[acb-diabetics] many articles

[Patricia LaFrance-Wolf]

1.%% Practical Steps to Improving the Management of T1DM: .. 2/16/10; Int J
Clin Pract. 2010;64(3):  Diabetes affects 246 million people worldwide - of

these, approximately 22 million adults and 0.4 million children have T1.
The impact of DM-related complications on patients and healthcare systems is

significant, with reported cumulative incidences of proliferative
retinopathy, nephropathy and cardiovascular disease (CVD) of 47%, 17% & 14%,
respectively,

after 30 years of DM. T1 is an autoimmune disease, in which environmental
factors are thought to trigger the autoimmune destruction of pancreatic
ß-cells

in genetically susceptible individuals. .widespread genetic screening for
susceptibility to the disease is not yet possible. ..  Conclusion -
glycaemic

– as well as CV – targets are still not being met by a considerable
proportion of patients. We hope the recommendations presented here by the
Global Partnership

for Effective Diabetes Management  provide guidance on where gaps remain and
how to address them..  management of T1 is complex for both patients and
health

professionals, and it is through the multidisciplinary team that these
recommendations can be best implemented.  Sidebar  What's Known: The
majority of

patients do not achieve glycaemic goals because of barriers related to
insulin dose adjustment, self-monitoring of blood glucose and fear of hypo-
glycaemia. 

Living with DM is not easy, and achievement of glycaemic goals requires the
patient to undertake self-care behaviours with relentless vigilance.
Structured

education supported by a multidisciplinary team approach can play an
integral role in helping overcome these barriers.

 

2.%%Role of GLP-1 Agonists in Type 2 Diabetes Therapy   With traditional
therapies, we still see that patients still don’t reach their glycemic
target. 

This presentation will discuss new therapies called incretin-based
therapies.  Both GLP-1 agonists and DPT-4 inhibitors are incretin-based
therapies. GLP-1

agonists are injections; they produce weight loss.   DPT-4 inhibitors are
pills, given 1-2 per day, and they do not produce wt. loss.  Decisions about

which to take

are made on an individual basis. Life style interventions are the initial
therapy for T2.  For those whose glycemic target is not reached with
lifestyle

changes, then GLP-1 agonists are a next step. Exenatide was the first GLP-1
agonist to market - it is an injection which is given twice a day.  It has

a profound effect during the postprandial phase.  If a patient gives himself
an injection before eating, his glucose level stays the same although he is

taking in carbohydrates.  However,  exenatide is effective for 6-8 hr only;
2 shots a day therefore don’t cover 24 hours. Liraglutide, on the other
hand,

has 13 hr. effect.  The body is able to build up a steady state with it.  A
patient is therefore exposed to drug levels for 24 hr.  Exenatide is useful

for those who have postprandial problems, but it does not reduce fasting
blood sugar.  Liraglutide, on the other hand, is useful for patients with
both

problems because it but does not cause postprandial hypoglycemia and can
reduce fasting blood sugar levels. All incretin-based therapies cause
patients

to gain weight. . Part of the popularity of metformin is that it is weight
neutral or causes some weight loss.  This is a psychological advantage for
the

use of this drug in

combination with incretin therapy. GLP-1 agonists can be compared to
insulin. The major difference between it and GLP-1 agonists is that
Liraglutide is

easier to administer and there is no concern about monitoring and adjusting
the dose with Liraglutide. The costs for GLP-1 agonists are also less.
Insulin

requires glucose self- monitoring which is expensive and painful.  Agonists
cause nausea, but it decreases over time.  With Exenatide nausea persists
far

longer, and didn’t decrease to the low levels seen in Liraglutide.   With
Liraglutide, the nausea goes away in a week or so, stays low, and doesn’t
come

back.  Exenatide has time criticality about it since it is taken twice a
day.  A patient can’t take it just whenever he wants.  It needs to be taken
30-60

minutes before a meal to get maximum benefit.  Liraglutide, since it is only
once a day, does not have any time-criticality about it. It’s a trade-off;

you trade off the ease of dosage of Liraglutide vs. the better glucose
control of Exenatide.  Future studies are looking at once weekly vs. once
daily

administration  of these drugs. Exenatide could be partnered with insulin,
but other combination studies are needed with these drugs.

