Issues and Updates

With Federal Funding allow that if this system could not pro- tes, which he sees as the next big chal- vide enough suitable healthy tissue, then lenge in diabetes research. Diabetes has Ban Lifted, Fetal researchers could use tissue from in- been reversed in animals with drug- duced abortions. induced diabetes using islet transplanta- Tissue Research Will Some researchers believe the tion. Dr. Lafferty intends to work with banks cannot deliver sufficient suitable mice that are genetically susceptible to Continue in Earnest tissue under their current restrictions. diabetes—to not only reverse diabetes, Dr. Delbert Dayton, chief of Develop- but to keep it from recurring, all using Researchers are poised and invigorated mental Biology, Genetics, and Teratology islet transplantation. His latest experi- to reinitiate pursuit of an important line at the National Institute of Child Health ment calls for transplanting human fetal of treatment research for insulin-depen- and Development, who has been in- islet tissue into scid mice (which have no immune system). dent diabetes mellitus (IDDM) in fetal volved in the coordination of the bank, tissue transplantation—now that the ban says the tissue has not been readily avail- Dr. Lafferty notes that there is able because of logistical problems in- on federal funding for such research has little difference between fetal pancreas volved in collecting tissue from women been lifted by President Clinton. Prom- tissue and adult pancreas tissue. In fact, who miscarry or spontaneously abort. what some people see as the advantage of ising results observed in early research The first months of the bank's inception, using fetal tissue—reduced immuno- conducted over the past 5 yr—much of it he says, have served for "developing genecity—does not hold true in the fetal showing that IDDM patients require sig- standards for and characterizing of tis- pancreas. Fetal pancreas tissue is actually nificantly less insulin after transplanta- sue, and for developing logistics," which more immunogenic than adult tissue. tion—have encouraged researchers re- he and others believe will show that re- However, one substantial difference is in garding the tremendous potential fetal lying on the two specified sources will availability. Healthy, suitable adult pan- tissue carries. not provide enough tissue. Many in the creas tissue for transplant research is ex- Basic and clinical research using research community, including Drs. tremely difficult to obtain because adult fetal tissue has continued even during Dayton and Kevin Lafferty, a longtime pancreases are difficult to procure— the ban—albeit on a markedly limited diabetes researcher in transplantation at mainly because high-quality organs go to basis—because of the positive results be- the Barbara Davis Center for Childhood transplant surgery. Fetal tissue, relatively ing observed. The research community Diabetes, believe this will eventually lead speaking, is more easily obtained for continued to work within the framework to President Clinton's lifting of restric- medical and scientific research. that was set up; in this case, it was with- tions on tissue from induced abortions In addition to questions of avail- out the support of the federal govern- just as he has lifted the funding ban. ability, fetal tissue researchers have had ment—a situation that always inhibits Dr. Lafferty says that he did not to juggle sizable financial demands. Dr. private funding and support as well. originally feel that the federal ban would Lafferty notes that an adult pancreas ob- Fetal tissue sourcing continues to impede diabetes research, but his own tained through an organ procurement depend exclusively on the National In- experience convinced him of the impor- agency can cost $25,000—a sum that stitutes of Health (N1H)- based fetal tis- tance of having greater access to fetal might consume the greater portion of an sue bank (which obtains tissue only from tissue: One of his projects involving islet entire research grant. (This was made spontaneous abortions and ectopic preg- transplantation had to be put on hold for particularly difficult by the dearth of pri- nancies), as authorized by former Presi- 6 mo because of a shortage of suitable vate funding that resulted from the fed- dent Bush in May 1992. However, the islets. Some of Dr. Lafferty's current work eral government's hands-off policy. Dr. establishing guidelines for the bank also focuses on controlling recurrent diabe- Lafferty comments candidly that,

