Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study

To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569307 and an estimated diabetic population of 37932 (15505 men and 22427 women). The level of arterial reconstruction and associated risk factors were ascertained.

RESULTS

A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P<0.05) and were less frequently smokers (P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05).

CONCLUSION

Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Changes in nutritional pattern, insulin sensitivity and glucose tolerance during weight loss in obese patients from a Mediterranean area

In order to study the nutritional pattern in obese subjects living in an area with a Mediterranean diet, as well as the modifications in nutritional behaviour, cardiovascular risk factors and insulin sensitivity induced by changes in nutritional pattern, 54 obese patients completed a 20-week behaviour programme. They prospectively fulfilled a food records diary in order to ascertain their nutritional pattern. Weight, body mass index (BMI). waist-to-hip ratio (WHR), blood pressure (BP), cholesterol, HDL-c, LDL-c, triglycerides, fasting and 2 h-post glucose load plasma glucose were determined at the onset and at the end of the study. Insulin sensitivity index (SI), and glucose effectiveness (Sg) were assessed by using the modified FSIVGTT. The usual diet in obese patients living in a Mediterranean country is low in carbohydrates (35%) and high in fats (43%), 55% of the latter being monounsaturated fatty acids (MUFAs), especially olive oil. After the educational programme they decreased the caloric intake to slightly over 700 Kcal/day, with a reduction of 36% in carbohydrates consumption, 18% in proteins and 43% in fats (46% in MUFAs). These modifications resulted in a decrease in weight, BMI, WHR, BP, and fasting and 2 h-post glucose load plasma glucose (all p < 0.05), whereas the lipoprotein profile did not change. In a similar way SI and Kg (glucose disappearance rate) increased, while fasting plasma insulin (FPI) decreased (p < 0.05) and Sg and I1+3 remained unaffected. Our results indicate that weight loss induced by caloric restriction improves insulin sensitivity rather insulin secretory capacity or glucose effectiveness, and all the cardiovascular risk factors but lipoproteic profile, that remains unchanged, probably because of the lower MUFAs consumption. These facts should be taken into account when recommending changes in the diet of obese patients with a Mediterranean-style diet.

Comparison between acarbose, metformin, and insulin treatment in type 2 diabetic patients with secondary failure to sulfonylurea treatment

The purpose of this study was to determine the most suitable treatment for Type 2 (non-insulin-dependent) diabetic patients with secondary failure to sulfonylureas (SFS). In a four-month comparative study, 36 Type 2 diabetic patients given SFS were allocated to three treatment groups: A (n = 12, M/F 6/6, HbAlc 9.1 +/- 1.6%) received 0.3 IU/Kg body weight (BW) of insulin-Zn between 10 and 11 p.m.; B (n = 12, M/F 6/6, HbAlc 9.2 +/- 1.6%) SFS plus 850 mg/day of metformin; and C (n = 12, M/F 6/6, HbAlc 9.5 +/- 2.4%) SFS plus acarbose 3 x 100 mg daily. Modifications in HbAlc, BW, blood pressure (BP), lipoprotein profile and insulin sensitivity were evaluated. HbAlc decreased in the three groups (A: 17.9 +/- 13.5%; B: 18.2 +/- 4.5%; C: 7.6 +/- 16.8%; all p < 0.05; A and B vs C = p < 0.05). BW increased in group A and decreased in the other groups. BP decreased statistically in group B. HDL-cholesterol increased (1.26 +/- 0.46 vs 1.49 +/- 0.36 mmol/L; p < 0.05) and triglyceride levels decreased (1.68 +/- 0.85 vs 1.16 +/- 0.43 mmol/L; p < 0.05) in group A. There were no significant changes in the other studied parameters. We conclude that, for Type 2 diabetic patients given SFS, both insulin and metformin plus SFS provided better glycaemic control than acarbose plus SFS. Metformin combined with SFS offered further advantages for the control of BW and BP.

Effects of different proportions of carbohydrates, polysaccharides/monosaccharides, and different fibers on the metabolic control in diabetic rats

Recent findings have suggested that diets with a high level of carbohydrates may impair the metabolic control of diabetes mellitus in humans. Moreover, other investigations have indicated that if the simple sugar content is increased in order to attain a proportion of polysaccharides/monosaccharides equal to 1, then neither the blood glucose nor the lipidic response show any change. We have studied the effect of increasing carbohydrates in the diet (59% v 82%), while maintaining cereal fiber levels constant (30%) and replacing cereal fiber in high carbohydrate diets by guar gum (30%) and lentil-derived leguminous fiber (30%) on the metabolic control of streptozotocin-induced diabetic rats. A study with different diets was performed for 3 weeks. An increase of carbohydrates in the diet produces an increase in the HbA1 concentration (1.9% v 3.9%, P less than 0.01) and in serum triglyceride levels (98.75 +/- 22.09 mg/dL v 144.50 +/- 3.52 mg/dL, P less than 0.05). Total cholesterol and HDL-cholesterol levels remained unchanged. The increase does not occur if the cereal fiber is replaced by lentil-derived leguminous fiber. In a second experiment, we substituted 50% of the complex carbohydrates in diets with 80% carbohydrates by glucose. Blood glucose, triglycerides, and HbA1 levels rose significantly in the four groups of rats that received diets containing 50% carbohydrates in glucose form. In addition, a test meal was carried out on day 19, consisting of 2.5 g of food/kg of wt. The maximum increase in blood glucose and the area below the glucose curve response was also significantly higher in the four groups of rats who received glucose in their diet.(ABSTRACT TRUNCATED AT 250 WORDS)