Good Blood Glucose Control Research Articles

Preventing Surgical Site Infections: Is it just too Sweet?

Dear Editor, We read with interest the article by Diana et al. [1] on measures to prevent surgical site infections (SSI) by surgeons. The survey reported that nutritional screening is being regularly conducted by 50% of surgeons before major surgery. It also found widely differing strategies adopted by surgeons to prevent SSI, with low adherence to the National Institute for Health and Clinical Excellence of the United Kingdom (NICE) guidelines. It is well known that diabetic patients who undergo cardiac surgery have greater perioperative mortality and morbidity, including SSI, compared with nondiabetic patients. For patients in noncardiac surgical specialties, the association between diabetes and morbidity is less clear. In a recent study, we found that in our database of 1,343 surgical patients, those with diabetes had a 1.6 times greater risk of postoperative complications than did patients without diabetes [2]. In addition, the data affirm the relationship between the presence of diabetes and SSI in cardiac surgical patients in the Chinese Asian population [3]. However, it may not be a simple matter of whether the patient has diabetes or not, but good perioperative blood glucose control can be equally important. Numerous studies in cardiac and noncardiac surgical patients have supported tight glucose control in the perioperative period, for example by continuous insulin infusion, to reduce morbidity and SSI. Such measures may also benefit nondiabetic patients undergoing major surgery, as it has been found that the blood glucose levels in this population can rise significantly at induction of anesthesia until the early postoperative period [4]. Clearly, some of these patients may have had undiagnosed glucose intolerance or diabetes in the first instance. Interestingly, a recent Cochrane Systematic Review in 2009 found that there is insufficient evidence to support strict perioperative glycemic control for prevention of SSI in adults [5]. The conclusion was based on five randomized controlled trials that are heterogeneous and cannot be incorporated into a metaanalysis. A review of our own database (and available evidence) has led us to adopt the use of continuous insulin sliding scale for all cardiac and noncardiac patients undergoing major surgery in order to improve perioperative blood glucose control. Apart from nutritional screening, we would also advocate diabetic screening, which may help identify those susceptible to SSI. As suggested by the Cochrane Review, large, well-conducted randomized trials are required to answer the question of whether these measures can truly reduce SSI.

Conversion from Intravenous Insulin to Subcutaneous Insulin After Cardiovascular Surgery: Transition to Target Study

No study of transition from intravenous to subcutaneous insulin after cardiac surgery with dose based on percentage of intravenous total daily insulin (TDI) has reported a clearly superior regimen for achieving target blood glucose. We compared three first-dose transition strategies for insulin glargine: two based on TDI alone and one that also took body weight into account. Mostly obese, type 1 and type 2 diabetes patients (n = 223) undergoing cardiac surgery were randomized to receive insulin glargine subcutaneously at 60% or 80% of TDI or in a dose based on TDI and body weight. Transition to subcutaneous insulin occurred 27.4 ± 6.6 h after surgery. Over the study period, mean proportion of blood glucose values within target range (80-140 mg/dL) were 0.34 ± 0.24, 0.35 ± 0.24, and 0.36 ± 0.22 in the 60% TDI, 80% TDI, and weight-based groups, respectively. This difference was not significant. Significantly more insulin corrections were needed in the 60% TDI group than in the weight-based group. There was only one incidence of hypoglycemia (blood glucose < 40 mg/dL). No subcutaneous insulin regimen implemented approximately 1 day after cardiac surgery showed significantly better control of blood glucose over the 3-day study period. Further studies are needed to determine optimal formulae for effecting an early transition to subcutaneous insulin after cardiac surgery or whether it is preferable and/or necessary to continue intravenous insulin therapy for an additional period of time.

Influence of glucose-lowering rate on left ventricular function in type 2 diabetes mellitus patients with coronary heart disease

