Diabetes & Chronicdisease

Diabetes

Coronary heart disease in diabetes

• It is more common and occurs earlier than in people eithout diabetes
• Women lose gender protection
• Myocardial infarction may be painless(silent)
• Albuminuria increases risk of vascular event


Compared to people without diabetes, people with type 2 diabetes have

• The same risk of heart attack as those who have already had a heart attack
• Two-to three-ford higher risk of heart failure


Sudden death occur more commonly in people with diabetes than among peers without diabetes of the same age

Myocardial infarction and diabetes

People with diabetes have poor prognosis even after adjustments for infarct size and risk factors

Prevention

Research shows the benefits of reducing the modifiable risk factors for atherosclerosis

Modifiable risk factors are

• Dyslipidaemia (especially LDL-C)
• Smoking and exposure to tobacco smoke
• High blood pressure
• Diabetes
• Central obesity
• Physical inactivity

Activity

TJ is newly diagnosed with diabetes. He smokes one pack of cigarettes. He smokes one pack of cigarettes a day and does not do any exercise. His blood pressure is 150/95 and his BMI is 30.
• What are his risk factors?
• What else should you assess?
• How will you approach him regarding his risk factors?

Retinopathy

Objectives

After completing this module participants will be able to

• Define retinopathy
• Discuss the risk factors for retinopathy
• Describe preventive strategies for retinopathy
• Explain the benefits and possible side effects of laser treatment to a person with diabetes

Eye diseases in people with diabetes

• Diabetic Retinopathy
• Diabetic Cataract
• Cranial nerve palsies leading to diplopia
• Diabetic papillopathy

Transient changes in vision

• Cause—changes in blood glucose levels cause osmotic changes in the lens of the eye
• As a result, visual acuity can increase or decrease
• This change is not permanent and will resolve when blood glucose levels stabilize

 

Retinopathy in people with diabetes

• A silent complication with no initial symptoms
• When symptoms occur, treatment is more complicated
• Screening for retinopathy is of the utmost importance

 

When to screen for retinopathy

type 1 diabetes: within 5 years of diagnosis
type 2 diabetes: at time of diagnosis
Thereafter, every 1 to 2 years, depending on the status of the retina
Women with pre-existing diabetes should be screened preconception, during the 1st trimester, as needed during the pregnancy and for 1 year following

 

Intensive therapy- type 1 diabetes

Diabetes Control and Complications Trial (DCCT)

• Primary prevention cohort: reduced risk of developing retinopathy by 76%.
• Secondary intervention cohort: reduced risk of progression retinopathy by 54%.

Epidemiology of Diabetes Interventions and Complications (EDIC)
• Intensive group continued to have protection

Intensive therapy- type 1 diabetes

UK Prospective Diabetes Study (UKPDS)
• Good glycogenic control: reduced progression of retinopathy by 20-30%.
• Tight blood pressure control: reduced progression of retinopathy by 34%.
Post(UKPDS)
• Despite loss of giycemic control, reduced risk of micro vascular complications continued after 10 years

Microalbuminuria

Objectives

After completing this module participants will be able to

• Define retinopathy
• Discuss the risk factors for retinopathy
• Describe preventive strategies for retinopathy
• Explain the benefits and possible side effects of laser treatment to a person with diabetes

Eye diseases in people with diabetes

• Diabetic Retinopathy
• Diabetic Cataract
• Cranial nerve palsies leading to diplopia
• Diabetic papillopathy

Transient changes in vision

• Cause—changes in blood glucose levels cause osmotic changes in the lens of the eye
• As a result, visual acuity can increase or decrease
• This change is not permanent and will resolve when blood glucose levels stabilize

 

Retinopathy in people with diabetes

• A silent complication with no initial symptoms
• When symptoms occur, treatment is more complicated
• Screening for retinopathy is of the utmost importance

 

When to screen for retinopathy

type 1 diabetes: within 5 years of diagnosis
type 2 diabetes: at time of diagnosis
Thereafter, every 1 to 2 years, depending on the status of the retina
Women with pre-existing diabetes should be screened preconception, during the 1st trimester, as needed during the pregnancy and for 1 year following

 

Intensive therapy- type 1 diabetes

Diabetes Control and Complications Trial (DCCT)

• Primary prevention cohort: reduced risk of developing retinopathy by 76%.
• Secondary intervention cohort: reduced risk of progression retinopathy by 54%.