668 DIABETES CARE, VOLUME 16, NUMBER 4, APRIL 1993 Issues and updates

"Whenever government gets involved in encourage private investment again, and science, it creates a problem.") In con- give a much-needed boost to an impor- trast, notes Dr. Lafferty, an amount of tant area of research and treatment. fetal tissue to do comparable research —SLR might be obtained for around $300. Time also has been a problem for fetal tissue researchers, as Dr. Lafferty noted in his own work. It can take Kelly West Award months to procure a suitable adult organ Recipient Calls through an agency, whereas the turn- around time on fetal tissue should be Attention to much quicker once details on logistics are worked out. Consequences of The debate over the use of fetal tissue for medical and scientific purposes Undiagnosed NIDDM began to take shape in 1988 when a request was made of the Department of Undiagnosed non-insulin-dependent di- Health and Human Services (DHHS) to abetes mellitus (NIDDM) is responsible approve research involving implanting for significant mortality and morbidity in Dr. Maureen Harris. human neural tissue in patients with Par- the U.S., and the problem, says Dr. Mau- kinson's disease. The request was denied reen Harris, recipient of the 1992 Kelly by then Assistant Secretary for Health West Award, lies principally in the lack Robert Windom, MD, who instead formed of sufficient screening. In her lecture Toward this end, Dr. Harris ad- a panel to discuss the ethical, legal, and (this issue, p. 642-52), Dr. Harris points vocates a change in the Clinical Practice scientific issues concerning fetal tissue re- out that the onset of NIDDM can occur Recommendations of the American Dia- search. Although that panel found no ob- up to 12 yr before it is diagnosed and betes Association for diabetes screening. jection to the use of fetal tissue for med- that the numbers of people affected are Currently, those recommendations list ical purposes, the discussion continued. staggering: "Among people >50 yr of age the fasting plasma glucose test as the But, another result of the panel's in the U.S. population, —10% have un- screening test of choice. Dr. Harris findings was the passing of a moratorium diagnosed diabetes. This is a very signif- would like to see that changed to the 2- h on the waiver of fetal research regula- icant proportion to have a disease that postchallenge glucose test. Although the tions. When the moratorium expired on conveys increased morbidity and mortal- reliability of the 2-h test might seem to 5 November 1990, a legislative battle be- ity, yet is totally untreated." make it the obvious choice, Dr. Harris gan. After more than a year of wrangling, Dr. Harris says the only way to says it meets with considerable resistance Congress passed legislation that over- begin to combat the massive public in the physician community—in fact, she turned the ban on funding fetal tissue health crisis posed is through more ef- says, most physicians are opposed to it research; however, in July 1992, Presi- fective and extensive screening pro- for general screening—although the rea- dent Bush vetoed the bill. He had already grams. She would like to see all doctors sons are not clear. authorized the fetal tissue bank in May and clinicians use 2-h postchallenge glu- But, Dr. Harris says, if the medi- 1992. cose assessments rather than the fasting cal community finds the test unaccept- Funding for the fetal tissue bank plasma glucose test because the 2-h val- able for general screening, then she feels was scheduled to expire in March 1993, ues are the most effective screen. The it must at least become essential for at which time President Clinton was to sensitivity of 2-h testing is 97%, its spec- screening individuals who fall into high- review its continuation. Dr. Dayton says ificity is 100%, and its positive predictive risk categories for developing diabetes the bank is not likely to continue as it is value is 100%, compared with only a (being overweight, family history of dia- currently structured—particularly since 31% sensitivity for fasting plasma glu- betes, being black or Hispanic). Dr. Har- legislation has not been enacted to allow cose testing. Dr. Harris suggests that the ris also would like to see high-risk indi- direct use of fetal tissue from induced merit of using 2-h postchallenge glucose viduals checked for impaired glucose abortions in research. For now, research- values as criteria for NIDDM would tolerance, but that, she acknowledges, is ers in many fields of medical and scien- quickly become apparent to clinicians as years away. tific study are excited that the federal they confirmed more (previously uni- The potential benefits to screen- funding ban has been lifted. This will dentified) cases. ing more extensively are clear. In her

DIABETES CARE, VOLUME 16, NUMBER 4, APRIL 1993 669 Issues and updates

lecture, Dr. Harris highlights studies chemistry from Yale University in 1968 alone, but these disturbances are thought showing that people diagnosed early in and an MPH in epidemiology from Johns to be dose related and can be minimized the progression of N1DDM are much eas- Hopkins University. She also serves as by having patients take the drug with ier to treat. Moreover, early diagnosis can director of the WHO Collaborating Cen- meals and by increasing dosage slowly. mean the difference between controlling ter for Diabetes Research, Training, and Metformin's manufacturer, Lipha the disease by diet and exercise and Education. Dr. Harris is a scientific re- Pharmaceuticals of New York (whose treating it with oral agents or even insu- viewer for several publications, including parent firm is Lipha of Lyon, France), is lin. In addition, when NIDDM is de- the American Journal of Public Health, the hoping the FDA will expedite the pro- tected early, individuals tend to have American Journal of Epidemiology, the cess: "It's been a long time since a diabe- fewer and less severe complications. Fi- American Journal of Metabolism, and Pub- tes drug has come up for approval," says nally, Dr. Harris notes that an earlier lic Health Reports. She has served as an Anita Goodman, MD, vice president of diagnosis catches the patient who still associate editor and as a member of the medical affairs at Lipha. Approval gener- may have a larger insulin secretory re- editorial board of Diabetes Care. ally takes an average of 22 mo after an serve—thus, his or her glycemia is not —SLR application is received, according to John yet totally out of control. Short in the FDA's endocrinology divi- The extent of undiagnosed sion. NIDDM and its consequences began to U.S. clinical studies of met- come to light in the late 1970s, around FDA Approval Sought formin, required by the FDA (and ar- the time when the National Diabetes ranged by Lipha), began in March 1988 Data Group and the World Health Orga- for Metformin as and involved 28 research centers. ADA nization (WHO) published diagnostic professional members Mayer B. David- criteria for NIDDM. Dr. Harris called the NIDDM Treatment in son, MD, and Anne L. Peters, MD, both publication of these criteria the genesis of Cedars-Sinai Medical Center in Los for research of the problems of undiag- the U.S. Angeles, were among the researchers in- nosed NIDDM—work that has come to volved in the randomized double-blind fruition in the past 5 years. One goal of This month, the manufacturer of met- placebo-controlled multicenter studies. her lecture, she says, was to centralize formin, a biguanide first introduced in These investigations were completed in available information on the subject. 1957 and currently used in other coun- May 1991, after which time study par- Dr. Harris says that acknowledg- tries to treat NIDDM, plans to submit to ticipants were invited to take part in an ment of the problem of undiagnosed the U.S. Food and Drug Administration open-label continuation study that NIDDM has been analogous to the revo- (FDA) a new drug application for its ended in December 1992. lution that occurred with undiagnosed approval (this issue; D.K. Nagi and Each research center used a com- hypertension. In people with undiag- J.S. Yudkin, p. 621-29; J.A. Colwell, mon protocol in conducting the study. nosed hypertension, as in those with un- p. 653-55). Patients received glyburide alone, met- diagnosed diabetes, the effects of the dis- The FDA's assessment of met- formin alone, or a combination of the ease were evident and clearly posed a formin will include consideration of at two. "The combination of glyburide and tremendous public health problem. Con- least two issues of concern regarding its metformin, but neither alone, signifi- sequently, efforts were made to deal with use. The first is that another biguanide, cantly improved diabetic control [of] it head on. This, she says, is the kind of phenformin, introduced at the same time fasting plasma glucose and glycosylated movement now taking place regarding as metformin, was withdrawn in many hemoglobin [in the patients we stud- undiagnosed NIDDM, and she hopes her countries, including the U.S., in the ied]," reported Dr. Davidson at the work has brought a course for the future 1970s because it became associated with ADA 40th Annual Advanced Postgradu- into better focus. an unacceptably high incidence of lactic ate Course, held this past January in San Currently serving as director of acidosis. Metformin, however, with its Francisco. Dr. Goodman says that the the National Institutes of Health (NIH) different molecular structure, biological results of all the studies were consistent National Diabetes Group, National Insti- characteristics, and metabolism, does not along those lines—with the two drugs tute of Diabetes Digestive and Kidney seem to carry the same risk, if prescribed showing the greatest glucose-lowering Diseases, Dr. Harris began her career at appropriately. Second, some clinical tri- effect when used in combination. Met- NIH as a research fellow in 1968. She is als have reported side effects, mainly gas- formin is indicated for use in NIDDM a 1964 graduate of George Washington trointestinal disturbances (diarrhea, ab- patients who have not responded to diet University, where she received her BS in dominal discomfort, nausea, and therapy or sulfonylurea therapy and who chemistry, and she earned a PhD in anorexia), when metformin was given do not or will not take insulin. (Those

