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The University of Minnesota has the largest experience with pancreas transplantation of any institution, with 130 cases since 1966, including 116 in 98 patients between July 1978 and June 1985. Currently, 30 patients are insulin-independent, 19 for greater than one year, the longest for seven years. One-year patient and graft survival rates overall are 87% and 30%, respectively. Of 98 recipients, 49 had had previous kidney transplants, while 49 had not, and currently most of the pancreas recipients do not have uremia and have not had a kidney transplant but have early complications of diabetes. A total of 44 of the grafts were procured from related and 72 from cadaver donors. Although 32 of the 116 grafts (28%) failed for technical reasons, the most common cause of graft failure has been rejection. Various immunosuppressive regimens have been used in attempts to reduce the rejection rate, and one combination, low-dose cyclosporine-azathioprine-prednisone (triple therapy), has been particularly effective, with a one-year functional survival rate of 73% in recipients of technically successful grafts from human leukocyte antigen-mismatched cadaver or related donors (N = 20). The pancreas graft survival rates have improved gradually (43% for 1984 to 1985, N = 30; versus 27% for 1978 to 1983, N = 86) for transplants from both related and cadaver donors. Metabolic studies from most recipients with functioning grafts (insulin-independent) show normal or nearly normal results. Preliminary observations on secondary complications suggest a more favorable course in recipients whose grafts have functioned long term than in those whose grafts failed early.
West J Med 1985 Dec
PMID:One institution's experience with pancreas transplantation. 391 96

From December 1966 through December 1984, there were 561 pancreas transplants reported to the American College of Surgeons/National Institutes of Health Organ Transplant Registry, including 60 from 1966 through June 1977, 206 from July 1977 through December 1982 and 295 from January 1983 through December 1984. One-year graft function-survival rates (insulin-independent) in each of the three periods were 3%, 20% and 40%, and the corresponding patient survival rates were 40%, 72% and 77%. Currently 140 patients have functioning grafts, 76 for more than one year. Of the transplants since July 1977, one-year graft survival rates according to technique are 41% for enteric drainage (N = 155), 30% for polymer injection (N = 260) and 29% for urinary drainage (N = 47). Pancreas graft survival rates at one year according to whether or not the recipients have had a kidney transplant were 35% for recipients of simultaneous grafts (N = 281), 28% in recipients of a pancreas after a kidney (N = 112) and 26% in recipients of a pancreas only who did not have uremia (N = 106); corresponding patient survival rates were 69%, 83% and 83%. Overall, one-year pancreas graft survival rates according to whether the patients did or did not have end-stage diabetic nephropathy were 33% versus 25% and the corresponding patient survival rates were 73% versus 84% (P < .01). Patient survival rates were significantly higher in those without than in those with end-stage diabetic nephropathy. An analysis of technically successful grafts according to principal immunosuppressant showed one-year function rates of 46% in 258 cyclosporine-treated recipients and 26% in 143 azathioprine-treated recipients. Pancreas graft survival rates have progressively improved and the procedure has become safer with advances in surgical technique and immunosuppression. Pancreas transplantation is currently applicable to patients with diabetes mellitus whose complications are, or predictably will be, more serious than the possible side effects of long-term immunosuppression.
West J Med 1985 Dec
PMID:Pancreas transplantation--registry report and a commentary. 391 97

Ambulatory encounters in a community-based family practice residency program were analyzed using diagnosis clusters. During an 18-month period (July 1982 through December 1983), demographic information and clinical diagnoses for 44,453 successive patient visits were collected and stored in a computerized data base. The 30 most frequent diagnosis clusters accounted for 70% of all recorded clinical diagnoses. Comparison with NAMCS, USC-MAMP (Western Region) and Virginia studies revealed a younger, more indigent population with a higher frequency of visits for hypertension, prenatal and postnatal care, diabetes, chronic respiratory illness and congestive heart failure. Consistent with the other large ambulatory data sets, the general medical examination, hypertension and acute upper respiratory conditions were the most frequent diagnosis clusters. Differences with other reported data sets reflected the site-specific demographic characteristics of patients and providers, regional and environmental influences on the incidence of specific disease states and the relative abundance of other subspecialist physicians. Such local or regional data bases not only provide valuable information as to clinical content but also may help in identifying previously unrecognized health problems.
West J Med 1985 Jun
PMID:Diagnosis cluster frequency in a community-based family practice residency program. Comparison with large ambulatory data sets. 392 93