 

3.%% FDA  March 2010  FDA Patient Safety News Kidney Impairment with Byetta
To help clinicians weigh the benefits and risks of the diabetes drug Byetta

(exenatide), FDA is requiring that information about the risk of renal
impairment be added to the drug's labeling. From 4/05-10/08, FDA received 78
reports

of altered kidney function

in patients treated with Byetta.. these cases represent a small percentage
of the total number of patients treated with the drug. Byetta should not be

used in patients with severe renal impairment or end-stage renal disease.
For patients with moderate renal impairment, use caution when starting
Byetta

or increasing the dose. Monitor patients for signs and symptoms of altered
kidney function, including increased serum creatinine, changes in urination,

lethargy, increased BP,unexplained swelling, or dull ache in the mid to
lower back. Consider discontinuing the drug if a patient's kidney function
worsens

while using it. Patients receiving Byetta should be told to watch for the
signs and symptoms of altered kidney function and report these to their
healthcare

professional.

 

4.%% Does Pycnogenol® Improve Vision in Patients With Early Diabetic
Retinopathy? 2/23/2010  Pycnogenol Improves Microcirculation, Retinal Edema,
and Visual

Acuity in Early Diabetic

Retinopathy J Ocul Pharm Ther. 2009;25:  Summary -  double-blind,
placebo-controlled trial was designed to test the protective effects

of Pycnogenol®, an extract of French maritime pine bark that stimulates
endothelial nitric oxide to facilitate vasodilatation.  The drug as
evaluated for

its effects in early stages of retinopathy characterized by mild to moderate
retinal edema in the absence of hemorrhage or hard exudates in the macula

center. Visual acuity in the group receiving Pycnogenol® significantly
increased from a baseline average of 14/20 to 17/20 after 2 months.
Pycnogenol®

significantly improved both systolic and diastolic retinal blood flow. In
the current study, the authors conducted a randomized trial that also
demonstratedan

ophthalmologic benefit. However, patients underwent a diet & exercise
program,so the benefits of Pycnogenol® could not be isolated. .study was
limited

by the extremely selective sample: Participants had a mean age of about 52yr
and had had DM for a mean of about 6.5 years, making themquite young at
diagnosis.

More important, patients with hypertension were excluded. Thus, it is not
clearwhether the results would apply to the more general DM patient.
Medscape

Diabetes & Endocrinology © 2010 WebMD, LLC

 

5.%% Thiazolidinedione [TZD avandia, actos] Use Linked to Increased Fracture
Risk in Women 2/24/10 - TZD use is associated with an increased risk for
fractures

[FX] in women, particularly those older than 65. "Older women are already at
a higher risk of osteoporosis and osteoporosis-related FX, which might
explain

why they appeared to be the most affected by TZDs," the senior author said .
.this class of medications also can increase risk of congestive heart
failure

[19,070 patients] FX risk was greatest in women older than 65 yrs. Among
women, increased FX  risk was not evident until after 1yr of treatment with
TZDs

.. I encourage patients to talk with their physician about other suitable
options,"

 

6.%% Benefits of Early Intensive Insulin Therapy Can Persist Unless HbA1C
Levels Rise (Reuters Health) 2/23 - Intensive insulin therapy in T1DM
reduces

their risks of neuropathy and retinopathy over the long-term.  one team
used clinical and nerve conduction studies to compare rates of neuropathy
[603

former intensive-therapy & 583 former conventional-treatment subjects].. the
second paper, assessed the impact of intensive therapy in the original trial

on patients' risk of retinopathy. [1055 adults &156 adolescents]; In adults
former use of intensive therapy cut the risk of retinopathy by 57%.  teens

who had been given intensive therapy had higher mean HbA1c levels than
adults: 8.1% vs. 7.2%.  The current findings, the authors of both studies
agree,

emphasize the importance of maintaining HbA1c at as close to target values
as possible.

 

7.%% Mid- and Late-life Diabetes in Relation to the Risk of Dementia:
2/22/10; Diabetes. 2010;58(1):  Objective: We aimed to verify the
association between

DM and the risk of dementia, Alzheimer's

disease [AD], and vascular dementia in twins and to explore whether genetic
and early-life environmental factors could contribute to this association.

