Homeopathic Treatment for Diabetes

Reverse Diabetes Now

The creator of this program is Matt Traverso who has proven himself to be one of the best health specialists and fitness experts in the world. He is the man who knows how to use the best of natural ingredients to improve chronic diseases like diabetes. The easy to implement concepts and techniques taught in the Reverse Your Diabetes Today system use simple, but highly effective diet and lifestyle changes to cleanse your body from harmful acids and heal your pancreas, allowing it to produce and regulate insulin naturally again. Reverse Diabetes Today PDF is an extremely comprehensive treatment that encourages people to make positive changes in daily habits, more concretely, dieting, regularly exercising, and weight managing routines to reverse diabetics. Read more...

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Delivery of eye care for patients with diabetes

Patients should know that they have diabetes mellitus and that the condition requires care. General population screening for diabetes mellitus with existing methods is considered neither appropriate nor beneficial, although use of such methods to reach subpopulations with a very high prevalence of diabetes mellitus might be both appropriate and feasible for some Member States. Patients should receive adequate care for diabetes mellitus. The only means of preventing diabetic retinopathy is regulating blood sugar, blood pressure and other risk factors that can be controlled by patients, under the guidance of their care provider. Often, however, physicians do not care for diabetes patients in the manner indicated by the results of randomized controlled trials. Patients should undergo periodic eye examinations. Professional organizations advocate annual eye examinations for patients with diabetes and prompt treatment when indicated. Nevertheless, many patients with diabetes are not...

How People with Type Diabetes Successfully Manage Their Diabetes

The tricks to successfully managing type 1 diabetes and maintaining the near-normal blood-glucose levels necessary to stay 48, healthy are paying attention to your daily schedule, understand ing the effects of your lifestyle on blood sugars, and adjusting your insulin to maintain blood-sugar levels in the range you and your health-care team agree is right for you. Maintaining some consistency in mealtimes and meal sizes will help during the early stages of adjustment however, as time goes on you will learn how to adjust even if you have inconsistencies. For example, if you planned to eat a large Sunday breakfast of cereal, eggs, toast, and orange juice, you would check your blood sugar before starting to eat. If you found that your blood-sugar level was on the high side let's say 150 mg dL you would consider giving ten units of rapid-acting insulin, approximately four units more than the usual dose, because of your relatively high blood-sugar level and the greater carbohydrate content...

Chapter Five The Future of Diabetes

Quoted in University of Maryland Medical Center, University of Maryland Medical Center Performs Its First Islet Cell Transplant to Treat Type 1 Diabetes, May 16, 2002. www 40. Quoted in Erin Allday, 13,000 in S.F. to Discuss Diabetes Treatments, San Francisco Chronicle, June 6, 2008. www.sfgate.com cgi-bin article. cgi f c a 2008 06 06 MN9M113ARQ. DTL& tsp 1. diabetic ketoacidosis A dangerous medical condition in which ketones build up in the blood, which happens when the body is severely low in insulin. This occurs most often in people with type 1 diabetes. gland A bodily organ that produces chemical substances for use in the body. One example is the pancreas, which produces insulin. American Association of Diabetes Educators (AADE) Web site www.diabeteseducator.org or www.aadenet.org AADE is a multidisciplinary organization of more than ten thousand health professionals dedicated to advocating quality diabetes education and care. American Diabetes Organization 1701 N....

Exercising with Diabetes

In general, the best time to exercise is when glucose peaks, about sixty to ninety minutes after eating. This timing provides enough energy, allows calories to be burned, and avoids high blood sugar after eating. Also important is to learn how to determine the right insulin dosages before, during, and after exercise. Why Too much insulin before a workout can lead to too-low blood sugar, or hypoglycemia, while not enough insulin can cause too-high blood sugar, or hyperglycemia. Stress and heat can affect the blood glucose insulin balance, so these factors must also be taken into account. A good idea is to have some carbohydrates available during exercise in case blood sugar needs to be raised quickly. Eating carbohydrates helps to prevent hypoglycemia. And exercising with a partner who knows what to do in case of a diabetic emergency can add a safety factor as well as make exercise more fun.

Drug Therapy for Advanced Diabetics

Some people, however, will not have the benefit of this knowledge before their type-2 diabetes advances to a more dangerous stage. In severe hyperglycemia, the pancreas becomes burned out after producing high levels of insulin for a long time. Insulin levels drop as a result of decreased production, and blood glucose levels are allowed to rise to very high, toxic levels. Although diet and exercise, along with supplementation, are still strongly recommended, a number of prescription drugs might also be necessary. Sulfonylurea drugs stimulate pancreatic secretion of insulin. Unfortunately, they are often prescribed as first-line treatment for mild to moderate type-2 diabetics, even when their use is inappropriate. By increasing levels of insulin, which are already raised, sulfonylurea drugs actually hasten the progression of early type-2 diabetes by exhausting insulin receptors faster, which causes the pancreas to burn out more quickly. Sulfonylurea drugs should really be considered a...

Risk factors for diabetes

The increase in prevalence of type 2 diabetes is paralleled by the rising rate of obesity and metabolic syndrome. As body mass index (BMI) increases, the risk of developing type 2 diabetes increases correspondingly. The prevalence of type 2 diabetes is three to seven times higher in obese patients and is 20 times higher in those with a BMI greater 35 kg m2 than in those with a BMI between 18.5 and 24.9 kg m2 7-8 . This increased prevalence, however, may vary among ethnic groups. Obesity is a component of metabolic syndrome. The National Cholesterol Education Program Adult Treatment Panel (NECP-ATP III) defines metabolic syndrome using the objective clinical criteria given in Table 1 9 . Metabolic syndrome is defined as the presence of any three of the risk factors. The clustering of risk factors associated with this syndrome predicts development of manifest diabetes and cardiovascular disease. Hence, prevention of type 2 diabetes should aim to treat and prevent components of Fasting...

Type Diabetes The Twentieth and Twenty FirstCentury Epidemic

For years, type 2 diabetes was called adult-onset diabetes because it usually begins later in life. In recent years, however, as more children have become heavier at earlier ages, type 2 diabetes has increasingly been seen in teenagers and young adults. Of all peo- ple with diabetes, more than 90 percent have type 2 diabetes. Unlike type 1 diabetes, the development of type 2 diabetes is strongly influenced by lifestyle. There are two underlying causes of type 2 diabetes. One is the development of insulin resistance. This condition causes the tissues of the body to become less sensitive to the effects of insulin. As a result, sugar circulating in the blood does not leave the blood and enter the body's cells as easily. For the blood sugar to be lowered effectively and for the other jobs of insulin to be carried out, more insulin is required. The second cause of type 2 diabetes is the inability to increase insulin to cope with increased demand. Insulin resistance, decreased insulin...

Diabetes Complications

People with diabetes are vulnerable to a variety of complications over time. Health-care providers all agree that strict control of blood sugar makes complications less likely. This was shown clearly by the Diabetes Control and Complications Trial. Control of blood sugar is the best way to minimize the risk of complications. Even the very best control may not be able to eliminate all complications, and the risk of increases with the length of time you have diabetes. Diabetes complications affect the eyes, kidneys, nerves, and large and small blood vessels. Here is a list.

Principles In Eye Care For Patients With Diabetes

Diabetic retinopathy remains the leading cause of new-onset blindness in populations of working age, even in the United States (21) and other industralized countres. Despite clearly defined clinical standards for evaluating and treating diabetic retinopathy cost-effectively, for a variety of reasons (see below), effective treatments such as laser surgery are underused. It has been estimated that 50 of adults with diabetes mellitus in the United States do not receive the recommended annual eye care that would allow diagnosis and treatment of diabetic retinopathy (38-41). Studies have also shown that many persons who require sight-preserving laser surgery do not receive it (42,43). It has been reported that about 26 of patients with type 1 and 36 of those with type 2 diabetes mellitus have never had their eyes examined (44). These patients tend to be older, less educated and to have had a more recent diagnosis than those receiving regular eye care. They are also likely to live in rural...

Good News About Diabetes

Fortunately, modern medicine has brought hope to many diabetics, or people with diabetes. Unlike in centuries past, the cause of diabetes is now well known, and many medicines and other treatments can help diabetics control their illness. Some diabetics must take insulin several times a day, but others do not. Diabetics must be careful with their nutrition and watch their weight, monitor their blood sugar frequently, and stay active, but they can often live energetic, productive lives as well. Two people who have lived a very long time after being diagnosed with diabetes in childhood are Robert and Gerald Cleveland, brothers who live in Syracuse, New York. They developed diabetes shortly after the discovery of insulin in 1921, and more than seven decades later, neither one of them has developed any serious complications. Another remarkable diabetes success story is Gladys Dull. She has been taking insulin since 1924, just a few months before she turned seven. Gladys is believed to be...

Monitoring Blood Sugar

Successfully treating diabetes requires different strategies for the various types, and people with the illness must do what is best for them within those strategies. But two things are crucial monitoring blood glucose levels and, in many cases, using insulin and perhaps other drugs. Even diabetics who are able to carefully control their glucose can experience a wide range in levels, depending on many variables such as what they have eaten, their activity and stress level, illness, and the amount of sleep they get. Therefore, all people with diabetes must check their blood sugar several times a day and monitor its levels closely. First of all, people who can keep their blood glucose levels at ideal levels will feel A check of blood sugar levels must be done several times a day. The number of times is determined by the type of diabetes, the kind of treatment used, and how stable the person's glucose levels usually are. People with type 1 or 2 who are taking insulin need to test before...

With which antidiabetic medicines can metformin be combined

Metformin can be combined with all the other antidiabetic medicines (insulin-secretagogues sulfonylureas or meglitinides), a-glucosidase inhibitors (acarbose), thiazolidinediones (rosiglitazone or pioglitazone) and with insulin. The combination of metformin with sulfonylureas decreases the blood sugar more than each medicine separately. The coadministration of metformin with other antidiabetic medicines can cause hypoglycaemia. If there is sufficient pancreatic b-cell function, the hypoglycaemic action of metformin further augments the corresponding action of the other antidiabetic substances, as well as that of insulin. The regular monitoring of blood sugar levels is more imperative in patients receiving a combination of metformin with other antidiabetic substances.

