Diabetic control and complications

Diabetes mellitus and diabetic foot ulcer: Etiology, biochemical and molecular based treatment strategies via gene and nanotherapy

Diabetes mellitus (DM) is a collection of metabolic and pathophysiological disorders manifested with high glucose levels in the blood due to the inability of β-pancreatic cells to secrete an adequate amount of insulin or insensitivity of insulin towards receptor to oxidize blood glucose. Nevertheless, the preceding definition is only applicable to people who do not have inherited or metabolic disorders. Suppose a person who has been diagnosed with Type 1 or Type 2DM sustains an injury and the treatment of the damage is complicated and prolonged. In that case, the injury is referred to as a diabetic foot ulcer (DFU). In the presence of many proliferating macrophages in the injury site for an extended period causes the damage to worsen and become a diabetic wound. In this review, the scientific information and therapeutic management of DM/DFU with nanomedicine, and other related data were collected (Web of Science and PubMed) from January 2000 to January 2022. Most of the articles revealed that standard drugs are usually prescribed along with hypoglycaemic medications. Conversely, such drugs stabilize the glucose transporters and homeostasis for a limited period, resulting in side effects such as kidney damage/failure, absorption/gastrointestinal problems, and hypoglycemic issues. In this paper, we review the current basic and clinical evidence about the potential of medicinal plants, gene therapy, chemical/green synthesized nanoparticles to improving the metabolic profile, and facilitating the DM and DFU associated complications. Preclinical studies also reported lower plasma glucose with molecular targets in DM and DFU. Research is underway to explore chemical/green synthesized nanoparticle-based medications to avoid such side effects. Hence, the present review is intended to address the current challenges, recently recognized factors responsible for DM and DFU, their pathophysiology, insulin receptors associated with DM, medications in trend, and related complications.

The DIabetic Retinopathy Candesartan Trials (DIRECT) Programme, rationale and study design

The DIabetic Retinopathy Candesartan Trials (DIRECT) Programme consists of three randomised, double-masked, parallel, placebo-controlled studies to determine the impact of treatment with candesartan on diabetic retinopathy. In Type 1 diabetes, 1,700 patients without retinopathy will be randomised into a primary prevention study, and 1,200 with non-proliferative retinopathy into a secondary prevention study. In Type 2 diabetes, 1,600 patients with non-proliferative retinopathy will be randomised. Patients will be followed for at least three years. Eligible patients must be normotensive (systolic blood pressure [SBP] 130 mmHg and diastolic blood pressure [DBP] 85 mmHg) without antihypertensive medication in Type 1 diabetes, and either normotensive or treated hypertensive (SBP 160 mmHg and SBP 90 mmHg) and not taking angiotensin-converting enzyme inhibitors or AT(1)-receptor blockers in Type 2 diabetes. All patients will be normoalbuminuric, based on two overnight urine collections. The primary endpoint is based upon retinal photographs, graded to the Early Treatment of Diabetic Retinopathy Study scale. A two-step increase on this scale defines incidence, and a three-step increase defines progression of retinopathy. The main secondary endpoint for each study is change in urinary albumin excretion rate. A positive outcome of the DIRECT Programme would be an important step forward in the clinical management of patients with diabetes.

Standards of care of diabetic patients in a typical English community

BACKGROUND

Poole has a well-established system of sharing care of patients with diabetes between hospital and general practitioners. Very few comprehensive audits of the effectiveness of such a system, which is being adopted in many areas of the UK, have been carried out.

AIM

A study was set up to survey structure, process and outcome of care for as many diabetic patients in the Poole area as possible, and to feed the results back to individual practices.

METHOD

Structure criteria were assessed by self-completion questionnaire. Process and outcome criteria were assessed by visits to practices and examination of individual patient notes. A total of 37 practices were visited and the notes of 3974 patients reviewed. Results were analysed by practice and for the district as a whole, and were sent to each practice for comparison.