Objective To explore the influence of glucose-lowering rate on left ventricular function in patients with type 2 diabetes mellitus (T2DM). Methods One hundred and thirty-two cases of type 2 diabetes mellitus and 135 cases of type 2 diabetes mellitus with coronary heart disease (T2DM+CHD)received intensive glucose lowering therapy. Then, after measuring left ventricular ejection fraction (LVEF) and E/A ratio, the variation was analyzed. Results LVEF was significantly higher than that before intensive therapy in T2DMsubgroup with glucose-lowering rate less than 6 m mol · L-1 · d-1( P＜0.05 ). So was T2DM+CHD subgroup with glucose-lowering rate less than 4 mmol· L-1 · d-1 (P＜0.05). LVEF was significantly lower than that before intensive therapy in T2DM+CHD subgroup with glucose-lowering rate greater than 4 mmol · L-1 · d-1( P＜0. 05 ),while by the end of following up for 3 months, LVEF stepped up and no significant difference was observed between subgroups ( P ＞ 0. 05 ). The E/A ratio stepped up in both subgroups after intensive therapy ( P ＜ 0. 05 ).Conclusions For T2DM patients with coronary heart disease, excessively fast glucose-lowering rate may impair left ventricular function. Long-term good control of blood glucose restores the impaired left ventricular function causes by excessively fast glucose-lowering rate. After intensive therapy, left ventricular diastolic function finally improves in both subgroups regardless of the glucose-lowering rate and coronary heart disease. Key words: Diabetes mellitus, type 2; Coronary disease; Left ventricular function; Glucose-lowering rate

Acarbose insulin glargine combined on treatment of elderly diabetic

Objective To investigate insulin glargine combined acarbose treatment of senile diabetes therapy. Methods 246 cases type 2 diabetes were treated in out - patient or in hospital from January 2008 to January 2010 who were randomly divided into treatment group( 126 ) and control group (120). Treatment group patients treated with insulin glargine combined acarbose treatment, and control group were treated by Protamine zinc mixed recombinant human insulin injection treatment;To observe clinical effects and β -cell function. Results Comparison of two groups of blood glucose time, P ＜ 0. 05; Two groups of insulin daily dose, the incidence of hypoglycemia,P ＜ 0. 01 ;Treatment before and after the C peptide + insulin release test comparison, P ＜ 0. 05; Conclusion Insulin glargine combined acarbose can achieve good control of blood glucose and reducing insulin dosage, reducing the incidence of low blood sugar, which an improvement of β cell function. It is a good drug compliance and treatment program in elderly type 2 diabetes. Key words: Insulin glargine combined acarbose; Senile diabetes; Efficacy

Initiale Sequenztherapie mit Insulin Glargin, Metformin und Exenatid bei Erstmanifestion eines Typ-2-Diabetes

HISTORY AND ADMISSIONS FINDINGS: A 54-year-old man was admitted to hospital for treatment of a newly diagnosed type 2 diabetes. He had polydipsia and polyuria and had lost 11 kg in weight over four weeks. Further diagnoses were visceral obesity and arterial hypertension. Laboratory tests revealed highly elevated blood glucose parameters (HbA1c 14,9 %, fasting glucose 280 mg/dl, maximal postprandial glucose 430 mg/dl and 320 mg/dl before the meal) and triglyceride (2219 mg/dl). The patient was initially treated with a combination of insulin glargine and metformin. After a few days exenatide was added, as the patient wanted to be able to go without insulin. He was given a structured diabetes education and motivated to have five to six hours' of physical activity and a low glycemic diet. After a few days normal glucose levels had been achieved. After one month the insulin treatment was discontinued. The continuing treatment with metformin, 1000 mg twice daily, and exenatide, 5 mg twice daily, prolonged remission of beta-cell dysfunction and maintained normal blood glucose levels for seven months. After reduction of the metformin dosage (500 mg twice daily) and discontinuance of exenatide as well as a reduction of his physical activity (because of joint pain) for six months, the glucose control worsened. When exenatide was administered again, good control of postprandial blood glucose, but not of fasting glucose was achieved. Initial combination treatment with insulin glargine, metformin and exenatide may be beneficial in a subgroup of patients with newly diagnosed type 2 diabetes, markedly elevated blood glucose and free fatty acid levels (glucolipotoxicity). This should be further investigated in randomized controlled trials.

Good control and few hypos possible with basal insulin starts

Evidence from a recently published study on the efficacy of complex insulin regimens in type 2 diabetes shows that good blood glucose control with a low rate of major hypoglycaemia is possible

Glimepiride monotherapy in achieving good blood glucose control in type-2 diabetes mellitus: a prospective observational study