How often should Type diabetics measure their blood glucose levels with a portable meter

Patients with Type 2 DM do not have the high variability of blood glucose values that Type 1 patients have. Consequently, as already mentioned, much fewer measurements are needed to evaluate blood sugar control. When SMBG is recommended by the treating physician, the precise frequency and timing of the measurements is individualized, depending on the type of therapy, drug doses, achievement or not of glycaemic targets and training of the patients. In those using insulin, SMBG should be daily. In the not so frequent case that the patient uses an intensive insulin regimen, measurements should follow the same pattern as in Type 1 DM. Regardless of the frequency of measurements, determination of some post-prandial values (two hours after a meal) is considered essential, especially in cases where fasting blood sugar values are not compatible with HbAlc values.

How failing kidney function affects diabetes management

To achieve good blood sugar control in the presence of failing kidney function is a difficult task for patient and doctor. There are various reasons for this. In some people with diabetes the insulin sensitivity changes, for reasons that are often unclear the tissues no longer respond as well to insulin. This can lead to a worsening of the diabetes. Insulin - whether made by the body or injected as a drug - is partly broken down in the kidneys. When the kidneys are not functioning properly, less insulin is metabolized, so that the effect of the insulin is prolonged. This partially compensates for the reduced insulin sensitivity mentioned above, but can also result in hypoglycaemia -dangerously low blood sugar. Someone who has advanced nephropathy often also suffers from other complications of diabetes. These may include damage to the nerves that regulate the gastrointestinal tract. Then food is no longer digested and absorbed properly. Typical signs are bloating, feeling full,...

What is the most important study available as regards the prevention of complications of DM in Type diabetics

This is the United Kingdom Prospective Diabetes Study (UKPDS) from 1998. This study concerned the roughly decennial follow-up of individuals diagnosed with Type 2 DM. A comparison was performed between conventional (with diet only) and intensive treatment of DM with pills (glibenclamide (glyburide), chlorpropamide, glipizide, metformin and acarbose) and or insulin, with regard to the prevention of chronic diabetic complications (HbAlc lower by 0.9 percent in the intensive treatment group). Only information received by patients who were treated with glibenclamide, chlorpropamide and metformin were statistically significant enough to allow conclusions to be reached regarding blood sugar control. Diabetes in Clinical Practice Questions and Answers from Case Studies. Nicholas Katsilambros et al. 2006 John Wiley & Sons, Ltd. ISBN 0-470-03522-6 This study showed that the intensive treatment of DM with glibencla-mide, chlorpropamide, metformin or insulin can considerably decrease the...

What are the indications for the use of an insulin pump

According to the American Diabetes Association (ADA), the indications are as follows The following indications for application of a continuous insulin infusion pump have been established 1. Type 1 diabetics, in whom every effort to achieve satisfactory diabetic control with an intensified insulin therapy regimen fails (unsatisfactory HbAlc level, intense fluctuations of blood glucose levels during a 24-hour period, intense 'dawn phenomenon'). 2. Type 1 diabetics who manifest frequent and or severe hypoglycemias, especially in the night. 3. Type 1 diabetics who have developed decreased perception of hypoglycaemia (hypoglycaemia unawareness). 4. Type 1 diabetics who manifest high sensitivity to insulin and need a small total daily dose of insulin. 5. Type 1 diabetics who lead an erratic way of life, who have a circular work schedule, who are submitted to intense physical or mental lassitude at work, who for professional or personal reasons are not in a position to receive their main and...

Type and Type Diabetes

The two main forms of diabetes are called type 1 and type 2 diabetes. Although they have different causes and, to a great extent, affect different categories of people, they share three main features. First, type 1 and type 2 diabetes are both characterized by metabolic abnormalities that include high levels of blood sugar in the circulation, as well as increased levels of other nutrient breakdown products that are released from their storage sites. See Table 1.1. Second, decreased insulin secretion or a decreased sensitivity to insulin action is the reason for these metabolic abnormalities. In the case of type 1 diabetes, the body makes no or very little insulin because the insulin-secreting islets have been harmed or destroyed. In type 2 diabetes, the body cannot meet the increased insulin demands brought on by a condition called insulin resistance. table i.i How We Diagnose Diabetes table i.i How We Diagnose Diabetes Diabetes* level Prediabetes level *To make a diagnosis of...

Controversy Is Glucosamine Safe in Diabetes

In 1999 a letter to the journal Lancet raised questions about whether glu-cosamine supplements could increase glucose (blood sugar) levels, cause insulin resistance, and lead to or aggravate diabetes. The questions raised in this letter were widely reported in the University of California Berkeley Wellness Letter, the Tufts University Health & Nutrition Letter, and other publications toward the end of that year (the delay resulting from publication schedules). These newsletters warned that glucosamine supplements could lead to or worsen diabetes. were speculative and based only on limited animal research. In contrast, clinical experiences with humans indicated that glucosamine supplements had a tendency to slightly lower blood sugar levels, which would reduce the risk of diabetes. One researcher reported that glucosamine supplements improved wound healing, reduced headaches, and eased inflammatory bowel disease in patients. None of these side benefits were reported by the...

Can Sugar Cause Diabetes

Many people have the mistaken idea that eating too much sugar causes diabetes. Since diabetes used to be called Sugar Disease and is so closely linked with the blood sugar called glucose, it is easy to see the reason for this mistake. But evidence shows that simply eating lots of sugar does not cause diabetes. In fact, eating too much of anything carbohydrates, fats, or proteins can make you fat, and being overweight can cause diabetes. For overall health, eating a healthy diet with moderate amounts of a wide variety of wholesome foods is best. And do not forget the exercise. The idea that someone can develop diabetes simply by eating too many sugary foods is a common misconception. The idea that someone can develop diabetes simply by eating too many sugary foods is a common misconception. People with type 2 have a strong genetic tendency to develop diabetes. This means they often have one or more relatives who also have type 2. However, other causes also play a big role, especially...

Chapter The consequences of uncontrolled diabetes

A new approach to diabetes recognition and treatment is needed because the conventional wisdom has failed us. America is in the midst of a diabetes epidemic. Over the past 20 years, the number of adults diagnosed with diabetes has more than doubled, and children are being diagnosed with diabetes in alarming numbers. Diabetes has rapidly emerged as a leading culprit in the epidemic of heart disease that is sweeping the country, and it is a leading cause of amputation and blindness among adults. The long term consequences of uncontrolled diabetes are severe blindness, kidney failure, increased risk of heart disease, and painful peripheral nerve damage. Today, most practitioners focus treatment on strict blood sugar control. While diabetes is characterized by excess blood glucose (the form of sugar used by cells as energy), this simplified approach can actually hasten the progression of the most common form of diabetes and does nothing to address the damage it causes. It is crucial that...

Considering the Consequences of Type Diabetes

As you find out in this part, in an effort to control glucose, it's possible to overcompensate with insulin, leading to a condition of low blood sugar called hypoglycemia, a significant short-term complication. The long-term In this part, I also cover the emotional and psychological difficulties associated with a chronic disease such as diabetes, telling you what they are and how to deal with them.

Impaired insulin secretion and insulinstimulated glucose uptake

Glucose oxidation requires less oxygen than FFA oxidation to maintain ATP production. Thus, myocardial energy use is more efficient during the increased dependence on glucose oxidation with ischemia (approximately 11 more ATP is generated from glucose oxidation as compared with FFA oxidation). In the setting of relative insulinopenia (insulin resistance or frank DM) that is exacerbated by the stress of AMI, the ischemic myocardium is forced to use FFAs more than glucose for an energy source because myo-cardial glucose uptake is impaired acutely. Thus, despite acute hyperglycemia, a metabolic crisis may ensue as the hypoxic myocardium becomes less energy efficient in the setting of frank DM or insulin resistance. Insulin augments the translocation of GLUT-1 and GLUT-4 receptors to the sarcolemma and can diminish FFA release from myocytes and adipocytes 27 . Thus, the extent to which the myocardium expresses an intact response to insulin, therapeutic augmentation of oxidative glucose...

Diet And Insulin Therapy For

Once diet alone can no longer consistently ensure fasting glucose values below 5.5mmol l and a 1h post-prandial value below 7mmol l, the introduction of insulin should be considered (63). It is important to recognise that a small proportion of women will require insulin early in pregnancy and not to assume dietary non-compliance (92). Those requiring insulin are the most metaboli-cally compromised and tend to have both the highest perinatal complications and the fastest deterioration to diabetes after pregnancy (93). Insulin is also occasionally introduced in later pregnancy for obstetric rather than glycaemic reasons this might occur for accelerated foetal growth or unexplained polyhydramnios (94). It is important to stress that once insulin is introduced for the management of GDM the dietary management remains equally important. The need to limit weight gain remains for obese women who now need to balance this with having sufficient carbohydrate snacks throughout the day to prevent...

Are intensified regimens of basalbolus insulin administered in Type DM

There are many factors that render such a solution difficult to apply. The majority of patients with Type 2 DM are elderly and it would be exceptionally difficult for them to adapt themselves to the requirements of such a scheme. Even if some of them could ultimately familiarize themselves, very few would accept injecting insulin 4-5 times daily. Furthermore, the cost of supplying an intensified insulin scheme would be overwhelming, just when there exist no explicit data supporting the supremacy of such schemes in Type 2 DM. However, in certain selected patients (including in the failure of other types of therapy, in young and active patients with significant impairment of the insulin secretory capacity, in renal or hepatic insufficiency, and in pregnancy), basal-bolus insulin schemes are administered for Type 2 DM, on condition of course that explicit motivation and the ability to respond to the requirements of this type of treatment are clearly present in the patient. A 19 year old...

How is the followup done of individuals with DM who carry an insulin pump

These individuals should communicate with their doctor on an almost daily basis during the first weeks, until the blood sugar levels are controlled and there is certainty that the use of the pump and the measurement of the food carbohydrates are being performed correctly. Afterwards, these patients are followed in the same way as the other people with Type 1 DM, measuring their blood sugar levels at least four times daily and keeping records of the results and the units of insulin they receive. If control is good, the insulin users should repeat their education on the measurement of the food carbohydrates after about one year. Many patients who use an insulin pump feel that after a few months they can control their blood sugar levels without the help of their doctors and so they can omit visits. It should be stressed that this is wrong, because the follow-up of individuals with DM is not only limited to the regulation of the blood glucose levels, but also concerns the chronic diabetic...

Are Insulin Pumps Risky for Teens

Scientists from the Food and Drug Administration (FDA) have found that insulin pumps may pose risks for adolescents. Their review discovered thirteen deaths and more than fifteen hundred injuries related to the pumps over a decade. Sometimes the pump did not work correctly, but teens also took risks with their pumps or were careless, dropping their pumps or not taking proper care of them. Two teens may have tried to commit suicide by giving themselves too much insulin through their pumps. Teens like the pumps, which are worn on the body and send insulin into the body through a tube inserted under the skin, because they eliminate the need to inject insulin manually several times a day. However, teens using the pumps must still frequently monitor their blood sugar and adjust their insulin intake through the pump. Doctors are advised to carefully screen their diabetic teen patients to make sure they are able to use and care for their insulin pumps correctly. Because diabetic teens can be...

