DIABETES MELLITUS

[drmithila]

Diabetes mellitus affects 230 million people worldwide.1
There is a rising incidence and prevalence of diabetes mellitus.1 About 50% of people with diabetes mellitus are unaware of their condition.1 Approximately 25% of all diabetics undergoing surgery are undiagnosed on admission to hospital.2
Diabetics have a higher risk of certain diseases (for example, they are 4 times more likely to have cardiovascular disease).3 Diabetics have a higher perioperative risk.1 They are more likely because of their disease to require surgery and those undergoing surgery are likely to be less well-controlled and to have complications from their diabetes.
Surgeons and anaesthetists operating on diabetic patients should be familiar with the risks attached to being diabetic and to the particular risks of the particular surgery and of anaesthesia in diabetic patients.
Risks and complications of diabetes mellitus
Patients with diabetes mellitus are at risk of the complications of the disease. It is worth considering these in outline when considering how best to care for diabetic patients undergoing surgery.

Cardiovascular disease. The high risk of large vessel coronary artery disease in diabetic patients is well recognised with data from the Framingham study showing a risk in men and women between 2.4 and 5.1 times greater.3 Diabetes is the most common cause of myocardial infarction in people under the age of 30 years.
Peripheral artery disease is under-recognised as it is often asymptomatic. It is present in 25-30% of diabetics and is an important marker for systemic atherosclerosis (70% of such patients die from coronary heart disease, 5-10% from stroke).4
Renal disease. Diabetic nephropathy develops in close to 40% of patients with type 1 diabetes, and between 5% and 40% of patients with type 2 diabetes.
Diabetic retinopathy occurs in up to 20% of diabetic patients.
Neurological disease is common:
Peripheral neuropathy occurs in 30% of diabetic patients.
Autonomic neuropathy, although less common, is important as it causes hypotension and may diminish the autonomic response to hypoglycaemia (pallor, sweating, tachycardia).
Susceptibility to nerve palsies (mononeuritis) is increased.
Skin disease is more common.
Susceptibility to infection is increased.
Hypoglycaemia can occur.
Diabetic ketoacidosis can occur with trauma and surgical complications.
Perioperative risks and complications of diabetes mellitus
Interestingly, the risk of complications after coronary artery stenting5 may not be increased in diabetes. In another study of complications after renal transplantation there was no difference between diabetics and non-diabetic recipients6 and it seems that there are other greater risk factors for poor outcome (including age of donor and recipient, time awaiting transplantation, etc.).7 This perhaps illustrates that it is important in assessing risk of complications in diabetic patients undergoing surgery to consider the specific type of surgery and anaesthetic technique. There is evidence for higher risk in diabetics undergoing surgery and, when such evidence is lacking, it may in part be testament to the relative safety of modern surgery and anaesthesia.

However, the following risks and observations are worth considering in diabetic patients undergoing surgery:

Myocardial infarction postoperatively (may be silent, has a greater mortality). However, again it is not straightforward. In one study of cardiovascular complications in diabetics undergoing major vascular surgery, after controlling for specific comorbid conditions, the only independent association was between patients with insulin treatment and the risk of cardiovascular complications.8 Similarly, despite worse demographic and clinical characteristics, diabetic patients having coronary artery surgery had a low mortality and morbidity (comparable with control patients).9 Although diabetes may not be a risk factor for adverse outcome following coronary artery surgery, the long-term survival in diabetics remains significantly inferior compared with non-diabetics.10,11 However, other studies show a clear increase in risk of perioperative cardiac events in diabetics – for example, after renal transplant12 carotid endarterectomy13,14 and vascular surgery.15
Patients with diabetes mellitus undergoing percutaneous coronary intervention (PCI) are at increased risk for adverse outcomes.16 It is not clear how this compares with surgery.
Cardiac arrest as a consequence of autonomic neuropathy.
Chronic renal failure patients (diabetic nephropathy) have a worse outcome (complications and mortality) even accounting for the increased risk of associated conditions (hypertension, peripheral vascular disease).17,18
Stroke.This is consistent with the generally increased risk in diabetes mellitus, although again the surgical procedure and other risk factors for stroke (for example, smoking, anaesthetic technique) are important.19
Problems with lower limb ischaemia. This is consistent with high incidence of peripheral vascular disease.4
Heel pressure sores, particularly with peripheral neuropathy.
Postoperative wound infection.20
Other infections such as chest and urinary infections are more common in diabetics. Tuberculosis can occur particularly in elderly diabetics.2
Disruption and worsening of diabetic control (for example, from the stress of surgery, lack of oral intake, postoperative vomiting, etc.).
Poor perioperative diabetic control is associated with unfavourable outcomes in, for example, infra-inguinal bypass surgery.21
Poor intraoperative blood glucose control is associated with worse outcome after cardiac surgery in diabetic patients.22,23
Diabetes mellitus is a risk factor for prolonged intensive care after cardiac surgery24 and prolonged length of hospital stay after surgery.8
Preoperative assessment of the diabetic patient
A careful preoperative assessment should be done and may help improve outcome:25

To establish the history of the patient’s diabetes and the state of their diabetic control.
To look for complications of diabetes mellitus.
To establish the safest method of anaesthesia and surgery.
It is apparent from a review of the risks of surgery associated with diabetes mellitus that the assessment and reduction of risk require an individual assessment of the particular patient and the surgery being undertaken.

