Complicações macrovasculares do diabetes melito: peculiaridades clínicas, de diagnóstico e manejo / Macrovascular diabetic complications: clinical characteristics, diagnosis and management

O diabetes melito (DM) é um fator de risco independente para doença arterial coronariana, acidente vascular cerebral, doença vascular periférica e insuficiência cardíaca, que são as principais causas de morte nesses pacientes. Além disso, pacientes com DM e doença cardiovascular têm pior prognóstico, por apresentarem menor sobrevida, maior risco de recorrência da doença e pior resposta aos tratamentos propostos. Os avanços diagnósticos e terapêuticos das últimas décadas já mostram uma redução do risco de eventos cardiovasculares nesses pacientes, mas o risco absoluto desses é ainda duas vezes maior em relação ao dos pacientes não diabéticos. Portanto, é prioritária a adoção de um manejo intensivo, com controle rígido dos fatores de risco cardiovasculares. Esta revisão trata das principais características clínicas e apresenta uma abordagem prática do rastreamento, diagnóstico e tratamento da doença macrovascular nos pacientes com DM.

Diabetes mellitus (DM) is an independent risk factor for coronary heart disease, stroke, peripheral arterial disease and heart failure, which are the main causes of death in these patients. Moreover, patients with DM and cardiovascular disease have a worse prognosis than nondiabetics, present lower short-term survival, higher risk of recurrence of the disease and a worse response to the treatments proposed. In the last decades, diagnostic and therapeutic progress had already shown benefits concerning cardiovascular risk reduction in these patients, but their absolute mortality risk is still twice that of non-diabetic patients. Because of this, the adoption of intensive treatment, with strict cardiovascular risk factor control, is a priority. The present study presents the main clinical characteristics and also the practical approach for screening, diagnosis and treatment of patients with diabetic macrovascular disease.

Necesidad de nueva revascularización coronaria en pacientes diabéticos tratados con stents no recubiertos / New coronary revascularization in diabetics patients treated with bare metal stent

Antecedentes: Los pacientes diabéticos tratados con angioplastía coronaria (AC) poseen un mayor riesgo de reestenosis y por lo tanto de reintervención en comparación a los no diabéticos, lo que ha derivado en una mayor utilización de stents recubiertos con drogas en este grupo de pacientes. Objetivo: Analizar la incidencia de reintervención en pacientes diabéticos no seleccionados sometidos a una AC con stent no recubierto en el Hospital Regional de Concepción e identificar los predictores de la reintervención. Método: Entre Enero 2005 y Diciembre 2006, 571 pacientes fueron sometidos AC, de los cuales 108 (19 por ciento) eran diabéticos. En este grupo estudiamos sus características clínicas, factores de riesgo y los factores angiográficos tales como el vaso tratado, diámetro, longitud y número de stents. Mediante un seguimiento telefónico y de ficha clínica se determinó la existencia o no de una reintervención coronaria. Identificado elgrupo con reintervención coronaria, comparamos las variables clínicas y angiográficas y a través de un modelo de regresión logística se buscó identificar predictores de dicha intervención. Se utilizó t de student y test exacto de Fisher. Resultados: La edad promedio fue 61±10 años, 71(66 por ciento) hombres y 25 por ciento insulinorequirientes 47(44 por ciento) pacientes tenía dislipidemia, 93(86 por ciento) hipertensión y 26(25 por ciento) eran fumadores. La AC fue en contexto de un SCA s/SDST en 56(52 por ciento) pacientes, 38 (35 por ciento) por IAM en evolución y 12(11 por ciento) por angina estable. Se implantaron 138 stents (1,3 stent/pt) y fue exitosa en el 96 por ciento. En el seguimiento de 13,7 ±7 meses la mortalidad fue 4,6 por ciento y sólo 12(11 por ciento) pacientes fueron sometidos a una nueva revascularización, 75 por ciento de las cuales fue otra AC. De las reintervenciones, sólo 4(33 por ciento) pacientes tenía reestenosis, el resto fue por lesiones en otro vaso. La distribución de los factores de riesgo...

