Proportion Of Diabetic Patients Research Articles

Effect of Aging in the Perception of Health-Related Quality of Life in End-Stage Renal Disease Patients under Online-Hemodiafiltration.

This work aimed to evaluate how aging could influence patients' perception of health quality of life (HRQOL), as well as, the effect of aging on dialysis adequacy and in hematological, iron status, inflammatory and nutritional markers. In this transversal study were enrolled 305 ESRD patients under online-hemodiafiltration (OL-HDF) (59.67% males; 64.9 ± 14.3 years old). Data about comorbidities, hematological data, iron status, dialysis adequacy, nutritional and inflammatory markers were collected from patient's records. Moreover, HRQOL score, by using the Kidney Disease Quality of Life-Short Form (KDQOL-SF), was assessed. Analyzing the results according to quartiles of age, significant differences were found for some parameters evaluated by the KDQOL-SF instrument, namely for work status, physical functioning and role-physical, which decreased with increasing age. We also found a higher proportion of diabetic patients, a decrease in creatinine, iron, albumin serum levels, transferrin saturation and nPCR, with increasing age. Moreover, significant negative correlations were found between age and mean cell hemoglobin concentration, iron, transferrin saturation, albumin, nPCR, work status, physical functioning and role-physical. In conclusion, our results showed that aging is associated with a decreased work status, physical functioning and role-physical, with a decreased dialysis adequacy, iron availability and nutritional status, and with an increased proportion of diabetic patients and of patients using central venous catheter, as the vascular access. The knowledge of these changes associated with aging, which have impact in the quality of life of the patients, could be useful in their management.

Awareness, agreement, adoption and adherence to type 2 diabetes mellitus guidelines: a survey of Indonesian primary care physicians.

BackgroundTo assess the degree of awareness, agreement, adoption and adherence of physicians in Indonesia to type 2 diabetes mellitus guidelines, and their association with characteristics of the responders.MethodsQuestionnaire survey among General Practitioners (GPs) attending the Indonesian Association of Family Practitioners annual conference in November 2012. The proportion of GPs who were aware of, agreed with, adopted and adhered to the seven recommendations in the guidelines (screening for diabetes, diagnosis, lifestyle modification, use of sulfonylurea, target blood glucose, target blood pressure and use of statin) were calculated in the total number of responders.ResultsOf the 399 GPs participating, 383 (89%) were aware of the existence of Indonesian type 2 diabetes guidelines. Awareness for each recommendation varied from 66 to 91%. The recommendation to use a random blood glucose test for diagnosing patients with classic diabetes symptoms had the least awareness (265/399, 66%) and least agreement (163/399, 41%). The recommendation on statin use was the least adopted (192/399, 48%), while the least adherence (7/399, 2%) was found for the recommendation on screening for diabetes for patients with risk factors. Years of practice experience and proportion of diabetes patients seen in their practice were independently related with adherence to statin prescription.ConclusionsHigh awareness of the Indonesian type 2 diabetes guideline does not necessary lead to adoption or adherence to recommendations important for outcomes and quality of care. The awareness-to-adherence model helps in identifying barriers for the use of guidelines.

Tight computerized versus conventional glucose control in the ICU: a randomized controlled trial

The blood glucose target range and optimal method to reach this range remain a matter of debate in the intensive care unit (ICU). A computer decision support system (CDSS) might improve the outcome of ICU patients through facilitation of a tighter blood glucose control. We conducted a multi-center randomized trial in 34 French ICU. Adult patients expected to require treatment in the ICU for at least 3 days were randomly assigned without blinding to undergo tight computerized glucose control with the CDSS (TGC) or conventional glucose control (CGC), with blood glucose targets of 4.4-6.1 and <10.0 mmol/L, respectively. The primary outcome was all-cause death within 90 days after ICU admission. Of the 2,684 patients who underwent randomization to the TGC and CGC treatment groups, primary outcome was available for 1,335 and 1,311 patients, respectively. The baseline characteristics of these treatment groups were similar in terms of age (61 ± 16 years), SAPS II (51 ± 19), percentage of surgical admissions (40.0%) and proportion of diabetic patients (20.3%). A total of 431 (32.3%) patients in the TGC group and 447 (34.1%) in the CGC group had died by day 90 (odds ratio for death in the TGC 0.92; 95% confidence interval 0.78-1.78; p = 0.32). Severe hypoglycemia (<2.2 mmol/L) occurred in 174 of 1,317 patients (13.2%) in the TGC group and 79 of 1,284 patients (6.2%) in the CGC group (p < 0.001). Tight computerized glucose control with the CDSS did not significantly change 90-day mortality and was associated with more frequent severe hypoglycemia episodes in comparison with conventional glucose control.