The Troglitazone in the Prevention of Diabetes Study

The Troglitazone in the Prevention of Diabetes (TRIPOD) study evaluated 236 Hispanic women with gestational diabetes and a mean BMI of 30 kg m2. This trial used 400 mg day of troglitazone, and demonstrated a 55 relative risk reduction of diabetes with a number needed to treat of 15 patients for 2.5 years. The 121 women on placebo developed diabetes at a rate of 12 yearly, compared with 5 among the 114 that received troglitazone. Additionally, lowered plasma insulin levels were found in 89 of individuals on troglitazone. The decreased secretory demands on the P-cells caused by the reduction in insulin resistance not only delayed the development of diabetes, but preserved P-cell function (14). In an analysis of the 84 women who were still nondiabetic 8 months after the study medications had to be stopped, the rate of progression to type 2 diabetes was 21 in the placebo group and 3 in the troglitazone group, for a 92 risk reduction. This would not have been seen if the glitazone was...

Financial And Social Impact Of Type Diabetes

The burdens of type 1 diabetes provide the rationale for current discussions regarding disease prevention. These burdens include medical, social, psychological, and financial elements. Several studies on costs have noted a large financial burden related to diabetes (100), and the most current estimate in the United States places the annual medical and social costs of diabetes at 97 billion (101). Estimates focused solely on type 1 diabetes appear less frequently in the literature. Reports from England and Wales (102), Israel (103), and Spain (104) note meaningful expenses in type 1 diabetes both in the short-term and on a lifetime basis. Studies that describe the economic costs of diabetes often consider the direct or medical costs of the disease and, less frequently, the indirect costs of diabetes. Examples of indirect costs include the value assigned to morbidity, disability, and premature mortality associated with type 1 diabetes. From an economic perspective, the most important...

How does diabetes affect the kidneys

Generally, the changes produced in the kidneys by diabetes occur very slowly, taking place over years (Table 2.2, Figure 2.4). If they are recognized early, they can - with the right treatments - be reversed. The changes start, at the onset of diabetes, with an increase in the size of the kidneys and in the amount of blood passing through them. This first, early stage is known as 'the hypertrophy and hyperfunction stage' (stage 1) because of the enlarged kidneys, enriched in blood. Even at this stage, a rise in the amount of protein in the urine is often observed. If the diabetes is properly controlled, these changes can usually be reversed within weeks or months. The protein also disappears from the urine. The progression of these changes in the kidneys depends strongly on the state of the body's metabolism. If the blood composition is good - that is, if the haemoglobin A1c (HbAlc) concentration is near-normal, namely between 6 and 7 , the diabetes will barely affect the kidneys in...

Oral Medications for Type II Diabetes

Since their introduction in the late 1950s, oral hypoglycemic agents have helped millions of people with Type II diabetes maintain control of their blood glucose levels. There are now several different kinds of oral medications for diabetes that act in very different ways. Follow the hyperlinks for more detailed information. 1. Pills that help put more insulin in the bloodstream the Sulfonylurea (sulfa containing) Type Pills You can only take a sulfa-containing pill for your diabetes if your liver and kidney function are good. 2. A new pill that helps put more insulin in the bloodstream The newest pill for persons with Type 2 diabetes, released in the spring of 1998, is called Prandin. It is meant to be used either alone or in combination with the Glucophage pill (see below). It is taken just before a meal and helps put more insulin in the bloodstream. It's not yet clear who would get the most benefit from it, but it may be useful if you are taking Glucophage but still do not have...

Pathophysiology of Adipose Tissues Obesity and Insulin Resistance

In contrast, genetic predisposition to obesity and or T2D when excess calories are consumed is common in the population for instance, polymorphisms in the peroxisome proliferator-activated receptor- (PPAR- 2) gene may have a broad impact on the risk of obesity and insulin resistance. A minority of people is heterozygous for the Pro12Ala variant of PPAR-7 and is less likely to become overweight and less likely to develop DM when overweight than the majority of Pro homozygotes in the population 15 . One striking clinical feature of overweight individuals is a marked elevation of serum NEFAs, cholesterol, and triacylglycerols irrespective of the dietary intake of fat. Obesity is obviously associated with an increased number and or size of adipose tissue cells. These cells overproduce hormones, such as leptin, and cytokines, such as TNF-a, some of which appear to cause cellular resistance to insulin 16 . At the same time, the lipid-laden adipocytes decrease...

How are doses of prandial insulin determined

One of the main advantages of the basal-prandial insulin regimens is, as already mentioned, the liberation of the schedule and the content of the diabetic's meals. The first objective is achieved thanks to the action profile of the newer insulin analogues. The liberation of the content of the meal is achieved thanks to the calculation of a suitable dose of 'prandial' insulin, depending on the carbohydrate content of the meal. A prerequisite for the application of a system of carbohydrate measurement is the right training of the diabetic in the basic principles of the diet, so he or she learns to calculate the number of 'equivalent' carbohydrates of each meal. Each 'equivalent' constitutes roughly 10-15 grams of carbohydrates. As an example, a slice of bread (30g) contains one equivalent. In the beginning, the patient is helped by special charts. The next step is the determination of the units of insulin that are required in order to absorb each equivalent, without disturbing the...

The Natural History Of Type Diabetes

Although both insulin resistance and impaired insulin secretion precede the development of postprandial hyperglycemia and the subsequent type 2 diabetic phenotype, insulin resistance is more prominent in the prediabetic state and plays an important role in the pathogenesis of macrovascular disease. Insulin resistance is commonly the earliest manifestation in the development of type 2 diabetes, typically originating 5-10 years before postprandial glucose levels in the diabetic range (200 mg dL). As long as the P cell is able to compensate by increased insulin production, normal glucose tolerance is maintained. Thus, not all patients with insulin resistance will develop diabetes (8). Insulin resistance can be worsened by genetic factors, elevated free fatty acids, hyperglycemia, pregnancy, obesity, sedentary lifestyle, aging, and various medications (i.e., steroids, cw-retinoic acid, estrogens, nicotinic acid, oral contraceptives, phenothiazines, and antipsychotic agents). Insulin...

Are there conditions for the application of basalbolus insulin regimens

Provided there is an indication for their administration, the basic condition is the acceptance of the regimen by the patient, after of course his or her thorough and objective briefing with regard to the necessity, functionality and precise way of application. The details of the treatment should be analysed and it should be emphasized that, together with the multiple injections, it is absolutely essential that the patient regularly monitors (at least four times a day) the glucose levels in the capillary blood. Acceptance by the patient assumes that a powerful incentive exists to achieve the best blood sugar control. This motivation is based on correct briefing and on factors such as age, maturity, educational level and psychological situation of the individual. Often, more than one meeting with the doctor is required before the individual with Type 1 DM is convinced that the intensive regimen constitutes the best choice for managing the disease.

Continuous Subcutaneous Insulin Infusion Pumps

Continuous subcutaneous insulin infusion via the external insulin infusion pump is an alternative to multiple daily injections for patients with labile glucose levels and frequent episodes of hypoglycemia. These pumps attach to the body through flexible plastic tubing with a needle inserted subcutaneously in the abdominal area. Weighing 4-6 oz, and measuring 2-3 in wide by approximately 4 in long, these pumps can be easily worn on a belt or slipped into a pocket. The patient needs to clean the needle and tubing apparatus every 2 days with refillable cartridges holding enough insulin for approximately 48 hours. These pumps provide greater flexibility in lifestyle, meal schedules, and travel. Blood glucose should be determined frequently to ascertain the correct insulin dose being delivered. The patient sets the pump to deliver a basal level of insulin during a period in the day. This can be varied for different times, depending on insulin use, by setting the pump at different rates....

Comparison Of Type And Diabetes

Although more than 80 of diabetic ESRD patients have type 2 diabetes, renal pathology and structural-functional relationships have been less well studied in type 2 diabetic patients. Although, several reports indicate a high incidence of nondiabetic renal lesions in type 2 diabetic patients, this may represent selection bias toward biopsy of atypical cases, as the frequency of finding other diseases, in substantial measure, reflects local institutional biopsy policies and criteria (62). In fact, when biopsies in type 2 diabetic patients are done only for research purposes, the frequency of changes diagnostic of other conditions is low (Fioretto P, personal communication). Moreover, an autopsy study of type 2 diabetic patients did not confirm a high incidence of nondiabetic glomerulopathies in proteinuric cases, arguing against the findings of aforementioned studies (63). Most studies of type 2 diabetic patients show that renal lesions are more heterogeneous in comparison with those in...

Diabetic Patients Requiring

The course from the onset of diabetes to the clinically evident nephropathy (proteinuria) and then to ESRD lasts 15-25 yr and occurs in approximately one-third of both type 1 and 2 diabetic patients, who then require RRT dialysis or kidney transplantation. In recent years, the frequency of DN has continuously increased, and since 1990 has become the fastest growing cause of chronic kidney disease (CKD) and the leading cause of ESRD worldwide, especially in the industrialized countries (1). Thus, during the last three decades among ESRD patients, the percentage of diabetic patients with ESRD admitted for RRT has dramatically increased in all racial groups, which is a reflection of the growing incidence of diabetes in the general population. DN is now responsible for 44 of all new patients who require RRT in United States, whereas the incident counts and adjusted rates of new patients starting RRT whose ESRD was due to diabetes increased from 2530 (12.5 per million population pmp ) in...

Diabetes in Association with APECED

The prevalence of type 1 diabetes in our Finnish patients with APECED is 18 (see Table 2), in contrast to 0.5 in the background population. Lower frequencies of 2-4 have been reported for patients from the United States and Italy (2,49), but the difference could be merely the result of patient selection (e.g., with respect to age). Of our 16 patients with diabetes, 14 were clinically considered to have type 1 diabetes. The Pre-diabetic patients Non-diabetic patients

Clinical trials of stents versus CABG involving diabetic patients

The Coronary Angioplasty versus Bypass Revascularisation Investigation (CABRI) was one of the largest trials of PTCA versus CABG and had follow-up over a 4-year period (Kurbaan etal., 2001). Complete revascularisation was mandatory, and in the percutaneous group new devices such as atherectomy or stents were allowable at the operator's discretion. A total of 1054 subjects, of whom 125 (12 ) had diabetes, were randomised to CABG or PTCA 37 of the CABG group received an IMA graft. Diabetic patients had a higher mortality rate than non-diabetic patients. Diabetic patients randomised to PTCA had a higher mortality rate than diabetic patients randomised to CABG (CABG vs. PTCA 8 63(12 ) vs. 14 62(23 )). Post-revascularisation angiographic evidence of residual CHD was consistently significantly greater in PTCA than in respective CABG subgroups. At 1 year, diabetic patients treated with stenting had the lowest event-free survival rate (63 ) because of a higher incidence of repeat...