670 DIABETES CARE, VOLUME 16, NUMBER 4, APRIL 1993 Issues and updates

who refuse insulin often have a psychol- pute has been ongoing, and in November intrastate commercial driving and insu- ogical aversion to giving themselves an 1992, the Federal Highway Administra- lin-treated diabetes." However, ADA has injection, note both Drs. Davidson and tion (FHWA) submitted proposed rules raised some concerns as well. Goodman.) In addition, because met- for granting waivers to insulin-using di- First, one of the qualifying con- formin often promotes weight loss in abetic drivers of CMVs to the American ditions states that to receive a waiver, an NIDDM patients, it may be more appro- Diabetes Association (ADA) and other insulin-using diabetic driver must have priate for obese rather than lean patients. organizations for comment. ADA has re- been operating a CMV for a 3-yr period The NIDDM patients studied by sponded generally favorably, but with immediately before applying. Thus, only Drs. Davidson and Peters were obese and some recommendations. individuals in states that already allow failing the maximal dosage of glyburide The debate over insulin-using di- people with insulin-dependent diabetes (20 mg/day). But, "when they continued abetic drivers obtaining CMV licenses in to operate CMVs would be eligible. It and added metformin," says Dr. Good- all states and therefore for interstate further means that even in those states, man, "they did very well." Dr. Davidson travel goes back some years. Petitions only those individuals who already have believes that metformin, alone or in com- from ADA and two individuals request- CMV licenses would be granted waivers. bination with a sulfonylurea, would be a ing prevention of blanket prohibition ADA suggests that these restrictions may successful therapy in patients who do against insulin-using diabetic individuals in fact be prohibitive and would there- not respond to sulfonylureas alone. operating CMVs were first sent to the fore alter important statistical data that If metformin gains approval for FHWA in 1986. Eventually, in October the FHWA hopes to assemble. Moreover, marketing in the U.S., NIDDM patients 1990, the FHWA published proposed re- ADA contends that 3 yr of non-CMV would have something else to try before visions that would allow people with in- driving experience is sufficient to be they are forced to take insulin. Currently, sulin-treated diabetes to obtain waivers granted a waiver. says Dr. Goodman, if these patients are to operate CMVs. Second, ADA recommends clari- not successful with glyburide (a sulfonyl- The revisions as proposed, how- fication of another condition that states urea), there is nothing else for them ex- ever, were generally considered unfavor- (that to be permitted a waiver) an indi- cept insulin. Dr. Davidson underscores able, which prompted the FHWA to con- vidual must have no suspensions or re- the point and adds that many patients in tract with the University of Pittsburgh to vocations of his or her driver's license for whom sulfonylureas are ineffective study the risks involved. The research any motor vehicle. ADA suggests that would much rather try metformin than team involved concluded that, indeed, this condition be revised to read that if take insulin. the risk of accident would be increased the suspension or revocation of the driv- In the meantime, Lipha Pharma- (at least 3.5 times higher than that ex- er's license was the result of poor diabe- ceuticals is looking for a U.S. marketing pected in the general CMV-driving pop- tes control, then there may be cause for partner, in the hopes that metformin will ulation), but it did not recommend blan- denial. ADA points out that not all driv- win FDA approval. ket restrictions against insulin-using ing violations committed by diabetic —KL1 drivers. drivers are diabetes related and therefore The FHWA proposal suggests a views the condition as discriminatory 3-yr waiver program that would allow under the Americans With Disabilities diabetic individuals to operate CMVs if Act. Proposed FHWA all waiver requirements are met. The Dr. Tom Songer, an ADA mem- Regulations for FHWA sees the waiver program as a tem- ber and recipient of an ADA Career porary solution to a serious problem that Development Award, and Dr. Ronald Insulin-Using ultimately will entail substantive changes A. LaPorte, associate editor of Diabetes in standing regulations. However, the Care and ADA member, were two of the Commercial Motor FHWA proposal would allow for the col- principal authors on the University of lection of additional data for study and Pittsburgh study. Both responded enthu- Vehicle Operators review. The waivers are set at 3 yr be- siastically to the proposed FHWA regula- cause the hope is that new rules will be tions, calling them a "first big step" in The passage of the Americans With Dis- in place at the end of that time. changing the existing blanket restrictions abilities Act in 1990 brought to the fore The proposed waiver rules have for people with diabetes who would like the issue of insulin-using diabetic indi- been submitted to and commented on by to operate CMVs. viduals being legally entitled to operate ADA President-elect Dr. James R. Gavin, At issue is an individual's right to commercial motor vehicles (CMVs) in all who called the proposal "... a respon- choose the line of work in which he states and for interstate travel. This dis- sible approach to the issue of inter- and engages, but in a broader sense, it is the