Evaluation of preoperative neutrophil-lymphocyte ratio and platelet-lymphocyte ratio in patients undergoing major vascular surgery

Background: This study aims to examine whether preoperative neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) had a preoperative prognostic role and its association with survival in patients undergoing major vascular surgery. Methods: Between June 2005 and December 2012, 838 consecutive patients (593 males, 245 females; mean age 63 years; range, 10 to 99 years) who underwent major vascular surgery in our clinic were included. The NLR and PLR were determined by dividing the absolute neutrophil and platelet count by the absolute lymphocyte count. Results: The mean mortality risk was 2.85 (range 1.67- 4.87) in patients with a NLR of &#8805;5 and 3.76 (range 2.31- 6.12) in patients with a PLR of &#8805;200. The proportion of diabetic patients was significantly higher for patients with NLR &#8805; 5 ( 63.7%; p = 0 .000) a nd P LR &#8805; 200 ( %53.8; p = 0.003). Conclusion: Our study results showed that increased levels of NLR and PLR were directly correlated with mortality and inversely correlated with survival in the postoperative period and that diabetic patients were under a higher risk.

Temporal changes in patient characteristics and prophylactic pharmacotherapy among 156,496 patients referred for coronary angiography between 2000 and 2009 - a nationwide study

Background: Coronary angiography (CAG) holds a central role in the diagnosis of coronary heart disease. We studied the temporal trends in patient characteristics in a nationwide cohort of patients referred for CAG between 2000 and 2009. Methods: Patients undergoing their first CAG between 2000 and 2009 were identified in the nationwide Danish Heart Register. Trends in patient characteristics, pharmacological treatment and comorbidity prior to CAG were analyzed by logistic regression models. Results: A marked increase in the number of acute (5,943 to 10,707) as well as elective (17,294 to 25,550) procedures was observed between 2000-2001 and 2008-2009. Further, mean age increased from 61.8 to 63.9 years (p for difference <0.0001) and proportion of females increased from 33% to 37% (p for difference <0.0001). In 2008-2009 a lower proportion of patients with chronic heart failure (12.3% vs. 8.8%) and a higher proportion of diabetic patients (10.9% vs 12.7%) were referred for CAG compared to 2000-2001. Although the use of statins, antithrombotic therapy, ACE-inhibitors and, beta-blockers prior to angiography increased during the study period, prophylactic pharmacotherapy was still underutilized in 2008-2009 (Figure). Odds ratios for the use of statins, ACE-inhibitors and, antithrombotics in 2008-2009 were 3.42 [3.27; 3.57], 1.85 [1.77; 1.93] and, 1.43 [1.37; 1.49], respectively (2000-2001 used as reference). Elective patients received more prophylactic pharmacotherapy than acute patients (p<0.0001). ![Figure][1] Figure 1 Conclusion: During a 10 year period there was a substantial increase in CAG procedures, increased mean age and, increased proportion of females. Use of prophylactic drugs prior to angiography increased markedly, but treatment frequency may still be too low; however this remains to be further investigated. [1]: pending:yes

Skeletonized versus pedicled internal thoracic artery and risk of sternal wound infection after coronary bypass surgery: meta-analysis and meta-regression of 4817 patients.

