Middle-aged Diabetic Patients Research Articles

The effect of physical activity on sleep quality in middle-aged diabetic patients

The effect of physical activity on sleep quality in middle-aged diabetic patients

ARTERIAL HYPERTENSION AND ATHEROGENIC DYSLIPIDEMIA ARE LEADING RISK FACTORS FOR CORONARY ATHEROSCLEROSIS IN YOUNG AND MIDDLE-AGED IN DIABETIC PATIENTS WITH ACUTE CORONARY SYNDROME

Objective: To study the incidence of coronary atherosclerosis in young and middle-aged diabetic (DM) patients with acute coronary syndrome (ACS) against the background of arterial hypertension (AH). Design and method: Seventy-six DM patients admitted with a diagnosis of ACS (59 men,17 women) were included, ages from 36 to 59 years (mean 55.5 years). History of DM less than 1 year in 16 patients; 1-5 years in 24 patients and 5-12 years in 36 patients. The mean of HbA1c was 8.1% (6.2-10.9%). Diagnosed the grade 1 of AH was in 32 (42%) patients; grades 2-3 in 44 (58%) patients. All patients underwent coronary angiography (CAG) with stent implantation in criminal artery. Blood tests for low-density lipoprotein (LDL-C) and high-density lipoprotein (HDL-C), NT-proBNP, renin, aldosterone, creatinine were performed. As a control group 115 patients (101 men, 14 women) with ACS without diabetes mellitus included, mean age was 54.5 years (37-59 years). Mean of HbA1c was 5.4% (4.9-5.8%). Grade 1 of AH was diagnosed in 72 (62.6%) patients; grade 2-3 in 43 (37.4%) patients. Results: According to CAG, lesions in one vessel of coronary artery (CA) was found in 18 (23.7%) diabetic and in 64 (55.7%) without diabetes patients; lesions in 2 vessels of CA - in 40 (52.6%) diabetic and in 35 (30.4%) without diabetes patients. Lesions in 3 vessels of CA was found in 18 (23.7%) diabetic and in 16 (13.9%) without diabetes patients. The incidence of multivessel CA lesions in diabetic was 76.3% and 44.3% without diabetes patients. LDL-C was 4.14 ± 1.45 mmol/l in diabetes and 3.66 ± 1.26 mmol/l without diabetes (p = 0.0334); HDL-C was 1.30 ± 0.42 mmol/l in diabetes and 1.15 ± 0.32 mmol/l without diabetes (p = 0.0046). In 67.1% diabetic patients and in 52.1% without diabetes renin and aldosterone levels exceeded the norm. NT-proBNP was 880 pg/ml (397-2530 pg/ml) in diabetes had significantly higher than 739 pg/ml (272-1576 pg/ml) without diabetes (p = 0.0001). Conclusions: In young and middle-aged DM patients, arterial hypertension and atherogenic dyslipidemia are the leading risk factors for atherosclerotic CA lesions.

Designing the Architecture of a Convolutional Neural Network Automatically for Diabetic Retinopathy Diagnosis

Diabetic retinopathy (DR) is a leading cause of blindness in middle-aged diabetic patients. Regular screening for DR using fundus imaging aids in detecting complications and delays the progression of the disease. Because manual screening takes time and is subjective, deep learning has been used to help graders. Pre-trained or brute force CNN models are used in existing DR grading CNN-based approaches that are not suited to fundus image complexity. To solve this problem, we present a method for automatically customizing CNN models based on fundus image lesions. It uses k-medoid clustering, principal component analysis (PCA), and inter-class and intra-class variations to determine the CNN model’s depth and width. The designed models are lightweight, adapted to the internal structures of fundus images, and encode the discriminative patterns of DR lesions. The technique is validated on a local dataset from King Saud University Medical City, Saudi Arabia, and two challenging Kaggle datasets: EyePACS and APTOS2019. The auto-designed models outperform well-known pre-trained CNN models such as ResNet152, DenseNet121, and ResNeSt50, as well as Google’s AutoML and Auto-Keras models based on neural architecture search (NAS). The proposed method outperforms current CNN-based DR screening methods. The proposed method can be used in various clinical settings to screen for DR and refer patients to ophthalmologists for further evaluation and treatment.

The Prognosis of Diabetic Foot Ulcer is Independent of age? A Comparative Analysis of the Characteristics of Patients with Diabetic Foot Ulcer in Different age Groups: A Cross-Sectional Study from China.

