Saving The Limb In Diabetics With Disease Of The Leg Or Foot

Main Category: Diabetes
Also Included In: Vascular
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Endovascular treatment for arterial recanalization in diabetic patients with critical limb ischemia (CLI) and foot lesions is currently accepted and indicated as the first choice treatment.

In most cases, different or multiple arterial accesses must be considered, and antegrade CFA* is the treatment of choice. Other options include retrograde popliteal, proximal retrograde anterior tibial, distal retrograde or antegrade pedal, and distal retrograde posterior tibial. These treatments can also be explored in combination. This was explained by Dr. Marco Manzi, Chief, Policlinico Abano Terme (Vincenza, Italy) at the 37th annual VEITHsymposium™ at the Hilton Hotel (New York, NY).

Dr. Manzi pointed out that different kinds of techniques must be considered for a "tailored" endovascular approach related to the grade of arterial disease. The length of lesions, wound related artery and the anatomical site of foot wounds are some considerations. The initial differentiation is between non-calcificated and calcificated arteries. With calcified arteries, it is mandatory to use a coronaric-like strategy in order to avoid any intimal dissection in both focal and long stenosis/occlusions.

"It is possibile to decide for a subintimal dissection as "the last resort" but we must know that we will have few probabilities to get the true lumen distally and many to compromise collaterals. Most failed procedures will be in this group, in our experience around 12-15% of all patients," explained Dr. Manzi.

In non calcificated arteries both subintimal and intraluminal techniques can be performed with a very high acute success rate and final limb salvage rate.

Low profiles, balloons and guidewires can be used for tibial vessels in non-calcificated situations; 0,014 platforms are mandatory for foot arteries and calcificated tibial vessels. Pedal-plantar Loop techniques, when possibile, avoid retrograde distal punctures and permit the rescue of ruptures or dissections with a statistical significative improvement in TcPO2 post-procedural measurements.

Sidebar:

CLI is a severe obstruction of the arteries which seriously decreases blood flow to the extremities (hands, feet and legs) causing severe burning pain, skin ulcers or sores. CLI is often present in individuals with severe peripheral arterial disease. Patients often awake at night from the pain. CLI is not to be ignored. Patients should consult a vascular surgeon who may offer conservative treatment or an intervention such as a stent.

* Antegrade CFA: The preferred vascular access to perform percutaneous intervention of the infrapopliteal vessels.

Source:
VEITHsymposium

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Diabetics Must Make Diet And Lifestyle Choices To Lower The Risk Of Cardiovascular Disease

Main Category: Heart Disease
Also Included In: Cardiovascular / Cardiology;??Diabetes;??Preventive Medicine
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Diabetics can face a five times increase in the risk of developing cardiovascular disease (CVD) than non-diabetics. This leads to a seven to ten year reduction in life expectancy and a higher probability of suffering a fatal heart attack. These sad statistics have prompted the European Society of Cardiology (ESC) to mark World Diabetes Day(1) on 14 November 2010 by emphasising the simple measures that diabetes patients should adopt to slow-down the progression of CVD and greatly improve their quality of life.

The urgency of addressing this issue is highlighted by forecasts of 330 million diabetes cases worldwide by 2050. This figure represents a staggering 3% of the predicted global population. The mechanisms that link the onset of diabetes with subsequent development of CVD include above-average lipid levels, inflammation of vascular walls, high blood pressure, and an excess of 'bad' cholesterol produced by the liver. Additionally, the effects of continuing to smoke are particularly potent for diabetics, with a dramatic increase in mortality rates being an inevitable outcome. Despite this, most diabetics can greatly alleviate the symptoms of CVD by making sensible diet and lifestyle choices.

Speaking for the ESC, Professor Joep Perk of the School of Health and Caring Sciences at Linneaus University in Sweden, and Board Member of the European Association of Cardiovascular Prevention and Rehabilitation (EACPR) says, "The impact of growing obesity levels is pushing Type 2 diabetes into an epidemic. It is a very serious problem for healthcare providers due to the cost of treatment, but also for cardiologists who now see diabetes prevention as one of the main health challenges. Around 60% of cardiovascular patients nowadays are pre-diabetic or diabetic, a significant increase from our experience of 20 years ago."