RESULTS

The overall prevalence of diabetes in the area was 1.61%, with a marked preponderance of elderly patients (14.1% were over 80). The overall male to female ratio was 1.2:1. The structure questionnaire pinpointed deficiencies in audit facilities, completeness of diabetic registers, and in general use of optometrists and chiropodists. Process criteria analysis showed that, within the last 13 months, 44% of patients under sole care of a general practitioner had undergone full eye examination, cholesterol levels had been checked in 25%, smoking status in 50%, and some foot inspection had been carried out in 57%. Glycaemic control and blood pressure had been measured in over 75% of patients. Outcome analysis showed, in those patients in which they were measured, mean glycosylated haemoglobin (Hba1c) to be 8.07% (upper limit of normal, ULN = 6.5%), some degree of retinopathy to be present in 17.3%, hypertension in 27%, and hypercholesterolaemia in 33%.

CONCLUSION

Standards of care of diabetics by general practitioners in the Poole area are not optimal, although they are as good as those reported for other districts. Glycaemic control was generally poor, especially in those patients needing insulin to control the disease. Vascular disease risk factors need to be targeted, and eye examination systems and chiropody services improved.

Diabetes mellitus and morbidity and mortality risks after coronary artery bypass surgery

Of 1025 patients (912 men, 113 women) who underwent coronary artery bypass grafting and were followed up for a mean of 7.4 years, 45 (4.4%) had diabetes mellitus. Norwegian population is 1.8-2%). Early mortality was not significantly greater among diabetics than in non-diabetics (2.2 vs. 3.1%, odds ratio--OR-0.44, confidence interval--CI- 0.05-3.56). Diabetic patients had no increased risk of perioperative myocardial infarction (OR = 0.87, CI 0.36-2.10) or of low-output syndrome necessitating intraortic balloon pumping (OR = 0.42, CI 0.55-3.05), and no excess incidence of late non-fatal myocardial infarction (relative risk = 0.69, CI 0.10-1.28) or late chronic heart failure (OR = 2.50, CI 0.5-11.0). Long-term mortality was increased in the diabetic patients (relative risk 1.87, CI 1.60-2.14). Thus diabetes did not entail heightened risk of early mortality, perioperative myocardial infarction or low-output syndrome. Nor was there excess risk of recurrent angina pectoris, late non-fatal myocardial infarction or chronic heart failure among the diabetic patients, but the late mortality risk was increased.

Diabetes mellitus and the St Vincent Declaration. The economic implications

Diabetes mellitus imposes significant costs both on individuals and on healthcare delivery systems. Chronic diseases such as diabetes mellitus have lifetime costs, and so resources spent on interventions now may not bring benefits, in terms of reduced complications, for many years. In Europe, the St Vincent Declaration, which includes targets for the reduction of diabetes mellitus-related complications, is an important initiative set up to address quality and education issues relevant to people with diabetes mellitus. The Declaration is to be welcomed as focusing attention on diabetes mellitus, and its implementation may lead to a reduction in healthcare expenditure on complications in future years. The aims of the St Vincent Declaration are to set goals and 5-year targets to improve quality of life and life expectancy for people with diabetes mellitus and to reduce the serious complications associated with the disease. Achievement of these targets will depend on good organisation and management of services to people with diabetes mellitus, but the aims are a clear signal that the importance of prevention and education have been recognised. A major barrier to the implementation of the Declaration is financial. If more people are diagnosed and treated, more services will be required. This will incur costs, although future benefits will be gained in terms of a reduction in complications.

Microalbuminuria: pathogenesis, prognosis and management

The development in recent years of sensitive assays specific for albumin has facilitated extensive investigation of the pathophysiology and clinical significance of microalbuminuria. It is now clear that the appearance of microalbuminuria represents a crucial event in the natural histories of diabetes mellitus and essential hypertension. It reflects the presence of generalized vascular damage and is strongly predictive of subsequent renal failure, cardiovascular morbidity, and death. Therapeutic interventions, including strict diabetic and blood-pressure control, can reduce microalbuminuria and improve the overall prognosis. The detection and treatment of microalbuminuria in these high-risk groups should now form an integral part of their management. Large-scale screening programmes are also recommended for insulin-dependent diabetics.