[13693 twins = 65 yrs] diabetes was identified in 10.4% subjects, including
1.9% T1. The prevalence of T2 was 9.8% female % 11.2%  males. Conclusion - 

DM increases the risk of AD and vascular dementia.  The risk effect is
stronger when DM occurs at mid-life than in late life. These findings add to
the

growing evidence of a link between diabetes vascular damage, and
neurodegenerative changes in the brain. [see also #16]

 

8.%% ADA  - Different myocardial insulin resistance mechanisms in patients
with T2 and left ventricular dysfunction (LVD) 3/3/10 .. when these results

were compared with an animal model, investigators found a correlation
between IRS1-PI3K activation and a reduction in the expression of  GLUT4 in
the heart

of insulin resistant ob/ob  mice, and an increase in GLUT4 levels at the
sarcolemma of mice with LVD. The authors conclude that these findings
demonstrate

a disease- specific insulin resistance in the heart (l. Eur Heart J 2010,
31(1):

 

9.%% ADA Elevated circulating sex hormone-binding globulin (SHBG) levels
reduce the risk of T2DM 3/2/10 The risk of T2 was reduced in subjects with
elevated

circulating SHBG levels, and the results obtained were similar in men and
women. These findings suggest that SHBG and sex hormones are involved in the

development of T2   Hum Mol Genet 2010, 19(3): 

 

10.%% ADA Diab Profes Resources Online   Manual Closed-Loop Insulin Delivery
in Children and Adolescents With Type 1 Diabetes:

3/1/10  Closed-loop systems could reduce the risk of nighttime hypoglycemia
in children % adolescents with T1 [19 patients age 5-18] 17 patients
underwent

33 closed-loop and 21 continuous infusion nights. During closed-loop
delivery, there were no events when plasma glucose concentration was lower
than 3.0

mmol/L, compared with 9 events during standard treatment. Lancet  Vol. 375,
No. 9716,

 

11.%% ADA Vitamin B12 Deficiency: A Chronic Complication of Metformin
Therapy That Can Cause Irreversible Neuronal Damage

3/1/10   Because metformin-induced malabsorption often causes the depletion
of Vit B12, vitamin levels should be monitored each year in patients with
DMdiabetes

who receive long-term metformin therapy.  Dr. D Bell, suggests that an
annual 1,000 mcg vitamin B12 injection could be a cost-effective alternative
method. 

Vitamin B12 malabsorption can cause irreversible neuronal damage, as
demonstrated in the case report of a 69-year-old man who had "very low" B12
levels

and experienced a hematocrit drop.. After receiving Vit B12 therapy, the
hematocrit level returned, but the patient experienced numbness in the feet
and

had bilateral loss of pinprick and vibration sense above the ankle and also
had brisk ankle jerks.  These neuropathic symptoms did not improve or worsen

after one year.  Metformin-induced B12 malabsorption affects about 30% of

patients with diabetes who receive metformin therapy but is often
unrecognized or mis-diagnosed as diabetic neuropathy.

 

12.%%Heartwire  - Call for Increased Awareness, Identification of
Prediabetes 3/4/10   Less than 10% of adults in the US with prediabetes are
aware that

they are at high risk of developing  diabetes.  "We know from clinical
trials that people at high risk of DM--blood sugar levels higher than normal
but

not high enough to be diabetic--can reduce their risk of diabetes through
lifestyle modifications that include dietary changes, increased physical

activity, and weight loss," the author said.. "The first step in getting
people to do something and getting lifestyle-modification programs into
place

is being able to efficiently identify people at risk and increase awareness
of that risk." The team found of 1402 adults they surveyed but only 7.3%
had

been told they were "borderline" diabetic; had impaired glucose tolerance;
had blood sugar higher than normal but not high enough to be called DM; or
had

a prediabetes condition. . physician advice is key because the proportion of
people who actually tried to change their behavior was higher if they had

been advised to do so by a healthcare professional. 

 

13.%% MNTD Stress Affects Brain Function In Older People With Type 2/23/10
[ 900 subjects 60 - 75 with T2] the study found brain function slowed down

in those who had higher levels of the stress hormone

cortisol in their blood. The author said  "This study shows that older
people with DM who have higher levels of stress hormones in their blood are
more

likely to have experienced cognitive decline. It may be that by regulating
cortisol levels, we could help improve [this decline]  Scientists evaluated

mental abilities with a range of tests, which included looking at memory and
assessing how quickly participants processed information. They compared this

with general intelligence levels, using vocabulary tests, to work out
whether brain function in participants had diminished over time. Factors
such as

education, cardiovascular disease, smoking and mood were also taken into
account.