Background: With younger onset age of type 2 diabetes mellitus (T2DM), the incidence of diabetic foot ulcer (DFU) in young and middle-aged adults is also increasing. Elucidating the distinctive characteristics of DFU in different ages and exploring the influence of age on the prognosis of DFU are crucial to the improvement of DFU treatments. Methods: 684 patients hospitalized for DFU in the department of endocrinology were recruited and assigned into the young and middle-aged group (age <65 years old) and the elderly group (age ≥65 years old). Demographic data and clinical features were compared between two groups. Results: Compared with the elderly group, the young and middle-aged group had higher proportion of males (72.3% vs 49.6%, P < .01) and smokers (52.5% vs 35.8%, P < .01), shorter duration of diabetes mellitus (155 months vs 196 months, P < .01), higher levels of glycosylated hemoglobin (9.3% vs 8.7%, P < .01), lower ratio of ankle-brachial index <0.9 (25.8% vs 51.1%, P < .01) and higher levels of c-reactive protein and erythrocyte sedimentation rate (14 mg/L vs 10 mg/L, P < .05; 36 mm/h vs 30 mm/h, P < .05). The prevalence of diabetic peripheral neuropathy and Wagner Grade were similar in two groups. Of note, the prognosis was similar in different age groups, as there were no significant differences in the healing rate (59.7% vs 60.1%, P > .05), healing time (30 days vs 22 days, P > .05) and minor amputation rate (11.9% vs 8.7%, P > .05). Conclusions: We found that no evidence to suggest a better prognosis with younger DFU patients. Compared with elderly ones, young and middle-aged patients were characterized by a higher proportion of smoking, worse glycemic control, higher inflammatory biomarkers but less severe lower limb ischemia, indicating that smoking cessation, strict blood glucose control and early detection of infection were crucial for improving the prognosis of young and middle-aged diabetic DFU patients.

Efficacy Analysis of Team-Based Nursing Compliance in Young and Middle-Aged Diabetes Mellitus Patients Based on Random Forest Algorithm and Logistic Regression.

Objective Long-term hyperglycemia in young and middle-aged diabetic patients can be complicated with diabetic ketoacidosis, stroke, myocardial infarction, infection, and other complications. The objective was to explore the application value of machine learning in predicting the recurrence risk of young and middle-aged diabetes patients with team-based nursing intervention. Methods Clinical data of 80 patients with diabetes treated in the Department of Endocrinology from 2019 to 2020 were retrospectively collected. The data set was divided into 70% training set (n =56) and 30% test set (n =24). All the selected research cases were intervened by the team-based management mode involving family and clinical doctors and nurses. The degree of diabetes knowledge learning, the level of blood glucose changes, and the psychological state of the patients were evaluated. The random forest (RF) algorithm and logistic regression prediction model were constructed to predict the risk factors of diabetes recurrence. Results There was no significant difference in the degree of diabetes knowledge learning, the level of blood glucose changes, and the psychological state between the training set and the test set (P > 0.05). The FPG, HbA1c, and 2hPG of recurrence group patients were significantly higher than those of nonrecurrence group patients, and the difference was statistically significant (P < 0.05). In descending order of importance based on the RF algorithm prediction model were glucose, BMI, age, insulin, pedigree function, skin thickness, and blood diastolic pressure. The accuracy of RF and logistic regression prediction models is 81.46% and 80.21%, respectively. Conclusion The team-based nursing model has a good effect on the blood glucose control level of middle-aged and young diabetic patients. Age, BMI, and glucose values are risk factors for diabetes. The SF algorithm has a good effect on predicting the risk of diabetes, which is worthy of further clinical application.

A Meta-Analysis of the Effects of Tai Chi on Glucose and Lipid Metabolism in Middle-Aged and Elderly Diabetic Patients: Evidence from Randomized Controlled Trials.