It is suggested that the internal thoracic artery (ITA) harvesting technique influences the incidence of sternal wound infection (SWI) after coronary artery bypass graft (CABG). To determine if there is any real difference between skeletonized vs pedicled ITA, we performed a meta-analysis to determine if there is any real difference between these two established techniques in terms of SWI. We performed a systematic review using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for studies that compared the incidence of SWI after CABG between skeletonized vs pedicled ITA until June 2012. The principal summary measures were odds ratio (OR) with 95% confidence interval (CI) and P values (statistically significant when <0.05). The ORs were combined across studies using the weighted DerSimonian-Laird random effects model and weighted Mantel-Haenszel fixed effects. Meta-analysis, sensitivity analysis and meta-regression were completed using the software Comprehensive Meta-Analysis version 2 (Biostat, Inc., Englewood, NJ, USA). Twenty-two studies involving 4817 patients (2424 skeletonized; 2393 pedicled) met the eligibility criteria. There was no evidence for important heterogeneity of effects among the studies. The overall OR (95% CI) of SWI showed a statistically significant difference in favour of skeletonized ITA (fixed effect model: OR 0.443, 95% CI 0.323-0.608, P < 0.001; random effect model: OR 0.443, 95% CI 0.323-0.608, P < 0.001). In the sensitivity analysis, the difference in favour of skeletonized ITA was also observed in subgroups such as diabetic, bilateral ITA and diabetic with bilateral ITA; we also observed that there was a difference in the type of study, since non-randomized studies together demonstrated the benefit of skeletonized ITA in comparison with pedicled ITA, but the randomized studies together did not show this difference (although close to statistical significance and with the tendency to favour the skeletonized group). In meta-regression, we observed a statistically significant coefficient for SWI and proportion of diabetic patients (coefficient -0.02, 95% CI -0.03 to -0.01, P = 0.016). In conclusion, skeletonized ITA appears to reduce the incidence of postoperative SWI in comparison with pedicled ITA after CABG, with this effect being modulated by the presence of diabetes.

Coaching of Physicians by RNs to Improve Diabetes Care

The purpose of this study is to describe preliminary results of an innovative quality improvement intervention focused on improving physician practice patterns in diabetes care via Coaching Physicians by RN certified diabetes educators (CDEs), a program called "CPR for Diabetes Care." METHODS The program identified primary care physicians with optimal diabetes control rates below the system aggregate (n = 195). Physicians with the lowest rates (n = 74) were targeted for comprehensive intervention. All other low-performing physicians practicing in the same clinic system (n = 121) comprised the comparison group. Data were obtained from electronic diabetes registries for 2007 and 2008. Each physician had a set of measures from 2 points in time. Measures included optimal diabetes scores and the 5 component measures of the optimal diabetes care bundle (A1C <7, low-density lipoprotein cholesterol <100, blood pressure <130/80, aspirin use if older than 40, and no tobacco use). T tests and difference-in-difference models were used to examine changes over time. Optimal diabetes scores increased 11.7 points (from 14.7% to 26.4%) for intervention physicians and 4.0 points (from 29.7% to 32.9%) for comparison physicians. The improvement was greater for the intervention group. The greatest component improvements were in control of blood pressure and cholesterol. CONCLUSIONS Coaching low-performing physicians dramatically improved the proportion of diabetes patients with optimal diabetes control. The CPR for Diabetes Care program represents an innovative and effective way to address the long-standing problem of disseminating and sustaining quality improvement efforts by focusing on low-performing physicians.

Diabetische Neuropathien: Klinische Manifestationsformen, Früherkennung und Zuweisung zu einem Neurologen

In diabetes mellitus, it is expected to see a common, mainly sensitive, distal symmetrical polyneuropathy (DPN) involving a large proportion of diabetic patients according to known risk factors. Several other diabetic peripheral neuropathies are recognized, such as dysautonomia and multifocal neuropathies including lumbosacral radiculoplexus and oculomotor palsies. In this review, general aspects of DPN and other diabetic neuropathies are examined, and it is discussed why and how the general practitioner has to perform a yearly examination. At the present time, some consensus emerge to ask help from neurologist when faced to other forms of peripheral neuropathies than distal symmetrical DPN.