Epidemiology of Diabetes Interventions and Complications (EDIC)
• Intensive group continued to have protection

Intensive therapy- type 1 diabetes

UK Prospective Diabetes Study (UKPDS)
• Good glycogenic control: reduced progression of retinopathy by 20-30%.
• Tight blood pressure control: reduced progression of retinopathy by 34%.
Post(UKPDS)
• Despite loss of giycemic control, reduced risk of micro vascular complications continued after 10 years

Microalbuminuria

Objectives

Type 1 diabetes

   Indicates increased risk fo end Stage renal disease

Type 2 diabetes

    Indicates increased risk fo a vascular event.

All the guidelines emphasize the need for intensive, aggressive management of cardiovascular risk factors

 

Interventions: glycogenic control (1 of2)
    DCCT provided good evidence that tight glucose control prevents/delays onset of micro albuminuria
    DCCT did not provide evidence that good control delays progression once microalbuminuria is present

Diabetic Nephropathy

Treatment

    Adults with persistent albuminuria (2.0mg/mmol in men, 2.8mg/ml in women) should be started on an ACE or ARB regardless of blood pressure
    Intensive treatment of blood pressure to achieve target <130/80 mmHg>
   Reduce salt in diet
   Reduce alcohol consumption

Estimated glomerular filtration rate (eGFR)(1 of 2)

   May underestimate actual renal function especially in women, the young and the obese     Not accurate when eGFR > 60ml/min, but sufficiently accurate for clinical purposes when <60
    Risk of CVD increases as eGFR falls
    Risk of CVD increases as albuminuria increases

 

Estimated glomerular filtration rate (eGFR)(2 of 2)

<60 ml/min

    – osteodystrophy
   – anaemia
<30 ml/min

    – Pre-dialysis
<15 ml/min

    – Dialysis and transplant

 

Treatment of end Stage Renal Disease ESRD

  •  Prepare for eventual dialysis     
  • Peritoneal dialysis
  •  Haemodialysis
  • Renal transplantation

DIABETIC NEUROPATHY AND PERIPHERAL VASCULAR DISCULAR DISEASE


Objectives

After completing this module the participant will be able to


»    Differentiate between peripherals neuropathy and peripheral vascular disease (PVD)
»   Discuss risk factors for peripheral neuropathy and PVD
»   Discuss screening methods for both peripheral neuropathy and PVD
»   Describe some of the clinical manifestations of peripheral neuropathy and PVD


Some Statistics

»   People with diabetes are 25 times more likely to lose a foot then people without diabetes
»   More than 1 million people lose a leg every year due to diabetes (every 30 seconds)
»   70% of all leg amputations happen to people with diabetes
»   5 years after a lower limb amputation up 70% of people may have died

Some Statistics

49-85% of amputations can be prevented through a care strategy that combines


»   Prevention
»   Multi-disciplinary treatment of ulcers
»   Appropriate organization
»   Close monitoring
»   Education of people with diabetes and health professionals


Activity

How and when do people have their feet examined in your country? What conditions put people at high risk of injury in your country?

Peripheral Neuropathy – sensory motor

»   most common form of neuropathy
»   Affects approximately 50% after 15 year
»   Affects long nerves(feet and legs) first
– glove and stocking distribution
»   Bilateral
»   Equal symptoms in both limbs

Charcot’s Arthropathy – Treatment


»   Acute phase
Non weight-bearing
Total contact cast
»   Chronic phase
Orthopedic surgery


Peripheral vascular disease

»    Causes:   Decrease perfusion due to macro vascular disease.
» Sites :     more distal
Tibial and personal arteries (Segment between the knee and the ankle but aortic to knee less frequently)

Peripheral vascular disease in diabetes

»   15 to 40 times more likely to have a lower limb amputation
»   people over 70 years have 70-fold increased risk of amputation


Characteristics of atherosclerosis in diabetes

»   More common
»   Affects young age group
»   No sex difference
»   Smokers
»   Faster in progress


Peripheral vascular disease

»   Symptoms
– Intermittent claudicating
 Rest pain
»   No Symptoms
 Inactivity
 Neuropathy

Signs of vascular disease

»   Diminished or absent pedal pulses
»   Cool skin with a bluish tinge
»   Damage to nails
»   Absence of haïr on the feet and legs




Chronic Kidney Disease


Objectives

 

After completing this module the participant will be able to

    Discuss the risk factors for chronic kidney disease (CKD)
    Discuss the progression of CKD
    Describe the screening measures and target levels for microalbuminuria
    Discuss management strategies for CKD
    State caution to be recognized with use of certain medications

Chronic kidney disease (CKD)