New theoretic developments in transplantation biology indicate that it is possible to reduce the immunogenicity of a graft by removing antigen-presenting cells (leukocytes) from the tissue before grafting. Also becoming apparent is that cellular replacement therapy, the grafting of cells or clusters of cells, can be used to treat metabolic disorders such as type I diabetes mellitus. In the past, immune rejection has been a major problem and long-term patient immunosuppression is not warranted in patients with type I diabetes. Results of studies in animals show that under defined genetic conditions, mature islet tissue or immature fetal proislets may be transplanted across major histocompatibility barriers without a requirement for recipient immunosuppression. We are now ready to commence applying this technology clinically. These developments will initially be very experimental and limited in scope but should accelerate as data emerge from the initial trials.
West J Med 1985 Dec
PMID:Pancreatic islet transplantation--experimental experience and clinical potential. 393 38

This study collected data regarding the accuracy of five currently marketed meters for home use of self-monitoring of blood glucose (SMBG). Data regarding ease of operation of each glucose meter as well as cost and availability of meters and necessary materials were compiled. Fasting blood glucose (BG) samples were drawn from patients in the adult and pediatric diabetes clinics at the University of Kansas College of Health Sciences and Hospital. Specimens were tested by a clinical laboratory as well as by each meter. Unadjusted meter readings of whole BG were plotted against laboratory readings of serum glucose and displayed in scattergrams. Scattergrams showed decreased machine accuracy in upper and lower BG ranges. Whole BG values (meter readings) were adjusted to serum glucose levels by multiplication by 1.12. Adjusted values were compared with laboratory serum values using ANOVA for repeated measures and Dunnett's Multiple Comparisons Test: ANOVA and Dunnett's Multiple Comparisons Test showed only Glucochek II (Medistron, Ltd., West Sussex, England; distributed in U.S. by Larken Industries, Lenexa, Indiana) using Dextrostix reagent strips (Ames Division, Miles Laboratories, Elkhart, Indiana) having a statistically significant difference from laboratory values (P less than 0.01). This meter was recently revised and may show changed accuracy readings. Each meter exhibited inherent advantages and disadvantages regarding price, calibration, strip utilization, and ease of operation, which must be considered before recommendation by the health care provider.
Diabetes Care
PMID:Comparison of five glucose meters for self-monitoring of blood glucose by diabetic patients. 394 47

Careful evaluation was carried out in 93 men older than 50 with erectile dysfunction. Their mean age was 61 years and the disorder had been present for a mean of 4.5 years. While 14 men (15%) had psychosocial factors that may have been pertinent, only 2 scored poorly on an Affect Balance Scale and 3 were receiving psychoactive medications. Results of nocturnal penile tumescence were abnormal in 91%. In 39% penile-brachial pressure indices were suggestive of pelvic vascular disease and in 9% were consistent with a pelvic "steal syndrome." Pelvic or peripheral nerve conduction disorders were also commonly seen in 54%. Endocrinopathy may have contributed to the dysfunction in 35%. Twenty-one men had diabetes mellitus, two new cases of hypothyroidism were discovered and hypogonadism was diagnosed definitely in four and considered likely in five others. Coexisting medical conditions were found in more than 90% of the men, especially hypertension, use of antihypertensive medications and atherosclerotic disease. Previous prostatectomies (19%) and vasectomies (30%) were common in the surgical histories. Given the wide range of disorders uncovered in older men complaining of impotence, diagnostic study of potential causes may lead to a more rational approach for the evaluation and management of these men.
West J Med 1985 Apr
PMID:Evaluation of impotence in older men. 401 64