DIABETES CARE, VOLUME 16, NUMBER 4, APRIL 1993 671 Issues and updates

first crack in the door that can only open relation to glucose uptake and insulin to 10-fold in obese mice compared with wider for people with diabetes. Dr. La- resistance in diabetes. Their results sug- lean control mice, whereas the amount of Porte synthesizes the position by point- gest that obesity is directly correlated TNF-a mRNA expression in spleen tis- ing out that although there is "no ques- with elevated levels of TNF-a, which sue did not differ. tion . . . that there is an increased risk for may inhibit peripheral glucose uptake, Elevated levels of local TNF-a people with insulin-using diabetes- and inversely correlated with GLUT4, protein, which may inhibit glucose up- ... the challenge is to identify who is at the lack of which may contribute to in- take, and circulating TNF-a protein, greater risk instead of imposing blanket sulin resistance. which may lower glucose utilization, restrictions on all people with insulin- Gokhan S. Hotamisligil, MD, were found in obese, insulin-resistant using diabetes." who, along with Bruce M. Spiegelman, animals. Local TNF-a protein per unit of Work on this issue continues. PhD, and Narinder S. Shargill, PhD (an tissue DNA was secreted about twice as From November 1992 to January 1993, ADA professional member), conducted much from obese adipose tissue as lean the FHWA and the Department of Trans- the studies, says, "If our finding of ele- tissue. Circulating TNF-a protein was portation sponsored Zero-Base Motor vated TNF-a in obese, diabetic animals is detectable in 58.3% of obese db/db ani- Carrier Regulatory Review forums na- true for humans, and if our finding that mals compared with 25% of lean ani- tionwide to review existing and proposed TNF-a can be neutralized with TNF-a mals. regulations, clear up confusion, and receptor immunoglobulin G (TNFR IgG) These observations led the re- spark fresh ideas. ADA used the forum to in animals also is true for humans, then searchers to also investigate whether reiterate its recommendations. The reso- immediate application of these findings TNF-a could be neutralized and what lution of this particular issue, which con- would entail human clinical trials of the results would be. They found that cerns individual rights, has implications TNFR-IgG injections to block TNF-a ac- neutralization caused increased periph- for all people with disabilities. tivity. This could be a therapeutic for eral uptake of glucose in response to —SLR better blood glucose control in obesity- insulin in genetically obese, insulin- linked diabetes." resistant, diabetic animals. The research- In this study, TNF-a gene mRNA ers neutralized TNF-a with TNFR IgG in expression was induced in the adipose fa/fa rats. TNFR-IgG-treated animals ex- Tumor Necrosis tissue of genetic animal models of obesity hibited a 2- to 3-fold higher rate of in- and diabetes, but not in chemically in- sulin-stimulated glucose uptake, indicat- Factor—A Role in duced animal models of either obesity or ing an increased sensitivity to insulin. diabetes alone. The researchers exam- In addition, when they intro- Obesity and Diabetes? ined db/db mice, ob/ob mice, fa/fa rats, duced TNF-a into adipose tissue, it low- and tub/tub mice, all characterized by ered GLUT4 mRNA expression—a defi- Obesity has long been highly correlated varying degrees of obesity and insulin- cit of which has been associated with with the development of NIDDM. Now, resistant diabetes. They compared the obesity-linked insulin resistance. a study published in the January 1993 genetic animal models with a monoso- "Healthy people have a certain level of issue of Science suggests that tumor ne- dium glutamate (MSG) animal model of GLUT4," says Dr. Hotamisligil, "The crosis factor-a (TNF-a) may be one obesity (without diabetes) and a strepto- larger (more obese) you are, the less mechanism through which obese indi- zocin (STZ) animal model of diabetes GLUT4 you have. GLUT4 mRNA expres- viduals develop diabetes. The research (without obesity) and found no induce- sion is lower in fat tissue compared with team studied animal models, and sug- ment of TNF-a mRNA expression in the lean, and fat tissue produces TNF-a." gests that further investigations to con- adipose tissue of either the MSG-induced Therefore, he says, "production of firm their findings among humans could obese mice and rats or the STZ-induced TNF-a may be responsible for the down- eventually lead to a new treatment for diabetic rats. regulation of GLUT4 [which lessens glu- obesity-linked diabetes (one that might Elevated levels of TNF-a mRNA cose uptake]." involve inhibition of TNF-a). expression, which may lower glucose Dr. Hotamisligil stresses that Researchers at the Dana-Farber utilization, were found in the adipose TNF-a and GLUT4 studies now need to Cancer Institute in Boston, Massachu- tissue of obese, insulin-resistant animals. be done among humans. The research setts, who studied four animal models Researchers examined TNF-a gene ex- team noted that "obese animals and hu- with varying degrees of obesity and dia- pression in the adipose and spleen tissue mans (by definition) have an excessive betes, measured TNF-a and GLUT4 with of lean and obese db/db mice. The amount of adipose tissue that frequently regard to genetic expression, levels in amount of TNF-a mRNA per unit RNA includes an elevated number of fat cells." obese compared with lean animals, and in adipose tissue was elevated at least 5- This would tend to exacerbate the over-