Diabetics with CVD are urged to follow the ESC recommendations for patients which, quite simply, are summarised as:

-- Eat a healthy diet

-- Exercise more

-- Stop smoking

-- Limit alcohol intake

"Following this common sense advice will have a very positive impact on the progression of CVD. Although it would be good advice for non-diabetics, for diabetics it is literally a matter of life or death," says Professor Perk. "The complications of CVD when added to the underlying effects of diabetes are a dangerous combination that should be avoided at all costs. This is why we stress the importance of diet and lifestyle changes to manage the progression of CVD."

There are encouraging signs that prevention strategy in a wider sense is climbing higher up the healthcare agenda. The pioneering work of the Chronic Disease Alliance(2) has recently been recognised by the prestigious European Health Award 2010. The Alliance was formed by the European Society of Cardiology and nine other not-for-profit healthcare organisations including the International Diabetes Federation. Its role is to give scientific guidance to the EU and other regulators in order to promote policies that will lead to long-term health improvements in the population. One example, for instance, is to limit the salt content in prepared foods. The objective of these policies is to encourage better diet and lifestyles which are key to the prevention of so many chronic diseases a very timely message to mark World Diabetes Day 2010.

Sources: European Society of Cardiology (ESC), AlphaGalileo Foundation.

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A Dry AMD Treatment?; Some Long-Term Diabetics Escape PDR

Main Category: Eye Health / Blindness
Also Included In: Seniors / Aging;??Diabetes;??Clinical Trials / Drug Trials
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At the American Academy of Ophthalmology (AAO) - Middle East-Africa Council of Ophthalmology (MEACO) Joint Meeting yesterday, Oct. 17, researchers reported progress on two top eye disease challenges: treating advanced "dry" age-related macular degeneration, and preventing blindness in people with diabetes. The Joint Meeting is in session October 16 through 19 at McCormick Place, Chicago. The AAO-MEACO meeting is the world's largest, most comprehensive ophthalmic education conference.

Proven Arthritis Drug Shows Promise versus Dry AMD

While ophthalmologists can turn to several medications for patients with vision-threatening "wet" age-related macular degeneration (AMD), there are no effective treatments for advanced "dry" AMD, the more common form. Today a research group led by Jason S. Slakter, MD, New York University School of Medicine, reports on a phase-two clinical trial of fenretinide, a synthetic derivative of vitamin A. Risk of developing wet AMD decreased almost two-fold in dry AMD patients who took the medication. Geographic atrophy (GA) lesion growth was also reduced in the fenretinide group. This reduced growth correlated with lowered blood levels of the biomarker retinol binding protein (RBP) - an indication that fenretinide was working. Patients whose RBP decreased 60 percent or more also had the most significant reductions in lesion growth. GA lesions degrade the area of the eye called the retinal pigment epithelium (RPE), which can result in significant vision loss.

Advanced AMD, in either wet or dry form, can destroy the detailed, central vision we need to recognize faces, read, drive, and enjoy daily life. It is a major cause of vision loss in the United States. In the advanced wet form abnormal new blood vessels develop under the retina, then bleed or leak fluid and form scars. Advanced dry AMD sometimes abruptly converts to the wet form.

Fenretinide works on three key AMD disease mechanisms: it has strong anti-inflammatory properties, inhibits abnormal blood vessel growth (angiogenesis) and reduces vitamin-A derived toxins such as A2E and lipofuscin. These toxins accumulate in the RPE and interfere with its ability to nourish light-receptor cells in the retina.

"Evidence from our study and others points to fenretinide's potential to treat and prevent diseases of the retina," Dr. Slakter said.

This randomized controlled trial included 246 patients at 30 sites around the United States. Tests showed that patients' visual acuity and other markers of eye health were not adversely affected by fenretinide. Side effects, including delayed ability to adapt to dark conditions, were minor and reversible when the medication was stopped. Years of use of fenretinide to treat cancers, rheumatoid arthritis, and other diseases have shown it to be safe and well tolerated. ReVision Therapeutics, the company supporting the continued clinical development of fenretinide, is planning a Phase 3 clinical trial to begin in 2011.