Aims Glimepiride is a sulphonylurea antihyperglycemic agent for oral therapy of type-2 diabetes mellitus. This study was carried out to evaluate glimepiride monotherapy in controlling blood glucose (HbA1c) in type-2 DM patients, its dosage, and safety profile. Methods This was a prospective observational study carried out at 4 private clinics in Semarang, Jambi, Mojokerto and Medan between October 2006 and September 2007 in outpatients of both gender, aged &gt; 20 years, with type-2 DM, HbA1c &gt; 7%, and received no oral antidiabetic treatment for at least 3 months. Glimepiride tablet was given once daily for 3 months. Results From 74 eligible patients, 18 patients were lost to follow-up and 56 patients completed this 3 months study, consisting of 26 treatment-naive patients and 30 previously treated patients. The initial and final doses of glimepiride were similar in both treatment-naive patients and previously treated patients (initial 2.0 mg, final 2.3 mg). The meanreduction of HbA1c levels was 1.8% (absolute) for all patients, higher in naive patients (2.3%) compared to previously treated patients (1.3%). Based on BMI, the mean reduction of HbA1c in 20 normal weight patients was 1.3%, and more marked in 20 obese patients (2.4%). The mean reduction of FBG levels in all patients was 54 mg/dL, more pronouncedin naive patients ( 83 mg/dL) compared to previously treated patients (30 mg/dL), but not affected by body weight. Bodyweight was increased during the study by a mean of 0.9 kg. No adverse event was encountered in any patient during 3 months monotherapy with glimepiride in the present study. Conclusion Glimepiride monotherapy in the present observational study in daily practice for 3 months was shown to be effective in reducing HbA1c and FBG levels, especially in treatment naive patients. Glimepiride in the present study was associated with weight gain, although not statistically signifi cant. No adverse event was reported in the present study. (Med J Indones 2009;18:170-8)

Diabetic retinopathy and blockade of the renin–angiotensin system: new data from the DIRECT study programme

The pathogenesis and medical management of diabetic retinopathy is reviewed. The importance of good control of blood glucose and blood pressure remain key elements in the prevention and treatment of diabetic retinopathy, and a number of specific metabolic pathways have been identified that may be useful additional targets for therapeutic intervention. Trial data, however, aimed specifically to answer the questions of optimum medical management are limited, so the DIRECT study of renin-angiotensin blockade using oral candesartan 32 mg daily is a welcome addition to our knowledge. This arose from the promising improvement of retinopathy outcomes in the EUCLID study of lisinopril in type I diabetes. In DIRECT, 5 years of candesartan treatment in type I diabetes reduced the incidence of retinopathy by two or more steps (EDTRS) in severity by 18% (P=0.0508) and, in a post hoc analysis, reduced the incidence of retinopathy by three-step progression by 35% (P=0.034). In type I diabetes patients there was no effect on progression of established retinopathy. In contrast, in type II diabetes, 5 years of candesartan treatment resulted in 34% regression of retinopathy (P=0.009). Importantly, an overall significant change towards less-severe retinopathy was noted in both type I and II diabetes (P<or=0.03). Although there is still no absolute proof that these effects were specific to RAS blockade, or just an effect of lower blood pressure, it is reasonable to conclude that candesartan has earned a place in the medical management of diabetic retinopathy, to prevent the problem in type I diabetes and to treat the early stages in type II diabetes.

Rapid-acting insulin secretagogues: a clinical need?

The history of achieving adequate insulin secretion in Type 2 diabetes has interesting parallels with Type 1 diabetes. Initial insulin secretagogue therapy involved short-acting sulphonylureas--tolbutamide being introduced 40 years ago--and early insulin therapy used unmodified (soluble) insulin. Subsequently, long-acting sulphonylureas and insulin were introduced, but more recently short-acting agents have become popular again. This approach was endorsed by the European non-insulin-dependent diabetes mellitus guidelines of 1989/1993. The trend at present is to match modern rapid-acting agents (such as repaglinide or the rapid-acting insulin analogues) to physiological meal-time insulin requirements in both types of diabetes. The fundamental reasons for tailoring therapy to meal-times fall into two categories: a pathophysiological rationale and a behavioural rationale. The pathophysiological rationale for tailoring treatment to mealtimes is based on the importance of restoring the mealtime insulin secretion profiles of patients with Type 2 diabetes to physiological levels to re-establish the tight control of blood glucose levels seen in healthy individuals. The behavioural rationale is derived from the observation that most people with Type 2 diabetes are overweight and would like to reduce calorie consumption, but that the risk of hypoglycaemia does not allow them to be flexible over their day-to-day calorie intake. These observations suggest that the matching of a meal-time pharmacodynamic profile to a patient's eating habits would provide a knowledge-based rationale for achieving good blood glucose control once dietary means alone are inadequate. Evidently, this can be usefully combined with other pharmacological approaches (insulin sensitizers or basal insulin). The need for combination therapy is increasingly likely as the defect in insulin secretion progresses.