Surgical And Interventional Management Of Cad In Diabetics

Several clinical trials have demonstrated that outcomes after myocardial revas-cularization are different in diabetic patients compared to nondiabetic patients. These differences should influence treatment decisions. Over the last decade, percutaneous coronary intervention (PCI) has gained increasing acceptance as an alternative to CABG surgery in selected patients. However, several reports demonstrating reduced long-term survival in diabetic patients treated with standard coronary balloon angioplasty have led to concerns regarding the use of PCI in this group of patients. A complete understanding of the mechanisms responsible for the reduced survival is of critical importance in the management of diabetic patients. The operative and procedural management of diabetics with symptomatic CAD will be discussed based on the type of intervention employed. This section will detail the short- and long-term clinical outcomes associated with standard balloon PCI, PCI with stents, and CABG...

Potential Risks Of Surgery In Diabetic Patients

There have been surprisingly few studies on postoperative mortality and morbidity comparing diabetic with non-diabetic subjects. Diabetes was certainly considered to be a major risk factor for surgery in past decades. An American study in 1963 reported a 5 mortality postoperatively in a large (487) group of surgical diabetic patients, the major causes of death being ketoacidosis, infection and myocardial infarction (Galloway and Shuman 1963). It is likely, however, that methods of management were highly sub-optimal compared with modern management principles. A more recent study (Hjortrup et al 1985), using modern treatment methods, has shown no difference in mortality between diabetic and non-diabetic subjects (2.2 versus 2.7 respectively). Some specific surgical procedures may have increased risk in diabetic patients, however, notably vascular procedures. Thus, aortic and lower limbs revascularization procedures carry increased mortality in diabetic compared with non-diabetic...

Chronic complications of diabetes

The results of the Diabetes Control and Complications Trial in the USA have established unequivocally the relationship between glycemic control and the incidence or progression of diabetic microvascular complications. Such complications occur in both type 1 and type 2 diabetic patients, although the latter patients often die because of major vascular disease before microvascular complications become advanced. More than 40 of type 1 diabetic patients will survive for more than 40 years, half of them without developing significant microvascular complications. The United Kingdom Prospective Diabetes Study (UKPDS) has also provided pivotal information on the relationship between glucose control and complications in type 2 diabetes diabetes mellitus (DM). It has demonstrated, in a significant way, the beneficial effect of an improvement in blood glucose control on subsequent risk of developing specific diabetic complications.

Role Of Diabetes In The Genesis Of

There are several clinical, angiographic, and biological features particular to DM that increase the propensity for developing CAD in diabetic patients. In the aggregate, these risk factors increase the likelihood for sustaining a clinical event and have important prognostic implications. Endothelial dysfunction, platelet and coagulation abnormalities, and metabolic disorders associated with DM play a major role in accelerating the process of atherosclerosis and generating coronary thrombosis. The interplay of these factors and processes affects healing after arterial wall injury. The diffuse and distal nature of coronary atherosclerosis may contribute to incomplete revascularization and may increase the risk of surgical or percutaneous revascularization in diabetic patients.

Grafting in Diabetic Patients

Clinical outcomes in diabetic patients following coronary revascularization procedures with bypass surgery (CABG) or percutaneous coronary intervention (PCI) are worse than in nondiabetics. Current evidence suggests that CABG is preferable to PCI for revascularization in patients who have diabetes and multi-vessel coronary artery disease. Most trials have not used contemporary adjunctive therapies, such as GP Ilb IIIa inhibitors and prolonged dual antiplatelet therapy. It is conceivable that implementation of these evidence-based therapies may improve clinical outcomes significantly in diabetic patients who undergo PCI. In the future, emerging technologies, such as drug-eluting stents and soluble receptor for advanced glycation end products, may further improve outcomes after PCI and make it the preferred revascularization modality in diabetics.

Other Issues Relating To Infection And Diabetes

Current guidelines from the Centers for Diseases Control (CDC) recommend that all diabetic patients receive influenza and pneumococcal vaccination. Despite these recommendations, a recent review by the CDC and the Council of State and Territorial Epidemiologists (CSTE) suggested that only 52 of diabetic patients reported receiving the influenza vaccination in the past 12 mo and only 33.2 recalled receiving pneumococcal vaccination at all. When prescribing antibiotics in the diabetic patient, particular caution is warranted to avoid nephrotoxicity as well as the potential for eye toxicity. Also, when administering oral antibiotics, the effects of gastropathy on oral absorption should be considered. Maintenance of good hygiene, particularly in the context of foot care, is crucial in patients with diabetes.

Dietary control of conventional risk factors cholesterol blood pressure type diabetes and obesity

One mechanism that may contribute to the association between high blood pressure and CHD is called 'endothelial dysfunction'. The endothelium, the innermost layer of all blood vessels, is critical in determining the contractile state of the underlying smooth muscle.136 Through the release of a number of substances, the endothelium modulates several other functions, including platelet aggregation, leucocyte adhesion and migration, smooth muscle cell proliferation and lipid oxidation, all of which participate in the atherosclerotic process. The term 'endothelial dysfunction' has been used to describe a constellation of abnormalities in these regulatory actions of the endothelium, and 'endothelial dysfunction' has been reported in conditions such as hypercholesterolaemia, HBP, diabetes and hyperhomocysteinaemia. For instance, in patients with HBP, there is an imbalance in the bioactivity of Another cause of endothelial dysfunction in the context of traditional risk factors of CHD...

Use of Pharmacotherapy for CAD and MI in Diabetics

In women and in non-insulin-requiring diabetics. Many factors, including a MI prognosis among diabetic patients. evaluated results from 4529 diabetic patients from a total sample of 43,073 pa- J firmed the important benefit of thrombolysis in diabetic patients. The absolute reduction in mortality was greater in diabetic patients than in nondiabetics (3.7 vs. 2.1 ), despite a greater 35-day mortality rate in diabetics (13.6 vs. 8.7 ). Diabetics also had a modestly higher absolute risk of developing hemorrhagic stroke than nondiabetics (0.6 vs. 0.4 ). This difference was not statistically significant. 2. Insulin-Glucose Infusion Long-term mortality in diabetic patients who are hospitalized for acute MI may be reduced by an insulin-glucose infusion followed by multidose insulin treatment. In the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study, an infusion of insulin and glucose followed by daily subcutaneous injections of insulin resulted in a 52...

Summary of findings comparing CABG with PTCA in diabetic patients

Recurrent ischaemia leading to angina, repeat revascularisation and cardiac mortality is more common after PTCA than with CABG, because PTCA more commonly results in incomplete revascularisation and an appreciable risk of ischaemia. Incomplete revascularisation is an independent predictor of adverse outcome (Cowley etal., 1993). Whilst several trials have found CABG to be superior to PTCA in diabetes (O'Keefe etal., 1998 Weintraub etal., 1998, 1999), whereas one other trial (Halon etal., 2000) and the Duke University registry (Barsness etal., 1997) did not. Overall, surgical revascularisation for multivessel CHD in diabetic patients, particularly in insulin-treated patients, is associated with a survival advantage compared with PTCA. However, studies with long-term follow-up beyond 10 years have indicated that the survival benefits of surgery may be attenuated. van Domburg etal. (2002) reported on 1041 surgically treated patients (8 diabetes) and 704 (11 ) medically treated patients...

Management in Noninsulinrequiring Diabetes

There is general agreement that diabetic patients not on insulin treatment, undergoing surgery of less than major severity, can be managed conservatively by observation only (Allison et al 1979 Podolsky 1982 Hirsch et al 1991 Alberti and Marshall 1998 Schade 1988). Surprisingly, there has been very little critical evaluation of this presumed optimal therapy, though the information that is available does support a conservative approach. Thus Thompson and colleagues (1986) measured plasma glucose and metabolite responses to three groups of male patients undergoing transurethral surgery to the bladder or prostate gland. The groups were non-diabetic, Type 2 diabetic patients treated with intravenous glucose and insulin ('GKI infusion') (Alberti, Gill and Elliott 1982), and Type 2 patients treated conservatively. There was no significant difference between the two diabetic groups in terms of peri- and postoperative blood glucose levels. Plasma insulin and metabolite levels were actually...

B Cabg Surgery in Patients with Symptomatic CAD and Diabetes Mellitus

As described previously, the BARI trial has shown that patients with DM and angiographic multivessel CAD randomized to an initial strategy of CABG surgery have a striking reduction in mortality compared to diabetic patients randomized to balloon PCI. Further, post hoc analyses of three smaller trials comparing CABG with balloon PCI in patients with stable CAD demonstrated potentially conflicting results in diabetic subjects. In the CABRI trial, diabetic patients fared worse in a manner similar to that seen in BARI. By contrast, the RITA-1 and EAST trials demonstrated similar outcomes in diabetic patients treated with CABG or balloon PCI. Results from retrospective studies and registries bear on the role of CABG in diabetic subjects. A caveat in the interpretation of these results is that such databases of diabetic patients who have undergone coronary intervention may not be generalizable to more unselected groups. Further, the prognosis in such nonrandomized cohorts can be influenced...

Impressive Reduction Of Risk For Cvd In Diabetic Patients By Antihypertensive Treatment

There is strong evidence for a beneficial effect of BP reduction on CVD risk in T2DM, and these benefits have been demonstrated with all classes of antihypertensive drugs. In recent years many antihypertensive intervention studies (19-34), which have included a representative number of diabetic patients, have been published. All these intervention studies illustrate that BP lowering is very important for improving the poor prognosis of diabetic patients. Disagreements in the outcome of different clinical trials can easily be explained by heterogeneity of these studies. The included patients showed a wide variation concerning initial BP values and lowering of BP values. Most of the patients had long-standing diabetic disease, however the exact duration of diabetes and or hypertension was not reported in most of the studies. The follow-up of the hypertensive patients ranged from 2 to 8 years and only newly diagnosed patients were only enrolled in the United Kingdom Prospective Diabetes...