Diabetes mellitus is associated to a more severe and extensive coronary artery disease. Coronary angioplasty (PTCA) has been demonstrated to have similar immediate results compared with patients without diabetes; however, diabetic patients exhibit a higher rate of restenosis and target lesion revascularization. Aim: to study the real incidence of a new interventional procedures in diabetics patients who were treated with bare metal stents. Methods: From January 2005 to December 2006, 571 patients were submitted to PTCA at the Hospital Regional de Concepcion. 108 patients (195) were diabetics. Clinical characteristics, risk factors, and angiographic findings were tabulated. Telephone follow up was used to determine the performance of coronary re intervention. A logistics regression model was used to identify predictors of coronary re intervention. Results: The mean average age was 61±10 years, 66 percent were men and 25 percent required insulin treatment. Dyslypidemia was present in 86 percent, hypertension in 86 percent and 25 percent were smokers. Indication for PTCA was acute coronary syndrome in 52 percent, myocardial infarction in 35 percent and stable angina in 11 percent. They received 1,3 stents/pts and immediate success rate was 96 percent. During follow up (13,7±7 months) global mortality was 4,6% and only 12 (11 percent) patients had a second revascularization procedure, 67 percent of them performed in non stentedcoronary arteries. Four revascularizations (33 percent) were due to significant in-stent restenosis, seven (58 percent) to other significant lesions and 1 to subacute stent thrombosis. In the univariate and multivariate analysis we didnot find independent clinical or angiographic factors as predictors of new revascularization. However, it wasmore frequent in patients with proximal left anterior descending artery stents and long lesions (58 percent and 50 percent, respectively). Conclusion: In our experience, need for repeat...

Angioplastia con stents liberadores de rapamicina en diabéticos tipo 2: Experiencia del Hospital DIPRECA / Angioplasty stenting with Sirolimus (Rapamycin) eluting stents in type 2 diabetic patients

Background: Drug-eluting stents have been developed to reduce the rates of restenosis after coronary angioplasty. Several studies have demonstrated that rapamycin eluting stents are reliable and effective. Aim: To report the experience in our Health Centre with rapamycin-eluting stents. Patients and methods: Forty two stents with rapamicine were implanted to 32 diabetic patients, between June 2002 and December 2004. After the procedure, subjects were clinically followed-up for an average period of 19.9+9.9 months, evaluating functional capacity, angina pectoris, dyspnea, need for hospital admission, acute coronary events and cardiac death. In those subjects clinically suspected to have restenosis, a coronary angiography was performed. Results: Twenty-nine subjects (90.6 percent) remained asymptomatic, two subjects (6.3 percent) developed angina pectoris but restenosis was ruled out, and one subject (3.1 percent) died. Conclusions: The use of rapamycin-eluting stents in these patients was safe and successful with no evidence of clinic restenosis. These positive results are similar to those reported in the Diabetes Study.

Fluoroscopy guided chemical lumbar sympathectomy for lower limb ischaemic ulcers.

The purpose of this study was to assess the effectiveness of chemical lumbar sympathectomy in relieving pain and healing ischaemic ulcers in patients with peripheral vascular diseases. Thirty-one consecutive patients with ischaemic/ gangrenous lower limb ulcers, referred to the BPKIHS, Pain Clinic were observed prospectively after chemical lumbar sympathectomy using modified Reid Technique with 3 ml of 70% alcohol each at L2 and L3 level under fluoroscopic guidance. Pain relief and ulcer healing were noted in the follow up. Moreover, patients' abilities to resume at least part of their day to day work were also noted at three months follow up. Of the total 31 patients, 16 had Buerger's disease and the remaining 15 had non-Buerger's ischaemic ulcers of which 7 were diabetic. There was significant decrease in the pain score from mean+/-SD of 8.3+/-0.9 (pre-block) to 4.2+/-2.5 (post-block after 3 days) in zero to 10 Numerical Analogue Scale (NAS). By 3 months, 6 patients declined for follow up; 19(76%) of the remaining 25 patients reported pain relief, 18(72%) reported healing or decrease in the size of ulcers and 11(44%) were able to resume at least part of their usual work. Minor complications occurred in 5 patients and amputation was needed in 6 patients. Fluoroscopy- guided chemical lumbar sympathectomy is feasible, safe and effective in relieving pain and promoting ulcer healing in patients with ischaemic lower limb ulcers due both to Buerger's disease and non-Buerger's peripheral vascular diseases.