Prevention of diabetic retinopathy

Most patients with diabetes develop retinopathy if they live long enough; 50% of patients with type 1 diabetes and 30% of those with type 2 diabetes can expect to develop sight-threatening retinopathy in their lifetime and need intervention to reduce the risk of vision loss. 1 Stefansson E Bek T Porta M Larsen N Kristinsson JK Agardh E Screening and prevention of diabetic blindness. Acta Ophthalmol Scand. 2000; 78: 374-385 Crossref PubMed Scopus (195) Google Scholar Good control of blood glucose and blood pressure greatly reduces this risk. 2 Bek T Lund-Andersen H Hansen AB Johnsen KB Sandbæk A Lauritzen T The prevalence of diabetic retinopathy in patients with screen-detected type 2 diabetes in Denmark: the ADDITION study. Acta Ophthalmol. 2008; (published online Sept 23.)https://doi.org/10.1111/j.1755-3768.2008.01207.x Crossref Scopus (32) Google Scholar Further reduction of the retinopathy risk with drug therapy is a desirable goal, and several classes of molecules have been tested for this effect. Effect of calcium dobesilate on occurrence of diabetic macular oedema (CALDIRET study): randomised, double-blind, placebo-controlled, multicentre trialCalcium dobesilate did not reduce the risk of development of CSME. Full-Text PDF

Islet transplantation and antioxidant management: A comprehensive review

Islet transplantation as a promising treatment for type 1 diabetes has received widespread attention. Oxidative stress plays an essential role in cell injury during islet isolation and transplantation procedures. Antioxidants have been used in various studies to improve islet transplantation procedures. The present study reviews the role of oxidative stress and the benefits of antioxidants in islet transplantation procedures. The bibliographical databases Pubmed and Scopus were searched up to November 2008. All relevant human and animal in-vivo and in-vitro studies, which investigated antioxidants on islets, were included. Almost all the tested antioxidants used in the in-vitro studies enhanced islet viability and insulin secretion. Better control of blood glucose after transplantation was the major outcome of antioxidant therapy in all in-vivo studies. The data also indicated that antioxidants improved islet transplantation procedures. Although there is still insufficient evidence to draw definitive conclusions about the efficacy of individual supplements, the benefits of antioxidants in islet isolation procedures cannot be ignored.

Refill adherence to oral antihyperglycaemic drugs in Sweden

Only 49% of the patients with T2D in Sweden that medicate with oral antihyperglycaemic drugs (AHGD) had good blood glucose control (HbA(1C) < 6.0%). The reason can be low medication adherence. The aim of this study was, therefore, to determine the adherence to different oral AHGD. Included were all patients in Sweden, older than 40 years and having at least two expenditures of AHGD between 1 December 2005 and 30 November 2006. After exclusions of inpatients and patients with unspecified daily dosage 171,220 patients (57% men) remained. Medication possession ratio (MPR) was used for estimating adherence and patients were regarded adherent if MPR >or=80%. The overall refill adherence average 90%, with mean MPR (SD) = 107% (30). Eighty-five percent of the patients in their 40s were adherent compared to 91% of the patients in their 80s. About 90.1% of the women were adherent whereas 89.5% of the men were adherent. Patients with an indication for the medicine were more adherent than patients without this information. We conclude that the unsatisfactory blood glucose control showed among many Swedish T2D patients is not the result of non-adherence to prescribed medication.

The timing of re-institution of good blood glucose control affects apoptosis and expression of Bax and Bcl-2 in the retina of diabetic rats

Hyperglycemia initiates a sequence of events that leads to the development of diabetic retinopathy. We explored the effect of re-institution of good blood glucose control on apoptosis and apoptosis related genes (Bax and Bcl-2) in the retina of diabetic rats. Fifty male Wistar rats randomly divided into five groups : normal control group (CON), diabetic rats with high blood glucose levels for 8 months group (DM) ,diabetic rats with good blood glucose control for 8 months group (DM(1)),diabetic rats with poor blood glucose control for 2 month followed by good blood glucose control for six additional months group (DM(2)), rats with poor blood glucose control for 4 months followed by good blood glucose levels for four additional months group (DM(3)). Expression of Bax and Bcl-2 in the retina was studied by immunohistochemistry and the apoptotic cells were stained using the TUNEL method. The apoptotic cell, expression of Bax and Bcl-2 and the ratio of Bax to Bcl-2 in the retina was increased in DM group compared with normal rats' (P < 0.01). There was no significant difference in apoptotic cells and the ratio of Bax to Bcl-2 between DM(1) group and CON group. The number of TUNEL positive cells and Bax to Bcl-2 ratio was partially reversed in DM(2) group. But glucose control had no effect on the apoptotic cells and the expression of Bax and Bcl-2 in DM(3) group. There was a positive correlation between apoptotic cells and Bax/Bcl-2 ratio in the retina (r = 0.808, P < 0.01). Good blood glucose control at early stage can decrease the number of apoptotic cells in the retina; the decreased apoptosis is correlated with the down-regulation of Bax to Bcl-2 ratio.