How is diabetic nephropathy treated Glycaemic control

Intensive DM treatment, aimed at achieving glucose values as close to normal as possible, was shown in large randomized studies to delay onset of microalbuminuria and its progression to macroalbuminuria, both in Type 1 (DCCT trial) and Type 2 diabetic patients (UKPDS study). Intensive treatment plays a primary role in the first two stages of the disease, with the possibility existing of complete reversal of damage. In the following stages, DM control has a secondary role with hypertension control gaining primary importance. In Type 2 diabetic patients with incipientl nephropathy, it is wise to use sulfonylureas carefully, discontinue metformin administration and use insulin if needed. The risk of prolonged hypoglycaemias from sulfonylurea administration when CRF occurs is high. Specifically, metformin administration is interrupted when creatinine is higher than 1.5 mg dl (132.6 mmol L) in men and > 1.4 mg dl (123.8 mmol L) in women, due to the heightened risk of lactic acidosis.

Peritoneal Dialysisrelated Complications In Diabetic Patients

Because CAPD offers several advantages as a home dialysis treatment that allows flexibility and enables patients to enjoy most of their activities, it has become increasingly popular among diabetic patients with ESRD. However, peritonitis and exit-site infections and protein loss with the accompanying malnutrition are some of the shortcomings of PD. Furthermore, long-term studies in PD patients with DN have demonstrated that the micro- and macrovascular disease of diabetes continue to progress after initiation of CAPD, leading to ongoing problems with cardiovascular disease, malnutrition, autonomic neuropathy, retinopathy, and PVD (43).

Treatment And Prevention Of Diabetic Nephropathy

Diabetic nephropathy is the most common cause of ESRD in the Western world and is responsible for almost a third of all the patients with ESRD in the United States. Approximately 20-30 of diabetic patients will develop kidney disease over their lifetime. However, possibly as a result of improvements in glycemic control and blood pressure therapy, the incidence of diabetic nephropathy seems to be declining (145-147). Therapies to prevent or delay the progression of diabetic nephropathy are thus critical and the various strategies effective at various stages are discussed below.

Predictors of restenosis after stenting in diabetic patients

Intravascular ultrasound studies have shown that restenosis in both stented and non-stented lesions is due to intimal hyperplasia (Kornowski etal., 1997 Levine etal., 1997 Van Belle etal., 1997), which is a smooth-muscle-cell proliferative response. In one series of 241 patients (n 63 with diabetes) who had 251 native lesions stented, follow-up angiography with intravascular ultrasound demonstrated the late lumen loss was more pronounced in both stented and non-stented lesions of diabetic patients (Kornowski etal., 1997). Results from registries and clinical trials indicate that diabetic patients have an increased risk of restenosis, repeat revascularisation and death after PCI (Rozenman etal., 2000 Van Belle etal., 2001). A useful retrospective study of clinical trial participants was performed at the Cardialysis Core Laboratory in Rotterdam (West etal., 2004). Restenosis occurred in 550 of 2672 (21 ) non-diabetic and 130 of 418 (31 ) diabetic patients (P < 0.001). Reduced body...

Cardiovascular Complications In Diabetes

Diabetes plays a powerful role in the development of cardiovascular diseases (810). The incidence of cardiovascular disease is two times higher in men with diabetes and three times higher in women with diabetes than nondiabetic subjects (10). Haffner et al. (11) reported that the risk of developing a myocardial infarction in type 2 diabetic patients without a previous history of myocardial infarction is similar to that of nondiabetic patients who have had a prior myocardial infarction. Diabetic patients have a twofold increase in the prevalence of hypertension compared with nondiabetic subjects (5). Hypertension is even more common in certain ethnic groups with type 2 diabetes. Almost twice as many African Americans and three times as many Hispanic Americans as compared with white non-Hispanic subjects have coexistent diabetes and hypertension (5). The coexisting hypertension and diabetes continue to rise dramatically in western countries as the overall population ages and as obesity...

Structuralfunctional Relationships In Diabetic Nephropathy

Mesangial expansion is the major hallmark of nephropathy in type 1 diabetic patients (42) and is, more or less, related to all other renal structural or functional alterations of the disease. Increased Vv(Mes glom) closely correlates with a decrease in peripheral GBM filtration surface density Sv(PGBM glom) . On the other hand, total filtration surface per glomerulus S(PGBM glom) is highly correlated with GFR across the spectrum from hyperfiltration to renal insufficiency in type 1 diabetes (42-45). Vv(Mes glom) is also related to the AER (42,46) and high blood pressure (20,42). Similarly, but less strongly than for Vv(Mes glom), GBM width is directly correlated with blood pressure and AER and inversely correlated with GFR (42,46). In fact, the rate of development of mesangial expansion and GBM thickening varies among patients (42,46). For example, relatively marked GBM thickening can be seen without remarkable mesangial expansion and vice versa, preventing a precise correlation...

Do diabetic individuals have a higher susceptibility towards infections compared to nondiabetics

Sufficient data do not exist to substantiate the opinion that diabetics, as a whole, have a higher susceptibility towards infections. However, some infections are more common in diabetic patients, and others present nearly exclusively in these people. Moreover, some infections have a more severe clinical course and manifest a higher frequency of complications in diabetics. The increased susceptibility of diabetics to certain infections is due to many factors. The polymorphonuclear neutrophils of diabetics have been found to have decreased chemotactic and phagocytic abilities. Furthermore, it seems that the ability of leukocytes to counter the microorganisms after the process of phagocytosis is diminished.

Insulin resistance and hyperglycaemia

Insulin resistance (hyperinsulinaemia) is a characteristic finding in patients with type 2 diabetes. It often clusters with obesity, central obesity, elevated blood pressure, elevated levels of total triglycerides, haemostatic abnormalities and low-grade inflammation (Laakso, 1996). This clustering of cardiovascular risk factors (the metabolic syndrome) predicts CAD events in non-diabetic subjects (Lempiainen etal., 1999) and in patients with type 2 diabetes (Lehto etal., 2000). Prospective studies are still missing to show that insulin resistance is an independent risk factor for CAD in patients with type 2 diabetes. Several population-based prospective studies have shown a positive association between hyperglycaemia and cardiovascular disease in type 2 diabetic patients (Laakso, 1999). However, this risk is not particularly strong for CAD.

Pathogenesis Of Hypertension In Diabetes

Several factors are involved in the pathogenesis of hypertension in patients with diabetes mellitus. These include genetic factors, sodium retention, and hyperin-sulinemia. Genetic predisposition plays an important role in the development of hypertension in both type 1 and type 2 diabetes. The higher prevalence of hypertension in certain ethnic groups, such as African Americans, suggests the role of genetic factors (5). Diabetic patients with hypertension are reported to have high frequencies of family history of hypertension (23). Elevated levels of sodium-lithium countertransport activity (24,25) and sodium-hydrogen countertransport activity (26) have also been found to play a role in the genetic predisposition to hypertension.

Animal Studies Of Renal Autoregulation In Diabetes Mellitus

Several studies in streptozotocin diabetic rats and dogs have suggested that hyperglycaemia induces impaired autoregulation of RBF and GFR 52,58-60 . Changes in vasoactive hormone activities have been suggested to contribute to impaired renal autoregulation 61,62 . Furthermore, a rise in growth hormones in diabetic patients induces glomerular structural changes, which may change the regulation of GFR 63 . Diabetic autoregulation impairment develops over time 58,59 , but impaired afferent arteriolar contraction during increased renal arterial pressure can occur in the early course of experimental diabetes 52,64 . Furthermore diabetes has been shown to impair TGF response 60,65 . Other investigators have however shown preserved 66 or even enhanced autoregulatory ability (shift of the autoregulation range to the left (fig. 1)) in rats with short time diabetes 67 .

Genetics Of Hspg Abnormalities In Diabetes

The existence of genetic polymorphisms in the N-deacetylase N-sulfotransferase enzymes has thus far not been reported. Animal experiments performed by Kofoed-Enevoldsen et al 40-42 support the influence of genetic factors in modulating the vulnerability of the N-deacetylase N-sulfotransferase enzyme towards diabetes-induced inhibition, as evident from studies involving different rat strains. Recently, a BamHI restriction fragment length polymorphism in the perlecan gene was found to be associated with diabetic nephropathy in Caucasian insulin-dependent diabetes mellitus 48 . However, in type 2 Japanese diabetic patients the BamHI HSPG2 genotype and allele frequencies were not significantly different between the patients with nephropathy and the patients without nephropathy 49 . No data are available on the role of variants of agrin in diabetes complications.

Renal Transplantation And Diabetes

End stage renal failure (ESRF) from diabetes is increasing and the number of diabetic patients receiving a renal transplant is growing. Diabetes is also a common metabolic complication following a successful renal transplant, due partly to the steroids used to prevent graft rejection and to the associated weight gain they cause. In one study involving 114 patients with normal glucose tolerance, a week before transplantation, only 36 (32 ) retained normal glucose tolerance 9 to 12 months post-transplant with 27 (24 ) patients becoming frankly diabetic. Both p-cell dysfunction and insulin resistance contribute to the development of diabetes post-transplant (1,2).

Coronary revascularization in diabetics

Diabetic patients who have coronary artery disease have significantly worse long-term outcomes compared with nondiabetic patients. The reasons for this are complex but relate, in part, to more extensive atherosclerosis, an increased risk of thrombosis, overexpression of mitogenic cyto-kines, higher oxidative stress, glycated end products, larger and more activated platelets, and more rapid progression of disease. Patients who have diabetes experience higher perioperative mortality rates compared with nondiabetics who undergo bypass surgery (CABG) 1,2 or percutaneous coronary intervention (PCI) 3,4 . Although outcomes after revascularization in diabetics are worse after either modality, CABG seems to be preferable to PCI in most patients who have multi-vessel disease (Fig. 1).

Features Of Pad In Diabetic Patients

Diabetic patients with PAD have several distinct features when compared with non-diabetic patients with PAD. A greater proportion of diabetic patients with PAD have concomitant hypertension (152). In addition, diabetic patients have more distal disease, (152,153) more progressive and severe disease, and they are more likely to undergo surgery and amputation for critical limb ischemia (148,152,153). The rates of gangrene or amputation of lower limbs are as much as 10 to 20 times more frequent in diabetic than in control subjects (154,155). The risk of amputation also increases with age. The annual amputation rates were 14 per 10,000 in patients less than forty-five years of age, 45 per 10,000 in diabetics between age forty-five and sixty-four, and 101 per 10,000 in those over sixty-five. Not surprisingly, duration of diabetes has been found to be a strong risk factor for amputation (155). Interestingly, the type of vessels affected may vary compared with non-diabetic patients with PAD...

