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purpose: To assess the status of the hypothalamic-pituitary-adrenal (HPA) axis in corticosteroid-treated patients whose prednisone dose had been tapered to physiologic doses. patients and methods: The design of the study was a retrospective chart review of 50 consecutive patients receiving 10 mg or less of prednisone daily at a university teaching hospital rheumatology clinic. Patients were given a rapid adrenocorticotropic hormone stimulation test, with cortisol levels obtained at baseline and after intravenous administration of cosyntropin. Charts were reviewed for duration of therapy, highest, current, and total cumulative steroid dose, and average daily steroid dose in each month of the preceding 2 years. results: Current steroid dose was the only significant indicator of HPA axis function. Patients receiving less than 5 mg of prednisone daily had a normal HPA axis response, whereas those receiving 5 mg or more had widely varied responses. Neither the total, the highest prednisone dose, nor the duration of therapy was a significant indicator of HPA axis recovery. conclusions: Spontaneous recovery of the HPA axis is usual for patients who are taking prednisone at daily doses of 5 mg or less. Return of normal HPA axis function can be achieved without alternate-day therapy in patients whose disease allows tapering to daily prednisone doses of 5 mg or less.

Marjorie K Mau1, Karynna Asao2, Jimmy Efird3, Erin Saito, Robert Ratner4, Muhannad Hafi4, Todd Seto51Department of Native Hawaiian Health; 3Biostatistics and Data Management Facility; 5Department of Medicine, John A. Burns School of Medicine, University of Hawai’i at Manoa; 2Claremont College; 4Medstar Research InstituteObjective: Heart failure (HF), a long term outcome of chronic methamphetamine use (MU), occurs more frequently in racial and ethnic minority populations at high risk for cardiovascular disparities. This study examined the association of socio-demographic and clinical risk factors with MU among heart failure patients who are Native Hawaiians (NH) or other Pacific Island peoples (PIP).Design/Setting/Patient population: Cross-sectional study of NHs and PIPs with advanced heart failure enrolled in the Malama Pu’uwai Study, a randomized control trial to test an educational intervention to reduce re-hospitalization and/or death. A total of 82 participants were enrolled between 6/1/06 to 12/31/07 and met the following eligibility criteria: 1) self-identified NH or PIP, 2) Left ventricular systolic ejection fraction ≤45%, 3) Age of 21 years or older. Data were analyzed by odds ratios (OR), 95% confidence intervals (CI), and multiple logistic regression analysis.Main outcome measure: Methamphetamine use.Results: Twenty-two percent of HF participants were identified as being current or prior methamphetamine users. Younger age and non-married status (combined never married or divorced/separated) were independently associated with MU after adjustment for sex, education, and other co-morbidities associated with HF (ie, age >50 years, OR = 0.16, 95% CI, 0.03–0.84; non-married status combined as never married OR = 8.5, CI, 1.5–47; divorced/separated OR = 11, CI 1.8–75).Conclusions: Risk factors associated with MU in NH and PIPs with heart failure include: younger age and being divorced/separated or never married. Health care providers should be aware of MU as a contributing factor in the approach and treatment of HF in NHs and PIPs.Keywords: Native Hawaiian and other Pacific Islander, ethnic minority, methamphetamine use, heart failure

OBJECTIVE—To estimate the cost-effectiveness of screening overweight and obese individuals for pre-diabetes and then modifying their lifestyle based on the Diabetes Prevention Program (DPP). RESEARCH DESIGN AND METHODS—A Markov simulation model was used to estimate disease progression, costs, and quality of life. Cost-effectiveness was evaluated from a health care system perspective. We considered two screening/treatment strategies for pre-diabetes. Strategy 1 included screening overweight subjects and giving them the lifestyle intervention included in the DPP if they were diagnosed with both impaired glucose tolerance (IGT) and impaired fasting glucose (IFG). Strategy 2 included screening followed by lifestyle intervention for subjects diagnosed with either IGT or IFG or both. Each strategy was compared with a program of no screening. RESULTS—Screening for pre-diabetes and treating those identified as having both IGT and IFG with the DPP lifestyle intervention had a cost-effectiveness ratio of $8,181 per quality-adjusted life-year (QALY) relative to no screening. If treatment was also provided to subjects with only IGT or only IFG (strategy 2), the cost-effectiveness ratio increased to $9,511 per QALY. Changes in screening-related parameters had small effects on the cost-effectiveness ratios; the results were more sensitive to changes in intervention-related parameters. CONCLUSIONS—Screening for pre-diabetes in the overweight and obese U.S. population followed by the DPP lifestyle intervention has a relatively attractive cost-effectiveness ratio.

