Friday, October 21, 2005
Abstract and Introduction
Diabetic foot syndrome is complex, affects up to 20% of patients with diabetes at least once in their lifetime, and is responsible for the vast majority of amputations in the United States and in Europe. Since its clinical history evolves from an initial nonulcerative phase, to an acute ulcerative phase, an eventual recurrence, and a chronic post-ulcerative phase, measurements related to such a complex condition should explore and exhaustively describe all aspects of the pathology. In the pre-ulcerative phase, evaluation and quantification of risk factors for the development of ulceration are the most important aspects. In this phase, neuropathy and peripheral vascular disease are addressed. In the ulcerative phase, measurements related to the ulcer, including size, location, involvement of deep structures, presence of ischemia, and infection, are all relevant to establish a therapeutic program and a prognosis of the pathologic condition. In the post-ulcerative phase, emphasis should be placed on determining the risk of recurrences and evaluating postural loads and gait imbalances secondary to the outcomes of the acute phase. Such evaluation is important in the prescription of orthesis and shoes that have a protective role with the at-risk foot and thus reduce the risk of recurrences. Measurements in the diabetic foot are of paramount importance to create a quantitative paradigm and reduce empiricism in clinical practice in the management of such a complex pathology.
Abstract and Introduction
The last ten years have seen a rapid expansion in the evidence-base for the reduction of cardiovascular risk in people with diabetes. Following the landmark Scandinavian Simvastatin Survival Study (4S), several other studies have shown the benefits of statins in people with diabetes, but much less data are available for the benefit of fibrates, and the main evidence to date comes from subgroup analysis of the Veterans Affairs High Density Lipoprotein Cholesterol Intervention Trial (VA-HIT). The Hypertension in Diabetes Study (HDS), nested within the United Kingdom Prospective Diabetes Study (UKPDS), proved that tight control of hypertension reduced microvascular and macrovascular events in people with diabetes, and the Heart Outcomes Prevention Evaluation (HOPE) and MICRO-HOPE studies suggested a benefit in reducing cardiovascular events with angiotensin-converting enzyme (ACE) inhibition, additional to blood pressure lowering effects. With regards to glycaemic therapy, the UKPDS has shown the benefit of metformin in reducing myocardial infarctions. The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) and Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROactive) studies will be presented later this year and will give information on the role of fenofibrate and pioglitazone respectively in reducing cardiovascular events in people with diabetes.
The brave new world of type 2 diabetes management embarked upon in the last decade has been truly monumental. It is easy to forget the compartmentalisation of care that preceded this with the diabetologist's primary role being the improvement of glycaemic control. The importance of viewing diabetes not so much as a disease of too much sugar associated with microvascular disease to a state of premature cardiovascular death which is associated with hyperglycaemia and microvascular disease was heralded as recently as 1996 when the evidence was still lacking. This review describes some landmark cardiovascular studies over the last 10 years in type 2 diabetic patients in the fields of lipids, hypertension and glycaemic control and discusses the use of specific drugs such as statins and ACE inhibitors.
Section 1 of 5
Next Page: Lipids