Changes in Pharmaceutical Treatment of Diabetes and Family Financial Burdens

Recent changes in diabetes treatment guidelines and the introduction of new, more expensive pharmaceuticals appear to increase the financial challenges for nonelderly adults with diabetes. The authors used Medical Expenditure Panel Survey data to examine changes in the prevalence of diabetes and comorbidities, diabetes treatment, financial burdens, and the relationship between high financial burdens and patient characteristics. From 1997-1998 to 2006-2007, the total number of nonelderly adults treated for diabetes nearly doubled, from 5.4 to 10.7 million, and the proportion of diabetes patients using multiple drugs to treat their condition increased significantly. About a fifth of diabetes patients spent 10% or more of their family income on health care, and about one in nine spent 20% or more of their family income on health care. In 2006-2007, diabetes patients who were older, female, in poor health, or lacked insurance were more likely than others to have high burdens.

Abstract P206: Control of Cardiovascular Risk Factors among Diabetic Patients in an Outpatient Setting

Background: Previous studies have shown that cardiovascular risk factors among Hispanic and Black patients with type 2 diabetes are poorly controlled, but no studies have been conducted in Asian American populations. Objective: To examine racial/ethnic differences in control of cardiovascular risk factors in patients with type 2 diabetes across Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese), compared to Non-Hispanic Whites (NHWs) in a multi-specialty healthcare organization in California. Methods: Electronic health records of 12,804 active primary care Asian American (n=4,594) and NHW (n=8,210) patients, ages 35 years and older, with type 2 diabetes were examined from 2007-2009. Diabetes was classified through ICD-9 codes, abnormal laboratory values, or use of anti-diabetic medications. Sex-age directly standardized prevalence rates and multivariate adjusted odds ratios (OR) were calculated for attainment of the following cardiovascular risk factor goals: glycosylated hemoglobin (A1C) &lt; 7%, blood pressure (BP) &lt; 130/80 mmHg, and low-density lipoprotein cholesterol (LDL-C) &lt; 100 mg/dL, and simultaneous control (A1C, BP, and LDL-C). ORs were calculated accounting for race/ethnicity, age, sex, BMI, insurance, and number of clinic visits. Results: The ranges of standardized goal attainment rates among Asian American subgroups and NHWs were as follows: A1C (58.5% in Filipinos to 75.3% in Vietnamese), BP (39.9% in Vietnamese to 53.4% in Chinese), LDL-C (50.3% in Koreans to 65.5% in Asian Indians), and simultaneous control (18.1% in Filipinos to 24.8% in Chinese). After adjusting for patient characteristics, Asian Americans had significantly lower odds of A1C goal attainment (OR=0.76, 95% CI: 0.69-0.85), and higher odds of LDL-C goal attainment (1.17, 1.05-1.29), compared to NHWs. Among Asian subgroups, Asian Indians, Filipinos, Japanese and Koreans had significantly lower odds of goal attainment for A1C, compared to NHWs. Asian Indians (OR= 1.15, 95% CI: 1.01-1.32) and Chinese (1.28, 1.12-1.46) had significantly higher odds of goal attainment for BP, compared to NHWs. Odds of LDL-C goal attainment were also significantly higher for Asian Indians (1.29, 1.11-1.49) and Filipinos (1.19, 1.01-1.39), compared to NHWs. Conclusion: Among our type 2 diabetes patients, Asian Americans have worse control of A1C, despite better control of LDL-C and BP, compared to NHWs. There is also significant heterogeneity in control of cardiovascular risk factors among Asian American subgroups. Optimal simultaneous goal attainment was seen in a small proportion of diabetes patients. Achieving goals for cardiovascular risk factors is difficult and health care providers may need to alter their treatment focus for different racial/ethnic groups.

Is Previous Pregnancy Affected By Diabetes Mellitus Protective against Poor Glycemic Control at the Start of Subsequent Pregnancies?