A microcirculação no diabetes: implicações nas complicações crônicas e tratamento da doença / Microcirculation in diabetes: implications for chronic complications and treatment of the disease

A microangiopatia diabética ainda é responsável por importante taxa de morbidade e mortalidade relacionada à doença. O dano endotelial parece ser o fator desencadeante na patogênese das complicações microvasculares. O diabetes mellitus e outras doenças metabólicas estão associados à disfunção endotelial, que é o marcador mais precoce conhecido da aterosclerose. Alterações da reatividade microvascular estão presentes tanto em portadores de diabetes mellitus quanto em indivíduos com fatores de risco para essa doença. A avaliação das funções endotelial e microvascular é possível através de diferentes métodos invasivos ou não. O controle adequado do diabetes mellitus é capaz de retardar ou talvez mesmo prevenir a doença microvascular. A disfunção microvascular, quando expressa somente por alterações da reatividade microvascular, pode ser melhorada com a correção de fatores de risco ou uso de drogas.

Diabetic microangiopathy is responsible for an important rate of morbidity and mortality related to the disease. Endothelial damage seems to be the triggering factor in the pathogenesis of microvascular complications. Diabetes mellitus and other metabolic diseases are associated to endothelial dysfunction, the most precocious known marker of atherosclerosis. Changes on microvascular reactivity are present in patients with diabetes mellitus, as well as in individuals with risk factors for this disease. Evaluation of endothelial and microvascular functions is possible using different invasive or preferentially non-invasive methods. Adequate control of diabetes mellitus might postpone or perhaps even prevent the microvascular disease. Microvascular dysfunction, when seen only by changes on microvascular reactivity, could be ameliorated with correction of risk factors or drug treatment.

Estado atual do tratamento da coronariopatia crônica em pacientes diabéticos: evidências e controvérsias baseadas em ensaios clínicos / State-of-the-art in the treatment of chronic coronariopathy in diabetic patients: evidences and controversies based in clinical trials

Diabetes mellitus é um dos principais fatores de risco para a doença arterial coronária. A doença progride de forma mais acelerada em pacientes diabéticos e está associada com pior prognóstico. Embora a revascularização miocárdica garanta alívio rápido dos sintomas em pacientes com doença arterial coronária documentada, não existe substancial evidência de benefício prognóstico, salvo em situações anatômicas específicas. Adicionalmente, o benefício das terapias de revascularização é atenuado pela presença de anormalidades metabólicas secundárias à resistência à insulina e significantes co-morbidades. Nos últimos anos, avanços na terapêutica clínica (estatinas, antiplaquetários potentes, novos anti-hipertensivos) e técnicas de revascularização cirúrgica e percutânea ocorreram, sendo que o emprego de stents farmacológicos parece ser uma promissora opção terapêutica nesses pacientes. A estratégia de tratamento do paciente diabético com coronariopatia crônica deve levar em consideração a patogênese multifatorial da doença e visar uma intervenção agressiva do controle dos níveis glicêmicos e de todos os fatores de risco modificáveis, aliada à mudança no estilo de vida. Os efeitos não-metabólicos dos sensibilizadores de insulina sobre a vasculopatia e mortalidade nesses pacientes também estão em discussão. Estudos clínicos em andamento deverão definir o impacto das novas modalidades terapêuticas sobre o prognóstico dos pacientes diabéticos.

