Efectividad de la cirugía arterial en pacientes diabéticos en un período de cinco años / Effectiveness of arterial surgery in diabetic patients over a period of five years

Introducción: La macroangiopatía diabética constituye un serio problema para los pacientes que la portan y la cirugía revascularizadora constituye una alternativa de tratamiento. Objetivo: Demostrar la efectividad de las cirugías arteriales realizadas en pacientes diabéticos en un período de cinco años. Métodos: Estudio descriptivo, retrospectivo, en 71 historias clínicas de pacientes portadores de macroangiopatía diabética que recibieron cirugía arterial en el Instituto Nacional de Angiología y Cirugía Vascular (enero/2011- diciembre/2015). Se analizaron las variables: edad, género, color de la piel, supervivencia de la extremidad, estado de permeabilidad de los injertos y frecuencia de fallecimientos, que en su conjunto medirán la efectividad de la cirugía. Resultados: Hubo un incremento lineal de las cirugías revascularizadoras. La edad media fue de 64,5 ± 9,7 años, con un 67,6 por ciento de mayores de 60 años y más del 60 por ciento eran hombres. El 52,9 por ciento tenía piel blanca, el 80,3 por ciento tuvo grado 4 según Fontaine y el 66,2 por ciento tenía oclusión arterial severa. En más del 90 por ciento se realizó cirugía derivativa o endarterectomía, el 87,3 por ciento tuvo afectado el sector infrainguinal y en el 64,8 por ciento sobrevivió la extremidad. No se registraron muertes perioperatorias ni fallecidos a los seis meses. El 63 por ciento de las cirugías fueron permeables a los seis meses. Conclusiones: Las cirugías arteriales son efectivas pues la mayoría de los pacientes mantienen la extremidad afectada y no se registran fallecimientos perioperatorios ni a los seis meses de evaluación, además, la mayor cantidad de injertos resultaron ser permeables en ese tiempo(AU)

Introduction: Diabetic macroangiopathy is a serious problem for patients who suffer it; and revascularization surgery is an alternative to its treatment. Objective: To show the effectiveness of arterial surgeries performed in diabetic patients over a period of five years. Methods: Descriptive, retrospective study in 71 clinical records of patients with diabetic macroangiopathy who received arterial surgery at the National Institute of Angiology and Vascular Surgery (January / 2011- December / 2015). The variables analyzed were: age, gender, skin color, survival of the limb, state of permeability of the grafts and frequency of deaths, which as a whole will measure the effectiveness of the surgery. Results: There was a linear increase in revascularization surgeries. The mean age was 64.5 ± 9.7 years, with 67. 6 percent of people over 60 years old, and more than 60 percent were men. 52.9 percent had white skin, 80.3 percent had grade 4 according to Fontaine and 66.2 percent had severe arterial occlusion. In more than 90 percent, derivative surgery or endarterectomy was performed; 87.3 percent had affectations in the infrainguinal sector and in 64.8 percent the limb survived. There were no perioperative deaths or deaths at six months. 63 percent of the surgeries were permeable at six months. Conclusions: Arterial surgeries were effective because the majority of patients maintained the affected limb and there were no perioperative deaths neither at the six months evaluation; in addition, most of the grafts were permeable in that time(AU)

Lower limb ischaemia in patients with diabetic foot ulcers and gangrene: recognition, anatomic patterns and revascularization strategies.

The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients.

Pie diabético en joven trabajador / Diabético foto in a Young worker

El pie diabético viene determinado por la neuropatía que se produce en el paciente con diabetes y el traumatismo sobre el pie con la microangiopatía propia de la diabetes asociada o no a la macroangiopatía. Presentamos un paciente joven con mal control de la glucemia y de la lesión trófica que pudo conservar la funcionalidad de la extremidad con un tratamiento adecuado (AU)

The diabetic foot is determined by the result of a peripheral neuropathy that evolves with high blood sugar levels over a long time, together with macrotraumatisms over the feet in a diabetic foot already affected with microangyopathy. A macroangiopathy might be also involved. We present the case of a young patient with high blood sugar levels and a diabetic ulcer, who was able to preserve the function of his foot after a correct treatment (AU)

Cardiac rehabilitation completion is associated with reduced mortality in patients with diabetes and coronary artery disease.

