Recently, various intensive treatment regimens have been attempted in patients with insulindependent diabetes (IDDM), because prevalent conventional insulin therapy with insulin injections once or twice daily does not achieve euglycemic control.
This study was performed to examine the feasibility of achieving near-normal glucose excursion in IDDM by giving multiple subcutaneous insulin injections (MSII) using Pen Pump Infuter (Markwell Medical Inst.)(Pen).
Glycemic control with MSII by Pen was undertaken in 20 patients, who had been admitted because of their poor glycemic control under conventional insulin therapy (CIT) and they were given four preprandial injections of Actrapid insulin with Pen. We compared glycemic control during CIT and MSII by Pen as measured by mean blood glucose (MBG) and M-value. The following results were obtained: 16 of 20 patients gained better glycemic control with MSII by Pen, and MBG (214.1±48.7 mg/dl, mean±SD) and M-value (64.2±35.5) under CIT fell significantly to 173.8±34.0 mg/dl and 36.5±24.5, respectively (p<0.001).
It was recognized that, in the patients who could gain better glycemic control, their daily insulin requirements were less and also their residual B-cell functions were not so completely exhausted when compared with those who failed to achieve good control. In these poorly controlled cases, near-normal glycemic control throughout a 24-hour period could be attained with the addition of subcutaneous ultralente insulin injection in the morning. Concerning the distribution of insulin requirements at each preprandial injection, the dose before breakfast tended to be greater than that of any other injection. The influence of higher plasma cortisol levels in the morning was thought to be a factor in this phenomenon.
It is concluded that MSII by pen, if necessary supplemented by ultralente insulin injection, is useful for the treatment of IDDM, and that the simplicity and convenience of Pen may allow its long-term use and assure good activity for outpatients.

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Diabetic gangrene occurring in the lower limbs of diabetics with microangiopathy is very difficult to cure. In the majority of cases, blood glucose is not controlled and the condition is accompanied by neuropathy. Heretofore, there has been no treatment other than to rely on dietary therapy and to prescribe insulin to improve the diabetic condition. However, based on their experience in the treatment of chronic arterial occlusive disease ulcers and referring to the idea of continuous subcutaneus insulin infusion, the authors have devised the following method of local intra-arterial infusion of a PGE₁-insulin-urokinase mixture. A catheter was inserted in a superficial femoral artery of the affected limb; it was connected to a continuous infusion pump, and through it, a physiological saline solution containing PGE₁, insulin and urokinase was administered. Within 10 days to three weeks, the wound disappeared with good granulation. Within approximately eight weeks, a complete healing of the lesion was achieved in all 10 patients. This local concentrated PGE₁ infusion procedure produced diffuse peripheral vasodilatation, permitting increased blood flow into ischemic tissues. This increased blood flow hastened the healing of the wound in synergic association with activation of the cellular metaolism and recanalization of the occluded vessels by combined intra-arterial insulin and urokinase. Further, the treatment led to improvement of uncontrolled subcutaneous A-V shunts due to the restoration of the vasmotor function of the autonomic nervous system, thus contributing to the improvement of peripheral circulation. Attention should be drawn to the fact that the cure of wounds was successfully achieved by the local concentrated infusion procedure even prior to attaining significant improvement in the systemic diabetic condition. These results indicate the effectiveness of this procedure, thus demonstrating its remarkable usefulness in the treatment of diabetic gangrene.

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This report describes a comparative examination of adult rat pancreatic islets maintairned in either monolayer or free-floating cultures.
The insulin secretion of freshly collagenase-isolated rat islets and islets which had been maintained in either free-floating or monolayer cultures for two weeks was measured during incubation in a medium containing 5.5 mM D-glucose, then in a 16.7 mM D-glucose concentration, and finally in a combination of 16.7 mM D-glucose and 3-isobutyl-1-methylxanthine (IBMX, 1.0 mM).
The insulin secretion of the monolayer islet culture was markedly enhanced by stimulation of glucose at the high concentration and in combination with IBMX. In addition, the monolayer islets had the highest insulin content.
This data suggests that the most favorble conditions for long-term survival of isolated islets in culture may be obtained when the islets form a monolayer.