Diabetes mellitus is a powerful risk factor for coronary artery disease. Diabetics demonstrate accelerated coronary atherosclerosis and worst prognosis following cardiac events. Although myocardial revascularization procedures result in more effective relieve of symptoms in patients with known coronary artery disease, there is no substantial evidence that this strategy improves outcome, except for specific situations. In addition, the benefit of myocardial revascularization is attenuated by the presence of metabolic abnormalities related to insulin resistance and other significant co-morbidities in diabetic patients. New advances recently developed for the clinical treatment of diabetes, as well as surgical and percutaneous approaches of myocardial revascularization, such as drug-eluting stents, seem to be promising therapeutical strategies for diabetic patients. Most importantly, treatment of type 2 diabetics with chronic coronary artery disease should consider the multifactorial pathogenesis of the disease and combine aggressive control of glycemic levels, strict management of all conventional risk factors, and lifestyle modification. The metabolic effects of insulin sensitizers over cardiovascular disease and mortality are under discussion. Ongoing clinical multicenter trials will probably define the real impact of new therapeutic modalities over the prognosis of diabetic patients.

Intervenção coronária percutânea no diabetes mellitus: análise da prática médica atual / Percutaneous coronary intervention in diabetes mellitus: an updated analysis of medical practice

Os pacientes com diabetes e cardiopatia isquêmica são freqüentemente considerados para a realização de revascularização miocárdica com o objetivo de diminuição do risco de eventos cardiovasculares ou melhora da qualidade de vida. Na prática clínica, as decisões quanto à realização de cirurgia ou intervenção coronariana percutânea são freqüentemente difíceis, devido à gravidade dos casos, extensão da doença e presença de co-morbidades. Além disso, a maioria dos dados disponíveis na literatura origina-se da análise de subgrupos de ensaios clínicos delineados para estudos da população em geral, não para diabéticos. O objetivo deste estudo foi revisar a literatura quanto à intervenção coronária percutânea em pacientes com diabetes, além de mostrar dados mais recentes dos resultados deste procedimento no Serviço de Hemodinâmica do Instituto de Cardiologia do RS.

Patients with diabetes and coronary artery disease are frequently considered for myocardial revascularization procedures, aiming at cardiovascular events risk reduction and a better quality of life. In clinical practice, decisions concerning surgery or percutaneous coronary intervention are frequently difficult, because of cases' severity, disease extension and co-morbidities association. Beyond that, the bulk of literature information was generated by subgroup analysis of randomized clinical trials, which were designed for the general population, not for diabetics. The aim of this study was to review literature on coronary percutaneous intervention in diabetic patients, and also to show recent data from the experience in this procedure at the Catheterization Laboratory of the Cardiology Institute of RS.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Diabetics with Multivessel Coronary Artery Disease: The Korean Multicenter Revascularization Registry (KORR)

This study was designed to assess the relative merits of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD), particularly for Korean diabetics. Among 3,279 patients with MVCAD who were recommended for revascularization were enrolled from nine centers in Korea, 2,154 were selected after statistical adjustments for the disparities between two groups. Survival rates were not significantly different for three years between two groups. Among diabetic patients, the three-year mortality rate in PCI group was 1.9-fold higher than that of CABG group, although it was not statistically significant (PCI 19.8%, CABG 11.4%, p=0.14). The three-year mortality rate was similar between the two groups in non-diabetics (PCI 8.3%, CABG 10.0%, p=0.50). The 30-day rate of cerebrovascular event was higher in CABG group, for both diabetic (CABG 3.6%, PCI 0.0%, p<0.001) and non-diabetic patients (CABG 2.4%, PCI 0.0%, p<0.001). Short- and long-term revascularization rates were higher in PCI group than in CABG group. As a conclusion, this Korean registry demonstrates that PCI was associated with comparable survival rates and lower short-term morbidity, but a greater requirement for repeated revascularization compared with CABG in Korean diabetics.