Erectile Dysfunction In Diabetes

In recent years, there has been a seismic change in the recognition and management of diabetic patients with erectile dysfunction (ED). Fundamental to this is the recognition that ED represents a vascular complication of the disease. Cardiovascular disease increases the risk of ED, but ED itself is probably a risk factor for cardiovascular disease. The estimated prevalence of ED in diabetic populations is of the order of 38-55 making it one of the most common complications of diabetes in men. ED in diabetes is most likely to be as a result of a defect in nitric oxide-mediated smooth-muscle relaxation as a consequence of autonomic nerve damage and endothelial dysfunction. Large vessel disease and hypertension may also contribute. In today's climate, male diabetic patients with ED are much more likely to seek advice and treatment. Every opportunity for them to so do should be made available and routine enquiry into sexual function,

Diabetes Mellitus and Clinical Aspects of Breast Cancer

Diabetes Mellitus and Breast Cancer Screening Screening mammography has been shown to reduce breast cancer mortality and is recommended by clinical practice guidelines for all women between the ages of 50 and 69 years. With current antidiabetic treatment, many patients with diabetes do not have additional comorbidity and thus may benefit from screening, yet in several countries diabetes may adversely affect attendance to screening mammography. Beckman et al. 38 found that American diabetic patients were less likely to undergo screening mammography, probably due to compromised attitude of their primary care physicians to preventive medicine and to high costs of mammography. Lipscombe et al. 39 investigated mammography rates in a large Canadian cohort, consisting of 69,168 women with diabetes and 663,519 women without diabetes. Although all patients were fully insured, diabetic patients had about one-third lower chances to perform screening mammography. On the other hand, a study from...

Dietary Salt Intake And Diabetic Nephropathy

Systemic blood pressure elevation accelerates the progression of diabetic nephropathy in both type 1 and type 2 diabetic patients 93 , and effective antihypertensive treatment reduces albuminuria and the rate of decline in GFR in these patients. Extracellular fluid volume expansion due to impaired renal sodium excretion is the most clinically important mechanism that leads to the development of secondary hypertension in diabetic and non-diabetic patients with chronic renal disease 94 95 . Regardless of which specific antihypertensive agent is used, sodium restriction and treatment with loop diuretics is of major importance for the management of hypertension in these patients 95 . Recent short-term studies have demonstrated that the antiproteinuric effect of blockers of the renin-angiotensin-system RAS and nondihydropyridine calcium channel blockers is enhanced during dietary salt restriction independently of the blood pressure reduction in both diabetic and non-diabetic renal diseases...

Abnormal Activity Of The Enzymes Responsible For Gag Sulfation In Diabetes

Approximately 40 lower in hepatocytes from streptozotocin diabetic rats as compared with control cells 39 . Furthermore, Kofoed-Enevoldsen et al 4042 found a reduction in N-deacetylase N-sulfotransferase activity in streptozotocin diabetic rats. In humans, the activity or gene expression of N-deacetylase N-sulfotransferase has been evaluated in cell cultures of skin fibroblasts obtained from diabetic patients with without diabetic nephropathy. Neither the activity of N-deacetylase N-sulfotransferase in type 1 diabetics 43 nor mRNA levels of N-deacetylase N-sulfotransferase 1 and 2, in type 2 diabetic patients 44 levels were altered. Interestingly, only the N-deacetylase N-sulfotransferase 2 gene expression was down-regulated by diabetes, but this was only in skin fibroblasts, not in mesangial cells 44 . It should be recognized that N-deacetylase N-sulfotransferase 1 and 2 enzymes are not the only enzymes involved in HS-PG sulfation. Indeed, N-deacetylase N-sulfotransferase 3,...

Distribution Of The Hspg Metabolism Abnormality In Diabetes

The available data are contradictory. Studies using biochemical techniques to measure GAG content in the intima of the aorta of patients with type 2 diabetes mellitus have observed a reduction of HS 46 , suggesting that the abnormalities in HS metabolism are not necessarily restricted to the kidney, although there has not been any examination of any possible relationship with coexistent diabetic nephropathy. The staining of skin basement membranes by JM-403, the monoclonal antibody that reacts with HS-GAG side chains, was significantly reduced in type 1 diabetic patients with diabetic nephropathy, as compared to patients with long-standing diabetes without nephropathy 47 . However, similar findings were observed also in patients with ESRD of non- diabetic origin 47 . The more recently discovered anomalies in HS-PG seem to be restricted, at least in type 2 diabetes, to the kidney taking into account the observation of the tissue distribution of agrin 36 , of the finding that increased...

Type diabetes and CHD

Type 2 diabetes predisposes to macrovascular complications such as myocardial infarction, peripheral vascular disease and stroke. Epidemiological studies have shown that the risk of CHD is increased two- to six-fold in patients with type 2 diabetes compared with non-diabetic subjects (Pyorala et al., 1987 Stamler et al., 1993). Indeed, in the non-diabetic subjects, there has been a substantial decline in mortality from coronary heart disease in many parts of the world in recent years. The effect was considerably less in adults with diabetes with perhaps even an increase in women with diabetes (Gu et al., 1999). More than 50 per cent of diabetic patients have evidence of CHD at diagnosis, which does not take into account the high prevalence of sub-clinical CHD in the diabetic population (Kuller et al., 2000). Conversely, among people with established CHD, there is a high prevalence of diabetes. In fact, one-quarter of patients who had myocardial infarction in the PROCAM Study have...

Glucose Insulin Infusions

During moderate or major surgery, elderly Type 1 and Type 2 diabetic patients should receive insulin, intravenously even if preoperative diabetes control has been good. However, for Type 2 patients undergoing minor surgery, regular glucose monitoring only may be required if their control has been good. For those with poor control, intravenous insulin is appropriate. During surgery the two options are either a combined infusion of glucose, potassium and insulin, or separate glucose potassium and insulin infusions. In this context insulin is necessary to maintain good glycaemic control while preventing proteolysis and lipolysis, while glucose provides energy and prevents hypoglycaemia (Alberti 1991). When glucose is given as 100 mL of 5 dextrose per hour, short-acting insulin doses of 1.5-2.0 U h are usually sufficient together with 10-20 mMol potassium chloride per litre of glucose. Perioperative glucose monitoring is essential. Because of the risks of separate infusions running at...

Favorable Glp Actions In Type Diabetes Beyond The Insulinotropic Effect

GLP-1 inhibits glucagon secretion (32,33). In type 2 diabetes, excessive glucagon secretion in relation to the plasma glucose aggravates fasting hyperglycemia by stimulating hepatic glucose output (34). Exogenous administration of GLP-1 in type 2 diabetic patients leads to a significant suppression of glucagon secretion together with a normalization in fasting plasma glucose (29). The counterregulatory response of glucagon secretion in hypoglycemia is unaffected by GLP-1 administration (35). GLP-1-based therapies will therefore not bear an intrinsic risk for hypoglycemia (36). Concerning gastrointestinal functions, GLP-1 slows gastric emptying and inhibits gastric acid secretion (18). In the central nervous system, GLP-1 acts as a neurotransmitter in the hypothalamus and stimulates satiety directly (37). Continuous GLP-1 application over 6 weeks in type 2 diabetic patients produced significant weight loss due to reduced food intake and increased satiety (37,38). Whether the effects of...

Outcomes in Diabetic Patients

Meta-analyses of ACE inhibitor trials provide compelling evidence that ACE inhibitors reduce cardiovascular events and mortality related to acute myocardial infarction (MI) and heart failure (90,91). Because diabetes is an independent risk factor for CVD (92) and the RAS and diabetes appear to interact at multiple levels, it is possible that diabetes may affect the efficacy of ACE inhibition on CVD. Several recent reports have provided retrospective analyses of data from diabetic subgroups, which participated in large ACE inhibitor trials. Although some of these trials were not designed to specifically address the effects of ACE inhibition in diabetes, comparison of the relative effects of ACE inhibition in the diabetic and nondiabetic subgroups may provide important insight into the role of the RAS in CVD in diabetes. An underlying question regarding the vascular protective effects of antihypertensive therapies is whether these effects are mediated via the reduction in BP or whether...

Diabetic Patients With Hypertension Have A Significantly Higher Risk For Cvd Than Nondiabetic Patients

Hypertension increases CV risk in type 2 diabetes mellitus (T2DM) enormously, as clearly demonstrated in the Multiple Risk Factors Intervention Trial, in which 350,000 men between 35 and 57 years of age were followed up for twelve years (3). The absolute risk of CV death was three-fold higher in those who were diabetic, even after adjusting for other common risk factors such as age, race, income, serum cholesterol and smoking. Importantly, the risk at any given level of systolic blood pressure (SBP) was 2.5-3 times higher in those with T2DM than in the non-diabetic patients at every level of SBP assessed (3). Hypertension is also thought to play a major etiologic role in the development of diabetic nephropathy (DN) and diabetic retinopathy (4,5). As a result, many experts and authors have argued that blood-pressure (BP) management is the most critical aspect of the care of patients with T2DM. Recently, findings from the Strong Heart Study (6) demonstrated that the high risk for CVD...

Clinical Trials Relevant To Treatment Of Hypertension And Prevention Of Cardiovascular Complications In Diabetes

Treatment of hypertension is crucial for the reduction of cardiovascular complications. There have been a considerable number of prospective randomized trials showing the benefits of treating hypertension in diabetes. The SHEP (Systolic Hypertension in the Elderly Program) trial showed that treatment of isolated sys- -o tolic hypertension in elderly type 2 diabetic patients with a diuretic, chlorthali-done, was associated with a significant decrease in the 5-year rates of cardiovas- S cular events and mortality compared to placebo (66). Similarly, in the Systolic Hypertension in Europe (Sys-Eur) Trial, treatment of isolated systolic hypertension in elderly patients with type 2 diabetes with an intermediate-acting calcium channel blocker, nitrendipine, showed a significant decline in cardiovascular J events and mortality compared to placebo (67). In both of these studies, the absolute risk reduction with active treatment compared with placebo was significantly larger for diabetic...