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Clofibrate has long been used as a hypolipidemic drug. Recently, it has been shown to improve glucose tolerance without increasing serum insulin levels during challenge tests in diabetics. We have studied the effect of 2-(p-chlorophenoxyisobutyrate)(CPIB)(the active form of clofibrate) on insulin actions and insulin receptors in isolated rat adipocytes.
CPIB stimulated conversion of [2-³H]-glucose to total lipids (lipogenesis) dose-dependently within therapeutic dose limits (0-200μg/ml). CPIB (200μg/ml) stimulated lipogenesis approximately 2-fold and enhanced the insulin responsiveness of lipogenesis about 2-fold compared with nontreated adipocytes. CPIB also stimulated [³H]-2-deoxyglucose transport to adipocytes and enhanced this effect of insulin at lower insulin concentrations.
However, there was no significant difference between CPIB-treated and non-treated adipocytes in ¹²⁵I-insulin binding capacity. When cultured human lymphocytes (IM-9) were exposed to 200μg/ml CPIB over 24 hr, there was also no significant difference in ¹²⁵I-insulin binding capacity between control and treated cells.
These results demonstrate that CPIB has insulin-like effects on rat adipocytes, which can not be attributed to change in the affinity of insulin receptor sites, and suggest that CPIB acceleratets the post-receptor mechanism.

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Pancreatic exocrine function in hyperinsulinemia was studied in the rat with islet-cell tumors (ICT) induced by streptozotocin and nicotinamide in the in vitro isolated perfused pancreas. A significant amount of insulin was detected in the portal effluent from the pancreas with ICT, even in the hypoglycemic state. (2.8 mM glucose). In addition, the pancreas with ICT secreted an extremely high amount of insulin in response to both glucose (8.3 mM) and caerulein (0.1 ng/ml) stimulation. However, the function of normal B cells in the pancreas with ICT was assumed to be suppressed by the preexisting tumor-induced hyperinsulinemia, since the insulin secretory response to glucose and caerulein after removal of ICT was less than that of the control pancreas from which a similar weight of normal pancreatic tissue had been removed. On the other hand, the amylase output from the ICT pancreas in response to 0.1 ng/ml of caerulein, both before and after removal of ICT, was significantly lower than that from the control, although there was no difference in pancreatic juice flows from the two groups. These results suggest that local high concentration of insulin around the acinar cells via the islet-exocrine portal system through the exocrine tissue is more important in maintaning acinar cell function than regional or systemic hyperinsulinemia induced by islet cell tumors.

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The P₅₀ of the oxyhemoglobin dissociation curve (ODC) was determined in 204 treated diabetic patients with and without retinopathy and in 24 non-diabetic and non-smoking healthy volunteers. None of the patients were acidotic. The 204 patients were divided into 4 groups as follows:
47 diabetics designated group 1 and having no retinopathy.
51 diabetics designated group 2 and having non-proliferative retinopathy.
53 diabetics designated group 3 and having pre-proliferative retinopathy.
53 diabetics designated group 4 and having proliferative retinopathy.
Each of the four groups was divided again into two subgroups by hemoglobin concentration (below 13 g/dl and above 13 /dl) or HbAi (below 9 % and above 9 %).
RESULTS:
I. P₅₀ in vivo pH and P₅₀ pH 7.4 were not significantly different among all diabetic groups from 1 to 4 compared with the normal control group.
II. The 2, 3-DPG concentration was significantly higher in individuals having below 13 g/dl of hemoglobin than in those having above 13g/dl of hemoglobin in all subgroups, but P₅₀ was not significant in any of the subgroups.
III. The 2, 3-DPG concentration was higher in individuals having above 9 % of HbAi than in those having below 9% of HbAi in groups 3 and 4. However only group 3 was statistically significant. There was no difference in P₅₀ among all groups.
IV. In groups 3 and 4 the correlation between P₅₀ pH 7.4 and 2, 3-DPG was calculated for groups having a combination of hemoglobin less than 13 01/ and HbA₁ greater than 9 % and for the groups having a combination of hemoglobin greater than 13 g/dl and HbA₁ less than 9%. There was no correlation between the 2, 3-DPG and P₅₀ pH 7.4 in patients of group 4 having both hemoglobin below 13 g/dl and HbAi above 9 %.
We conclude that in group 4, consisting of diabetic patients with proliferative retinopathy showing less than 13 g/dl hemoglobin and more than 9 % HbAi, the 2, 3-DPG concentration may affect the ODC as only a slight possibility of a shift to the right.