Effect of the GLP-1 Analog Liraglutide on Glycemic Control and Weight Reduction in Patients on Metformin and Rosiglitazone: a Randomized Double-Blind PlaceboControlled Trial. B. ZINMAN*, J. GERICH, J. BUSE, A. LEWIN, S. L. SCHWARTZ, P. RASKIN, P. M. HALE, M. ZDRAVKOVIC, L. BLONDE, University of Toronto, Canada; Rochester University Medical School, NY; North Carolina University Medical School, Chapel Hill, NC; National Research Institute, Los Angeles, CA; DGD Research, San Antonio, CA; Texas University, Dallas, TX; Novo Nordisk, Princeton, NJ, USA; Bagsvaerd, Denmark; Ochsner Medical Center, New Orleans, LA, USA This 26-week randomized trial compared the efficacy and safety of two doses of liraglutide (lira; 1.2 and 1.8 mg, OD) to placebo (plb) in patients with Type 2 DM on metformin 2 g (met; 1 g, BD) and rosiglitizone 8 mg (rosi; 4 mg, BD). Subjects were previously treated with 1 or more oral antidiabetic drugs (OADs). 533 subjects were randomized (mean age 55.1±10.2 years, mean BMI 33.5±5.2 kg/m, mean HbA1c 8.3±1.0%). All patients received run-in rosi and met therapy before being randomized to lira or lira plb. Lira 1.2 mg and 1.8 mg reduced HbA1c more than placebo (ANCOVA, p

Cutaneous insulin allergy remains a clinical problem despite the use of highly purified human insulins. We used in vitro lymphocyte-transformation studies to examine the reactivity of various insulin formulations in diabetic patients with (n = 4) and without (n = 8) cutaneous allergies. Nonspecific response to concanavalin A demonstrated a >40-fold response in both groups. Control patients did not respond to the addition of commercial insulin preparations (stimulation index [SI]

During the past half century, the number of persons with diagnosed diabetes in the United States has increased 4- to 6-fold (1). Recent large clinical trials from Asia, Europe, and North America have demonstrated that behavioral and medication interventions can delay or prevent the development of type 2 diabetes in persons with impaired glucose tolerance, which is defined by a plasma glucose level between 7.77 mmol/L (140 mg/dL) and 11.04 mmol/L (199 mg/dL) 2 hours after a 75-g oral glucose load (2–6). The Diabetes Prevention Program (DPP) randomly assigned 3234 nondiabetic persons 25 years of age or older with impaired glucose tolerance and fasting glucose levels between 5.27 mmol/L (95 mg/dL) and 6.94 mmol/L (125 mg/dL) to placebo; a lifestyle-modification program with the goals of at least a 7% weight loss and 150 minutes of physical activity per week; or metformin, 850 mg twice daily (4). The mean age of participants was 51 years, and the mean body mass index was 34.0 kg/m2; 68% were women and 45% were members of minority groups (4). The average follow-up was 2.8 years. Compared with the placebo intervention, the lifestyle intervention reduced the incidence of type 2 diabetes by 58% and the metformin intervention reduced the incidence of type 2 diabetes by 31% (4). We have previously described the costs of the DPP interventions and their cost-effectiveness within the 3-year trial period (7, 8). In this analysis, we project the costs, health outcomes, and cost-effectiveness of the DPP lifestyle and metformin interventions over a lifetime relative to the placebo intervention. Context The Diabetes Prevention Program (DPP) showed that lifestyle changes or metformin effectively decreased the development of type 2 diabetes in adults with impaired glucose tolerance. The economics of these interventions is important to policymakers. Contribution This cost-effectiveness model estimates that the DPP lifestyle intervention would cost society about $8800 and metformin would cost about $29 900 per quality-adjusted life-year saved. While lifestyle intervention had a favorable cost-effectiveness profile at any adult age, metformin was not cost-effective after age 65 years. Implications The cost-effectiveness of lifestyle intervention to prevent type 2 diabetes in high-risk individuals is within the range that American society typically finds acceptable for health care interventions. -The Editors

