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3 Lipoprotein abnormalities in diabetes Circulating lipoproteins are just as dependent on insulin as is the plasma glucose In type 1 diabetes, moderately deficient control of hyperglycemia is associated with only a slight elevation of LDL cholesterol and serum triglycerides and little if any change in HDL cholesterol Once the hyperglycemia is corrected, lipoprotein levels are generally normal However, in obese patients with type 2 diabetes, a distinct diabetic dyslipidemia is characteristic of the insulin resistance syndrome Its features are a high serum triglyceride level (300 400 mg/dL), a low HDL cholesterol (less than 30 mg/dL), and a qualitative change in LDL particles, producing a smaller dense particle whose membrane carries supranormal amounts of free cholesterol These smaller dense LDL particles are more susceptible to oxidation, which renders them more atherogenic Since a low HDL cholesterol is a major feature predisposing to macrovascular disease, the term dyslipidemia has preempted the term hyperlipidemia, which mainly denoted the elevated triglycerides Measures designed to correct the obesity and hyperglycemia, such as exercise, diet, and hypoglycemic therapy, are the treatment of choice for diabetic dyslipidemia, and in occasional patients in whom normal weight was achieved, all features of the lipoprotein abnormalities cleared Since primary disorders of lipid metabolism may coexist with diabetes, persistence of lipid abnormalities after restoration of normal weight and blood glucose should prompt a diagnostic workup and possible pharmacotherapy of the lipid disorder 28 discusses these matters in detail
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The clinician should be aware of the limitations of the selfmonitoring glucose systems First, a few of the older meters (such as the One Touch Profile) are calibrated against whole blood glucose concentrations even though the test strip measures the glucose in the plasma fraction This means the displayed values are 10% to 15% lower than the laboratory glucose result Second, increases or decreases in hematocrit can decrease or increase the measured glucose values The mechanism underlying this effect is not known but presumably it is due to the impact of red cells on the diffusion of plasma into the reagent layer Third, the meters and the test strips are calibrated over the glucose concentrations ranging from 60 mg/dL to 160 mg/dL, and the accuracy is not as good for higher and lower glucose levels When the glucose is less than 60 mg/dL, the difference between the meter and the laboratory value may be as much as 20% Fourth, glucose oxidase based amperometric systems underestimate glucose levels in the presence of high oxygen tension This may be important in the critically ill who are receiving supplemental oxygen; under these circumstances, a glucose dehydrogenase based system may be preferable The accuracy of data obtained by glucose monitoring requires education of the patient in sampling and measuring procedures as well as in proper calibration of the instruments Bedside glucose monitoring in a hospital setting requires rigorous quality control programs and certification of personnel to avoid errors e Continuous glucose monitoring systems Three continuous glucose monitoring systems are currently available for clinical use The DexCom and MiniMed Medtronic systems involve inserting a subcutaneous sensor (rather like an insulin pump cannula) that measures glucose concentrations in the interstitial fluid for 72 hours In the MiniMed system, the measured glucose values are wirelessly transmitted to the screen of their insulin pump In the DexCom system, the data are transmitted to a separate pager-like device with a screen Both systems allow the patient to set alerts for low and high glucose values Patients still have to calibrate the devices with periodic fingerstick glucose levels, and since there are concerns regarding reliability, it is still necessary to confirm the displayed glucose level with a fingerstick glucose before making interventions such as injecting extra insulin or eating extra carbohydrates Clinical trials with these systems show that they do enable some patients to improve control without increasing the risk of hypoglycemia The individual glucose values are not that critical what matters is the direction and the rate at which the glucose is changing, allowing the user to take corrective action The wearer also gains insight into the way particular foods and activities affect their glucose levels The other main benefit is the low glucose alert warning These systems are not covered by insurance and the initial cost is about $800 to $1000, and the sensor, which has to be changed every 3 days or so, costs about $35 This adds up to an out-of-pocket expense of about $4000 annually The Glucowatch system from Animas Technologies measures glucose in interstitial fluid extracted through intact skin by applying a low electric current (reverse iontophoresis) This process can cause local skin irritation, and sweating distorts the glucose measurement For these reasons, the system is not widely used
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