Classified as having CKD when
♣    Classic diabetic nephropathy ((persistent albuminuria regardless of level of kidney function)
♣    Significantly reduced kidney function (estimated globular filtration rate(eGFR) of < 60 ml/min)


StageDescriptionGRF
1.Kidney damage /normal or high GFR> 90 mL/min
2.Kidney damage /mlld reduction in GFR60-89
3.Moderately impaired30-59
4.Serverly impaired15-29
5.Advanced or on dialysis< 15

Risk factors

    Poor glycaemic control
    Hypertension
    Genetic predisposition
    Hyperlipidaemia
    Ethnicity
    Long disease duration
    Smoking


Gynae & Obstetrics

The Obstetrics and Gynaecology Department provides modern comprehensive diagnostic and treatment modalities in a caring environment for women throughout all seasons of life.


Our specialised medical team offers advanced maternity services for normal and high risk pregnancies, postpartum and family planning services, infertility screening and treatments, and all endoscopic gynaecological operations in addition to conventional gynaecology surgeries and medical therapies.


Orthopaedics

The Obstetrics and Gynaecology Department provides modern comprehensive diagnostic and treatment modalities in a caring environment for women throughout all seasons of life.


Our specialised medical team offers advanced maternity services for normal and high risk pregnancies, postpartum and family planning services, infertility screening and treatments, and all endoscopic gynaecological operations in addition to conventional gynaecology surgeries and medical therapies.

Controlling risk factors

• Lifestyle intervention: decrease saturated and trans fat intake, increase monounsaturated fat intake, lose weight, exercise, stop smoking
• Lipid-lowering agents
• ACE inhibitors
• Aspirin
• Glycogenic Control

Activity

For whom is aspirin recommended?
What does should be taken?
What are the side effects of aspirin?
What are the contraindications to aspirin?
Is there any other medicine that can be used if aspirin is contraindicated?

Risk factors

•   Poor glycogenic control
•   Long duration of diabetes
•   Hypertension
•   Nephropathy
•   Pregnancy

Screening tests

    Fundoscopy (through dilated pupils) – by a specialist ophthalmologist or a specially trained member of the health care team.
•   Retinal photography- images read by trained specialists

Diabetic Retinopathy

 

1.    Non-proliferative diabetic retinopathy: minimal, mild, moderate, severe
2.    Proliferative Diabetic retinopathy (PDR): early PDR, high-risk or advanced PDR.
3.    Maculopathy, macular oedema seen most often

Classification

   Proliferative Retinopathy: new vessels

Vitreous haemorrhage

•   See a black mark across the vision.
•    Some blood will be reabsorbed
•   Vitrectomy may be necessary

Risk factors

Screening tests

    Fundoscopy (through dilated pupils) – by a specialist ophthalmologist or a specially trained member of the health care team.
•   Retinal photography- images read by trained specialists

Diabetic Retinopathy

 

1.    Non-proliferative diabetic retinopathy: minimal, mild, moderate, severe
2.    Proliferative Diabetic retinopathy (PDR): early PDR, high-risk or advanced PDR.
3.    Maculopathy, macular oedema seen most often

Classification

   Proliferative Retinopathy: new vessels

Vitreous haemorrhage

•   See a black mark across the vision.
•    Some blood will be reabsorbed
•   Vitrectomy may be necessary

Risk factors


Screening tests

    Fundoscopy (through dilated pupils) – by a specialist ophthalmologist or a specially trained member of the health care team.
•   Retinal photography- images read by trained specialists

Diabetic Retinopathy

1.    Non-proliferative diabetic retinopathy: minimal, mild, moderate, severe
2.    Proliferative Diabetic retinopathy (PDR): early PDR, high-risk or advanced PDR.
3.    Maculopathy, macular oedema seen most often

Classification

   Proliferative Retinopathy: new vessels

Vitreous haemorrhage

•   See a black mark across the vision.
•    Some blood will be reabsorbed
•   Vitrectomy may be necessary

Diabetic peripheral neuropathy - Risk factors

One of the most sublime experiences we can ever have is to wake up feeling healthy after we have been sick.

Peripheral vascular disease non-invasive evaluation (2 of2)


»   Doppler ultrasound
 Measures pressure at brachial, pedal and toe arteries
 Ankle Brachial Index (ABI)
< 0.9 abnormal

0.9 to 1.0 normal

>1.3 non-compressible

»   Duplex arterial imaging – allows narrowing or obstruction of blood vessels to be localized

Peripheral vascular disease



Treatment
»   Quit smoking
»   Walk through pain
»  Surgical intervention

Ophthalmology

ENT

Neuro Physician