Individuals with diabetes are increasingly persuing employment in fields previously restricted as a result of the development of chronic complications. Improved glycemic control resulting from use of sophisticated insulin delivery and monitoring systems has also led to the recognition of recurrent hypoglycemia as a potential major clinical and occupational hazard. No data concerning the occupational safety of individuals with insulin-treated diabetes mellitus (ITDM) are available. We review the literature on diabetic drivers in an effort to examine the impact of certification of ITDMs as commercial drivers. In the absence of significant worldwide experience with ITDMs as commercial drivers, the discussion is necessarily based on projected accident rates derived from data on frequency of hypoglycemia. These studies are universally flawed by variable definitions of hypoglycemia, ascertainment bias, and patient selection. They do, however, provide a worst-case/best-case scenario for discussion. It is imperative that any expansion of employment opportunities for ITDMs be followed carefully with prospective studies to assess the impact on public safety.

The effect of acute and chronic stimulation of the breast was studied in 11 nonpostpartum women in both follicular and luteal phases of menstruation. In no subject did an increase in secretion of prolactin (PRL) result from either solitary or multiple episodes of stimulation of the breast over 24 hours. After 2 weeks of stimulation, three patients noted increased secretion; however, on rechallenge, this was found to be the result of testing in luteal versus follicular phase, rather than of the stimulation of breast itself. We concluded that breast stimulation, either acute or chronic, had no appreciable impact on secretion of PRL, but, rather, the phase of menstruation may influence basal secretion of PRL. Normal ranges may have to be recalculated to take this into account after larger numbers of women are studied.

The Diabetes Prevention Program is a randomized clinical trial testing strategies to prevent or delay the development of type 2 diabetes in high-risk individuals with elevated fasting plasma glucose concentrations and impaired glucose tolerance. The 27 clinical centers in the U.S. are recruiting at least 3,000 participants of both sexes, approximately 50% of whom are minority patients and 20% of whom are > or = 65 years old, to be assigned at random to one of three intervention groups: an intensive lifestyle intervention focusing on a healthy diet and exercise and two masked medication treatment groups--metformin or placebo--combined with standard diet and exercise recommendations. Participants are being recruited during a 2 2/3-year period, and all will be followed for an additional 3 1/3 to 5 years after the close of recruitment to a common closing date in 2002. The primary outcome is the development of diabetes, diagnosed by fasting or post-challenge plasma glucose concentrations meeting the 1997 American Diabetes Association criteria. The 3,000 participants will provide 90% power to detect a 33% reduction in an expected diabetes incidence rate of at least 6.5% per year in the placebo group. Secondary outcomes include cardiovascular disease and its risk factors; changes in glycemia, beta-cell function, insulin sensitivity, obesity, diet, physical activity, and health-related quality of life; and occurrence of adverse events. A fourth treatment group--troglitazone combined with standard diet and exercise recommendations--was included initially but discontinued because of the liver toxicity of the drug. This randomized clinical trial will test the possibility of preventing or delaying the onset of type 2 diabetes in individuals at high risk.

At the beginning of the Diabetes Prevention Program, half of the participants had the metabolic syndrome. Both the lifestyle intervention and metformin therapy reduced the incidence of the syndrome...