 

14.%% MW US FDA Panel Sees Patient Errors With Insulin Pumps

(Reuters) Mar 05 - Diabetics who wear insulin pumps appear more

likely to experience problems from improper use than a device defect, FDA
said problems with insulin pumps have occurred across the industry and asked

the panel of outside experts for ways to minimize risks from malfunctions.
Makers of the pumps include Medtronic Inc, Roche Holding AG, and Johnson &
Johnson.

Panel members said "The risks associated with people are much greater than
those associated with known defects of the technology, the failure rate to
all

of us seems extremely, extremely low." The advisers said patient education
on proper settings and other matters was key to minimizing complications.
They

said risks from malfunctions also were minimal

as long as patients checked blood sugar regularly and had other insulin
sources available. About 375,000 adults with T1 used the pumps in 2007, up
from

130,000 in 2002. Agency reviewers examined nearly 17,000 reports of health
problems in pump users over a three-year period. Many reports were
incomplete,

making it hard to tell if problems were related to a device malfunction,
improper use or diabetes complications, FDA staff said."Some discussion
between

FDA and industry would be worthwhile in trying to figure out how to make the
(medical device reporting) system more useful,"

 

15.%% MW Diabetes Mellitus and Exercise 3/01/2010  During exercise,
whole-body oxygen consumption may increase by as much as 20-fold, and even
greater

increases may occur in the working muscles. To meet its energy needs under
these circumstances, skeletal muscle uses, at a greatly increased rate, its

own stores of glycogen and triglycerides, as well as free fatty acids
derived from

the breakdown of adipose tissue triglycerides and glucose released from the
liver. To preserve central nervous system function, blood glucose levels are

remarkably well-maintained during exercise. Hypoglycemia during exercise
rarely occurs in nondiabetic people.

 The metabolic adjustments that preserve normoglycemia during exercise are
in large part hormonally mediated. .These hormonal adaptations are
essentially

lost in insulin-deficient patients with T1s. The purpose of this position
paper is to update and crystallize current thinking on the role of exercise
in

patients with T1 & 2 .Conclusions - The recent Surgeon General's Report on
Physical Activity and Health underscores the pivotal role physical activity

plays in health promotion and disease prevention. It recommends that
individuals accumulate 30 min of moderate physical activity on most days of
the week.

it is becoming increasingly clear that the epidemic of T2DM sweeping the
globe is associated with decreasing levels of activity and an increasing
prevalence

of obesity. Thus, the importance of promoting exercise as a vital component
of the prevention, as well as management of T2  must be viewed as a high
priority.

For people with type 1 diabetes, the emphasis must be on adjusting the
therapeutic regimen to allow safe participation in all forms of physical
activity

consistent with an individual's desires and goals. 

 

16.%% MNTD Eye Condition Linked To Weakened Brain Power In People With
Diabetes 3/5/10   Diabetic retinopathy [DR]could be associated with poorer
memory

and diminished brain power in people with T2DM. [1066 people with T2;age
60-75yrs] Subjects completed 7 tests looking at memory, logic and
concentration

to establish their level of brain function. Those with DR had worse average
scores on most of the individual tests as well as on general cognitive
ability

compared to those without the condition. results were independent of age and
gender. The team leader said: "These findings suggest that the severity of

diabetic retinopathy is independently associated with cognitive dysfunction
in [this group].. either  cerebral microvascular disease, as indexed by
retinopathy,

may lead to cognitive decrements in old age or that poorer cognitive ability
makes DM management more difficult, and in turn promotes the development of

cerebral microvascular disease. "It is also possible that a third
unidentified factor is causing both DR and the cognitive changes. "The
results provide

insights into the specific underlying mechanism of cognitive dysfunction in
T2 which is possibly due to a break-down of blood brain barrier (similar to

changes in blood-retinal barrier as seen in DR). . cognitive impairment in
T2 may therefore be amenable to treatment and preventive strategies targeted

at this small vessel

disease."

 

17.%% Eye (2010) 24,Optimal current and future treatments for diabetic
macular oedema   M S Blumenkranz  Department of Ophthal Stanford University,
Abstract

- Diabetic retinopathy is the most common cause of vision loss in
working-age adults. Both inflammation and vascular endothelial growth factor
(VEGF) play

a critical role, modern and emerging treatments have centred on both laser
photocoagulation and new pharmacologic strategies to improve the prognosis.