This research review aimed to evaluate the effect of practicing Tai Chi on glucose and lipid metabolism in middle-aged and elderly diabetic patients. Furthermore, it aimed to provide a theoretical basis for the practice of Tai Chi as a way to improve glucose and lipid metabolism in middle-aged and elderly diabetic patients. Therefore, we searched for randomized controlled trials on the practice of Tai Chi in middle-aged and elderly diabetic patients in Chinese- and English-language electronic databases, such as Web of Science, PubMed, the Cochrane Library, EMBASE, Google Scholar, CNKI, Wanfang Database, and Weipu. We collected articles published no later than August 1, 2020. The methodological quality of the included studies was evaluated according to the standards of the Cochrane Collaboration System Evaluation Manual (version 5.1.0). Finally, 14 articles were included, showing an average Physiotherapy Evidence Database scale score of 6.57. The articles were meta-analyzed using Stata 14.0 software, showing that practicing Tai Chi improved middle-aged and elderly diabetic patients' fasting blood glucose (WMD = −0.60, 95% CI [−1.08, −0.12], p=0.015), glycosylated hemoglobin (WMD = −0.87, 95% CI [−1.60, −0.14], p=0.019), total cholesterol (WMD = −0.48, 95% CI [−0.83, −0.14], p=0.006), triglycerides (WMD = −0.21, 95% CI [−0.37, −0.04], p=0.014), and low-density lipoprotein cholesterol level significantly (WMD = −0.32, 95% CI [−0.63,−0.00], p=0.050). Conversely, patients' high-density lipoprotein cholesterol levels (WMD = 0.09, 95% CI [−0.01, 0.17], p=0.136) showed no obvious improvement. In conclusion, practicing Tai Chi in sessions lasting longer than 50 minutes (at least three times per week, for at least 12 weeks) can effectively improve glucose and lipid metabolism in middle-aged and elderly diabetic patients. However, several other factors affect glucose and lipid metabolism; therefore, further high-quality research is needed. Protocol registration number: INPLASY2020120107.

Well-being of young and middle aged diabetic patients with medication according to combination of non-pharmacological treatment: a path analysis

Well-being of young and middle aged diabetic patients with medication according to combination of non-pharmacological treatment: a path analysis

The lived experience of late midlife hemodialysis patients with diabetic nephropathy

Background: Diabetic nephropathy is the primary reason that patients receive hemodialysis (HD), a frequent and lifelong treatment. However, HD is burdensome for middle–aged individuals, who still have personal and professional responsibilities, and can have a significant and disruptive impact on their lives.Aim: This study seeks to better understand the daily life experiences of middle-aged patients with diabetic nephropathy who are receiving HD.Methods: This qualitative study used purposive sampling to recruit participants from a teaching hospital in southern Taiwan from November 2014 to May 2015. The data was collected through in-depth interviews from 12 middle-aged diabetic nephropathy patients receiving HD. Data analysis was performed using Colaizzi’s phenomenological method.Results: The significant statements were categorized into four themes and 10 subthemes: (1) Mental and physical suffering: shock and refusing HD, loss of control in certain aspects of life, burdened with complications from diabetes and HD conditions. (2) Social isolation: barriers to normal life and leisure activities, financial hardship resulting in reduced self-esteem. (3) Moving toward a new adjusted lifestyle: acknowledging illness and accepting HD, changing their perspective towards HD, learning to improve their own health, and (4) End-of-life evaluation: appreciation of life and death, coming to terms with mortality, and increased time spent with their families.Conclusions: The findings of this study showed that middle-aged patients receiving HD typically underwent a process of mental and physical suffering to adaptation and end-of-life reflection. These findings can help health care providers and family members better understand the experiences and hardships of patients receiving HD, which allows for better support and improved nursing care.

Human Brown Adipose Tissue Density Assessed by Near-Infrared Time-Resolved Spectroscopy Inversely Correlates with the Body Mass Index in Patients with Type 2 Diabetes