AIMS: Cardiac rehabilitation (CR) reduces the risks of mortality and hospitalisation in patients with coronary artery disease and without diabetes. It is unknown whether patients with diabetes obtain the same benefits from CR. METHODS: We retrospectively examined patients referred to a 12 week CR programme between 1996 and 2010. Associations between CR completion vs non-completion and death, hospitalisation rate and cardiac hospitalisation rate were assessed by survival analysis. RESULTS: Over the study period, 13,158 participants were referred to CR (mean ± SD, age 59.9 ± 11.1 years, 28.9% female, 2,956 [22.5%] with diabetes). Patients with diabetes were less likely to complete CR than those without diabetes (41% vs 56%, p < .0001). Over a median follow-up of 6.6 years, there were 379 deaths in patients with diabetes vs 941 deaths among those without diabetes (12.8% vs 8.9%). Of the non-completers, patients with diabetes had a higher mortality rate compared with those without diabetes (17.7% vs 11.3%). In patients who completed CR, mortality was lower: 11.1% in patients with diabetes vs 7.0% in those without diabetes. In patients with diabetes, CR completion was associated with reduced mortality (HR 0.46 [95% CI 0.37, 0.56]), reduced hospitalisation (HR 0.86 [95% CI 0.76, 0.96]) and reduced cardiac hospitalisation (HR 0.67 [95% CI 0.54, 0.84]). The protective associations were similar to those of patients without diabetes. In multivariable adjusted analyses, all of these associations remained significant. CONCLUSIONS: Patients with diabetes were less likely to complete CR than those without diabetes. However, patients with diabetes who completed CR derived similar apparent reductions in mortality and hospitalisation to patients without diabetes.

Cardiac rehabilitation in African Americans: evidence for poorer outcomes compared with whites, especially in women and diabetic participants.

BACKGROUND: Cardiac rehabilitation (CR) improves coronary artery disease risk factors and mortality. Outcomes after CR in African Americans (AAs) compared with whites have not been studied extensively. METHODS: A total of 1,096 patients (169 AAs, 927 whites) were enrolled in a 36-session CR program for ischemic heart disease or postcardiac surgery. The program consisted of exercise, lifestyle modification, and pharmacotherapy. RESULTS: After CR, quality of life, blood pressure, and low-density lipoprotein cholesterol improved significantly in both AAs and whites, although to a lesser degree in AAs. Whites also had significant improvements in weight and triglyceride concentrations. Overall, mean peak exercise capacity, measured in metabolic equivalents (METs), improved by only 1.6 (95% CI 1.3-1.8) in AAs compared with 2.4 (2.3-2.6) in CCs (P< .001 for AAs vs CCs). African American women had the least improvement in METs, but changes were still significant (1.1 [CI 0.9-1.4]). The subgroup with the least improvement in METs was AA diabetic patients (1.4 (CI 1.1-1.7]). CONCLUSION: African Americans derive a significant benefit from CR, but not to the same degree as whites, based on changes in risk factors and in exercise capacity. Within both ethnic groups, both women and diabetic patients appeared to have markedly less improvement.

Cardiac rehabilitation in patients with type 2 diabetes mellitus and coronary disease: a comparative study.

INTRODUCTION AND AIMS: Diabetic patients have a 2-4 times higher risk of cardiovascular disease than non-diabetic individuals. The aims of this study are to evaluate the effects of a cardiac rehabilitation program (phase II) in patients with diabetes and coronary disease and to compare the results with regard to control of cardiovascular risk factors and improvement in functional capacity with coronary patients without diabetes. METHODS: This was a prospective study of patients diagnosed with ischemic heart disease referred for a cardiac rehabilitation program between January 2009 and June 2013. The population was divided into two groups: diabetic and non-diabetic. Patients were assessed at the beginning of phase II and three months later and the following parameters were recorded: body mass index, waist circumference, lipid profile, blood glucose and glycated hemoglobin in diabetic patients, blood pressure, smoking, physical activity level (using the International Physical Activity Questionnaire) and functional capacity (on treadmill stress testing). RESULTS: The study population consisted of 682 patients (253 diabetic and 429 non-diabetic). Diabetic patients were significantly older, had a worse cardiovascular risk profile (higher prevalence of overweight, dyslipidemia, hypertension and sedentary lifestyle) and lower functional capacity. At the end of phase II, there was a statistically significant improvement (p<0.05) in all risk factors and functional capacity, which was similar in both groups, except for body mass index, triglycerides and functional capacity. CONCLUSIONS: Diabetic patients may benefit from a cardiac rehabilitation program and achieve comparable results to non-diabetic patients.