Case of ischemic retinopathy induced by chemotherapy with paclitaxel and carboplatin

Abstract Purpose To report a case of ischemic retinopathy induced by chemotherapy for non‐small cell lung cancer (NSCLC). Methods Case report. A 59‐year‐old man was diagnosed with NSCLC, and began treatment with both paclitaxel and carboplatin on June 1, 2007. Thereafter, he consulted our department for a fundus examination due to diabetes mellitus. Results Corrected visual acuity was 3/20 in both eyes. In spite of good control of blood glucose, shown by an HbA1c level of 5.8%, large numbers of soft exudates and retinal hemorrhages were observed in both eyes. Although no microaneurysm was found, non‐perfusion areas were revealed in the nasal retina by fluorescein angiography. We performed laser photocoagulation for the non‐perfusion areas in the retina of the left eye, however, retinopathy gradually progressed. We suspected a side effect from the chemotherapy and consulted with the attending physician. After changing the anticancer drugs, the soft exudates and retinal hemorrhages decreased and promptly disappeared. In January 2008, a vitreous hemorrhage was found in the left eye. Fluorescein angiography showed no neovascularization in the retinas of both eyes, however, the non‐perfusion areas were increased in the left. Following additional laser photocoagulation, the vitreous hemorrhage disappeared. Conclusion It is important to remember that anticancer drugs can induce severe retinopathy. Patients should be followed even after retinopathy is improved for possible recurrence.

Tight Glycemic Control in the Hospital

Single center randomized controlled trials could demonstrate a benefit of strict glycemic control on the mortality and morbidity outcomes for critically ill patients. Although observational studies also demonstrate a benefit of tight glucose control for patients in general wards, direct evidence is still lacking. Overall, the implementation of glucose control both in the very controlled setting of an intensive care unit and even more so in the clearly less controlled setting of a general ward has proven to be difficult. Standardization of all required working steps to establish glycemic control needs to be considered to be able to achieve safe and good blood glucose control. Recent developments from diabetes technology will have an important impact in facilitating glucose control in the hospital, although the already established workflows in hospitals will require a substantial reconsideration of diabetes-oriented technology to allow an area-wide implementation and acceptance by health care personnel.

A natural history and framework for managing diabetic foot ulcers

When treating diabetic foot ulcers it is important to be aware of the natural history of the diabetic foot, which can be divided into five stages: stage 1 - normal foot; stage 2 - high risk foot; stage 3 - ulcerated foot; stage 4 - infected foot; stage 5 - necrotic foot. This covers the entire spectrum of foot disease but emphasizes the development of the foot ulcer as a pivotal event in stage 3, demanding urgent and aggressive management. Diabetic foot wound care in all stages needs multidisciplinary management to control mechanical, wound, microbiological, vascular, metabolic and educational aspects. Achieving good metabolic control of blood glucose, lipids and blood pressure is important in each stage, as is educational control to teach proper foot care appropriate for each stage. Aggressive management of diabetic foot ulceration will reduce the number of feet proceeding to infection and necrosis and thus reduce the number of major amputations in diabetic foot patients.

Clinical Trial Of Glimepiride Compared With Glibenclamide For Efficacy And Safety In Type 2 Diabetes Mellitus In Jos, Nigeria

Objective: The study was undertaken to compare the efficacy and safety of Glimepiride against Glibenclamide in the management of patients with type 2 DM in Jos, Nigeria. Study design: An open, randomised controlled trial. Setting: Diabetes Clinic of the Jos University Teaching Hospital, Jos, Nigeria. Subjects: Seventy four type 2 diabetic patients were randomised to either Glimepiride or Glibenclamide for at least 12 weeks. Measurements: Fasting plasma glucose (Primary outcome variable) and fasting plasma total cholesterol (TC), triglycerides (TG), HDL-cholesterol, and compliance (Secondary outcome variables) were the efficacy variables of interest. Adverse events and the laboratory variables of full blood count, liver function tests, electrolytes, urea, uric acid, and creatinine were the safety outcome variables. Results: Satisfactory blood glucose control was achieved in the majority (88.7%) of patients on 1-6mg Glimepiride daily and 5 to 20mg Glibenclamide daily. The proportion of patients who had good blood glucose control was significantly higher in the Glimepiride-treated group (85.7%) than in the cohort treated with Glibenclamide (52.8%), P