Background: Near-infrared time-resolved spectroscopy is a non-invasive method that facilitates analysis of human brown adipose tissue (BAT) density. We measured BAT density in middle-aged patients who had type 2 diabetes by this method and examined the relationship using clinical parameters. Methods: We studied 33 Japanese middle-aged diabetic patients (30 male and 3 female, age 53.8±10.1 years, BMI 25.4±4.5, and HbA1c 7.2±1.1%). Tissue hemoglobin concentration (tHb) of the supraclavicular region was measured using near-infrared time-resolved spectroscopy, and normalized by subcutaneous fat thickness at the measurement sites. Results: The average tHb concentration was 51.1±17.7 μM and lower than 77.8 μM—the value equivalent to the detection threshold of BAT by standard FDG-PET in young adults. Univariate regression analysis showed that the tHb of the supraclavicular region was inversely correlated with BMI (r = −0.55, p=0.0009), but the tHb of the deltoid region was not (r = 0.04, p = 0.31). Other parameters showing significant correlations with BAT mass included systolic blood pressure (r = −0.47, p = 0.01) and insulin treatment (r=0.45, p=0.01). Multivariate regression analysis suggested that BMI (β=−0.42, p=0.005), systolic blood pressure (β=−0.29, p=0.042), and insulin treatment (β=0.34, p=0.015) independently account for BAT density. Conclusion: Our findings suggest that BAT density in middle-aged diabetic patients may relate to obesity more closely than previously thought. Disclosure H. Waki: Research Support; Self; MSD K.K., Novartis Pharma K.K., Boehringer Ingelheim Pharmaceuticals, Inc., Sanofi K.K., Ono Pharmaceutical Co., Ltd., Kyowa Hakko Kirin Co., Ltd., Takeda PHarmaceutical Co., Ltd.. N. Watanabe: None. S. Fuse: None. Y. Kurosawa: None. T. Yamauchi: Research Support; Self; Novo Nordisk Inc., Daiichi Sankyo Company, Limited, Sanofi, Takeda, Tanabe-Mitsubishi. R. Kime: None. T. Hamaoka: None. T. Kadowaki: Consultant; Self; Novo Nordisk A/S, AstraZeneca, Merck Sharp &amp; Dohme Corp.. Research Support; Self; Kissei Pharmaceutical Co., Ltd., Taisho Pharmaceutical Co., Ltd., Sanofi, Kyowa Hakko Kirin Co., Ltd., Novo Nordisk A/S, Astellas Pharma, Daiichi Sankyo Company, Limited, Takeda, Mitsubishi Tanabe Pharma Corporation, Ono Pharmaceutical Co., Ltd., Merck Sharp &amp; Dohme Corp., Nippon Boehringer Ingelheim Co. Ltd.. Speaker's Bureau; Self; Astellas Pharma, AstraZeneca, Merck Sharp &amp; Dohme Corp., Ono Pharmaceutical Co., Ltd., Takeda, Eli Lilly and Company, Nippon Boehringer Ingelheim Co. Ltd., Novo Nordisk A/S.

A cross-sectional study of impact of lifestyle determinants on middle-aged male diabetic patients

Background: India, now designated as diabetes capital of the world, is facing a serious threat from this pandemic. General awareness about the risk factors precipitating this illness is the need of the hour. Objective: To analyze the effect of cigarette smoking, alcohol consumption, and total energy consumption among middle-aged male diabetic patients and compare it with healthy middle-aged men. Materials and Methods: This cross-sectional study was done among 100 middle-aged men, 50 diabetic patients without complication or other comorbidities and 50 healthy individuals aged between 30 and 50 years, regarding their cigarette smoking, alcohol consumption, and total calorie intake. Comparison was done among the two groups. Result: There was a significant association between cigarette smoking and diabetes (p = 0.026). There was an increased association between occasional alcohol consumption among nondiabetic subjects (22%) when compared with diabetic patients (12%), but it was not statistically significant. Moreover, total energy consumption was significantly higher among diabetic patients (1,392 kcal/day) when compared with nondiabetic subjects (1,062 kcal/day). Conclusion: Cigarette smoking was found to be a significant risk factor for diabetes. In addition, increased energy consumption worsened the diabetes. Alteration in lifestyle, inculcating healthy eating practices, cessation of smoking, and routine physical activity should be stressed to the general public. Only then, it is possible to contain this pandemic.

Association of hsCRP and soluble fraction of E-selectin with diabetic and non-diabetic individuals

doiBackground and aims: It is known that endothelial dysfunction and low-grade inflammation are important element of diabetic complications. The soluble E-selectin is a marker of endothelial dysfunction and C-reactive protein is the most important inflammatory marker. The present study is done to investigate the effect of diabetes on these two markers. Methods: The present hospital based case control study was conducted in the department of Biochemistry with the collaboration of department of Medicine of Burdwan Medical College, Burdwan, west Bengal India. All subjects were selected by simple random sampling between March 2011 and May 2013. Blood level of these soluble E-selectin and high sensitive C-reactive protein were measured in two hundred diabetic and two hundred age, sex and other non-modifiable as well as modifiable risk factors matched non-diabetic healthy controls. Results: Compared with control value of high sensitive C-reactive protein and soluble E-selectin levels were higher in diabetic subjects (p &lt; 0.001). Our present study shows that levels of adhesion molecules and high sensitive C-reactive protein were higher in diabetic than non-diabetic. Conclusion: These data suggested that an increased level of inflammatory markers and adhesion molecules among diabetic compared with non-diabetic subjects. This suggests that chronic uncontrolled hyperglycemia contributes to progression of atherosclerosis associated with life-threading complications in middle-aged diabetic patients. DOI: http://dx.doi.org/10.3126/jaim.v3i1.10697 Journal of Advances in Internal Medicine 2014;03(01):17-22