Aims/hypothesis: Poor glycemic control at conception, a strong risk factor for birth defects, is frequently attributed to low rates of pre-conceptual counseling. The objective of this study was to determine if counseling during a first pregnancy with diabetes improved glycemic control at conception in subsequent pregnancies. Methods: Case controlled. 71 diabetic women previously followed during pregnancy at a single tertiary center were divided into two groups, those with diabetes at the start of a previous pregnancy, and those without. The two groups were compared for glycemic control at conception; hemoglobin A1C ≥ 7 was considered poor control. The two groups were also compared for very poor control (hemoglobin A1C ≥ 9), pre-conceptual counseling, and preconceptual folic acid use. Results: Poor glycemic control at conception was as prevalent in the 29 previous diabetic patients as in the 42 first-time diabetic patients (51.7% vs. 57.1%, p=0.7). There was no difference in the proportion of diabetic patients with very poor control (17.2% vs. 23.8%, p=0.5), pre-conceptual counseling (6.9% vs. 4.8%, p=1.0) and folic acid use (32.1% vs. 31.0%, p=0.9). Conclusions/interpretation: Previous pregnancy affected by diabetes did not improve glycemic control in a subsequent pregnancy. Expanding the counseling these patients receive in our institution should be considered.

Linagliptin as add-on therapy for type 2 diabetes - An overview

The pathogenesis of type 2 diabetes (T2D) can result in decreased levels of glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), which under normal circumstances increase insulin secretion and suppress glucagon release. A new form of drug therapy known as dipeptidyl peptidase 4 (DPP IV) inhibitors has focused on increasing the circulating levels of these "incretin" hormones in order to improve glycemic control in patients with T2D. The DPP IV inhibitors saxagliptin, vildagliptin, linagliptin, alogliptin and sitagliptin function by inhibiting the enzyme DPP IV, which breaks down GLP-1 and GIP, and have had significant success. However, with most DPP IV inhibitors being extensively excreted renally, this is a significant issue, as a large proportion of diabetic patients suffer from renal complications. Linagliptin is a novel DPP IV inhibitor that is excreted primarily by the hepatic route, with little need for dose adjustment in patients with renal impairment. It therefore represents a major advancement in the pharmacotherapy of patients with T2D.

Controlled trial of an intervention to improve cholesterol management in diabetes patients in remote Aboriginal communities

Objectives. Aboriginal communities have a high prevalence of diabetes and heart disease, and limited resources to address them. The objective of this study was to test the effectiveness of prioritizing care with audit and feedback on cholesterol management of diabetic patients.Study design. A controlled before-after intervention trial was conducted among health care providers in Oji-Cree reserves in Sioux Lookout Zone, Ontario. Two communities were randomized to receive an interactive educational workshop and chart audit with feedback on cholesterol management; 2 control communities received usual care.Methods. The primary outcome measure used was the proportion of patients on statins, and the secondary outcome measure was the proportion of patients with LDL>2.5 mmol/L or TC/HDL>4.0 on statins. Outcomes were assessed by chart review at baseline and 10 months post-intervention.Results. Patients in the 2 intervention communities (n=170) and the 2 controls (n=170) were comparable at baseline. The intervention did not increase the proportion of diabetic patients on statins overall or in the subset of patients with elevated cholesterol. The proportion of patients with elevated cholesterol on statins went from 46% to 53% (p=0.48) in the intervention group and from 47% to 50% (p=0.25) in the control group.Conclusions. Audit and feedback listing patients requiring treatment did not increase statin prescription rates in diabetic patients in remote Aboriginal settings. This may be due to elevated baseline rates, the low intensity of feedback and the constraints of the practice environment, such as low staffing and high staff turnover.

Some thoughts on the future of home hemodialysis

Some thoughts on the future of home hemodialysis

Acute Myocardial Infarction in the Evening Has a Worse Prognosis. Circadian Rhythm, Does It Matter?

