Despite the wealth of information available concerning the various systemic complications of chronic diabetes, the effects of this disease on the metabolism of minerals and the integrity of bone, particularly bone fragility, are not yet fully appreciated. The earliest influence of the diabetic environment on bone is seen in the increased prevalence of skeletal malformations in the foetuses of diabetic mothers. Hypoplasia or deformities of the extremities, dislocation of the hips and agenesis of the sacrum or lumbar vertebrae occur three to five times as frequently among these infants as among non-diabetic controls (1). The second category of bone abnormalities known to occur in those with diabetes results from the continuing trauma following diabetic neuropathy and is characterized by focal osteolysis, bone fragmentation, sclerosis and Charcot's neurogenic arthropathy. This condition is usually evident in the small bones of the feet and less frequently involves the knees, upper extremities or vertebrae (2). Hand abnormalities, including carpal tunnel syndrome, sclerodactyly, acro-osteolysis and Dupuytren's contracture also occur more frequently in diabetes. Diabetic muscle infarction is a rare complication seen in poorly controlled diabetics with advanced microvascular complications (3). Late complications of diabetes may also impact negatively on skeletal health, e.g. renal osteodystrophy, falls and fractures secondary to poor vision, neuropathy or cerebrovascular disease.
Fracture toughness, the ability of the bone material to resist to crack initiation and propagation is another determinant of fracture risk besides bone strength. Nuclear magnetic resonance spectroscopy (NMR) and reference point indentation (RPI) have been shown to be useful clinical surrogates to assess fracture toughness. In their study, Granke et al. (68) showed that the fracture toughness properties decreased with age. NMR-derived properties such as pore water RPI-derived tissue stiffness correlated with fracture toughness on human femoral bone.
Insulin has been shown to have anabolic actions on bone in vitro (92). Furthermore, in knockout models of insulin receptor substrate 1 or 2 (IRS1; IRS2), the main intracellular substrates of the insulin receptor, bone formation and resorption are markedly reduced (93, 94). The administration of insulin to animals with experimental diabetes has also been shown to correct the decreased bone turnover that characterizes the chronic diabetic state (71, 95). Insulin deficiency as a cause of the low bone formation in T1DM therefore appears attractive. However, no changes in bone turnover were observed in global knockout of the mouse insulin receptor (IR), subsequently rescued by transgenic expression of the human IR in the liver, pancreas and brain, but not bone (96). Decreased insulin signalling alone cannot therefore account for the low bone turnover in T1DM. These knockout mice have elevated insulin levels which increase IGF1 signalling. Sufficient signalling through either IR or IGF1 is therefore required for optimal bone turnover (80, 97). Human data support the notion that the lack of insulin may affect negatively osteoblasts. In T1DM adolescents, bone phosphatase alkaline (ALP), osteocalcin and IGF1 levels were significantly lower compared to healthy controls (75) and lower IGF1 were associated with osteopenia (33). The decreased levels of IGF1 seen in T1DM but not in T2DM are not fully explained.
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Drug abuse treatment programs and university-based research centers collaborate to test emerging therapies for alcohol and drug disorders in the National Drug Abuse Treatment Clinical Trials Network (CTN). Programs participating in the CTN completed organizational (n = 106 of 112; 95% response rate) and treatment unit surveys (n = 348 of 384; 91% response rate) to describe the levels of care, ancillary services, patient demographics, patient drug use and co-occurring conditions. Analyses describe the corporations participating in the CTN and provide an exploratory assessment of variation in treatment philosophies. A diversity of treatment centers participate in the CTN; not for profit organizations with a primary mission of treating alcohol and drug disorders dominate. Compared to N-SSATS (National Survey of Substance Abuse Treatment Services), programs located in medical settings are over-represented and centers that are mental health clinics are under-represented. Outpatient, methadone, long-term residential and inpatient treatment units differed on patients served and services proved. Larger programs with higher counselor caseloads in residential settings reported more social model characteristics. Programs with higher social model scores were more likely to offer self-help meetings, vocational services and specialized services for women. Conversely, programs with accreditation had less social model influence. The CTN is an ambitious effort to engage community-based treatment organizations into research and more fully integrate research and practice. PMID:17875368
Recent research has shown that women and men differ in substance abuse etiology, disease progression, and access to treatment for substance abuse. Substance abuse treatment specifically designed for women has been proposed as one way to meet women's distinctive needs and reduce barriers to their receiving and remaining in treatment. However, relatively few substance abuse treatment programs offer specialized services for women, and effectiveness has not been fully evaluated. This article reviews the literature on the extent and effectiveness of substance abuse treatment programming for women and provides an overview of what is known about the components of successful treatment programs for women. Thirty-eight studies of the effect on treatment outcomes of substance abuse treatment programming for women were reviewed. Seven were randomized, controlled trials, and 31 were nonrandomized studies. In our review, six components of substance abuse treatment programming for women were examined: child care, prenatal care, women-only programs, supplemental services and workshops that address women-focused topics, mental health programming, and comprehensive programming. The studies found positive associations between these six components and treatment completion, length of stay, decreased use of substances, reduced mental health symptoms, improved birth outcomes, employment, self-reported health status, and HIV risk reduction. These findings suggest that to improve the future health and well-being of women and their children, there is a continued need for well-designed studies of substance abuse treatment programming for women. 2b1af7f3a8