Who are diabetic foot patients? A descriptive study on 873 patients

BackgroundDiabetic foot ulcer (DFU) as the leading cause of lower limb amputation is one of the most important complications of diabetes mellitus (DM). Patient and physician’s education plays a significant role in DFU prevention. While effective treatment and formulation of prevention guidelines for DFU require a thorough understanding of characteristics of DFU patients and their ulcers, there are reports that not only patients’ but also physicians’ information about these characteristics is inadequate. So we conducted this study to investigate these characteristics.MethodsNecessary data was collected from medical archives of DFU patients admitted between 2002 and 2008 in two university hospitals.Results873 patients were included. Mean age was 59.3 ± 11.2 years and most of the patients developed DFU in 5th and 6th decades of their life. 58.1% were men. 28.8% had family history of DM. Mean duration of DM was 172.2 months. Mean duration of DFU was 79.8 days. Only 14.4% of the patients had Hemoglobin A1C < 7%. 69.6% of the patients had history of previous hospitalization due to DM complications. The most prevalent co-morbidities were renal, cardiovascular and ophthalmic ones. Most patients had “ischemic DFU” and DFU in their “right” limb. The most prevalent location of DFU was patients’ toes, with most of them being in the big toe. 28.2% of the patients underwent lower-limb amputations. The amputation rate in the hospital where the “multidisciplinary approach” has been used was lower (23.7% vs. 30.1%).ConclusionsNumber of patients with DFU is increasing. DFU is most likely to develop in middle-aged diabetic patients with a long duration of DM and poor blood sugar control who have other co-morbidities of DM. Male patients are at more risk. Recurrence of DFU is a major point of concern which underscores the importance of patient education to prevent secondary ulcers. As a result, educating medical and nursing personnel, applying screening and prevention guidelines, and allocating more resources are of great importance regarding treatment of DFU patients. Application of the “multidisciplinary approach” can reduce the rate of amputations. Primary care physicians might be furnished with the information presented in the present study.

Safety of metformin in diabetic patients at high altitude area

Sixty-one newly-diagnosed diabetic patients from high altitude area were treated individually plus metformin 1.5 g/d for 14 days. The difference of oxygen partial pressure was 3.5 mm Hg (1 mm Hg=0. 133kPa) between altitude 2 260 m and 2 780 m districts. In these patients, their serum lactic acid was increased before treatment. At altitude 2 780 m district, serum lactic acid in middle-aged and elder groups were even higher [(3.90±0.85 vs 3.65±0.70), (4. 67±0.80 vs 3.69±0.78) mmol/L, both P＜0. 05＝. After 14-day treatment, serum lactic acid in middle-aged diabetic patients remained statistically unchanged [(4.50±0.50 and 3.79±0.62 ) mmol/L, P＞0.05], while that in elder patients was increased significantly [(5.59±0.55 and 5.27±0.43 ) mmol/L,P＜0. 05]. The results suggested that metformin should not be used or be used carefully in elder diabetic patients at high altitude area. Key words: Hypoxia; Diabetes mellitus; Blood lactic acid; Metformin

Effects of renal dysfunction on cardiovascular events in diabetic patients with hypertension: Challenge-DM Study subgroup analysis

This study investigated the relation between renal dysfunction and cardiovascular events in patients from the Challenge-DM Study (a large-scale investigation of Japanese diabetic patients with hypertension on candesartan therapy). The subjects were 4706 patients in whom renal function could be assessed at the time of registration among 16860 patients analyzed in the Challenge-DM Study. The definition of renal dysfunction (low GFR) was an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) calculated by the formula for Japanese. The low GFR group was older, and had a high proportion of females and a high prevalence of cerebrovascular or cardiovascular disease (CVD) compared to the normal GFR group (eGFR ≥ 60 ml/min/1.73 m(2)). Univariate Cox regression analysis of cardiovascular events showed a significant increase in the incidence of primary events and total events in the low GFR group. Among patients <65 years old, the same results were obtained, but no differences were found between the low GFR and normal GFR groups aged over 65 years. Multivariate Cox regression analysis was done with patient characteristics at registration and the presence/absence of achieving the target blood pressure and HbA(1c) before the event as explanatory variables. As a result, low GFR was not the main cause of cardiovascular events, but it had a significant influence on primary events and total events among patients <65 years old. Low GFR may be an independent risk factor for cerebrovascular and CVD among young and middle-aged Japanese diabetic patients with hypertension on candesartan therapy.

