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
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)
» 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
» 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)
| Stage | Description | GRF |
|---|---|---|
| 1. | Kidney damage /normal or high GFR | > 90 mL/min |
| 2. | Kidney damage /mlld reduction in GFR | 60-89 |
| 3. | Moderately impaired | 30-59 |
| 4. | Serverly impaired | 15-29 |
| 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
