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diabetes

Diagnosis of Peripheral Arterial Disease

Diagnosis of Peripheral Arterial Disease

Teaser: 

Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Nicholas Morrissey, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.

Prevalence of peripheral arterial disease (PAD) increases with age. PAD is not only associated with disability (e.g., claudication, limb loss), but also with increased mortality from cardiac and cerebrovascular events. A thorough assessment of symptoms, risk factors and physical signs--including ankle-brachial indices--can be sufficient to determine whether PAD is present. Further testing--such as Duplex examination, magnetic resonance imaging and conventional arteriography--is often required to determine progression and accurate localization of lesions, as well as to direct therapeutic intervention. Early detection of PAD can help prevent functional impairment and death in the elderly.
Key words: atherosclerosis, peripheral arterial disease, ankle-brachial index, diabetes, claudication.

Scale Tips in Favour of Hormone Therapy for Diabetic Women with CHD

Scale Tips in Favour of Hormone Therapy for Diabetic Women with CHD

Teaser: 

Women with coronary heart disease (CHD) who were randomly assigned to postmenopausal hormone therapy had a 35% lower risk for developing diabetes mellitus than those assigned to placebo, according to an analysis of data from the Heart and Estrogen/progestin Replacement Study (HERS).

Observational studies in the past have found that postmenopausal women taking hormone therapy have lower fasting glucose or hemoglobin A1c levels than women not taking hormones, while only a few of these studies have found a corresponding reduction in incidence of diabetes. To date, there has been no prospective, controlled trial evaluating the effect of postmenopausal hormone therapy on the development of diabetes. To address these unresolved issues, investigators analysed data from HERS, a randomized, double-blind, placebo-controlled trial of 0.625mg conjugated estrogen plus 2.5mg medroxyprogesterone acetate for the prevention of coronary events in postmenopausal women with established CHD.

In the 2,763 women enrolled, fasting serum glucose was measured at baseline, at one year and at the end of trial visit; participants were followed for an average of 4.1 years. Self-report of diabetes or disease complication, initiation of therapy with diabetes medication, or a fasting glucose level of 6.9mmol/L or greater was taken as an indication of diabetes, whereas women with fasting glucose levels between 6.0 and 6.9mmol/L were classified as having impaired fasting glucose.

Analyses found that women with and without diabetes at baseline who were assigned to placebo had significantly worse fasting glucose values compared with women in the hormone therapy group, who experienced no significant change in glucose measurements. A similar pattern was seen among women with impaired fasting glucose. Furthermore, the cumulative incidence of diabetes was 6.2% for women in the hormone therapy group compared with 9.5% for those assigned to placebo (p=0.006). This 35% lower risk for diabetes was primarily attributed to the fact that women in the hormone group maintained lower fasting glucose levels than women in the placebo group. Other characteristics commonly associated with diabetes, such as body mass index, hypertension, dyslipidemia and smoking, were not found to be responsible for the treatment effect.

In the present study, for every 30 women treated for about four years, hormone therapy was found to prevent one case of diabetes. However, all must now be well aware of the increased risks for venous thromboembolic events, stroke and breast cancer with long-term hormone therapy use. Therefore, although hormone therapy is not a viable approach to diabetes prevention in women with heart disease, these data allude to the important metabolic benefits of hormone therapy which warrant further investigation.

Source

  1. Kanaya AM, Herrington D, Vittinghoff E, et al. Glycemic effects of postmenopausal hormone therapy: The Heart and Estrogen/progestin Replacement Study. Ann Intern Med 2003;138:1-9.

Strategies for the Management of Hypertension in the Diabetic Patient

Strategies for the Management of Hypertension in the Diabetic Patient

Teaser: 

David H. Fitchett MD, FRCP(C), St Michael's Hospital, University of Toronto, Toronto, ON.

For the diabetic patient, hypertension more than doubles the risk of myocardial infarction, stroke and cardiovascular death, and is central in the development of diabetic nephropathy. Control of hypertension is an important vascular protective measure. However, the thresholds and goals of antihypertensive treatment have fallen as trials have shown improved outcomes with blood pressures reduced to 120/80mmHg or less. Although reducing blood pressure to the lower target levels must be the primary goal of treatment, the use of diuretics and angiotensin-converting enzyme inhibitors should be considered as first-line therapy in the diabetic patient. Both agents have been demonstrated to improve a wide range of cardiovascular outcomes compared to other antihypertensive medications.
Key words: diabetes, hypertension, nephropathy, blood pressure control.