Common variants in the TCF7L2 gene help to differentiate autoimmune from non-autoimmune diabetes in young (15–34 years) but not in middle-aged (40–59 years) diabetic patients

Type 1 diabetes in children is characterised by autoimmune destruction of pancreatic beta cells and the presence of certain risk genotypes. In adults the same situation is often referred to as latent autoimmune diabetes in adults (LADA). We tested whether genetic markers associated with type 1 or type 2 diabetes could help to discriminate between autoimmune and non-autoimmune diabetes in young (15-34 years) and middle-aged (40-59 years) diabetic patients. In 1,642 young and 1,619 middle-aged patients we determined: (1) HLA-DQB1 genotypes; (2) PTPN22 and INS variable-number tandem repeat (VNTR) polymorphisms; (3) two single nucleotide polymorphisms (rs7903146 and rs10885406) in the TCF7L2 gene; (4) glutamic acid decarboxylase (GAD) and IA-2-protein tyrosine phosphatase-like protein (IA-2) antibodies; and (5) fasting plasma C-peptide. Frequency of risk genotypes HLA-DQB1 (60% vs 25%, p = 9.4 x 10(-34); 45% vs 18%, p = 1.4 x 10(-16)), PTPN22 CT/TT (34% vs 26%, p = 0.0023; 31% vs 23%, p = 0.034), INS VNTR class I/I (69% vs 53%, p = 1.3 x 10(-8); 69% vs 51%, p = 8.5 x 10(-5)) and INS VNTR class IIIA/IIIA (75% vs 63%, p = 4.3 x 10(-6); 73% vs 60%, p = 0.008) was increased in young and middle-aged GAD antibodies (GADA)-positive compared with GADA-negative patients. The type 2 diabetes-associated genotypes of TCF7L2 CT/TT of rs7903146 were significantly more common in young GADA-negative than in GADA-positive patients (53% vs 43%; p = 0.0004). No such difference was seen in middle-aged patients, in whom the frequency of the CT/TT genotypes of TCF7L2 was similarly increased in GADA-negative and GADA-positive groups (55% vs 56%). Common variants in the TCF7L2 gene help to differentiate young but not middle-aged GADA-positive and GADA-negative diabetic patients, suggesting that young GADA-negative patients have type 2 diabetes and that middle-aged GADA-positive patients are different from their young GADA-positive counterparts and share genetic features with type 2 diabetes.

Activated, Type I Collagen (CellerateRx) and Its Effectiveness in Healing Recalcitrant Diabetic Wounds

To review the authors' experience with activated type I collagen in the treatment of recalcitrant wounds in the diabetic population resulting from minor trauma and/or venous stasis disease. With regard to activated collagen, CellerateRx's patented activated collagen fragments are a fraction of the size of the native collagen molecules and particles found in other products, delivering the benefits of collagen to the body immediately. A 2-case presentation wherein patients were treated with CellerateRx (activated, fragmented, and nonintact type I collagen) in a gel and powder form. Two middle-aged diabetic male patients with lower extremity wounds refractory to conservative wound care. Complete resolution of recalcitrant wounds in 6 to 7 weeks. Wound resolution was evident when using the authors' practice protocol, which includes the application of activated collagen. The inherent properties of type I collagen may contribute to a more rapid healing process.

Case report: diabetic myonecrosis of the neck complicated by infection in an islet transplanted patient

Diabetic muscle infarction, also known as diabetic myonecrosis, is an uncommon neuromuscular complication of longstanding diabetes. It usually involves the thigh or calf muscles. Patients typically present with severe pain in the affected area. This complication is more often seen in middle-aged diabetic patients with poorly controlled glycemia. We describe a 38-year-old female Type 1 diabetic patient who developed acute neck pain 3 weeks following islet transplantation.