672 DIABETES CARE, VOLUME 16, NUMBER 4, APRIL 1993 Issues and updates

production of TNF-a. But, if most obese About 100 young people attend From the newly elected regional people have elevated levels of TNF-a, the YLC each year, where they engage in youth chairs, the delegates also choose then why don't they all develop diabetes? a variety of seminars and discussions. one individual to serve as the ADA Na- In fact, "a very high percentage of obese One set of workshops, organized and tional Youth Spokesperson. Tradition- people do [develop diabetes]," says Dr. conducted by the youths, provides train- ally, the spokesperson addresses attend- Hotamisligil, "in fact, most obese people ing in organizing community activities ees at the ADA annual meeting in June do." He also points out that obesity in- for people with diabetes. Training might and serves as a member of the national volves multiple factors and most likely include instruction on producing a youth programs committee and the YLC plan- depends on more than one mechanism. newsletter or organizing a support ning committee. This year's committee is "Our research suggests that TNF-a is one group, implementing a fundraiser, plan- chaired by William Clarke, MD, a pedi- potential mechanism," he says, "but we ning a statewide youth conference, or atrician and endocrinologist with the don't know how much of obesity-linked creating a program for preschoolers. University of Virginia, and includes four diabetes is dependent on TNF-a, and we Workshops led by groups of medical other medical professionals in addition don't know what kind of molecular professionals, including physicians, to the YLC representatives. events lead from obesity to diabetes." nurses, dieticians, social workers, and For more information on the The researchers also hope to see psychologists, cover issues such as dia- ADA Youth Leadership Congress, con- other teams investigate "the possible in- betes complications, insulin pump ther- tact Gwen Birmingham, ADA commu- volvement of TNF-a in other aspects of apy, diet, exercise, relationships, preg- nity programs department, ADA Na- obesity . . . and in the development of nancy, stress, and public speaking. tional Center, Tel: (703) 549-1500, ext. frank diabetes." During the conference, youths 303. —KLl also have an opportunity to visit with —Kll federal legislators from their state to dis- cuss diabetes-related issues. Informal ADA Youth sessions on diabetes management, as well as leisure activities—including tours The following were Leadership Congress of Washington, DC—are all part of the event. elected to the to Convene for 10th The YLC has been funded for 10 consecutive years by The Nutrasweet Professional Section as Straight Year Company. The grant covers expenses for two new youth delegates from each ADA of February 1993: "To provide young people with a vision affiliate to attend. Delegates must be of what ADA stands for and to encourage 16-21 yr of age, can be diabetic or non- them to want to be involved with ADA. diabetic, and must be involved with or To meet with people from across the willing to become involved with ADA. VISITING NURSING ASSOCIATE, BIRMINGHAM, AL country, form friendships, and know Sean Buckley says his first involvement CARMEN ADRIANA ALVAREZ, MD, that [we] are not the only ones with with ADA came when he attended one of EGGERTSVILLE, NY diabetes." These things, says Sean Buck- its camps for children with diabetes. At SHANNON AMUNDSEN, SEBASTOPOL, CA ley, youth chair of the 1993 American 16, he attended the 1986 congress as a LEILA MARIA B. ARAVDO, PHD, Diabetes Association (ADA) Youth Lead- new delegate. Delegates are chosen SALVADOR, BAHIA, BRAZIL DOUGLAS A. BALLAINE, RANCHO ership Congress (YLC), are the principal through selection processes within each CUCAMONGA, CA objectives of the annual gathering. affiliate, which usually involve an appli- LARRY J. BESKI, DENVER, CO Buckley, along with youth co- cation and interview. DAN T. BOWUN, LEE'S SUMMIT, MO chair and friend Joby Jobson, will help While at the congress, youth del- MARY BREEN, RN, SALEM, NH run the 1993 congress, which is being CATERINA CANALE, MS, RD, FLUSHING, egates elect five peers to serve as national NY held April 16-19 at the Key Bridge Mar- regional youth chairs. These chairper- DEBORAH CHRISTIAN, RAHWAY, NJ riott in Arlington, Virginia. This year sons help plan and implement the next VINCENT B. CIBELLA, DPM, GENEVA, OH marks the event's 10th anniversary and congress and work with ADA's volunteer MICHAEL CONNOR, DPM, WILTON, CT will feature as one of its speakers Mike regional teams to increase youth involve- LYNN C. COPPOLO, RN, COOPERSTOWN, NY Moore, a former ADA National Youth ment in ADA activities and fundraisers. JOHN A. CORBETT, PHD, ST. LOUIS, MO Spokesperson, who has attended several Regional teams consist of three adults for KATHLEEN E. CURTIS, NEW BERLIN, WI of the congresses. each of five regions in the country. LINDA DAVENPORT, LAKELAND, FL