Focal and grid photocoagulation, as described in the ETDRS trials, remain
the gold standard of treatment. New classes of agents include long- acting
steroid

formulations delivered as intravitreal injections and also anti-VEGF agents.
In addition, studies are under way to evaluate potential benefits from other

novel agents, including those acting on the mammalian target of rapamycin
pathway. In limited numbers of direct head-to-head comparisons, both
steroids

and anti-VEGF agents appear to be superior to conventional photocoagulation
in reducing macular oedema in the first 4–6 months after treatment, although

laser photocoagulation appears to be superior at time points of 1–2 years.
In addition, there appear to be significant potential long-term
complications

of steroids including cataracts and glaucoma that may limit their use in
certain patients. New methods of the laser delivery including shorter pulse
durations

and pattern scanning may also improve the effectiveness and risk profile of
laser from the patient prospective. Finally, multi-modality therapy may play

an increasingly important role.

 

18.%% Eye (2010) 24, Why do patients still require surgery for the late
complications of Proliferative Diabetic Retinopathy   Aim - To briefly
review and

discuss the literature on why patients still require surgery

for the late complications of proliferative diabetic retinopathy (PDR).

The reasons for incomplete coverage of screening and screening failures can
be divided into non-modifiable and potentially modifiable risk factors. The

potentially modifiable group includes glycaemic control, BP control, lipid
control, and cessation of smoking in T1

Conclusion - Surgery for the late complications of PDR continues to be
required even in some patients who have received optimal medical care and
optimal

laser treatment. There are certain modifiable risk factors that could be
altered and further research is needed in specific fields, particularly with
regard

to the adequacy of laser treatments, the use of anti-VEGF agents in iris
neovascularisation, and in the role of psychological support in reducing the
type

of late complications leading to surgery for PDR.

 

19.%% Eye (2010) 24,  Surgical management of the late complications of
proliferative diabetic retinopathy [PDR]  The late complications of  (PDR)
comprise

vitreous haemorrhage, tractional retinal detachment, combined
tractional–rhegmatogenous retinal detachment, and severe fibrovascular
proliferation (including

macular distortion or dragging, tractional macular oedema, and media opacity
due to fibrovascular tissue).This article will review the indications,
techniques,

and outcomes of vitrectomy surgery to treat these conditions. A careful
assessment of the surgical anatomy, with particular attention to the
configuration

of vitreoretinal attachments, is important when determining the precise
surgical procedure required. The surgical outcome after diabetic vitrectomy
has

steadily improved with advances in vitreoretinal surgical instrumentation
and technique. Significant post-operative complications may, however, occur
including

cataract formation, recurrent vitreous cavity haemorrhage , rhegmatogenous
retinal detachment, and neovascular glaucoma. Most patients will regain or
retain

useful vision after diabetic vitrectomy, although the visual outcome does
remain unpredictable. The development of adjunctive pharmacotherapy should
enable

further improvements in visual outcome in the future.

 

20.%% NYTimes Mar 14, 2010  Diabetes Heart Treatments May Cause Harm
Three aggressive treatment strategies doctors had expected would prevent
heart

attacks among people with T2DM  and some who are the verge of developing it
have proved to be ineffective or even

harmful, new studies show. An estimated 21 million Americans have T2, the
kind once known as adult-onset, and they are at enormous risk for heart
disease.

The only measures proved to reduce their chances — avoiding cigarettes  and
taking medication to lower bad

cholesterol and BP  — still leave diabetics with a heart attack  risk
equivalent to that of a nondiabetic who has already had a heart attack.

So doctors began trying other strategies they hoped would help: getting
blood pressure to a normal range; raising levels of good cholesterol and
lowering

levels of dangerous triglycerides; or modulating sharp upswings in blood
sugar after a meal. It is not known how many doctors have been encouraging
patients

to take these measures, but medical specialists say it seemed reasonable and
tempting to do so. The new studies could save a lot of people from taking

drugs that will not help them. The papers were presented at an American
College of Cardiology meeting  Sunday and are being published online by The
New

England Journal of Medicine.

 

In T2DM, the body is resistant to the hormone insulin, leading to abnormally
high blood sugar levels  that can cause eye, kidney and nerve disease. But

heart disease is what kills most patients. A quarter to a third of heart
attack patients have DM, even though diabetics constitute just 9% of the
population.

And 25% of heart attack patients are on the verge of diabetes, with
abnormally high blood sugar levels.