One-year follow-up after primary coronary intervention for acute myocardial infarction in diabetic patients. A substudy of the STENT PAMI trial

OBJECTIVE - This analysis was undertaken to determine the composite incidence of cumulative adverse events (death, reinfarction, disabling stroke, and target vessel revascularization) at the end of the first year after acute myocardial infarction, in diabetic patients who underwent coronary stenting or primary coronary balloon angioplasty. METHODS - From the STENT PAMI trial, we analyzed the 6-month angiographic and 1-year clinical outcomes of 135 diabetic (112, noninsulin dependent) patients who underwent the randomization process of the trial and compared them with 758 nondiabetic patients. RESULTS - Coronary stenting did not significantly reduce the primary composite clinical end point when compared with PTCA (20 vs. 30 percent, p=0.2). A significant benefit from stenting was observed in patients with noninsulin dependent diabetes, with a trend toward a lesser need for new revascularization procedures (10 vs. 21 percent, p<.001), with a significant reduction in the primary composite clinical end point at 1 year (12 vs. 28 percent, p=. 04). At 6 months, the restenosis rate were significantly reduced only in nondiabetic patients (18 vs. 33 percent, p<. 001). Diabetic patients had the same restenosis rate (38 percent) either with stenting or balloon PTCA. CONCLUSIONS - Coronary Stenting in diabetics noninsulin dependent offered a significant reduction in the composite incidence of major clinical adverse events compared with balloon PTCA

Estudio comparativo de la angioplastia coronaria en pacientes con diabetes: resultados clínicos y angiográficos inmediatos y evolución clínica en el primer año / Comparative study of coronary angioplasty in diabetic patients: clinical and angiographic results and clinical evolution at 1 year of follow up

Background: The success of revascularization procedures for coronary artery disease could be lower in diabetic patients. Aim: To report the results of coronary angioplasty in diabetic and non diabetic patients. Patients and methods: All angioplasty procedures performed between 1996 and 1999 were recorded. Demographic data, procedure details, hospital outcome and evolution at one year of follow up were analyzed. Results: During the study period, 358 patients were treated; of these, 79 were diabetics. Despite the greater severity of coronary lesions among diabetic patients the clinical success of the procedure was 92.4 percent in diabetics and 91.8 percent in non diabetics. Hospital mortality was 1.3 pecent in diabetics and 0.7 percent in non diabetics. Major complications occurred in 3.8 percent of diabetics and 3.2 percent in non diabetics. One year survival was 95.9 percent for diabetics and 98 percent in non diabetics. There were five late cardiac deaths among non diabetics and 3 among diabetics during the year of follow up. The frequency of new revascularization procedures was 4.3 percent in diabetics and 8.3 percent in non diabetics. Event-free survival was 95.6 percent in diabetics and 89.2 percent in non diabetics. Conclusions: Results of angioplasty were similar in diabetic and non diabetic patients in terms of hospital outcome and late follow-up

Musculo y diabetes: ensayo preliminar con captopril / Muscle and diabetes: preliminary essay with captopril

Se estudiaron 7 pacientes diabéticos tipo I con el fin de establecer las características de los capilares y las fibras del músculo esquelético, y el efecto de la administración durante 8 semanas del inhibidor de la enzima convertidora Captopril. Se mantuvo a los pacientes con el mismo tratamiento que tenían. Se midieron los niveles de hemoglobina glucosilada al comienzo y a los 3 meses de iniciar el estudio. Se tomó biopsia del músculo cuadrícepts para análisis con microscopía de luz y electrónica. El grupo experimental recibió el Captopril en dosis de 12,5 mg cada 12 horas, a diferencia del grupo control que no recibió nada adicional al tratamiento de la diabetes. La biopsia muscular se repitió después de 8 semanas. En ambos grupos se observó un aumento de la capacidad oxidativa de las fibras musculares mediante la reacción histoquímica de la diaforasa de la nicotinamida adenina denucleótido reducido. Los capilares musculares alterados no se modificaron en su morfología y hubo una tendencia a la disminución del índice capilar por fibra. Los niveles de hemoglobina glucosilada disminuyeron en los dos grupos, por lo cual los resultados no se pudieron atribuir solamente al Captopril