Endothelial function measures as predictors of diabetes or in prediabetes

There is a wealth of data suggesting a potential role for endothelial dysfunction in insulin resistance (Fonseca and Jawa, 2005). Although the direction of causality remains somewhat debated, circulating elevations in several endothelial-derived factors, cell adhesion molecules and t-PA, have been shown to predict risk for type 2 diabetes independently of other predictors (Meigs etal., 2006). Similar results have been seen with physiological tests of endothelial function. For example, Steinberg etal. (1996) showed that severely obese (mean body mass index 34kg m2) insulin-resistant individuals with normal glucose tolerance have the same degree of impairment in blood flow and vascular reactivity as those people with established type 2 diabetes. Similarly, when Caballero etal. examined endothelial function and vascular reactivity in two groups at risk for developing type 2 diabetes, subjects with impaired glucose tolerance and subjects with normal glucose tolerance but with a parental...

Registry information for PCI with stenting in diabetic patients

Other data also suggest that outcomes after PCI can be similar to those after CABG in diabetic patients with multivessel CHD. In one registry of 9586 patients (n 1714 (18 ) diabetes), 970 patients had multivessel disease CABG was performed in 318 (33 ), PCI in 351 (36 ) and 301 (31 ) were treated medically (Kapur etal., 2003). In-hospital mortality was 3 in the CABG group and 2 in the PCI group, and 1-year mortality was 7 in the CABG group, 9 in the PCI group and 10 in the medical

Potential and Proven Risk Factors for Atherothrombosis in Patients with Type Diabetes

All major pathophysiological pathways leading to accelerated atherothrombosis are disturbed in patients with type 2 diabetes. However, to prove that a risk factor is contributing to a higher risk of cardiovascular disease in patients with type 2 diabetes, two conditions must be fulfilled. First, a potential risk factor has to be associated with cardiovascular risk in longitudinal studies. Secondly, evidence from trials is needed to demonstrate that normalisation of a risk factor reduces the cardiovascular event rate. Many potential risk factors from atherothrombosis in patients with type 2 diabetes have been studied in a cross-sectional setting. With respect to endothelial function, previous studies have shown that subjects with insulin resistance or type 2 diabetes have an impairment in their ability to increase blood flow to peripheral insulin-sensitive tissues, at least partly due to their inability to induce NO-mediated vasodilatation (Creager etal., 2003). However, endothelial...

Possible Role Of Hyperfiltration As A Risk Marker For Diabetic Nephropathy

In certain IDDM patients, glomerular hyperfiltration is especially marked and sustained during many years, and it has been suggested that such hyperfiltration represents a pathogenetic factor for later development of diabetic nephropathy. This suspicion is supported by the apparent analogy between the characteristic early renal hemodynamic changes in human IDDM and in animal models of diabetes. Thus, in experimental diabetes a normalisation of the high GFR or the high intraglomerular hydraulic pressure by pharmacological or dietary means, has attenuated progression of renal disease 71 . In human diabetes retrospective data has suggested that marked hyperfiltration is associated with later nephropathy 12,72 . Two studies later questioned these early observations (75,76), but long-term prospective studies have confirmed an associations between glomerular hyperfiltration and later development of nephropathy. In a swedish cohort of normoalbuminuric adolescent patients multiple regression...

Cardiovascular Disease In Type Diabetes

Type 1 diabetes is characterized by an absolute loss of beta cells such that there is almost a total absence of insulin secretion (1). The majority of patients who develop type 1 diabetes have an autoimmune process that destroys the beta cells. There is another group of individuals who have type 1 diabetes in which beta-cell function is severely reduced in the absence of autoimmune destruction and in which the etiology of the beta-cell dysfunction is unknown. In type 1 diabetes, -g Table 4 Differences in Metabolic Profiles Between Insulin-Sensitive and Insulin-Resistant Type 2 Diabetic Patients Insulin-sensitive Insulin-resistant as a consequence of the development of obesity, which appears to be a result of intensive insulin treatment (12) or poorly controlled glycemia that leads to hypertriglyceridemia, excessive activation of vascular cell protein kinase C, increased production of advanced glycosylation end products (AGEs), endothelial dysfunction, and oxidative stress (13). Type 1...

Ambulatory Blood Pressure And Diabetic Nephropathy

The implementation of 24-h ambulatory BP (24-h AMBP) in the study of diabetic nephropathy has underscored the role of blood pressure elevation even in the earliest phases of diabetic nephropathy. Higher 24-AMBP characterizes type 1 diabetic patients with high normal urinary albumin excretion 65 and a close association between increases in UAE and blood pressure was found in the transition from normo- to microalbuminuria 66 . In the above mentioned study of patients with low-grade microalbuminuria 41 differences in BP were undetectable with clinic BP (mean of three random zero measurements) but using 24-h AMBP, statistically highly significant differences between the two groups were demonstrated. Likewise, in a substudy of the HOPE study, highly significant reductions in night blood pressure were detected by 24-h AMBP 67 , - reductions that could account for a substantial part of the beneficial effects obtained. A critical appraisal of the insensitivity of clinical BP

Abnormal Hspg Metabolism In Diabetes

GAG abnormalities in diabetic nephropathy were originally investigated on the bases that albuminuria implies abnormal GBM permselectivity, and that GAGs, namely HS, were thought to be important determinants of GBM permeability. Indeed, a decreased 35S sulfate incorporation in the GBM of diabetic glomeruli has been observed 14-16 . In experimental animal models of diabetes, a reduced synthesis of glomerular PGs and basement membrane HS-PG was also found 17-19 . However, the finding of the reduced sulfate incorporation is not without controversy, and a marked increase in 35S sulfate incorporation in proteoglycans in diabetic tissues has also been observed 20 . Studies using biochemical techniques to measure the GAG content of kidneys obtained at autopsy demonstrated that the GBM of patients with diabetic nephropathy (it was not specified whether type 1 or type 2 diabetes) contained less GAGs than kidneys of non-diabetic controls 21,22 . That the synthesis of carbohydrate side chains of...

In Patients With Diabetes

Most diabetic patients with CHF have it in conjunction with some other known cause(s) of CHF, usually coronary artery disease and or hypertension. Thus, there are relatively few patients with CHF in whom the only predisposing factor is diabetes. Stated another way, although there is strong evidence that cardiomyopa-thy is caused by diabetes, it is unusual for it to account for overt CHF by itself. Moreover, in an individual patient, it is usually impossible to delineate the qualitative and quantitative contributions of diabetic cardiomyopathy as opposed to hypertension or ischemia caused by coronary artery disease. As noted above, diabetes in combination with hypertension and coronary artery disease is not merely additive, but interacts with either or both in a way that seems to potentiate myocardial failure. Accordingly, when diabetic patients have CHF in association with coronary artery disease, they typically have conventional manifestations of myocardial ischemia (i.e., acute and...

Which type diabetics should be offered bariatric surgery

Pories and Albrecht (2001) have demonstrated that over a 10-year period gastric bypass reduced mortality in a population of diabetic patients to 1 per cent for every year of follow-up, compared to 4.5 per cent per year in a matched group of diabetics who did not undergo bariatric surgery. In observational studies, gastric bypass, BPD and duodenal switch are associated with diabetes remission in 80-100 per cent of patients, although randomized studies looking at diabetes-specific endpoints are awaited. Pories et al. (1995) reported a small number of patients whose diabetes appeared to be resistant to bariatric surgery. Some of these were due to failures in operative technique, but most were older patients who had suffered with diabetes for longer and others whose type 2 diabetes was sufficiently severe to require insulin, presumably as a result of well-established islet secretory failure. It follows that it may be advisable to offer weight reduction surgery to younger diabetics and...

Alternative Proteomics Approach to Define Alterations in Urinary Proteome Profile in Patients With Diabetic Nephropathy

In addition to the classical proteomics approach described above, the alternative proteomics approach has also been applied to DN using CE-TOF MS to differentiate urinary proteome profile of patients with type 2 diabetes from that of the healthy controls (84). The urinary polypeptide pattern of patients with diabetes significantly differs from the normal. Moreover, there is a specific polypeptide pattern of diabetic renal damage in patients with high-grade albuminuria (urine albumin > 100 mg L). The urinary polypeptide profiles in diabetic patients can be classified into four types. Type A pattern is typically found in the diabetic state and the occurrence in healthy subjects is low. Type B pattern represents polypeptide profile observed mainly in healthy subjects and the frequency in patients with diabetes is low. Types C and D are the typical patterns of markers for diabetic renal damage of which the frequency in diabetes is increased and decreased, respectively (84). These data...

When Does Endothelial Dysfunction Occur In Diabetes

In type 1 diabetes, ED precedes and may cause diabetic microangiopathy, but it is not clear whether hyperglycemia is a sufficient cause of ED (30-36). In our view, it is more likely that hyperglycemia predisposes to the development of ED and that other factors, genetic or environmental, play a role in determining who among type 1 diabetic patients goes on to develop ED, nephropathy and aggressive angiopathy, and who does not. In type 2 diabetes, ED is present from the onset of the disease and is strongly related to adverse outcomes (4,16). Type 2 diabetes mostly occurs in the setting of the metabolic syndrome, but ED in type 2 diabetes is not explained by hypertension, obesity, or dyslip-idemia (37). It is not clear whether this diabetes-specific ED is caused by hyperglycemia or other factors. An important potential determinant is increased inflammatory activity (Fig. 1). In addition, part of the ED in type 2 diabetes may be primary, i.e., cause of diabetes rather than caused by...

Defects of hepatic glucose metabolism in diabetes mellitus

Turning our attention to hepatic glucose fluxes following a normal meal in type 1 and type 2 diabetic patients, studies have revealed significant alterations of hepatic glycogen storage (Figure 11.12), glycogen release and gluconeogenesis in both patient groups (Taylor et al.1996 Hundal et al. 2000 Bischof et al. 2001, 2002 Singhal et al. 2002 Krssak et al. 2004). A defect in hepatic glycogen storage was observed in glucokinase deficient maturity-onset diabetes of the young 2 (MODY-2) patients, in whom the impaired hepatic glucokinase activity is held responsible for a reduction in the contribution of glucose (the direct pathway) to hepatic glycogen synthesis (Velho et al. 1996). Lower glycogen synthesis (Bischof et al. 2001, 2002 Krssak et al. 2004) and unsatisfactory suppression of endogenous glucose production (Sinha et al. 2002 Krssak et al. 2004) contribute to postprandial hyperglycaemia in both pathologies. Increased gluconeogenesis is the key to postabsorptive hyperglycaemia in...