Complicaciones crónicas de la diabetes mellitas. Recomendaciones de la American Diabetes Association (ADA) 2011. Prevención y manejo / Chronic complications of diabetes mellitus. Recommendations from the American Diabetes Association 2011. Prevention and management

La diabetes mellitus (DM) es una de las enfermedades con mayor impacto sociosanitario, no sólo por su elevada prevalencia, sino, sobre todo, por las consecuencias de las complicaciones crónicas que genera. La hiperglucemia ocasiona daño tanto en el ámbito de la microcirculación como en los grandes vasos provocando lesiones macroangiopáticas y microangiopáticas. Las complicaciones macroangiopáticas se originan a partir de alteraciones o lesiones en los grandes vasos arteriales siendo las más importantes, desde el punto de vista clínico, la cardiopatía isquémica, la enfermedad cerebrovascular y la arteriopatía periférica. Las complicaciones microangiopáticas son consecuencia de alteraciones o lesiones de pequeños vasos siendo las más importantes, desde el punto de vista clínico, la nefropatía, la retinopatía y la neuropatía diabéticas(AU)

Diabetes mellitus (DM) is one of the diseases with greater impact public health, not only because of its high prevalence, but, above all, by the consequences of the chronic complications arising from this disease. Hyperglycemia generates damage both in the field of microcirculation and the great vessels causing injury, macroangiopathies and microangiopathies. Macroangiopathies complications are generated from alterations or injury in the great vessels of the arterial to the most important, being from the clinical point of view, ischemic heart disease, disease stroke and peripheral arterial disease. Microangiopathies complications are due to alterations or injury of small vessels being the most important, from a clinical point of view, nephropathy, retinopathy and diabetic neuropathy. Macroangiopathies complications are generated from alterations or injury in the great vessels of the arterial to the most important, being from the clinical point of view, ischemic heart disease, disease stroke and peripheral arterial disease. Microangiopathies complications are due to alterations or injury of small vessels being the most important, from a clinical point of view, nephropathy, retinopathy and diabetic neuropathy(AU)

Pre-operative rehabilitation evaluation of the dysvascular patient prior to amputation.

Lower-extremity amputation secondary to dysvascular disease, including diabetes and peripheral vascular disease, is a major health problem in the United States. Due to the increased comorbidities in this patient population, pre-operative rehabilitation evaluation by a multidisciplinary team is crucial to ensure optimal patient outcomes. This article discusses the key factors that may affect functional outcomes in this patient population and outlines important history and physical examination components that should be evaluated pre-operatively.

Prosthetic rehabilitation issues in the diabetic and dysvascular amputee.

Evaluation and management of diabetic and dysvascular patients with lower limb amputation begins with a thorough history and physical examination. A pre-prosthetic and prosthetic program of physical therapy, pain management, psychological assessment, and education helps patients resume functional mobility and gain acceptance of the limb loss. Physicians and prosthetic teams work together to design and prescribe the most appropriate prosthetic device for patients to reach maximal functional level. Careful monitoring of patients and a full understanding of patients' medical conditions help avoid complications and falls during rehabilitation. Long-term follow-up is necessary to assess fit and function of prosthetic devices.

Making diabetes education accessible for people with visual impairment.

PURPOSE: The purpose of this study was to identify changes needed to make the diabetes education materials and programs of the Diabetes Association of Greater Cleveland (DAGC) accessible for people who have visual impairment and diabetes (PVID). METHODS: Using the principles and techniques of participatory action research (PAR), 5 PVID and 4 staff members of a local diabetes association met once a month for a year to plan, implement, and evaluate progress toward full accessibility of all diabetes education materials and programs. The researcher served as facilitator. RESULTS: Four "transformational moments" are presented through which the PAR process enabled PVID and diabetes professionals to learn to understand and trust each other. Changes made to increase accessibility included production of 2 recordings for providing access to print information about diabetes; planning public education program publicity and locations for access; development of guidelines to help speakers make their diabetes education presentations accessible for people who cannot see slides and gestures; and presentation of an inservice for the entire staff of the diabetes association, including information about how they live with visual impairment, and common courtesies that make communication with PVID more effective. CONCLUSIONS: Diabetes education programs should include planning for full accessibility for PVID. Diabetes organizations should publish teaching materials in accessible format.

[Specific characteristics of amputations of the lower leg: the physicians view]. / Besonderheiten bei der Amputation der unteren Extremität aus der Sicht des Internisten.

Amputations are relevant problems not only for the surgeon. Physicians and dialectologists are also involved into the wound treatment, the coordination of the attending problems which leads to impaired wound healing (e.g. hyperglycaemia, infection, arterial occlusive disease). Internists should be part of the interdisciplinary setting and also of the decision for the necessary amputation. A well coordinated and interdisciplinary procedure allows to control appearing wound healing disturbances and to receive a functionally optimal result by employing minimal surgical interventions.

[Preserving amputations or resection techniques on the foot]. / Extremitätenerhaltende Amputations- und Resektionstechniken am Fuss.

The main causes for amputations on the lower extremities are dysvascular disease and/or diabetes mellitus. Especially in diabetics tissue preserving surgical techniques should be performed. Due to multimorbidity and high risk of an amputation on the other extremity, the so called "major amputations" ("transtibial" or "transfemoral") should be reduced. Especially in diabetics tissue preserving amputations on the foot or resection techniques on the foot are of importance to prevent major disabilities or handicaps on the patients. For this the surgeon has to have knowledge on all amputation levels on the foot as well as knowledge about prosthetic fitting or shoe techniques. With this a high percentage of good results will prevent the patient from major amputations.