Highlights from the American Heart Association’s Prevention Conference VI: Diabetes and Cardiovascular Disease

Highlights from the American Heart Association’s Prevention Conference VI: Diabetes and Cardiovascular Disease

Teaser: 

  • Office-based risk factor evaluation is mandatory in people with diabetes, and aggressive risk factor modification should be based on those results.
  • The metabolic syndrome commonly precedes the onset of diabetes by several years. Insulin resistance apparently predates the risk factors associated with metabolic syndrome, thus detection of insulin resistance relatively early in life offers the opportunity to identify, at an early stage, those people likely to develop blood fat abnormalities, high blood pressure (HBP) and, ultimately, diabetes.
  • A person with diabetes who smokes is at double the risk for cardiovascular disease (CVD). Therefore, every effort must be made to convince the patient to stop smoking.
  • HBP increases a diabetic patient's risk of coronary heart disease (CHD), stroke, kidney failure and heart failure. Treatment of HBP in people with diabetes should be intensive enough to reach blood pressure goals.
  • The common drugs to treat high blood pressure--diuretics, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers--are generally effective in treating patients with diabetes.
  • Assiduous treatment of high blood pressure in people with diabetes can delay the progression of diabetic nephropathy and retinopathy, as well as CVD.

Diet and Education in the Control of Diabetes in the Elderly

Diet and Education in the Control of Diabetes in the Elderly

Teaser: 

Tess Montada-Atin, RN, CDE
Care Leader

Marilyn Mori, RD
Lina Medeiros, MSW
Diabetes Education Centre,
Toronto Western Hospital
University Health Network
Toronto, ON

Diabetes is a chronic illness with significant short and long term complications.1 The Diabetes Education Centre (DEC) at the Toronto Western Hospital, University Health Network, supports people with diabetes, their family and friends to better understand and manage diabetes. The 1998 Clinical Practice Guidelines (CPG) for the management of diabetes in Canada, recommends initial and ongoing education for the person with diabetes as part of diabetes care and not just as an adjunct to treatment. Diabetes Education should be recognized as a life long commitment.2 Comprehensive management of diabetes should be planned around an interdisciplinary diabetes health care team,1-3 which can be through a DEC. To learn and use the varied complex skills required, people with diabetes need the support of such a team of expert professionals.1 Interdisciplinary interventions have been shown to improve glycemic control in the elderly. Studies have suggested that a team approach toward older people with diabetes improves blood glucose control, quality of life and adherence to therapy.3

Factors that affect glycemic control are diet, diabetes medications and exercise.

Straightforward Principles for Management of the Diabetic Foot

Straightforward Principles for Management of the Diabetic Foot

Teaser: 

Leslie Goldenberg, BSc, MD, FRCPC
Internal, Geriatric and Podologic Medicine
Assistant Professor of Medicine, University of Toronto
Medical Director, The Walking Mobility Clinics
 

The first principle in the care of the diabetic foot is to recognize the primacy of prophylactic care. Indeed, an ounce of prevention is worth the proverbial pound of cure, even in the patient who appears to be low risk and does not suffer from peripheral neuropathy or vasculopathy. Physicians and other health care professionals have a critically important role to play when it comes to educating their diabetic patients regarding daily foot care, with particular attention paid to the care of skin, nail and callus, proper footwear and strategies to prevent foot trauma and infection. Diabetes remains the most common cause of non-traumatic limb loss, and there is considerable suffering and economic impact associated with the management of chronic diabetic foot pain and sepsis. Two-thirds of diabetic amputations follow complications that are related to foot ulcers.

Pressure platform studies demonstrate that the patient placing a diminished load on the toes is an early finding in diabetic neuropathy. This reduction in the load on the toes leads to a corresponding increase in metatarsal head loads. In addition, there is a shift of loading on the forefoot, away from the medial side, with increasing load now borne under the mid-foot, a characteristic of weakness of the longitudinal arch (mid-tarsal loading).

The Danger of Fast Cars and Fast Foods

The Danger of Fast Cars and Fast Foods

Teaser: 

Diabetes is Increasing in Prevalence

Barry J. Goldlist, MD, FRCPC, FACP

Our theme for this first issue of the new millennium is diabetes mellitus in the elderly. It is an appropriate topic because there are two main factors driving the increase in the numbers of patients with diabetes; these are the aging of the population, and the increasing prevalence of obesity. Unfortunately, particularly in the 'young old' these two factors frequently coexist.

Diabetes, like many other chronic disorders, results from a combination of both genetic and environmental factors. The major environmental factor is the increasing obesity of our population, but the genesis of that obesity is very complex. Two of the factors involved are changing dietary patterns and decreased physical activity. As in most diseases, prevention is the most effective treatment. However, improving eating habits and increasing physical activity is not easy to achieve in large populations, particularly when cars and fast foods are omnipresent.

Diabetes mellitus is a major risk factor for renal failure and vascular disease in the elderly; yet, despite much evidence to the contrary, physicians are often hesitant to aggressively treat this population. At times, this might be the correct course, but often the hesitancy is based on misconceptions concerning life expectancy at various ages. A healthy 70-year-old woman has a life expectancy of about 17 years, or more than 20% of her entire life! Even at age 80, a healthy woman has 7-8 years of life expectancy ahead, or 10% of her life. These are substantial periods of time, and suggest that treatment to prevent further complications of diabetes is very well warranted. In fact, the same holistic approach to diabetes management that is used in younger patients is appropriate for many older diabetics, particularly that group of 'young old' aged 65-75.