Refer to the page 616-624 Recently Bae et al.1) reported that hospital presentation of patients with acute myocardial infarction (AMI) in the evening was linked to a higher rate of mortality for twelve months. In addition, congestive heart failure (CHF) was more prevalent in the evening onset of AMI. Therefore, it was concluded that the evening onset of AMI was indirectly related to a worse prognosis due to poor baseline left ventricular (LV) function. A finding consistent with previous reports was that the proportion of diabetes patients was higher in the evening onset of ST segment elevation myocardial infarction (STEMI).2) Since the mode of onset as the dependent variable in the baseline data was not considered, statistical analyses on factors related to evening onsets similar to the previous study were not available.2-4) LV function is the strongest prognostic factor in AMI. It is critical to ascertain the factors which are associated with depressed LV function at the time of hospital presentation.5) Consequently, symptom to door (STD) time or door to balloon time (DBT) should be the first theoretical reference for AMI. However, it is very difficult to define the real onset of AMI using chest pain as an indicator because the elderly, patients with diabetes and females have blunted or atypical symptoms. In this study, an important finding on the quality of care was addressed. DBT was longer in the evening or during off-duty hours. A worse outcome of pre-hospital delay or longer DBT was not observed, even with a higher proportion of STEMI in this study. This is because the effect can be diluted by patients with a very long STD time. STD time, which is pre-hospital time delay in STEMI was 419±573 minutes, which is better compared to the previous result of 699±144 minutes.4) However the large standard deviation is still challenging and the factors related to the pre-hospital time delay in Korea need to be further investigated. The natural course of AMI is inevitably followed by LV failure within a couple of days. As with the progression of infarction, increased wall tension and ischemia may allow the provocation of angina by a vulnerable myocardium resulting in a delayed presentation in the evening. Asymptomatic or neglected onset of AMI in the morning can present as CHF in the evening. Recurrent and gradual or slowly progressive ischemia in the morning may also result in AMI with CHF in the evening. As a pathophysiological perspective, Tanaka et al.6) suggested patients with non-plaque rupture are more likely to present in the evening. Nonetheless, an evening onset of AMI is not necessarily a delayed manifestation by a new onset of LV dysfunction from the morning since pre-existing LV dysfunction or ischemia could provoke ischemic symptoms in the evening. With overtime work, mental stress may aggravate pre-existing CHF in patients who have critical stenosis in the coronary vessel. Consequently, they would suffer from chest pain with a recumbent position in the evening. Other factors associated with an evening onset of AMI such as the reluctance to visit the hospital, poor social or familial support and behavioral factors such as smoking and drinking may be associated with CHF.7) History of CHF and Non-Q wave MI are well known factors linked to the evening onset of AMI.2) In the early 1990s, Kim et al.8) also reported that history of CHF is more frequently noted in the evening onset of AMI in Korean patients. In patients with pre-existing heart failure, limited duration of heart failure medications could also unveil ischemic symptoms in the evening. On the other hand, aspirin or beta-blockers may blunt the symptoms in the morning, potentially leading to pre-hospital delay.2) Hence, from the clinical viewpoint, AMI in the evening warrants a more sophisticated strategy to cope with all of these associated clinical problems. CHF was present in 20-40% of AMI patients on admission and pre-existing heart failure was present in approximately 10% of patients.5) Considering the mechanism of CHF at the onset of AMI and the prognosis, multi-vessel disease with single culprit lesion causing AMI is of particular interest. The net results of revascularization treatment are decided by the summation of the infarcted myocardium and the saved ischemic myocardium. Therefore, not only the quality of care for the culprit lesion but also the results of revascularization on non-culprit vessels may be important for long-term prognosis. As the optimal revascularization strategy for the non-culprit lesions in AMI patients with depressed LV function, outcome of percutaneous coronary intervention versus coronary artery bypass graft needs further study. Unlike previous studies in Western countries, a majority of Asian studies showed a clear double peak circadian rhythm in AMI.3),7),9),10) It is important to investigate whether this difference is due to racial/biologic factors or to socioeconomic factors in order to provide appropriate interventions.

Open study on the topical treatment of interdigital fungal infections in diabetic patients

A high proportion of diabetic patients experience fungal infections, and pharmaceutical strategies have varying success rates. A new alternative method, hydrophobic interaction, may provide a valuable treatment for these infections.