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To clarify the mechanism of the effect of the dopaminergic antagonist, metoclopramide, on orthostatic hypotension (OH) associated with diabetes mellitus, 24 diabetics with OH and 7 diabetics without OH were kept standing for 15 min. after an injection of 2ml saline (S-injection) and then, on the following day, for 15 min. after intravenous administration of 10 mg metoclopramide (M-administration). Blood pressure (BP) and pulse rate (P) were measured throughout the study. Plasma renin activity (PRA), aldosterone concentration (PAC), norepinephrine (PNE) and epinephrine (PE) were determined at 0 and 15 min.
(1) In 15 of the diabetics with OH, after upright posture following M-administration, orthostatic hypotension improved and P increased, especially in 10 patients, PNE and PAC increased significantly (p<0.05), and PRA showed a fairly good elevation compared with the results obtained after S-injection. In addition, these patients had milder diabetic complications or obesity.
(2) In the remaining 9 patients with OH, after upright posture following M-administration, there was no improvement in OH and no increase in P. Moreover, PRA and PNE showed only a slight increase, whereas PAC was elevated considerably compared with the results after S-injection. The patients also had severe diabetic complications or emaciation.
(3) There was no significant difference in PE after S-injection or M-administration in all patients.
(4) In 10 of the 15 diabetics with improvement of OH, PRA, PAC, PNE and PE, especially PRA and PNE following M-administration were significantly (p<0.05) higher than those of diabetics, in whom the OH did not improve.
(5) In diabetics without OH, there were no significant differences in BP and P after S-injection or M-administration, and PNE following M-administration increased significantly (p<0.05) compared with results obtained for diabetics, in whom the OH improved.
In conclusion, the improvement of OH caused by metoclopramide is probably related to milder diabetic complications or obesity, and the mechanism can be explained by increases in plasma renin, aldosterone, norepinephrine and epinephrine, especially renin and norepinephrine, and also by the enhancement of sensitivity of the blood vessels to catecholamines.

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To investigate whether skeletal muscles are resistant to insulin during starvation, insulin binding and biological effects on 2-deoxyglucose (2 DOG) uptake were studied in isolated rat soleus muscles from 48-hour starved rats.
Insulin binding to soleus muscles from starved rats was significantly increased compared with that from fed control rats at low and high concentrations of insulin. This increase of insulin binding was due to an increase of receptor capacity, not to a change of receptor affinity according to Scatchard analysis.
In both groups, basal 2 DOG uptake was comparable, but insulin-stimulated 2 DOG uptake in starved rats was significantly decreased compared with that in control animals. When the percent of maximal insulin effect on glucose uptake was plotted against insulin concentration, the dose response curve from starved rats was shifted to the left, suggesting increased insulin sensitivity in starved rats. To further characterize the effects of starvation on the glucose transport system, 2 DOG uptake ability of the muscle at various concentrations of hexose, in the presence or absence of a maximally effective insulin, was studied. When the data from these uptake curves were submitted to Hanes plot analysis and apparent Km and Vmax values were calculated, the Vmax value for the muscle from starved rats was significantly less than that from control rats without any change of Km values.
In summary, 48-hour-starvation led to an increase in the capacity of insulin receptor and a decrease in the capacity of the glucose transport system in isolated rat soleus muscles.

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To investigate whether skeletal muscles are resistant to insulin during starvation, the biological effects of insulin on glucose utilization were studied in isolated soleus muscles from 48-hour-starved rats.
The glucose utilization was measured at 5 mM glucose, at 37°C. Basal and insulin-stimulated glucose conversion to lactate was comparable in control and starved rats. Basal glucose incorporation into total liqids was decreased, although insulin-stimulated incorporation was not decreased in starved rats. On the other hand, glucose incorporation into glycogen in starved rats was significantly increased in the basal and insulin-stimulated states. This increase of glycogen synthesis may be due to an activation of glycogen synthase with a decrease of muscle glycogen content during starvation.
The glucose clearancerate, which reflects glucose transport, was measured at a trace concentration (1-2μM) of labeled glucose. In both groups, basal glucose clearance was comparable, but insulinstimulated glucose clearance decreased significantly in starved rats.
In conclusion, basal and insulin-stimulated glucose utilization was not decreased, although insulin-stimulated glucose transport was moderately reduced in starved rats.
Thus, in the skeletal muscle, starvation may not result in the severe insulin resistance reported in the adipocytes.