High blood sugar levels themselves increase the risk of heart disease, but
researchers found 2 years ago that rigorously controlling blood sugar did
not

prevent heart disease or deaths in people with T2. Researchers said the
failure was probably because most of those patients also had other problems
that

made their odds of heart disease soar, like high levels of LDL cholesterol,
low levels of HDL  cholesterol, high levels of triglycerides and high BP And

most were older and overweight. T2 “captures all these risk factors in one
patient,” said Dr. David Nathan, director of the diabetes center at

Mass. General Hospital. It seemed logical to look at the other risk factors.

 One large federal study  asked if getting high blood pressure down to a
level considered normal, a systolic pressure of no more than 120, would help
protect

diabetics from heart disease and save lives.., half of the study’s 4,773
participants took drugs to get their systolic BP to 120 or below. The rest
had

a BP goal of less than 140. But lower blood pressure did not prevent heart
attacks or cardiovascular [CV] deaths, and those with lower BP were more
likely

to suffer severe side effects from the drugs, like high potassium  levels or
dangerously low blood pressures. A second, less rigorous study, involving

6,400 patients with T2 and heart disease, asked whether getting systolic
blood pressure lower than 130 was any better than getting it to 130 to 140.
It

found that patients actually were worse

off: those with the lower BP ended up with a 50% greater risk of strokes,
heart attacks or deaths.  National BP treatment guidelines call for a
systolic

pressure of 130 or lower based on expert opinion and observational studies,
Now it is likely to be reconsidered when the group that sets the guidelines

prepares a report this year.

People with diabetes also tend to have low levels of HDL cholesterol and
high levels of triglycerides, a combination known to increase the risk of
heart

disease. And in some studies, treating that combination with a type of drug
called a fibrate reduced risk in diabetics and nondiabetics who were not
taking

statins. So it made sense to see if fibrates also helped T2  diabetics who
were taking statins. It did not,

concluded another arm of the federal study  involving 5,518 people with T2.
“It’s a disappointment,” said a lead study investigator. “But it’s very,
very

important,” because it says most people will not be helped by taking the
additional drug.  It means, said Dr. Denise Simons-Morton of the National
Heart,

Lung and Blood Institute, the project officer for the federal study, that
“doctors and patients now know that the inclination to do intensive
treatment

that people seemed to think would be better for cardiovascular risk
reduction wasn’t better.”  

A final study investigated the popular hypothesis that rapid rises in blood
glucose after a meal were dangerous and could lead to heart disease. Many
doctors

were giving drugs assuming the hypothesis was correct. The study, which
involved 9,300 patients at high risk for diabetes because their blood sugar
was

high, tested the drug nateglinide, which enhances insulin secretion. It also
tested a blood pressure drug. Neither decreased heart disease risk. “Neither

drug should be used in people with impaired glucose tolerance but not
diabetes in order to prevent cardiovascular events unless there is another
indication,

like significant hypertension,” said Dr. R. Califf, Duke U  chairman of the
study. Some, like Dr. Daniel Einhorn, Amer Asso of Clinical
Endocrinologists,

say the results of that study and the others would not necessarily dissuade
him from taking such intensive measures with individual patients.., The
lesson

is that while making logical leaps to aggressively treat patients with Type
2 diabetes was “totally understandable,” it was also dangerous. “Lower is
not

necessarily better.”  Dr. Nathan said. [note, since this is a short list I
have included most of this article] 

 

- Abbreviations:  DM - diabetes Mellitus;T1DM - type 1 diabetes mellitus
T2DM - type 2; DME - diabetic macular edema; GDM gestational diabetes; PDR -
proliferative

diabetic retinopathy;  FPG - fasting plasma glucose BP - blood pressure; CVD
- cardio-vascular disease; MI -myocardial infarction or heart attack ;HTN

- hypertension or high BP; OCT - optical coherence tomography; VA - visual
acuity  -ADA - Amer Diabetes Ass & ADA Professional Resource Online; FDA
Federal

Drug Adm. JHA - Johns Hopkins Alerts ; MW Medscape Web MD; NIH - National
Institutes of Health;  MNTD- Medical News Today  Definitions via online
Medical

dictionaries.  Disclaimer, I am a BSN RN but not a diabetic or diabetic
educator. Reports are excerpted unless otherwise noted. This project is done
as

a courtesy to the blind/visually impaired and diabetic communities. Dawn
Wilcox BSN RN Coordinator The Health Library at Vista Center; an affiliate
of

the Stanford Hospital Health Library.   contact above e-mail or 

thl at vistacenter.org     

            

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