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NIELS DE FINE OUVARIUS, MD, FRANK E. SALAFIA, MD, LAWRENCE, MA Topics include: New approaches to COPENHAGEN, DENMARK JAMES E. SHIELDS, PHD, INDIANAPOLIS, NIDDM, discussions of pathogenesis, JEFFREY DESANTIS, DPM, SANTA ANA, IN treatment with oral agents, and new ther- CA KATHLEEN SICILIANO, RN, FREEHOLD, NJ apies. DIANE D. DEUTSCH, BEVERLY HILLS, MI LABROS S. SIDOSSIS, GALVESTON, TX THOMAS A. DEUTSCH, MD, CHICAGO, IL BUM SOON P. SUJARIT, HIGH POINT, NC Fee: $45.00 for members of the Clinical SUSAN DIEKRAGER, MINNEAPOLIS, MN SUMIKO TAKAYAMA-HASUMI, MD, TOKYO, Society and $65.00 for nonmembers. MANNINO DOMENICO, MD, REGGIO JAPAN Contact: Helen Levine, 149 Madison Av- CALABRIA, ITALY JAIME E. VILLENA, LIMA, PERU enue, New York, NY 10016. Tel: 212- BONNIE S. DUTCHER, HOFFMAN ESTATES, WENDY R. VISHNY, MD, WILMETTE, IL 725-4925; Fax: 212-725-8916. IL HARRY L. WADSWORTH, MD, ST. LOUIS, DAVID A. EHRMANN, MD, CHICAGO, IL MO ANNA ENGLUND, MD, BEKELEY, CA NANCY WEIS, RD, CLINTON TWP, MI 2nd International Conference on Dia- PETER FASCHING, MD, VIENNA, AUSTRIA LAURA WHEELER, MPH, HAWTHORNE, betes and Native People JAMIE M. FLEGEL, GALVESTON, TX CA 19-21 May 1993 VITO N. GIARDINA, MD, BALTIMORE, MD PETER A. WIDEN, COLUMBIA, MO Honolulu, HI JORGE LUIS GROSS, MD, PHD, PORTO DEBORAH L. WINGARD, PHD, LAJOLLA, Sponsorship: Joint U.S.-Canada confer- ALGRE, RS, BRAZIL CA RICCARDO GUARISCO, MD, ROMA, ITALY Jo LYNN WOODRUFF, RN, VANCOUVER, ence cosponsored by the Hawaii Affiliate. ROBERT W. GUYTINE, MD, MIAMI, FL WA Topics include: Common problems in DONNA J. HASKINS, PORT ANGELES, WA KATSUYUKI YANAGISAWA, MD, SAPPORO, establishing effective programs and pro- KATHY HELMINK, RN, GOTHENBURG, NE HOKKAIDO, JAPAN viding care to Native American people; WILLIAM A. HINSON, MD, PENSACOLA, MOTOTAKA YOSHINARI, MD, FUKUOKA development and implementation of FL CITY, JAPAN SUE HIRSCH, POINT PLEASANT, NJ cross-cultural programs, focusing on WILLIAM S. HUGHES, DO, JOPLIN, MO what works, why it is successful, and GEORGA A. HUMPHREYS, RD, GREEN BAY, how to implement it in other communi- WI ties. MARY E. JUDE, MPH, BANGOR, ME ADA Events Contact: In mainland U.S., Dr. Robert JOSEPH KATZ, LOS ANGELES, CA JILL KEOUGH, MINNEAPOLIS, MN Young, NARTC, 1642 E. Helen Street, LISA LAMBERT, RN, CDE, EL SEGUNDO, 53rd Annual Meeting: 12-15 June Tucson, AZ 85719. Tel: 602-621-5560. CA 1993, Las Vegas Convention Center, In Hawaii, Waianae Coast Comprehen- DIDAC C. MAURICIO, MD, PHD, Las Vegas, NV. sive Health Center, 86-260 Farrington BARCELONA, SPAIN 12th International Diabetes Immunol- Highway, Waianae, HI 96792-3199. SCOTT C. MCCOID, IVORYTON, CT DENISE MCGOWAN, MD, NEW HYDE ogy Workshop: 15-17 April 1993, Tel: 808-696-7081. In Canada, Alethea PARK, NY Orlando Marriott, Orlando, FL. Kewayosh, Assembly of First Nations— EDNA G. MELENDEZ, MD, GUAYNABO, PR Consensus Development Conference: Diabetes Conference, 47 Clarence Street, CATHY MELVIN, BSN, CDE, EL CAJON, Treatment of Hypertension in Diabe- 3rd Floor, Atrium Building, Ottawa, On- CA tes: 25-27 May 1993, Orlando, FL tario KIN 9K1, Canada. Tel: 613-236- RHODA MURDY, WILUSTON, ND KOJU NAKANISHI, MD, TOKYO, JAPAN Prevention of Diabetes and Its Compli- 0673. PATRICA NELSON, RN, EL CAJON, CA cations: 5 November 1993, Sheraton LEO NISKANEN, MD, PHD, KUOPIO, Inn, Minot, ND. FINLAND EDWARD A. O'BRIEN, DPM, PRINCE Contact: Linda Cann, ADA, 1660 Duke FREDERICK, MD Other Events MARY OKSMAN, RD, EDEN, NY Street, Alexandria, VA 22314. Tel: 703- PATRICIA OSTANDER, MD, SACRAMENTO, 549-1500, x281 or x212. CA 5th International Symposium on Re- CRYSTAL PALMER, MED, MATTAPAN, MA Harold Rifkin Open Meeting: ceptor and Insulin Action MONGUILLON PASCAL, MD, BREST, New Approaches to NIDDM 4-7 May 1993 FRANCE PATRICIA T. PRESCOTT, MD, ELK GROVE, 17 April 1993 Munich, Germany CA New York, NY Topics include: Insulin-receptor func- SANDRA PUCZYNSKI, RN, MS, CDE, Location: The New York University tional domains, receptor cross talk and PITTSBURGH, PA Medical School. modulation, post-receptor signaling, MARIANNE RANIOL, MD, CUYAHOGA Sponsorship: The Clinical Society of the phosphatases in insulin action, insulin FALLS, OH COLLEEN ROETHKE, RN, MINNEAPOLIS, New York Downstate Affiliate of the and gene transcription, glucose trans- MN American Diabetes Association. port, insulin action in NIDDM and pre-

