Frequency of chronic complications of type II diabetes

Physiopathological Role of Neuroactive Steroids in the Peripheral Nervous System

Peripheral neuropathy (PN) refers to many conditions involving damage to the peripheral nervous system (PNS). Usually, PN causes weakness, numbness and pain and is the result of traumatic injuries, infections, metabolic problems, inherited causes, or exposure to chemicals. Despite the high prevalence of PN, available treatments are still unsatisfactory. Neuroactive steroids (i.e., steroid hormones synthesized by peripheral glands as well as steroids directly synthesized in the nervous system) represent important physiological regulators of PNS functionality. Data obtained so far and here discussed, indeed show that in several experimental models of PN the levels of neuroactive steroids are affected by the pathology and that treatment with these molecules is able to exert protective effects on several PN features, including neuropathic pain. Of note, the observations that neuroactive steroid levels are sexually dimorphic not only in physiological status but also in PN, associated with the finding that PN show sex dimorphic manifestations, may suggest the possibility of a sex specific therapy based on neuroactive steroids.

Sex-based differences and aging in tactile function loss in persons with type 2 diabetes

BACKGROUND

Recent evidence of significant sex-based differences in the presentation of Type 2 Diabetes Mellitus (DM) and its complications has been found in humans, which may contribute to sex-based differences in reduced functionality and quality of life. Some functionality, such as tactile function of the hands, has significant direct impact on quality of life. The purpose of the current study was to explore the impact of DM and sex on tactile function, with consideration of variability in health state measures.

RESEARCH DESIGN AND METHODS

A case-control single time point observational study from 2012-2020 in an ethnically diverse population-based community setting. The sample consists of 132 adult individuals: 70 independent community dwelling persons with DM (PwDM) and 62 age- and sex-matched controls (42 males and 90 females in total). The Semmes-Weinstein monofilament test was used to evaluate tactile sensation of the hands.

RESULTS

Tactile sensation thresholds were adversely impacted by sex, age, degree of handedness, high A1c, diagnosis of DM, and neuropathy. Overall, strongly right-handed older adult males with poorly controlled DM and neuropathy possessed the poorest tactile discrimination thresholds. When self-identified minority status was included in a secondary analysis, DM diagnosis was no longer significant; negative impacts of age, neuropathy, degree of handedness, and high A1c remained significant.

CONCLUSIONS

The data indicate significant impacts of male sex, age, degree of handedness, self-identified minority status, and metabolic health on the development of poor tactile sensation. This combination of modifiable and non-modifiable factors are important considerations in the monitoring and treatment of DM complications.

Correlation between Gensini Score and Duration of Diabetes in Patients Undergoing Coronary Angiography

Introduction The relationship between the duration of diabetes mellitus and coronary artery disease (CAD) is well established. Moreover, the Gensini score system is a reliable assessment tool for the severity of coronary artery disease (CAD). After an extensive literature search, we found that there is a knowledge gap about the relationship between the Gensini score and the duration of diabetes in our population. Therefore, the aim of this study was to find the relationship between the Gensini score and the duration of diabetes in patients undergoing a coronary angiography. Methods A cross-sectional study was conducted among 321 consecutively selected diabetic patients. Clinically diagnosed cases of diabetes on proper anti-diabetic treatment were included in this study. Patients with known severe CAD or history of coronary artery bypass grafting (CABG) surgery or primary coronary intervention (PCI) were excluded from the study. Coronary angiography was performed on all the patients and their Gensini score was calculated using the modified scoring schema. Duration of diabetes and other baseline risk factors were recorded for all patients. The relationship between the Gensini score and the duration of diabetes was assessed by calculating Pearson's correlation coefficient.  Results A total of 321 diabetic patients were included in this study, out of which 67.9% (218) were men and mean ± standard deviation age was 56.13 ± 7.67 years ranging between 40 to 70 years with a majority of the patients, 63.9% (205), being under 60 years of age. Along with diabetes, the most commonly observed risk factor was hypertension, which was observed in 77.6% (249) of the patients. Smoking and obesity were also observed in 18.7% (60) and 17.4% (56) of the patients, respectively. A significant positive correlation, 0.55 (p<0.001), was observed between the duration of diabetes and the Gensini scores. The correlation was found to be stronger in older patients (more than 60 years of age) with a correlation coefficient of 0.52 vs. 0.38, and male patients with correlation coefficients of 0.66 vs. 0.34. Conclusion A significant positive correlation between the Gensini score and the duration of diabetes mellitus was observed. This correlation is relatively stronger among male and older patients (more than 60 years of age).