Cardiovascular rehabilitation increase arterial compliance in type 2 diabetic patients with coronary artery disease.

AIMS: The effect of a cardiovascular rehabilitation program on arterial compliance in type 2 diabetes mellitus with coronary disease was studied. METHODS: Hemodynamic data and arterial compliance were measured with a tonometer (HDI/Pulse wave CR-2000) in coronary artery disease patients with (n=32) and without (n=24) type 2 diabetes before and after a 6-week multidisciplinary cardiac rehabilitation program. RESULTS: A decrease in heart rate and an increase in stroke volume without significant change in resting cardiac output were obtained in diabetic patients. Arterial compliance of both small and large arteries was significantly increased. In 10 diabetic patients, this increase could be related to an increase in the anti-hypertensive treatment and to the decreased blood pressure. In the 22 remainders, the small artery compliance was significantly increased independently of blood pressure change. CONCLUSIONS: Exercise training as well as optimization of diabetes and dyslipidemia treatment could explain the improvement of arterial compliance. If these changes are long-lasting and if they improve prognosis remains to be evaluated.

Secondary prevention of diabetic patients with coronary artery disease in cardiac rehabilitation: risk factors, treatment and target level attainment.

INTRODUCTION: Diabetic patients who have suffered from an acute coronary syndrome (ACS) or have had coronary artery bypass graft (CABG) surgery are at very high risk of recurrent cardiovascular events. Their prognosis, however, can be improved if the target values for blood pressure (BP < 130/80 mmHg) or low density lipoprotein cholesterol [LDL-C < 2.6 mmol/L (100 mg/dl), optionally < 1.8 mmol/L (70 mg/dl)] are achieved. It is not known what proportion of diabetic patients receives such stringent secondary prevention measures and achieves target level attainment for BP, lipids and glucose in cardiac rehabilitation (CR). METHODS: During 2003 to 2005, 11 973 diabetic (29.7%) and 28 370 non-diabetic patients (70.3%), predominantly after ACS (74 and 80%), were included in a nationwide registry. At entry and at discharge, patient characteristics, pharmacotherapy and blood pressure, lipids and blood glucose were recorded. In a mixed model approach, temporal changes between centres and within centres, respectively, were analysed. RESULTS: At discharge, a lower proportion of diabetic patients achieved normalisation of BP (in 2005: <140/90 mmHg: 78.4 vs. 82.9% in non-diabetic patients, p < 0.001) or <130/80 mmHg (45.5 vs. 49.8%), respectively. LDL-C < 2.6 mmol/L was more frequently attained in diabetic patients (68.2 vs. 66.5%), as was LDL-C < 1.8 mmol/L (28.8 vs. 23.0%). Fasting blood glucose was not changed during the observation period, as at discharge almost a quarter of all diabetic patients exceeded the threshold value of 7.0 mmol/L (126 mg/dl). In 2005 at discharge, statin therapy was administered in 93% in both diabetics and non-diabetics, acetylic salicylic acid in 79% in diabetics vs. 80% in non-diabetic patients (clopidogrel: 41 vs. 45%). CONCLUSION: Generally there is room for improvement in the management of cardiac risk factors for both patients groups. In diabetic patients in CR at high risk for recurrent cardiac events, in recent years an improvement of the lipid profile has been observed. Hypertension and glycaemia are still not optimally addressed.

Cardio-ankle vascular index measures arterial wall stiffness independent of blood pressure.

Although brachial-ankle pulse wave velocity (baPWV) is a non-invasive method of detecting arteriosclerosis, it is affected by changes in blood pressure (BP). Cardio-ankle vascular index (CAVI) is a new method for estimating arteriosclerosis, and it has been reported to be less influenced by BP. We investigated the influence of BP changes on CAVI and the correlation of CAVI to clinical factors and carotid arteriosclerosis. CAVI and baPWV in 35 non-diabetic and 33 diabetic subjects were measured in increased BP (after stair climbing) and rested BP (after 10min of rest). Intima-media thickness (IMT) of carotid arteries was measured by ultrasoundsonography. We achieved the following results: CAVI did not show a significant change with a change in BP in both non-diabetic and diabetic subjects. On the contrary, baPWV was significantly influenced by BP changes. Carotid artery IMT had a significant positive correlation with CAVI and baPWV. Multiple regression analysis revealed that significant risk factors of high baPWV were age and systolic BP. On the contrary, significant risk factors of high CAVI were age and hemoglobin A1c, while systolic BP was not relevant. Our findings suggest that CAVI is independent of BP and useful as an indicator of early arteriosclerosis in diabetic subjects.