Diabetic Painful and Insensate Neuropathy: Pathogenesis and Potential Treatments

Advanced peripheral diabetic neuropathy (PDN) is associated with elevated vibration and thermal perception thresholds that progress to sensory loss and degeneration of all fiber types in peripheral nerve. A considerable proportion of diabetic patients also describe abnormal sensations such as paresthesias, allodynia, hyperalgesia, and spontaneous pain. One or several manifestations of abnormal sensation and pain are described in all the diabetic rat and mouse models studied so far (i.e., streptozotocin-diabetic rats and mice, type 1 insulinopenic BB/Wor and type 2 hyperinsulinemic diabetic BBZDR/Wor rats, Zucker diabetic fatty rats, and nonobese diabetic, Akita, leptin- and leptin-receptor-deficient, and high-fat diet-fed mice). Such manifestations are 1) thermal hyperalgesia, an equivalent of a clinical phenomenon described in early PDN; 2) thermal hypoalgesia, typically present in advanced PDN; 3) mechanical hyperalgesia, an equivalent of pain on pressure in early PDN; 4) mechanical hypoalgesia, an equivalent to the loss of sensitivity to mechanical noxious stimuli in advanced PDN; 5) tactile allodynia, a painful perception of a light touch; and 5) formalin-induced hyperalgesia. Rats with short-term diabetes develop painful neuropathy, whereas those with longer-term diabetes and diabetic mice typically display manifestations of both painful and insensate neuropathy, or insensate neuropathy only. Animal studies using pharmacological and genetic approaches revealed important roles of increased aldose reductase, protein kinase C, and poly(ADP-ribose) polymerase activities, advanced glycation end-products and their receptors, oxidative-nitrosative stress, growth factor imbalances, and C-peptide deficiency in both painful and insensate neuropathy. This review describes recent achievements in studying the pathogenesis of diabetic neuropathic pain and sensory disorders in diabetic animal models and developing potential pathogenetic treatments.

Secondary prevention of diabetic patients with coronary artery disease in cardiac rehabilitation: risk factors, treatment and target level attainment

ABSTRACTIntroduction: Diabetic patients who have suffered from an acute coronary syndrome (ACS) or have had coronary artery bypass graft (CABG) surgery are at very high risk of recurrent cardiovascular events. Their prognosis, however, can be improved if the target values for blood pressure (BP < 130/80 mmHg) or low density lipoprotein cholesterol [LDL-C < 2.6 mmol/L (100 mg/dl), optionally < 1.8 mmol/L (70 mg/dl)] are achieved. It is not known what proportion of diabetic patients receives such stringent secondary prevention measures and achieves target level attainment for BP, lipids and glucose in cardiac rehabilitation (CR).Methods: During 2003 to 2005, 11 973 diabetic (29.7%) and 28 370 non-diabetic patients (70.3%), predominantly after ACS (74 and 80%), were included in a nationwide registry. At entry and at discharge, patient characteristics, pharmacotherapy and blood pressure, lipids and blood glucose were recorded. In a mixed model approach, temporal changes between centres and within centres, respectively, were analysed.Results: At discharge, a lower proportion of diabetic patients achieved normalisation of BP (in 2005: <140/90 mmHg: 78.4 vs. 82.9% in non-diabetic patients, p < 0.001) or <130/80 mmHg (45.5 vs. 49.8%), respectively. LDL-C < 2.6 mmol/L was more frequently attained in diabetic patients (68.2 vs. 66.5%), as was LDL-C < 1.8 mmol/L (28.8 vs. 23.0%). Fasting blood glucose was not changed during the observation period, as at discharge almost a quarter of all diabetic patients exceeded the threshold value of 7.0 mmol/L (126 mg/dl). In 2005 at discharge, statin therapy was administered in 93% in both diabetics and non-diabetics, acetylic salicylic acid in 79% in diabetics vs. 80% in non-diabetic patients (clopidogrel: 41 vs. 45%).Conclusion: Generally there is room for improvement in the management of cardiac risk factors for both patients groups. In diabetic patients in CR at high risk for recurrent cardiac events, in recent years an improvement of the lipid profile has been observed. Hypertension and glycaemia are still not optimally addressed.