Pie diabético: criterios de prevención, diagnóstico y tratamiento desde el punto de vista ortopédico / Diabetic foot: criterions of prevention, diagnosis and treatment from the Orthopedic point of view

Se realizó el tratamiento quirúrgico, por lesiones en los pies, a 76 pacientes diabéticos en el hospital Angel C. Padilla, durante un período comprendido entre los meses de julio de 1993 a octubre de 1994, fueron intervenidos quirúrgicamente 52 varones y 26 mujeres, se realizaron 84 cirugías mayores y 184 menores, correspondiendo a 3.4 operaciones por paciente, tuvieron un tiempo promedio de internación de 32.8 días, siendo el total de días de internación, en este período de 2495 días. El tiempo promedio de diagnóstico de la enfermedad fue de 11.7 años y el tiempo de evolución de las lesiones hasta que se comenzó con el tratamiento fue de 60 días. Se actualizan los criterios adoptados en el manejo de estos pacientes, respecto a la urgencia, a las lesiones específicas, tipos de amputaciones, determinación biológica del nivel de amputación y el impacto sobre la calidad de vida. Esta actualización es el resultado de la acción de la UNIDAD DE PIE DIABETICO creada en nuestro hospital y que reúne a especialistas en Endocrinología, Clínica Médica, Infectología, Cirugía Vascular, Traumatología y Ortopedia, Enfermería, Rehabilitación y Podología. En esta labor surge como imprescindible : 1. La necesidad de implementar un programa de educación continua a pacientes y familiares, 2. Posibilitar un manejo intensivo en consultorio externo incluyendo la habilitación de un quirófano para pacientes ambulatorios. Esta es una solución a considerar a fin de evitar el excesivo tiempo de internación para mejorar el rendimiento y disminuir gastos.

Mano diabética: evaluación clínica y alternativas de tratamiento / Diabetic hand, clinical evaluation and treatment alternatives

Durante años se ha manejado el concepto de "pie diabético" para agrupar las complicaciones vasculares que se presentan en las extremidades inferiores, en esta publicación, hacemos énfasis en dichas complicaciones pero a nivel de extremidades superiores, que aunque en frecuencia son mucho menores, no dejan de tener importancia en la repercusión hemodinámica del paciente. Se revisaron las publicaciones nacionales e internacionales sobre este tipo de complicaciones y no encontramos una con un número tan extenso de pacientes por lo cual lo consideramos de relevante importancia. Se presentan los casos clínicos de pacientes diabéticos con lesiones cruentas, de diversas etiologías en extremidades superiores acompañadas de un fondo isquémico, secundarias a macro y microangiopatía diabética. Los 18 casos correspondieron a pacientes institucionales derechohabientes del IMSS y de consulta privada. Dos casos correspondieron a lesiones por quemaduras eléctricas, tres a quemaduras por químicos álcalis o ácidos, un caso secundario o mordedura de gato. Los demás pacientes presentaron un trauma mínimo acompañado de infección y/o necrosis. Se revisan los tratamientos tópicos actuales para valorar la utilidad de las mismas empleando los que consideramos de actualidad, aprobados por los servicios de Angiología, se agruparon a los pacientes en tres grupos empleando para ello, los dextranómeros, el apósito hidrocoloide oclusivo y la ketaserina en gel. Esta última fue útil por su fácil manejo, costo reducido y disminución del tiempo de curación de los pacientes en sus áreas cruentas empleando para ello un lapso de cinco semanas para su curación completa. En relación a las otras sustancias tópicas fue más eficaz y no se presentaron complicaciones adversas en su manejo. Muchas úlceras vasculares son resultado de trastornos circulatorios tanto venosos como arteriales. El éxito de un tratamiento depende del diagnóstico correcto y de la atención específica a los problemas de predisposición, así como del eficaz cuidado de la zona afectada