Inpatient Hyperglycemia: Typical Versus Ideal Outpatient Follow-Up Care

M.G., a 54-year-old Hispanic woman, entered the Emergency Department with acute cholecystitis. Her chemistry profile revealed a random glucose of 325 mg/dl. She is 5 feet, 2 inches tall and weighs 186 lb. M.G. has had annual exams but was never told her blood glucose levels were high. Her parents both died from complications of type 2 diabetes. The Emergency Department staff initiated the hospital's routine diabetes orders. This included blood glucose measurements before meals and at bedtime, along with a supplemental scale of aspart insulin starting at 150 mg/dl. She was admitted for antibiotic therapy, but the surgeon preferred to perform her cholecystectomy as an outpatient procedure. The diabetes education team was consulted 3 days after the admission. Chart review revealed that M.G.'s blood glucose levels were still consistently > 150 mg/dl and that she received the sliding-scale insulin coverage but no routine basal or bolus doses. Insulin was not prescribed at discharge, and treatment was deferred to her primary care physician. Her hemoglobin A1c (A1C) was 8.2%. M.G. was taught blood glucose monitoring and normal levels, the basic pathophysiology of diabetes, and how to schedule an outpatient appointment. She was reminded of the importance of good blood glucose control before surgery. M.G. returned 10 days later for an outpatient cholecystectomy. Her blood glucose was 190 mg/dl preoperatively and 236 mg/dl postoperatively. She was sent home with instructions …

Advanced Glycation End Products (AGEs) and Cardiovascular Disease (CVD) in Diabetes

Accelerated atherosclerosis and microvascular complications are perhaps the leading cause of coronary heart disease, blindness and renal failure, which could account for disabilities and high mortality rates in patients with diabetes. Several mechanisms including endothelial cell damage, platelet activation and aggregation, hypercoagulability, and impaired fibrinolysis are involved in the pathogenesis of thrombogenic diathesis in diabetes. However, the underlying molecular mechanism is not fully elucidated. A recent clinical study, the Diabetes Control and Complications Trial-Epidemiology of Diabetes Interventions and Complications (DCCT-EDIC) Research, has revealed that the reduction in the risk of progressive retinopathy and nephropathy resulting from intensive therapy in patients with type 1 diabetes persist for at least several years, despite increasing hyperglycemia. In addition, intensive therapy during the DCCT also reduced the risk of cardiovascular events by about 50 % in type 1 diabetic patients 11 years after the end of the trial. These clinical studies strongly suggest that so-called 'hyperglycemic memory' causes chronic abnormalities in diabetic vessels that are not easily reversed, even by subsequent, relatively good control of blood glucose. Among various biochemical pathways implicated in diabetic vascular complications, the process of formation and accumulation of advanced glycation end products (AGEs) and their mode of action are most compatible with the theory 'hyperglycemic memory'. In this review, we discuss the role of AGEs in thrombogenic abnormalities in diabetes, especially focusing on the deleterious effects of these macroproteins on endothelial cell function, platelet activation and aggregation, coagulation and fibrinolytic systems.

Coronary heart disease and cardiovascular autonomic neuropathy in the elderly diabetic

Diabetes and old age come together to increase the frequency and severity of coronary heart disease. Often clinically nearly silent, symptoms frequently manifest dramatically, to such an extent that the question of screening should be raised, as in younger subjects. Preventing these manifestations relies on better management of the cardiovascular risk factors and obtaining good blood glucose control, but here progress remains necessary, which also requires adapting to the older patient's clinical and psychological condition. Cardiovascular autonomic neuropathy is a frequent degenerative complication in diabetics, particularly in the oldest subjects. The most severe types have serious clinical consequences, thus a higher mortality factor, but the mechanisms remain poorly understood. As for coronary heart disease, the therapeutic tools have expanded these last few years and should be thought out in relation to the geriatric evaluation, with the objective of improving these patients' quality of life. Therefore, a necessary distinction should be made between subjects who have aged successfully, whose management, ultimately, differs little from younger subjects, and frail elderly individuals for whom exploratory techniques and treatment should be adapted.