Financial disclosures: This research was supported by a grant to the Digital Angiography Reading Center; Dr. Slakter served as a consultant to Sirion Therapeutics.

Clues to Retinopathy from Survivors of 50+ Years of Diabetes

Doctors assume that the longer a person has diabetes, the more likely he or she is to develop serious eye disease and, if untreated, become blind. But a new study of patients who have had type 1 diabetes for at least 50 years tells a different story. Many of these patients appear to be protected against proliferative diabetic retinopathy (PDR), and the majority of them escape vision loss despite extremely long-duration diabetes, according to Jennifer Sun, MD, Beetham Eye Institute at Joslin Diabetes Center, a Harvard School of Medicine affiliate.

With one exception, development of PDR occurred within the first two decades in these Joslin patients (in 96 of 97 patients). If PDR did not develop during that period, then retinopathy progressed slowly and in some cases stopped altogether. PDR development was associated with higher blood pressure, but not with glycemic (blood sugar) control. This confirmed an earlier, larger study's surprising finding that neither glycemic control nor duration of diabetes correlated with the severity or presence of diabetic retinopathy (DR) in patients who successfully survived 50 or more years with type 1diabetes. Decreased blood levels of the protein tyrosine phosphatase SHP-1 was also associated with protection from development of any DR, and Dr. Sun recommends further study of SHP-1 to learn whether it might be a target for treatment.

"There is no doubt that lack of glycemic control is a major factor in the development of eye complications for patients with shorter-duration diabetes. But our data from this unique group of individuals who have survived extremely long-duration diabetes may help identify other factors that protect against retinopathy complications," said Dr. Sun. "These findings also suggest that protective mechanisms are activated very early in diabetes."

Source:
Mary Wade
American Academy of Ophthalmology

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Normal Blood Glucose Levels In Diabetics Presenting For Surgery Were Associated With Increased Risk Of Mortality From Non-Cardiac Surgery

Main Category: Diabetes
Also Included In: Cosmetic Medicine / Plastic Surgery;??Heart Disease;??Blood / Hematology
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A clinical study presented at ANESTHESIOLOGY 2010 discovered that diabetics who presented for non-cardiac surgery with near normal blood sugar levels were at increased risk of death, as compared with their non-diabetic counterparts.

Researchers at Cleveland Clinic looked at the relationship between blood sugar levels before surgery and the occurrence of complications and death after non-cardiac surgeries, comparing the relationship between those with diabetes and those without.

The study found that the relationship between blood sugar levels and the likelihood of complications after surgery was not significantly different between diabetics and non-diabetics. However, the research showed a significant difference between diabetics and non-diabetics in terms of the relationship between blood sugar levels before surgery and deaths within one year of surgery. Non-diabetic patients with high blood sugar levels had a higher risk of dying from non-cardiac surgery compared with diabetics with high blood sugar levels. Conversely, normal blood sugar levels in diabetics were associated with a higher risk of death within one year after non-cardiac surgery versus non-diabetics.

"It is possible that non-diabetics with high blood sugar were undiagnosed and thus, untreated diabetics," said Basem Abdelmalak, M.D., study investigator and Staff Anesthesiologist and Director of Anesthesia for Bronchoscopic Surgery at Cleveland Clinic. "It is also possible that diabetics who have lived with high blood sugar for long periods of time have become accustomed to this state and may have reset their metabolism, becoming unable to tolerate lower blood glucose levels. This is similar to what happens to patients with long-term high blood pressure."

About the Study

Researchers used specific data from surgeries on 61,536 patients who had elective surgery between January 2005 and November 2009. Overall, 15.8 percent had diabetes.

The study examined two main outcomes: in-hospital complications after surgery (including cardiac, neurological, urologic and infectious complications) and death within one year of surgery. The study analyzed such associations using both crude and adjusted figures. The adjusted figures took into account other factors that may have contributed to poor outcomes, such as age and heart disease.

"The usual treatment goal for diabetics is maintaining normal blood sugar levels," said Dr. Abdelmalak. "However, knowledge of a higher risk of dying may stimulate further research that potentially could affect how diabetics with hyperglycemia (high sugar) are managed for their non-cardiac surgery."

Source: American Society of Anesthesiologists (ASA)

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