The Quandary of Improving Hypertension Control in Diabetes

Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP: The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med 148: 717-727,2008 [OpenUrl][1][PubMed][2][Web of Science][3] Design. A prospective cohort study examining what proportion of diabetic patients with a triage blood pressure > 140 mmHg systolic or 90 mmHg diastolic received a treatment change during a single routine visit and to what extent certain provider and patient factors influenced the likelihood of change. Subjects. The study included 1,169 diabetic patients with elevated blood pressure treated by 92 primary care providers at nine Veterans Affairs facilities in three Midwestern states over 13 months. Patients were older (mean age 66 years) and were primarily male (97%) and white (80%). The mean systolic blood pressure was 154 mmHg (standard deviation: 113-228). Methods. The main outcome was the proportion of patients who had either intensification of blood pressure medication or a planned follow-up visit within 4 weeks. Data were obtained from patient surveys, provider surveys, medical records, and VA automated sources. Factors hypothesized to influence the likelihood of change were analyzed in a logistic regression model that assessed four categories of variables: clinical uncertainty; competing demands and prioritization of comorbid conditions; medication issues; and practice organizational characteristics. Results. A total of 573 (49%) patients with a triage blood pressure > 140 mmHg systolic or 90 mmHg diastolic had a treatment change: 511 had medications changes, and 62 had a plan for follow-up blood pressure measurement within 4 weeks. The likelihood of treatment change increased markedly as systolic and diastolic blood pressure increased. Providers were less likely to change medication if repeat blood pressure measurement was < 140/90 mmHg (13 vs. 61%, P < 0.001) or if the patient reported a home … [1]: {openurl}?query=rft.jtitle%253DAnnals%2Bof%2BInternal%2BMedicine%26rft.stitle%253DANN%2BINTERN%2BMED%26rft.issn%253D0003-4819%26rft.aulast%253DKerr%26rft.auinit1%253DE.%2BA.%26rft.volume%253D148%26rft.issue%253D10%26rft.spage%253D717%26rft.epage%253D727%26rft.atitle%253DThe%2BRole%2Bof%2BClinical%2BUncertainty%2Bin%2BTreatment%2BDecisions%2Bfor%2BDiabetic%2BPatients%2Bwith%2BUncontrolled%2BBlood%2BPressure%26rft_id%253Dinfo%253Apmid%252F18490685%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=18490685&link_type=MED&atom=%2Fdiaclin%2F26%2F4%2F158.atom [3]: /lookup/external-ref?access_num=000256372200001&link_type=ISI

Trends in cardiovascular risk factors and lifestyle behaviors among Spanish adults with diabetes (1993–2003)

Previous studies have observed high prevalences of high blood pressure (HBP), high blood cholesterol (HBC), obesity, and sedentary lifestyle among Spanish diabetic adults. These cardiovascular risk factors and unhealthy lifestyle behaviors occur more often in subjects with diabetes than in the general population. The aim of this study was to examine the trends in cardiovascular risk factors and lifestyle behaviors among Spanish adults with diabetes over the decade 1993–2003. Methods We used individualized data drawn from the 1993 ( N=20,880) and 2003 ( N=21,650) Spanish National Health Surveys. Subjects were classified as diabetes sufferers if they answered affirmatively to either or both of the following questions: “Has your doctor told you that you are currently suffering from diabetes?” and/or, “Have you taken any medication to treat diabetes in the last two weeks?” Cardiovascular risk factors analyzed included self-reported HBP and HBC. Lifestyle behaviors included obesity (body mass index ≥30), smoking status, and physical activity. We estimated and compared the prevalences and analyzed the time trends using logistic regression models. Results In both years studied, the prevalence of obesity and sedentary lifestyle was significantly higher among persons with than among those without diabetes, and current smoking was less frequent. The proportions of diabetes patients with HBP and obesity increased significantly from 39.5% and 20.1% in 1993 to 46.7% and 29.8% in 2003, with adjusted odds ratios of 1.32 (95% CI 1.07–1.62) for HBP and 1.88 (95% CI 1.44–2.46) for obesity. Conclusions The overall prevalence of cardiovascular risk factors and unhealthy lifestyle behaviors among diabetes patients has shown no improvement in the decade 1993–2003, and there have been significant setbacks, in particular the rise in obesity and HBP.