674 DIABETES CARE, VOLUME 16, NUMBER 4, APRIL 1993 Issues and updates

diabetes, insulin analogues, and new 2nd International Conference on 5th Postgraduate Course of Endocri- therapeutic approaches. Youth and Disability nology and 2nd International Sympo- Contact: Priv. Doz. Dr. H. Haring, lnsti- 20-24 June 1993 sium on Hypertension tut Fur Diabetesforschung, Kolner Platz Jerusalem, Israel 24-26 June 1993 1, D-8000 Munchen 40, Germany. Sponsors: Israel Society for Adolescent Granja, Portugal Health and the Israel Rehabilition Soci- Location: Hotel Solverde Effective Patient Teaching ety; Rehabilitation International, Interna- Deadline: 31 March 1993 for all lecture 2-4 June 1993 tional Association for Persons with Se- and communication submissions. Contact: Dr. lgnacio Salcedo, Servicio de Nashville, TN vere Handicaps, and the European Endocrinologia, Symposium 93, Hospi- Topics include: Patient teaching and ad- Society of Social Pediatrics in coopera- tion with the Disability Unit, United Na- tal Geral de Santo Antonio, 4000 Porto, herence promotion skills. tions Center, Vienna, Austria Portugal. Tel: 200-25-41/20073 54, Fee: $300.00. Self-study format $170.00 Topics include: Special problems of ad- X3091-2-3; Fax: 02-032-03-18. per 15 h course or $75.00 per 5-6 h olescents with physial, sensory, metal, or package. emotional disability; coping with chronic 4th International Congress on Pan- Contact: Elaine J. Boswell, Vanderbilt illness in adolescence; role of special ed- creas and Islet Transplantation Diabetes Research and Training Center, ucation; preparation for work, vocational 27-30 June 1993 315 Medical Arts Building, 1211 21st training, and rehabilitation; independent Amsterdam, The Netherlands Avenue South, Nashville, TN 37232- living and social integration; family dy- Topics include: Pancreas and islet trans- 2230. namics; community programs; the plantation, current developments in the chronically ill young persons; sports and early diagnosis of diabetes, and future 2nd Toronto Workshop on Computers recreation; and involvement of youth in approaches in prevention and treatment. and Computer Programs in Diabetes voluntary work with disabled persons. Contact: Tineke S. Roorda, Scientific Care Deadline: 1 March 1993 for submission Secretariat ICPIT 93, Department of Sur- 9-10 June 1993 of abstracts. gery, University Hospital Groningen, Toronto, Canada Contact: Orta Ltd, 2 Kaufman Street, P.O. Box 30-001, 9799 RB Groningen, Topics include: Computer software and P.O. Box 50432, Tel Aviv 61500, Israel. The Netherlands. Tel: 31-50-612301; telecommunications hardware with dia- Tel: 972-3-664825; Fax: 972-3- Fax: 31-50-614873. betes applications, care enhancement 660952. through remote (i.e., network) comput- 1st International Congress of the In- er-assisted patient management, insulin 2nd European Forum on Adolescent ternational Society for the Study of or tablet decision-making, computer col- Health Fatty Acids and lipids: Fatty Acids lected and/or interpreted self-blood glu- 20-24 June 1993 and Lipids from Cell Biology to Hu- cosemonitored data, computer-assisted Jerusalem, Israel man Disease patient education and counseling, mi- Sponsors: Israel Society for Adolescent 30 June 1993 - 3 July 1993 croprocessors for automating aspects of Health and the Israel Rehabilitation So- Lugano, Switzerland clinic management, automated data cap- ciety; Rehabilitation International; Inter- Sponsorship: Univerity of Milan, Italy ture in research protocols, and the im- national Association for Persons with Se- and the Fondazionne Giovanni Lorenzini vere Handicaps, and the European Medical Science Foundation. pact of information systems on psycho- Society of Social Pediatrics; Disability social issues, conventional clinical Unit, United Nations Center, Vienna, 11th International Symposium on Di- practice, income, professional medico- Austria. abetes and Nutrition legal liabilities, cost-containment poten- Topics include: Growth and develop- 1-3 July 1993 tial, and universal diabetes care stan- ment in adolescence, sexual health of Stirling, near Glasgow, United King- dardization. adolescents in Europe, eating disorders, dom Conditions: Contributed abstracts are and substance abuse. Deadline: 1 April 1993 for submission invited. Registration will be limited. Deadline: 1 March 1993 for submission of abstracts. Contact: Professor A.M. Albisser, Secre- of abstracts. Sponsorship: Diabetes and Nutrition tariat, c/o Diabetes Program, 52 Wen- Contact: Orta Ltd., 2 Kaufman Street, Study Group of the European Associa- dover Road, Toronto, Ontario, M8X 2L3 P.O. Box 50432, Tel Aviv 61500, Israel. tion for the Study of Diabetes. Canada. Tel: 416-231-2195; Fax: 416- Tel: 972-3-664285; Fax: 972-3- Topics include: Environmental factors 239-9702. 660952. and diabetes (nitrosamines, etc.), volatile