The prevalence of diabetes, the interrelationship of blood glucose, serum insulin, and lipids, and their relationship to ischemic heart dise ase in a rural Jamaican community were investigated. The people were mo stly of West African descent. Occupations were primarily agricultural w ith much physical labor. Approximately 80% of total claories in their d iet were from carbohydrates. Of 696 25-64 year old persons, a response rate of 77.3% was achieved. The patients, after an overnight fast, drank a 7-oz bottle of Glucola which was the equivalent of a 100 gm glucose load. Electrocardiograms (EKGs), blood pressure readings, a chest X-ray, and skinfold tests for obesity were done. A family history was obtained. Blood and urine specimens were taken before the glucose was given. 1 hour after the glucose was given, blood and urine specimens were also taken. Those with blood glucose of 180 mg% or more were given a 3-hour glucose tolerance test. Of the 525 persons who had the 1-hour test, 23 were found to be glycosuric. Of these, 11 were not shown to be diabetic by the 3-hour glucose test. Of the 502 with negative urines, 34 were positive on blood tests. The rates increased with age, except in the oldest age groups (p less than .05 for males and p less than .001 for females). There was no relationship between the number of live births and the 1-hour blood glucose tests. There was neither increase in the diagnosis of diabetes nor increase in variance with number of children. The known diabetics were fatter and had higher triglycerides than others. Cholesterol was higher in all male diabetics but not in females. Only 2 persons experiencing effort pain had EKG changes. Data from this study indicate that no statistically significant association exists between levels of glycemia and blood pressure or prevalence of cardiovascular disease. The physical fitness acquired from walking and working in a hilly area may be a factor.
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PMID:The prevalence of diabetes in a rural population of Jamaican adults. 466 90

Fifteen patients with maturity onset type diabetes, all of whom had received insulin for periods of one to thirty-five years, were admitted to hospital and insulin treatment was discontinued. Within 24 to 48 hours each patient was given an intravenous tolbutamide test, following which all were given either diet therapy alone or diet therapy plus oral agents. If significant hyperglycemia or ketonemia resulted, insulin therapy was reinstituted. Approximately 50 percent (8 of 15) of the patients showed improvement in fasting blood sugar levels following discontinuation of insulin. It was not possible to distinguish the insulin independent from the insulin dependent group using such criteria as age, sex, degree of overweight, insulin dosage, duration of diabetes or duration of insulin therapy. However, using the intravenous tolbutamide test it was possible to differentiate between the two groups. Those who did not require insulin responded to intravenous tolbutamide with a glucose decrease greater than 10 percent from the initial value. The insulin dependent group had either no glucose decrease or a rise in blood glucose following intravenous administration of tolbutamide.
West J Med 1974 May
PMID:Diabetes mellitus. Distinguishing between patients receiving insulin and those requiring insulin therapy. 483 80

Two West Indian men with no previous history of diabetes mellitus developed hyperosmolar non-ketotic diabetic coma. Intra-abdominal catastrophes secondary to mesenteric thrombosis played a major part in the death of these patients, in both of whom control of the hyperosmolar state had been achieved. Both patients had evidence of infarction of intestine at necropsy. Vascular thromboses are a major complication of this form of coma and must be considered when such patients develop signs of an acute abdomen.
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PMID:Hyperosmolar non-ketotic diabetic coma: with particular reference to vascular complications. 531 81

Reduced estrogen content has significantly decreased the risks of oral contraceptive (OC) use. However, the systemic effects of OCs, but it is unclear if this change is physiologically significant. Estrogen-mediated inhibition of cortisol levels may contribute to the impairment of glucose tolerance by OCs. Women at high risk for diabetes, older than 35, obese, with family history of diabetes, or who have had glucose intolerance during previous pregnancies should either not take OCs or take pregestin-only pills. OCs raise plasma triglyceride levels 30-50 mg per dl in users of all ages. High density lipoprotein (HDL) cholesterol is also affected, and cholesterol and triglyceride levelshould be measured before and during OC use. The risk of hepatic adenoma rises with duration of OC use; however, most adenomas diagnosed before hemorrhage have regressed with discontinuation of the contraceptive regimen. The most significant adverse effects of OC use involve the arterial and venous vascular systems. OCs appear to raise the blood pressure in nearly all women. Change in systolic pressure is consistently greater than in diastolic, suggestingthat the primary hypertensive effect of OCs is on blood volume and cardiac output. Accumulated data indicate that if OCs are not used by women older than 35 or by women who smoke or who are hypertensive, then risk of subarachnoid hemorrhage or other cerebrovascular complication is very small. The relative risk of myocardial infarction in OC users has been from 0-6 times greater than in nonusers; this may depend on other confounding risk factors. Reduction in estrogen content of OCs decreases risk accordingly. The preponderance of evidence indicates that prolonged use of OCs does not increase risk of breast disease or ovarian and endometrial cancer, and, in fact, may protect users from malignant lesions by suppressing gonadotropins and ovulation.
West J Med 1984 Jul
PMID:Systemic effects of oral contraceptives. 608 41


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