Incidence of microvascular complications of type 2 diabetes: A 12 year longitudinal study from Karachi-Pakistan

OBJECTIVES

To estimate the incidence of microvascular complications among subjects with type 2 diabetes at a tertiary care hospital.

METHODS

This retrospective longitudinal follow-up study assessed the data records of type 2 diabetic subjects who visited the outpatient department of Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, from January 2005 to April 2016. Subjects with gestational diabetes, type 1 diabetes and with history of any microvascular complication were excluded. Medical records were obtained through electronic database (Health Management System). Statistical analyses were conducted using STATA version 14 and SPSS version 20.

RESULTS

The incidence of microvascular complications was 92.8, 106.2, and 130.2 per 1000 person per years for retinopathy, neuropathy and nephropathy respectively. Retinopathy, neuropathy and nephropathy were significantly high among diabetic patients with duration of diabetes >10 years followed by 5-10 years. Incidence of retinopathy and nephropathy was significantly higher in patients who had HbA1c>7% than patients with HbA1c≤7% (p-value<0.05). Higher incidence rate of all three microvascular complications were seen in subjects with hypertension than subjects without hypertension.

CONCLUSION

A high incidence of microvascular complications is found in subjects with type 2 diabetes. Poor glycaemic control, longer duration of diabetes and hypertension was found to be associated with the occurrence of these complications.

Neuroactive Steroids and Sex-Dimorphic Nervous Damage Induced by Diabetes Mellitus

Diabetes mellitus is a metabolic disease where improper glycaemic control may induce severe complications in different organs. In this review, we will discuss alterations occurring in peripheral and central nervous system of patients with type 1 (i.e., insulin dependent diabetes mellitus,) or type 2 diabetes (i.e., non-insulin dependent diabetes mellitus), as well as related experimental models. A particular focus will be on the role exerted by neuroactive steroids (i.e., important regulators of nervous functions) in the nervous damage induced by diabetes. Indeed, the nervous levels of these molecules are affected by the pathology and, in agreement, their neuroprotective effects have been reported. Interestingly, the sex is another important variable. As discussed, nervous diabetic complications show sex dimorphic features in term of incidence, functional outcomes and neuroactive steroid levels. Therefore, these features represent an interesting background for possible sex-oriented therapies with neuroactive steroids aimed to counteract nervous damage observed in diabetic pathology.

Burn aggravated infected wart in a patient with type 2 diabetes: a medical challenge

An infectious wart of foot in a patient with diabetics is a medical challenge, and it gets worse when aggravated with burns. We present a case of a 67-year-old Pakistani man, diabetic for 20 years presented at our healthcare centre. While awaiting his culture sensitivity report, he was prescribed an empiric antibiotic therapy. Patient then travelled to Saudi Arabia for pilgrimage 3 days later with growth of Staphylococcus aureus and Proteus species in culture and sensitivity report; during his travel, he walked barefoot and the infected wart aggravated with severe burn. Patient continued empiric treatment for 14 days. On his arrival, infected wart worsened with dead burnt skin, heavy purulent discharge on plantar region. X-rays revealed marked arthritic changes. Cefepime 500 mg three times a day intravenously was initiated following wound debridement. Patient was switched to moxifloxacin 400 mg once daily postoperatively for 7 days until completely healed.

Axonal transport in a peripheral diabetic neuropathy model: sex-dimorphic features

Background

Disruption of axonal transport plays a pivotal role in diabetic neuropathy. A sex-dimorphism exists in the incidence and symptomatology of diabetic neuropathy; however, no studies so far have addressed sex differences in axonal motor proteins expression in early diabetes as well as the possible involvement of neuroactive steroids. Interestingly, recent data point to a role for mitochondria in the sexual dimorphism of neurodegenerative diseases. Mitochondria have a fundamental role in axonal transport by producing the motors’ energy source, ATP. Moreover, neuroactive steroids can also regulate mitochondrial function.

Methods

Here, we investigated the impact of short-term diabetes in the peripheral nervous system of male and female rats on key motor proteins important for axonal transport, mitochondrial function, and neuroactive steroids levels.

Results

We show that short-term diabetes alters mRNA levels and axoplasm protein contents of kinesin family member KIF1A, KIF5B, KIF5A and Myosin Va in male but not in female rats. Similarly, the expression of peroxisome proliferator-activated receptor γ co-activator-1α, a subunit of the respiratory chain complex IV, ATP levels and the key regulators of mitochondrial dynamics were affected in males but not in females. Concomitant analysis of neuroactive steroid levels in sciatic nerve showed an alteration of testosterone, dihydrotestosterone, and allopregnanolone in diabetic males, whereas no changes were observed in female rats.