This holistic approach includes paying detailed attention to all known risk factors. There is excellent evidence that effective blood pressure control, lowering lipids, and the appropriate use of ACE inhibitors and beta-blockers, is effective for reducing cardiovascular risk in patients with diabetes. Tight glucose control, lowering triglycerides, and increasing HDL are more controversial strategies to prevent complications in elderly patients with diabetes. Of course, early attention to any complications (e.g. foot care, eye care) is also critical in maintaining quality of life.

This edition will address some of the acute complications of diabetes (by Daniel Tessier), foot care (Leslie Goldenberg) and diabetic retinopathy (Mark Mandelcorn). The most important issue for many elderly patients is learning about the disease and its dietary control, and Tess Montada-Atin has written an excellent article on this topic. As well as our usual pot pourri of columns, there are articles on peripheral vascular disease in the elderly, recent developments in the primary care of dementia (Serge Gauthier), the difficulties in prescribing for older people, and an article on ethics. Fittingly, for this edition, our article on the biology of aging is focussed on mechanisms of insulin resistance.

I hope you enjoy this edition.

Controlling Sweets, Improving Eyesight

Controlling Sweets, Improving Eyesight

Teaser: 


Blindness is a Result of Diabetic Macular Edema

Mark Mandelcorn, MD, FRCS(C)
Vitreo-retinal Surgeon
Toronto Western Hospital 

It is astonishing that in the year 2000, nearly 80 years after the discovery of insulin, diabetes became the most common cause of blindness in North America. Everyone who looks after diabetics, therefore, has an important role to play in helping these patients reduce their risk of suffering the microvascular and macrovascular complications arising from diabetes. Recent clinical trials have once again confirmed the link between good blood sugar control and the reduced incidence of complications, such as blindness. Consequently, it is accepted that the first goal of treatment is optimum control not only of blood sugar but of other supervening problems, like hypertension, that may aggravate any existing complication, particularly diabetic retinopathy.

Diabetic retinopathy is said to occur in over 90% of type 1 diabetics (characterized by juvenile onset and insulin-dependence) and in a slightly lower percentage of type 2 diabetics (characterized by late onset and lack of insulin dependence). However, only about 25% of patients with diabetic retinopathy develop visual loss and only about 5% become blind.

Improved Glycemic Control Reduces Risk of Diabetes-Related Complications

Improved Glycemic Control Reduces Risk of Diabetes-Related Complications

Teaser: 

Daniel Tessier, MD, MSc, FRCPC, CSPQ
Sherbrooke Geriatric University Institute
Associate Professor, Faculty of Medicine
University of Sherbrooke

Introduction
The most recent Health and Nutrition survey in the United States demonstrated that the prevalence of diabetes is approaching 20% in Caucasian patients over the age of 70, and in certain ethnic groups, may be as high as 50%.1 Currently, the over 65 age group represents about 13 % of the total population, a percentage which is expected, by the year 2020, to increase to approximately 21% of the population. The majority of elderly diabetic patients have type 2 diabetes mellitus (DM), characterized by a gradually increasing glycemia that results from a combination of a resistance, at the cellular level, to the action of insulin, and a gradual decline of insulin secretion by the pancreas. A few years of asymptomatic disease may have elapsed prior to the diagnosis of DM being made, especially in the case of elderly patients. The following article will provide a brief review of the acute complications related to DM in the elderly with a particular focus on the evolution of the disease, side effects of treatment, and the vascular problems and acute infections that are often associated with this health problem.

Edmonton Protocol: The Pride of Canada

Edmonton Protocol: The Pride of Canada

Teaser: 

Julia Krestow, BSc, MSc
Freelance writer
Geriatrics & Aging

It is perhaps not since Banting and Best's discovery of insulin in 1921, that a discovery in diabetic research has held such potential for the treatment of this crippling disease. In May of this year, the University of Alberta achieved instant fame when a research team, led by Dr. Ray Rajotte, announced that it had successfully freed seven diabetics from their daily insulin injections. The team, which consisted of Dr. Jonathan Lakey and Dr. Greg Korbutt, and also included the transplant surgeon Dr. James Shapiro, reported their results at the American Society of Transplant Surgeons and the American Transplantation Society in Chicago. Dr. Shapiro has succeeded in transplanting donor insulin-producing, pancreatic islet cells into seven people, all of whom had, prior to the study, required up to 15 self-injected insulin shots on a daily basis.

Diabetes affects more than 2.25 million Canadians and is subdivided into two categories; Type 1 diabetes is usually diagnosed in children and occurs when the pancreas is unable to produce insulin. Type II diabetes, which accounts for approximately 90% of the cases and usually develops in adulthood, occurs when the pancreas does not produce enough insulin or when the body does not use the insulin effectively.