Reduced insulin-mediated glucose transport in skeletal muscle is a hallmark of the pathophysiology of T2DM (Type II diabetes mellitus). Impaired intracellular insulin signalling is implicated as a key underlying mechanism. Attention has focused on early signalling events such as defective tyrosine phosphorylation of IRS1 (insulin receptor substrate-1), a major target for the insulin receptor tyrosine kinase. This is required for normal induction of signalling pathways key to many of the metabolic actions of insulin. Conversely, increased serine/threonine phosphorylation of IRS1 following prolonged insulin exposure (or in obesity) reduces signalling capacity, partly by stimulating IRS1 degradation. We now show that IRS1 levels in human muscle are actually increased 3-fold following 1 h of hyperinsulinaemic euglycaemia. Similarly, transient induction of IRS1 (3-fold) in the liver or muscle of rodents occurs following feeding or insulin injection respectively. The induction by insulin is also observed in cell culture systems, although to a lesser degree, and is not due to reduced proteasomal targeting, increased protein synthesis or gene transcription. Elucidation of the mechanism by which insulin promotes IRS1 stability will permit characterization of the importance of this novel signalling event in insulin regulation of liver and muscle function. Impairment of this process would reduce IRS1 signalling capacity, thereby contributing to the development of hyperinsulinaemia/insulin resistance prior to the appearance of T2DM.

The prevalence of diabetes has been increasing at an alarming rate worldwide. Treatment of diabetes-related complications adds a huge financial burden on our health services, made worse in the current financial climate. The Eurodiale (European Study Group on Diabetes and the Lower Extremity) study was a prospective observational study conducted in 14 European centers in 2003 to 2004 and included data on characteristics of diabetic patients with foot ulcers, diagnostic and management procedures, health care organization, quality of life, and resource use. This was the first large multicenter study, included 1232 patients, and used an integrated approach for a multiorgan disease. The study has provided new insights into the intricacies involved in managing diabetic foot ulcers and how care can be improved. It has shown the differences in quality of care provided in different centers and also highlighted the need for more specific guidance related to diabetic foot disease.

Myxoedema coma is a rare and life-threatening illness the outcome of which has not been robustly studied in large numbers, partly due to its low incidence. Dutta and colleagues have explored outcome predictors in a developing country where access to thyroid function tests is more limited than in the Western world. Cardiovascular instability, reduced consciousness, persistent hypothermia, and sepsis all contributed to a poorer outcome, as has been demonstrated before, but a generic outcome predictor model was shown to be useful in this group of patients. Unfortunately, this observational study was unable to show differences in outcome based on replacement treatment methods and the mortality remains at 40%.

Access to reliable information is an essential component of effective self‐care in diabetes. We sought to explore sources of information used by people with diabetes, and their views on the adequacy of this information. We developed an investigator‐administered questionnaire. Seventy patients (of 75 approached) attending two diabetes centres in Glasgow, UK, participated in the study. The results showed that verbal information from specialist nursing staff in the diabetes centre was most used and preferred as a source of information. Twenty‐one percent (n=15) of participants said they had never received information on complications. Patients with higher levels of educational attainment were less likely to report being given this type of information (χ2=6.98, p<0.05). A higher proportion of those who reported receiving no information had type 1 diabetes (χ2=5.79, p<0.05). Few patients reported using the internet (n=13); those who did were younger (χ2=7.62, p<0.01) with a higher level of educational attainment (χ2=6.61, p<0.05). Current approaches to providing information to people with diabetes leave a perceived ‘information gap’. Our data strengthen the case for a systematic, validated and documented approach to the provision of information which is sensitive to local users' needs. Copyright © 2005 John Wiley & Sons, Ltd.

With widespread use of `atypical' antipsychotics for the treatment of psychiatric disorders, attention has focused on their association with obesity, diabetes and risk factors for cardiovascular disease. People with schizophrenia are more likely to develop diabetes than the general population, with antipsychotics appearing to add to this risk. The exact mechanism(s) by which antipsychotics cause hyperglycaemia, diabetic ketoacidosis and aggravation of pre-existing diabetes remain uncertain. Plausible mechanisms have been postulated for the promotion of obesity by these agents, with resultant insulin resistance and type 2 diabetes in some patients. Whatever the mechanism, careful consideration of potential risks and benefits is required in prescribing: people with schizophrenia are often exposed to antipsychotic agents in the long term and frequently have co-existing cardiovascular risk factors (smoking, poor diet, physical inactivity, social deprivation). Regular monitoring of body weight, blood glucose and serum lipids may help clinical management.

SUMMARYHyponatraemia is a very common electrolyte abnormality with varied presenting features depending on the underlying cause. The authors report the case of a 75-year-old, previously fit, gentleman who presented with weight loss, lethargy and blackouts. He required four admissions to the hospital over an 8-month period. Investigations revealed persistent hyponatraemia consistent with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion, macrocytic anaemia and partial hypopituitarism. Unfortunately, all other investigations that were performed failed to identify the underlying cause and a diagnosis of intravascular large B-cell lymphoma was only confirmed following postmortem studies. The authors recommend that endocrinologists should be involved at the outset in the management of patients with persistent hyponatraemia and that intravascular large B-cell lymphoma should be considered in the differential diagnosis of hyponatraemia. BACKGROUND

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