Conclusions

These findings suggest that sex-specific decrease in neuroactive steroid levels in male diabetic animals may cause an alteration in their mitochondrial function that in turn might impact in axonal transport, contributing to the sex difference observed in diabetic neuropathy.

Patterns, control and complications of diabetes from a hospital based registry established in a low income country

BACKGROUND

Diabetes registry enables practitioners to measure the characteristics and patterns of diabetes across their patient population. They also provide insight into practice patterns which can be very effective in improving care and preventing complications. The aim of this study was to assess the patterns, control levels and complications at the baseline of the patients attending clinic at the large tertiary care hospital in Karachi, Pakistan with the help of the registry. This can be used as a reference to monitor the control and also for a comparison between peer groups.

METHODS

This was a cross sectional study with the data obtained from diabetes registry collected with the help of pre-designed questionnaire. HbA1c was used as a central diabetes measure and other related factors and complications were assessed with it.

RESULTS

Only 16.6% of the participants had optimal HbA1c ≤ 7.0%. 52.9% of the patients were classified as having poor control defined by HbA1c of >8%. Three fourth of the study population were obese according to Asian specific BMI cutoffs and majority had type 2 diabetes with duration of diabetes ranging from less than one to about 35 years, mean(SD) duration being 7.6 years (7.1). Overall only 4% of the patients were on combine target of HbA1c, LDL and BP. Results of multivariable logistic regression showed that the odds of having optimal glycemic control increased by 3% with every one year increase in age. In addition, having longer duration of diabetes was associated with 56% lower odds of having good glycemic control. Moreover, having higher triglyceride levels was associated with 1% lower odds of having good glycemic control.

CONCLUSION

This highlights the large burden of sub optimally controlled people with diabetes in Pakistani population, a low income country with huge diabetes prevalence and ineffective primary health care system creating enormous health and economic burden.

Vacuum Assisted Closure- utilization as home based therapy in the management of complex diabetic extremity wounds

Objective:

Vacuum assisted closure is a reported technique to manage complex wounds. We have utilized this technique by using simple locally available material in the management of our patients on outpatient basis. The objective of this study is to present our experience.

Methods:

This study was conducted from June 2011 to June 2013 at Dow University Hospital and Aga Khan University Hospital, Karachi. There were 38 patients managed with vacuum assisted closure. Mean age was 56±7.8 years. Twenty three patients presented with necrotizing fasciitis and 15 patients with gangrene. Lower limbs were involved in majority of the patients. Debridement or amputations were done. Vacuum dressing was changed twice weekly in outpatient department. Wounds were closed secondarily if possible or covered with split thickness skin graft in another admission.

Results:

All the wounds were successfully granulated at the end of vacuum therapy. Mean hospital stay was 7.5 days. Vacuum dressing was applied for a mean of 20 days. There was reduction in the size of the wound. Thirteen patients underwent secondary closure of the wound under local anesthesia, 18 patients required coverage with split thickness skin graft and 7 patients healed with secondary intention.

Conclusion:

Vacuum assisted closure appeared to be an effective method to manage complex diabetic wounds requiring sterile wound environment.

Characteristics of a large cohort of patients with diabetes having at-risk feet and outcomes in patients with foot ulceration referred to a tertiary care diabetes unit

To identify in a large population cohort the clinical and biochemical characteristics of patients with diabetes at risk of foot ulceration and outcomes in those with foot ulcers. All patients with diabetes attending Baqai Institute of Diabetology and Endocrinology from January 2004 to April 2012 included in the study. Clinical, biochemical and socio-demographic data were collected and patients were categorised into those at no risk of ulceration, at risk of ulceration and those with foot ulcer, according to the University of Texas classification. Patients with foot ulceration followed for their final outcome, that is complete healing, persisted non-healed ulcer, lower extremity amputation, lost to follow-up or death. A total of 18 119 patients with diabetes underwent assessment, 3576 (19·7%) patients defined as at high risk for foot ulceration and 3731 (20·6%) presented with foot ulcer. Age, male gender, hypertension, higher glycated haemoglobin (HbA1c), history of smoking and presence of neuropathy were risk factors (P < 0·000) for foot ulceration. Amputation rate in patients with foot ulceration was significantly related to severity of ulceration at presentation. Preventive foot care practices were followed by 19·02% patients. One thousand eight hundred seventy three (50·2%) patients completely healed, 293 (11%) patients underwent amputation and 397 (10·1%) patients continued to be treated in the foot clinic. All patients with diabetes should be screened for neuropathy to identify those at risk of foot ulceration, as it is the major contributory factor for foot ulceration. The final outcome of foot ulceration was determined by the severity and grade of ulcer at presentation.