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We previ0usly reported that heart rate (HR) variation during deep breathing was predominantly affected by the parasympathicus and the maximum HR increase in response to standing was affected predominantly by the sympathicus. According to these HR variation tests, 21 diabetic patients were divided into three groups...8diabetics without autonomic neuropathy (group A), 6 diabetics with parasympathetic damage alone (group B) and 7 diabetics with both parasympathetic and sympathetic damage (group C). The responses of pancreatic hormones and catecholamines during insulin-induced hypoglycemia were investigated in 21 diabetics and 7 healthy controls. There were no differences in the rate of plasma glucose decrease and the nadir glucose concentrations among the control and three diabetic groups. The incremental areas of each hormone from O to 90 minutes after the end of insulin infusion were calculated.ΣΔglucagon (IRG) in contro1s and groups A, B, and C were 2, 210, 1, 888, 1, 248 and 844 Pg·min/ml, respectively. XAIRG in groups B and C were lower than that in controls.ΣΔpancreatiC polypeptide (PP) in controls and groups A, B, and C were 10, 684, 10, 861, 3, 855 and 2, 46g Pg·min/ml, respectively.ΣΔPP in groups B and C were significantly lower than those in the control group.ΣΔtepinephrine (PE) were 4.95ng·min/ml in controls, 6.87 in group A, 6.62 in group B and 1.22 in group C.ΣΔPE in group C was significantly lower than those in the other three groups. XA norepinephrine (PNE) in controls and goups A, B, and C were 3.36, 3.09, 2.24 and 1.15 ng·min/ml, respectively.ΣΔPNE in group C was lower compared with those in the other groups
These results suggest that cardiac parasympathetic and/or symnpathetic damge evaluated by HR variation tests were closely related to the hormonal responses of the pancreas and adrenal medulla during insulin-induced hypoglycemia and that HR variation tests are useful fbr evaluating para. sympathetic and/or sympathetic damage of the abdominal organs.

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We report a 66-year-old female patient, who showed an unusually high serum level of immunoreactive proinsulin (IRP) after treatment with bovine-porcine mixed insulin. On the 14th day of secondary heterologous insulin therapy, total-IRI, -CPR and-IRP levels in serum were 428μU/ml, 128 ng/ml and 49.3 ng/ml, respectively. Most of IRI and CPR activity consisted of antibodybound forms. Direct and competitive studies demonstrated that antibodies in the serum did not recognize the free C-peptide and matched only a little of the C-peptide portion of proinsulin (proinsulin specific antibody). However, insulin antibody level reached 64.3% in insulin-binding capacity and 1008 ng/ml, in antibody index. These antibodies were dissociated more easily from bound insulin by the addition of variable concentrations of cold porcine proinsulin, compared with antibodies from 7 other insulin-treated diabetic patients. After acid-ethanol extraction, most of the CPR and IRI activity corresponded to the proinsulin marker in Bio-Gel P 30 column analysis. This case has received 3 series of insulin treatment sufficiently recovering her metabolic state after each series to the extent that she did not need exogenous insulin administration for at least several months. After the 2nd series with heterologous insulin, insulin antibody and proinsulin levels in serum gradually decreased in parallel. Insulinoma, renal failure, insulin autoimmune syndrome and autosomal dominant familial hyperproinsulinemia, accompanied by hyperproinsulinemia, could be ruled out from laboratory findings and the screening of serum IRP levels in her family. The hyperproinsulinemia in this case was therefore likely to be due to insulin antibody which has high affinity for proinsulin. During the last series with human (recombinant DNA) insulin, she was brought under a good level of control without any remarkable rise of proinsulin or insulin antibody levels in her serum. She was since maintained a good condition without any hypoglycemic agents. In this case therefore, homologous insulin is better than the heterologous type with respect to antibody production.

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A comparison was made between the effects of anti-insulin receptor autoantibodies and normal human immunoglobulin G on the metabolic processes of isolated adipocytes. Anti-insulin receptor autoantibodies caused marked stimulation of glucose oxidation and glucose conversion to fatty acids, along with marked inhibition of lipolysis. Normal human immunoglobulin G, however, showed no metabolic effects on adipocytes. These observations indicate that only the anti-insulin receptor autoantibodies have an insulin-like metabolic effect. The present data thus suggest that the interaction of antibodies with adipocyte insulin receptors seems sufficient to produce the acute metabolic effects of insulin.

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