New insights into the pathogenesis of diabetic retinopathy--hormonal rather than metabolic factors are important.

Diabetic retinopathy has traditionally been viewed as a metabolite-driven, occlusive vasculopathy that affects both retinal microvascular haemodynamics and stricture; analogies to cholesterol-driven occlusive atherosclerosis of the macrovascular circulation were drawn. However this paradigm may no longer be appropriate. Recent evidence suggests that diabetic retinopathy from the beginning is the consequence of a complex hormonal dysfunction, which is related to insulin-dependent up- and downregulation of growth factors, to which metabolic, haemodynamic, endocrine, paracrine, and autocrine mechanisms contribute.

Outcome of critical foot ischaemia in longstanding diabetic patients: a retrospective cohort study in a specialised tertiary care centre.

BACKGROUND: We sought to establish risk factors predicting the outcome of foot lesions in longstanding diabetic patients with critical foot ischaemia (CFI). PATIENTS AND METHODS: We investigated retrospectively 98 consecutive diabetic patients with ischaemic foot lesions. The patients (mean age 70 years, duration of diabetes 21 years) were jointly cared for by specialised diabetologists and vascular surgeons; 75 patients were treated by arterial revascularisation. RESULTS: Good outcome (lesions healing) was observed in 53 patients (54%). Bad outcome was observed in 45 patients: not healing lesions (n = 5), major amputation (n = 19), and death in relation to the foot lesion (n = 21). Patients with good and bad outcome did not differ regarding age, sex, smoking status, type, duration and treatment of diabetes mellitus, presence of neuropathy, coronary heart disease, stroke, previous amputations, current revascularization, and localization of the foot lesion. The risk of bad outcome was increased 8.9 times in patients on dialysis for end-stage renal disease; 7.0 times if surgical complications were present; and 5.4 times with C-reactive protein (CRP) above the second quintile (cut-off value 8 mg/dl). CONCLUSION: Management of longstanding diabetic patients with ischaemic foot lesions leaves room for improvement. Dialysis treatment, elevated CRP levels and surgical complications were strongly predictive of non-healing lesions, major amputation and death.