Safety and efficacy of carvedilol in very elderly diabetic patients with heart failure

Beta-blockers are often cautiously prescribed to older heart failure diabetics because of the paucity of published data and their perceived unfavourable effects on glucose metabolism, in spite of the evidence of their effectiveness and safety in middle-aged diabetic patients. The aim of this study was to compare the safety, tolerability and efficacy of long-term administration of carvedilol in a group of elderly patients with chronic heart failure, with and without concomitant diabetes. Two hundred and fifty-two patients aged > or =70 years with heart failure and left ventricular ejection fraction < or =40% were followed in specialised heart failure clinics. Diabetes was present in 29.7%. Carvedilol was associated with conventional optimised treatment in 64% of diabetics and 65% of non-diabetics (P = NS). At baseline, diabetics presented with a longer duration of symptoms, higher Charlson comorbidity index, more frequent renal dysfunction and smaller left ventricular volumes than non-diabetics. New York Heart Association functional class and ejection fraction were similar in the two groups. At 1-year follow-up, tolerability (93.7 vs. 92.2%) and mean daily dose (24 +/- 17 vs. 23 +/- 14 mg/day) of carvedilol were similar in diabetics and non-diabetics. No worsening of fasting glucose, glycosylated haemoglobin and creatinine levels as well as the incidence of deaths and hospitalisations was observed in diabetics treated with carvedilol. Similar improvements in New York Heart Association class and mitral regurgitation severity were observed in diabetic and non-diabetic patients taking carvedilol. Ejection fraction showed a significant improvement, more pronounced in non-diabetics than in diabetics (+10 vs. +7 points; improvement of at least 10 points: 15 vs. 36%, P = 0.03). Similarly to younger ones, also in older patients, diabetes does not negatively influence the safety, tolerability and efficacy of carvedilol. However, diabetes remains a strong prognostic factor limiting the reversibility of left ventricular systolic dysfunction and the effect of treatment on subsequent outcome.

Routine Use of Bilateral Skeletonized Internal Thoracic Artery Grafts in Middle-Aged Diabetic Patients

The purpose of this study was to determine whether middle-aged diabetic patients aged less than 70 years could have routine use of bilateral skeletonized internal thoracic artery grafting without an increased surgical risk. Between January 1997 and December 2003, 712 consecutive patients aged less than 70 years underwent bilateral internal thoracic artery grafting. Among these, 164 were diabetic and underwent bilateral internal thoracic artery grafting without other preoperative selection than age. The postoperative results of these 164 nonselected consecutive diabetic patients were compared to these of the 548 nondiabetic patients. The operative mortality rate was 4.3% (7 patients) in the diabetic group and 2.4% (13 patients) in the nondiabetic group (p = not significant [NS]). Deep sternal wound infection was observed in 2 patients (1.1%) in the diabetic group and in 6 patients (1.2%) in the nondiabetic group (p = NS). There were no significant difference in the morbidity rate between the two groups except for renal failure without dialysis (6.7% in the diabetic group vs 2.0% in the nondiabetic group, p < 0.01). Routine use of bilateral internal thoracic artery grafting was performed in nonselected middle-aged diabetic patients without increased morbidity. The low rate of deep wound infections could be related to the skeletonized technique of internal thoracic artery harvesting.

Drug therapy of diabetes in the elderly

The prevalence of type 2 diabetes mellitus is increasing in the elderly. Although type 1 diabetic patients are living longer, over 95% of elderly people affected with diabetes have type 2 diabetes. This segment of the population, comprising men and women older than 65 years of age, is more likely to develop coexisting illnesses predisposing to the development of diabetes and complicating its management. In addition to changes in lifestyle, inherent age-related changes in carbohydrate metabolism contribute to the development of type 2 diabetes in old age. The long-term outcome of tight blood sugar control in the elderly is not known. Nevertheless the principles of management of type 2 diabetes in the elderly are essentially the same as in young- or middle-aged diabetic patients. Lifestyle modifications remain the cornerstone of medical therapy. When diet and exercise fail to achieve proper glycemic control, oral pharmacologic therapy and/or insulin therapy is indicated. The recently available oral glucose lowering agents in the market along with the newer types of insulin can be used in elderly diabetic patients. The effect of aging on metabolism and drug elimination kinetics must, however, be taken into consideration. In particular, it should be borne in mind that the risk of hypoglycemia is more deleterious in the elderly and should be avoided. In this review, the various pharmacologic agents available for the management of diabetes will be reviewed and some pertinent clinical guidelines will be suggested.