Revascularización inframaleolar con bypass de safena in situ / Lower limb revascularization with saphenous vein bypass

Este reporte es de revascularización arterial de miembros inferiores de tres pacientes para salvataje de isquemia severa de miembros usando bypass con safena mayor no reversa (in situ) hasta el nivel de arterias pedias sin usar microscopio ni cateter para valvulotomía. Nosotros aprovechamos las colaterales naturales de la safena mayor e interpusimos segmentos de vena safena reversa colateral como parte de un bypass compuesto. Al momento la patencia de los bypass es buena y permitió salvar los tres miembros. Estas operaciones han sido realizadas por el Servicio de Cirugía de Tórax y Cardiovascular del Hostipal Nacional "Almenzor Aguinaga Asenjo", del IPSS, Chiclayo, Perú; desde el 6. Julio. 92

Hyperbaric oxygen therapy in diabetic foot.

To study the effect of hyperbaric oxygen therapy in chronic diabetic foot lesions, a prospective controlled study was undertaken. Thirty diabetics with chronic foot lesions were randomised to study group (conventional management and 4 sessions of hyperbaric oxygen therapy) and control group (conventional management). The patients were assessed for average hospital stay, control of infection and wound healing. The control of infection spread was quicker. Positive cultures decreased from initial 19 to 3 in study group as against from 16 to 12 in the control group. (p < 0.05). This difference was most pronounced for Escherichia coli. Also, the need for major amputation was significantly less in the study group (n = 2) as against the control group (n = 7) (p < 0.05). The average hospital stay was not affected. We conclude that hyperbaric oxygen therapy can be safely used and is beneficial as an adjuvant therapy in chronic diabetic foot lesions.

Tratamiento prehipoglicemiante modificado en los pacientes con pie diabético neuroinfeccioso / Modified prehypoglycemic treatment in patients with neuroinfectious diabetic foot

Se evalúan los resultados del tratamiento insulínico prehipoglicemiante modificado (TIPHM) en el pie diabético neuroinfeccioso de 20 pacientes afectos, sin predominio macroangiopático, se comparan con un grupo control que recibió tratamiento insulínico tradicional. Fue significativo el mejor resultado final con el TIPHM pues el número de egresados sin mutilaciones aumentó del 40 al 56 %, las mismas disminuyeron, principalmente las mayores, del 30 al 10 %. El 95% de los pacientes egresados con un control glicémico muy bueno o bueno, cuando se cumplió el TIPHM, mejoró además el tiempo promedio en obtener el control en 1,3 dias. El problema de estadía decreció significativamente

Diabetic heart disease--current problems and their management.

Diabetic heart disease (DHD) is one of the most important contemporary management problems confronting the entire diabetic management team. DHD is multifactorial and multifaceted. The three major problems are: coronary artery disease (CAD), autonomic cardiac denervation and a specific heart muscle disease in diabetes (diabetic cardiomyopathy). Various other ancillary problems include obesity, hypertension, lipid aberrations and rheological alterations etc. CAD and diabetes mellitus (DM) have a greater association; the disease is more severe, sets in early and has many atypical features including painless, silent onset, delayed arrival at intensive coronary care unit, increased incidence of pump failure and arrhythmias and high case fatality rate. Autonomic cardiac denervation is an important and a common companion of diabetic peripheral neuropathy and has serious repercussions in DHD. Simple, sensitive screening tests may identify such a group so as to exercise caution in management. Various clinical (non-invasive, invasive and autopsy) and experimental studies provide evidence for the existence of a specific diabetic heart muscle disease comprising of small vessel disease and metabolic aberrations. Recent advances in literature and our own experience are reviewed. The practical management aspects of each facet, such as maintenance of high index of suspicion, early diagnosis and referral, close monitoring, role of rigid blood glucose control and specific role of each member of the diabetic team is outlined. The possible preventative strategies are discussed.