Treating Subjects with Type Diabetes with Multiple Injections Basal Bolus Therapy

Multiple injections with fast-acting insulin before the meals and intermediate or long-acting insulin at bedtime (basal-bolus regimen) is the first choice insulin regimen in most type 1 patients, but is not used very much in patients with type 2 diabetes. Nevertheless, prandial glucose regulation is an emerging concept, since epidemiological and mechanistic studies indicate that postprandial glucose contributes significantly to overall glycaemic exposure and also contributes to the vascular complications in type 2 diabetes 34,45 . Adding prandial insulin to basal insulin is a logical approach when the target of HbAlc cannot be achieved by the combination of basal insulin and oral therapy. Basal-bolus therapy represents the most physiological insulin regimen, but is more complex and the patient needs to be more educated and motivated for glucose monitoring. A few studies have evaluated the efficacy of multiple injections in type 2 diabetic patients. In the first study the efficacy and...

Risk For Development Of New Diabetes In Relation To Antihypertensive Drug Therapy

Because hypertension is often associated in large populations with impaired glucose tolerance, insulin resistance, and obesity, many patients with hypertension develop diabetes even when treated with placebo. Since in most diabetic patients combination therapy with two, or even three antihypertensive agents is likely to be required, the choice of which antihypertensive class should be given seems to be less problematic. When it comes to nondiabetic hypertensive patients, it seems to be more crucial. A meta-analysis of hypertension trials (91) involving about 116,000 patients, two-thirds of whom did not have diabetes at baseline, found an overall 25 reduction by RAS inhibition (27 for ACEi and 23 for ARB) in new-onset diabetes compared with other antihypertensive classes or placebo (91). Table 5 shows the

Diabetes as a Risk Factor for Stroke

The majority of diabetic patients have multiple risk factors for vascular disease, however diabetes remains an independent risk factor for stroke across all age groups (Wolf etal., 1983). This increased risk is not confined to patients with diabetes but also includes patients with impaired glucose tolerance (IGT), asymptomatic non-fasting hyperglycaemia and hyperinsulinaemia (Coutinho etal., 1999). The increase in risk conferred by diabetes also extends to patients with hypertension who already have a high absolute risk of cardiovascular disease (Kannel and McGee, 1979 Stamler etal., 1993). Accepting that type 2 diabetes is the predominant form of diabetes in stroke patients, the United Kingdom Prospective Diabetes Study (UKPDS) has demonstrated that over a 9-year period 20 of type 2 diabetic patients are likely to experience macrovascular complications (UK Prospective Diabetes Study Group, 1996). This is in contrast to an estimated 9 experiencing microvascular complications over a...

Pathophysiology of coronary artery disease in type diabetes see also Chapter

Knowledge from basic mechanisms of atherothrombosis to findings from clinical trials are needed to change evidence-based treatment guidelines of cardiovascular disease in patients with type 2 diabetes. Our understanding of the pathophysiology of atherothrombosis has substantially increased during recent years, and potential new mechanisms and risk factors for atherosclerosis and thombosis have been identified. For example, the role of inflammation in atherosclerosis has been officially accepted as an important risk factor for cardiovascular disease (Beckman etal., 2002). However, not all risk factors are easy or even possible to measure, and therefore their impact on CAD is difficult to prove. For example, it is quite easy to assay C-reactive protein (CRP) but more difficult to measure endothelial dysfunction. If a risk factor cannot be measured, it cannot have the status of a 'proven' risk factor for cardiovascular disease. In addition, a cardiovascular risk factor needs to be tested...

Non Dr Causes Of Decreased Vision In Older Diabetics

Cataract is the most common cause of deteriorating vision in the elderly population. The lens thickens and opacifies with age and the lens opacities seen in the diabetic population are usually consistent with these changes, although the increased metabolic insult to the lens in diabetic patients causes these changes to accelerate and occur prematurely (Figure 9.10). A rarer form of cataract seen only in the diabetic population and as a direct result of poor diabetic control in Type 1 patients may occur. This is termed the 'snow-flake' cataract which resembles white flakes occurring in the lens just under the lens capsule. Usually they do not affect vision but tend to make fundal examination difficult. Type 2 diabetics may present with blurring of vision due to increased myopia resulting from overhydration and swelling of the lens secondary to prolonged high blood glucose. These refractive effects reverse as the become symptomatic, or the lens opacity prevents screening for, or...

Progression of diabetic nephropathy

Impact of dietary protein restriction on the development of diabetic nephropathy Persistent microalbuminuria precedes and predicts the development of diabetic nephropathy in both type 1 66 and type 2 67 diabetic patients. Two randomised and controlled trials have evaluated the beneficial effect of long-term dietary protein restriction on the course of urinary albumin excretion in type 1 68 and type 2 69 diabetic patients without diabetic nephropathy. Dullaart et al. 68 performed a 2-year prospective and controlled trial with concealed randomisation in 30 type 1 diabetic patients with a mean urinary albumin excretion between 10 and 200 g min. Fourteen patients were assigned to a low protein diet pre-scribed 0.6 g kg day and 16 patients were assigned to continue their usual protein diet. The average protein intake during the study was 0.79 g kg day in the low protein diet group and 1.09 g kg day in the usual protein diet group p< 0.001, between groups . Although urinary albumin...

Overview of Diabetes Management Combined Treatment and Therapeutic Additions

Lessons from Recent Large Trials on Diabetes Treatment The Diabetes Control and Complication Trial (DCCT), a large multicenter study conducted on more than 1,400 type 1 diabetics (aged 12-39 years) for a period of 7-10 years, has established that close blood glucose control (even if complete normalization of glycemic level was not obtained) reduces the frequency of late diabetic complications. Patients were assigned randomly to either intensive insulin therapy (3 or more daily injections or insulin pump, glucose self-monitoring 4 or more times per day, and frequent contact with a diabetes health-care team) or conventional therapy (1 or 2 injections of insulin mixtures per day, less frequent monitoring and medical contacts). The target goals of therapy were markedly different. Compared to the conventional care group, the intensive care group showed lower glycated hemoglobin (by 1.5-2.0 ) and mean glucose level (by 60-80 mg dl), yet most of the intensive care patients group failed to...

Glycoprotein IlbIIIa inhibitor therapy and PCI in diabetic patients

The Evaluation of Platelet IIb IIIa Inhibition in Stenting (EPISTENT) trial was designed to assess the role of platelet GpIIb IIIa blockade for use in elective stenting (Marso etal., 1999). A total of 2399 patients with ischaemic heart disease and suitable coronary artery lesions were randomly assigned to stenting plus placebo (n 809 173 diabetes (21 )), stenting plus abciximab (n 794 162 diabetes (20 )), or balloon angioplasty plus abciximab (n 796 156 diabetes (20 )). The primary endpoint was a combination of death, MI or need for urgent revascularisation in the first 30 days, and this occurred in 87 (11 ) of patients in the stent plus placebo group, 42 (5 ) in the stent plus abciximab group and 55 (7 ) in the balloon plus abciximab group. In diabetic patients, the primary endpoint occurred in 12 of patients who received stent plus placebo compared with 6 in diabetics who received stent + GpIIb IIIa inhibitor therapy (P 0.04). These results indicated that platelet GpIIb IIIa...

Dyslipidaemia diabetes and stroke

The relationship between dyslipidaemia and cardiovascular disease is qualitatively similar in diabetic and non-diabetic patients, but for any given level of cholesterol the absolute risk is higher for diabetics. The evidence that dyslipidaemia is a risk factor for stroke is conflicting, with a recent meta-analysis showing no apparent association (Prospective Studies Collaboration, 1995). Many studies, however, fail to distinguish between strokes caused by cerebral infarction or primary intracerebral haemorrhage. Evidence from Caucasian and Asian population studies confirms a positive association between total cholesterol levels and risk of cerebral infarction, which may be offset by a negative correlation between cholesterol and risk of intracerebral haemorrhage (Iso etal., 1989 Yano etal., 1989). Epidemiological evidence of such associations does not prove cause and effect, but leads to concern that extrapolation from such data to clinical practice may put patients at risk. Indeed,...

Patients with diabetes mellitus

During a short-term high protein diet an increase in GFR and RPF has been demonstrated in most studies of type 1 diabetic patients with normo- and microalbuminuria 26-29 , while a short-term low protein diet induces a decline in GFR of 10 in these patients, although RPF remains unchanged 30-33 . In patients with diabetic nephropathy, however, no change in GFR in response to a high protein diet has been observed 34 . The setting of severe renal injury with maximal perfusion of residual renal tissue has been suggested in this setting. Three studies, using valid markers of GFR, have previously investigated the short-term impact of dietary protein restriction in diabetic nephropathy 35-37 . However, in two randomised crossover trials, neither Bending et al. 35 nor Pinto et al. 37 demonstrated any significant changes in GFR, measured by a continuous infusion technique with timed urine collections, during 3 weeks of dietary protein restriction achieved 0.64 g kg day in 10 type 1 diabetic...

Selection of antihypertensive drug in diabetes mellitus

ACE inhibitors, nondihydropyridine CCBs, TDs, and bBs reduced CV complications in patients who had diabetes and hypertension in several long-term, large, RCTs (Tables 3 and 4). Limited data is available with direct comparisons of various drugs in diabetic, hypertensive patients (Table 5). INSIGHT 70 ) that newer agents, such as ACE inhibitors and CCBs, are better than diuretics and bBs in reducing CV events in treating hypertension in the general population. Because diabetes is an important and independent risk factor for CV morbidity and mortality and because most diabetics die of CV complications 1 , subgroup analysis of diabetic, hypertensive patients in these trials revealed that most required multiple drugs for adequate control of their BP. In the CAPPP trial, diabetic patients who were on captopril had less cardiac mortality and all-cause mortality than did those who were on bBs or TDs 26 . The report did not further divide the impact of captopril over bBs or TDs. However, the...

Epidemic Of Type Diabetes

Epidemiological studies had already identified diabetes epidemic in 1970s. The extraordinarily high prevalence of type 2 diabetes was reported in Pima Indians (18) and also in the Micronesian Nauruans in the Pacific (19), and subsequently in other Pacific and Asian island populations (20). These studies showed that transition from traditional lifestyle to Western way of life resulted in obesity, lack of exercise, profound changes in the diet, and finally to type 2 diabetes. Potential for a future global epidemic of diabetes were highlighted. Since the 1970s several other studies have shown that type 2 diabetes has reached epidemic proportions in several developing countries as well as in Australian Aboriginals (21), African-Americans, and Mexican Americans (22). Table 2 shows the trends in the number of diabetic patients worldwide (23). Significant increase in the number of type 1 diabetic patients is expected, but the doubling of the number of diabetic subjects in the following 20...

Delicious Diabetic Recipes

Delicious Diabetic Recipes

This brilliant guide will teach you how to cook all those delicious recipes for people who have diabetes.

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