitian and nurse educator. With perseverance and careful follow up, most treatment goals can be achieved in these patients. The attitude of neglect and easy treatment goals that previously characterized the care of these patients are not justified.

We measured the alcohol sugars in sural nerves from 11 controls, 21 conventionally treated patients with diabetes and neuropathy, and 4 diabetics without neuropathy. The results were related to metabolic control and to clinical, neuropathological, and morphometric abnormalities in the nerves. The mean endoneurial glucose, fructose, and sorbitol values were higher in diabetic patients than in controls. Linear regression analysis revealed that nerve sorbitol content in the diabetics was inversely related to the number of myelinated fibers (P = 0.003). Mean nerve levels of myo-inositol were not decreased in the diabetic patients, with or without neuropathy, and were not associated with any of the neuropathological end points of diabetes. Our results indicate that myo-inositol deficiency is not part of the pathogenesis of human diabetic neuropathy, as had been hypothesized. Other accumulated alcohol sugars, however, were increased in diabetes and were associated with the severity of neuropathy. On repeat biopsy, six diabetics, treated for a year with the aldose reductase inhibitor sorbinil, had decreased endoneurial levels of sorbitol (P less than 0.01) and fructose (0.05 less than P less than 0.1), but unchanged levels of myo-inositol.

The relationship between hyperglycaemia and the chronic complications of diabetes has been disputed for many years. Some physicians believe that the evidence that hyperglycaemia is the primary determinant of the chronic complications is convincing; others believe the question remains unsettled. Several types of study provide information. In vitro and in vivo studies demonstrate biochemical alterations induced by hyperglycaemia which could lead to structural changes and diabetic complications. Animal models demonstrate that the complications develop with induction of hyperglycaemia and are ameliorated when blood glucose is returned toward normal. Many uncontrolled clinical studies demonstrate an association between diabetes control and complications but cannot prove causality. Controlled clinical trials have sometimes, but not always, shown functional changes suggestive of amelioration of complications with control of hyperglycaemia. A definitive clinical trial has not yet been completed. Pancreas transplantation has the potential of completely normalising blood glucose, but studies to date have been limited by small numbers of patients, the advanced state of complications, and the lack of adequate controls. On balance, the evidence is highly suggestive that hyperglycaemia is a major determinant of the chronic complications of diabetes. Even if the relationship is established, the risk involved in treatment programmes to achieve near normoglycaemia must be better defined so that potential risk versus benefit can be evaluated in the individual patient when making treatment decisions.

We studied the reproducibility of four tests of peripheral occlusive arterial disease in 54 subjects, 32 of whom had this disease. We found that the reproducibility of systolic blood pressures obtained at rest from the thighs, calves, and ankles approximated that of arm systolic and diastolic blood pressures, as did the ankle-to-arm systolic blood pressure ratios. The average of the tenth and ninetieth percentile ranges of the resting systolic blood pressure ankle-to-arm rations was ± 0.10. Systolic blood pressures from the fingers were somewhat less reproducible, and those from the toes were even more variable. Systolic blood pressure ankle-to-arm ratios measured after the patient had exercised were less reproducible than resting ratios. The average of the tenth and ninetieth percentile ranges of the 1-, 3-, 5-, and 10-minute ratios after exercise was −0.13 to +0.16. Skin temperatures from the fingers and toes were approximately as reproducible as systolic blood pressures from the arms and legs and as the resting ankle-to-arm blood pressure ratios. Pulse-volume recordings from the thighs, calves, ankles, feet, toes, and fingers were very poorly reproducible. We conclude that information on the reproducibility of these measurements is essential in the evaluation of noninvasive arterial tests that are used to determine the course of peripheral occlusive arterial disease. (J VASC SURG 1985;2:678-83.)

We measured distal sympathetic and vagal function in 73 consecutive patients with diabetic neuropathy seen at the Mayo Autonomic Reflex Laboratory. Postganglionic sympathetic failure measured proximally within the foot occurred as commonly as vagal failure (58% and 55%, respectively) and occurred much more frequently than did orthostatic hypotension (26%). Either vagal or distal sympathetic abnormalities occurred in isolation in about one in six patients with diabetic neuropathy. We conclude that distal sympathetic failure and vagal failure occur with equal frequency when sensitive and quantitative recording methods are used and that it is advantageous to test both systems, as only one may be involved in some patients.

Application of the principles of intensive insulin therapy in an attempt to achieve near-normal glycemia necessitates making many practical decisions for each patient. Often these decisions must be based on experience and opinion because the questions have not been studied adequately enough to be answered definitively. One approach to selection of patients, initiation of therapy, insulin management, blood glucose monitoring, and patient follow-up is reviewed.

The number of capillaries per mm2, minimum intercapillary distance, number of endothelial nuclei per capillary section, and percentage of capillaries closed were evaluated in transverse sections of fascicles of 45 control and 36 diabetic sural nerves. All controls and patients were prospectively studied to ascertain their diabetic and neuropathic status. An index of pathology was introduced and it was found to provide a sensitive and reliable measurement of the presence and severity of neuropathy. The number of capillaries and minimum intercapillary distance of diabetic nerves were not significantly different from those of controls (P greater than 0.05). Diabetic nerves exhibited a small but statistically significant increase in the number of endothelial nuclei per capillary that was positively correlated with the severity of neuropathy. The most striking abnormality was the statistically significant increase in the percentage of capillaries closed in patients with neuropathy as compared to those without neuropathy and controls. Among diabetics, this percentage increased with the severity of neuropathy (P = 0.008). The two capillary abnormalities that have been demonstrated may play a role in the development of diabetic polyneuropathy.

Excerpt To the editor: Kannel and associates in the January issue provide an excellent review of the epidemiologic data relating lipids and lipoproteins to atherosclerosis (1). On the whole, the st...