DIABETES CARE, VOLUME 16, NUMBER 4, APRIL 1993 675 Issues and updates

short-chain fatty acids, epidemiology Vaillant Couturier, 94807 Villejuif Ce- Contact: S. Ohsata, Kobe Convention and nutritional surveys, and implement- dex, France. Tel: 33-1-45-59-51-61; Center, 6-9-1, Manatojima-nakamachi, ing the dietary guidelines. Fax: 33-1-47-26-94-54. Chuo-Ku, Kobe 650, Japan. Tel: 078- Contact: Dr. Michael EJ. Lean, Royal 303-0055; Fax: 078-302-7303. Infirmary, Queen Elizabeth Building, Al- 12 th Danube Symposium on Diabetes exandria Parade, GB-Glasgow G12 2ER, Mellitus International Genetic Collaborative United Kingdom. Fax: 41-304-4844. 7-10 October 1993 Study Or Dr. B. Karamanos, Secretary of the Krakow, Poland The Institut de Morphologie Pathol- DNSG, Diabetes Center, Vas.Sofias 114, Deadline: 1 April 1993 for registration ogique Loveral, Center for Human Athens 115 27, Greece. Tel: 01-777- and abstracts. Genetics 5605; Fax: 01-770-6871. Topics include: Long-term diabetes Loveral, Belgium complication, insulin therapy, diabetes Conditions: Clinicians with patients 19th Annual Meeting of the Interna- mellitus in children, and gestational dia- who have total lipodystrophy Qipotro- tional Study Group of Diabetes in betes mellitus. phic diabetes, Berardinelli-Seip syn- Children and Adolescents Contact: Associate Professor Jacek drome) can enter an international genetic 2-6 September 1993 Sieradzki, Department of Endocrinology, collaborative study aimed at localizing On board the cruise ship Neptune in Medical Academy in Krakow, 31-501 the gene responsible for the disease. Par- the Aegean Sea Krakow, Kopernika 17, Poland. Tel: 48- ticipation consists of providing a single Contact: Dr. C. Bartsocas, Department 12-21-01-44; Fax: 48-12-21-40- blood sampling of affected patients, un- of Pediatrics, P & A Kyriakou Children's 54. affected siblings, and their parents. Hospital, GR-11527 Athens, Greece. Contact: Dr. Lionel Van Maldergem, Fax: 30-1-7796461. American Board of Internal Medicine Center for Human Genetics, IMPL, Allee Examinations des Templiers 41, 6280 Loveral, Bel- 29th Annual Meeting of the European 3 November 1993 gium. Tel: 32-71-471520; Fax: 32-71- Association for the Study of Diabetes Deadline: 1 January 1993 through 1 471520. 6-9 September 1993 April 1993 for registration. Istanbul, Turkey Contact: Registration Section, American Contact: Serpil Bagriacik, Osmanli Sok Board of Internal Medicine, 3624 Market 23, 80090 Taksim-lstanbul, Turkey. Tel: Street, Philadelphia, PA 19104. Tel: ADA Research Awards 90-1-245-04-15; Fax: 90-1-251-75- 1-800-441-2246; Fax: 1-215-243-1500. 60. ADA Career Development 7th International Congress on Obesity Award: Up to $75,000/yr for 3 yr to International Diabetes Epidemiology 20-25 August 1994 support new researchers with 2 - 5 yr of Group Meeting Toronto, Ontario, Canada postdoctoral/postfellowship research ex- 22-23 September 1993 Location: Westin Harbour Castle Hotel perience. Funds divided between salary Noumea, New Caledonia Participants may receive AM A Category and other grant support. Deadline: 1 May 1993 for submission of I study credits. Deadline: 2 August 1993 for 1 January abstracts. Contact: Continuing Education, Faculty 1994 funding. Sponsorship: Cosponsored by the Inter- of Medicine, University of Toronto, Med- Conditions: Applicants must be U.S. cit- national Diabetes Epidemiology Associa- ical Sciences Building, Toronto, Ontario, izens or have permanent resident status tion M5S 1A8 Canada. Tel: 416-978-2718; and hold full-time positions at U.S. uni- Topics include: Diabetes in the tropics; Fax: 416-978-7144. versity-affiliated institutes. IDDM, NIDDM, and malnutrition related ADA Research diabetes; diabetic pregnancy and fetal 15 th International Diabetes Federa- Award: Between $20,000 and $40,000/yr development; sex hormones and glyco- tion Congress for 2 yr to assist researchers, new or regulation; the insulin resistance syn- 6-11 November 1994 established, who have a novel, exciting drome; prevention of IDDM and NIDDM Kobe, Japan idea for which they need support. and their complications: feasibility, Location: Convention Center Deadline: 2 August 1993 for 1 January methods, and program evaluation. Topics include: Prevention of diabetes 1994 funding. Contact: Dr. B. Baulkau, Secretary and clarification of goals to reach by the Conditions: Applicants must be U.S. cit- IDEG, INSERM unit 21, 16 Ave. Paul year 2000. izens or have permanent resident status

676 DIABETES CARE, VOLUME 16, NUMBER 4, APRIL 1993 Issues and updates

and hold full-time faculty positions at samples does not qualify unless there has Deadline: 8 October 1993 for 1 July U.S. university-affiliated institutions. been a major in vivo intervention, and 1994 funding. Clinical Research Grant Program the protocol is designed specifically to Conditions: The investigator must be a Award: Up to $75,000/yr for 3 yr for quantitate the effect of the manipulation. U.S. citizen or have permanent residence studies that involve humans. Applicants must be U.S. citizens or have status and hold an appointment at a U.S. Deadline: 1 February 1993 for 1 July permanent resident status and hold full- research institution. The fellow must 1993 funding. time faculty positions at U.S. university- Conditions: Studies must focus on in- affiliated institutions. have an MD or a PhD and no more than tact human subjects in which the effect of Mentor-Based Postdoctoral Fellow- 3 yr of postdoctoral research experience. a change in the individual's external or ship Program Award: $30,000/yr for Contact: American Diabetes Association, internal environment is evaluated. In 3/yr for a postdoctoral fellow working 1660 Duke Street, Alexandria, Va 22314. vitro research on human blood or tissue with an established diabetes investigator. Tel: 703-549-1500, x362.

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