History and examination
Assessment of control should be made (records of HbA1c, etc.).
Cardiovascular disease:
Evidence of angina, intermittent claudication should be sought.
Examine for peripheral vascular disease.
Examine for postural hypotension (systolic fall of >30 mm Hg on standing).
Neurological disease:
Symptoms of numbness, pain, paraesthesia, leg ulcers, transient ischaemic attacks, etc.
Postural hypotension gives a late indication of autonomic neuropathy.
An assessment of heart rate variability (HRV) during deep breathing is a much better way of detecting autonomic neuropathy earlier.26
Renal disease:
Symptoms of polyuria may reflect glycosuria or renal failure.
Anaemia and hypertension should be detected as possible associated conditions.
Skin, feet and general examination:
The skin should be examined for sepsis.
Pressure areas (heels, buttocks, etc.) should be examined for sores.
Preoperative investigation
Should include:

Blood glucose (serial readings) and HbA1c (more relevant for long-term control). Blood glucose should be maintained at 4-10 mmol/L and it is very important to avoid hypoglycaemia. If blood sugar cannot be maintained below 13 mmol/L, surgery should be deferred (risk of ketoacidosis or hyperosmolar state.
FBC.
ECG (with Valsalva manoeuvre) to assess for ischaemic and other cardiovascular disease.
U&Es (assess for renal complications) and estimated glomerular filtration rate (eGFR), if available.
Urine analysis. Ketones (poor control), protein (possible renal complications) and bacteriology (for infection).
CXR. This may be indicated to screen for pulmonary infection, including tuberculosis.
Choice of anaesthetic
Local or general anaesthesia can be used.
Local anaesthesia:
Reduces the stress response
Hypoglycaemia readily detectable with the patient awake.
Postoperative nausea reduced.
Easy postoperative diabetic control.
There are disadvantages of regional blocks with cardiovascular disease and some neurological conditions.
General anaesthesia. Consideration should be given to:
The presence of cardiovascular and renal disease.
Prevention of intra-operative hypoglycaemia.
Autonomic neuropathy (It can mask hypoglycaemia and may exacerbate respiratory depression with opioids).
Avoidance of hypotension (increased risk of spinal cord infarction).
Protection of pressure areas.27
Perioperative management
Type 1 diabetes mellitus
It is usually best to admit patients 2-3 days before elective surgery, particularly if outpatient adjustments are difficult. There are different recommended routines but it is important that ward staff and those responsible for postoperative care have clear instructions. Complicated regimens can cause confusion amongst staff.

Ensure good preoperative control usually with short-acting insulin (or a mixture of short- and intermediate-acting insulin) twice daily. Extra short-acting insulin can be added if necessary.
Monitor blood glucose throughout the day.
On the day of surgery starve from midnight and do not give the first dose of insulin.
Operation should be as early as possible (i.e. put the diabetic patient first on the list).
Check glucose and electrolytes early on the day of surgery (defer if glucose >13 mmol/L or if there is significant electrolyte disturbance).
Start intravenous (IV) infusions of dextrose (500 mls 10% dextrose plus 10 units soluble insulin plus 10 mol KCl at 125 mls per hour). Check blood glucose and electrolytes at the end of the operation or at 1- to 2-hourly intervals.
Monitor blood glucose during surgery at least every 30 minutes. Continue this as long as blood glucose is between 5-10 mmol/L. Reduce insulin to 5 units if less than 5 mmol/L and increase to 15 units if blood glucose is 10-20 mmol/L (new infusion needed of course).
After surgery, check glucose every 2 hours and electrolytes every 6-12 hours, adjusting infusions as necessary.
Continue infusions but, when eating normally, restart subcutaneous insulin (as before surgery).
Type 2 diabetes mellitus
Preoperatively, control should be assessed.
Patients controlled by diet alone do not usually need any special measures, providing control on diet is adequate.
It is better to use short-acting drugs (for example, glipizide).
Remember that the hypoglycaemic effect of sulphonylureas is enhanced by some drugs (for example, aspirin, sulphonamides, anticoagulants).
Metformin should be discontinued 48 hours prior to and subsequent to surgery in order to reduce the risk of lactic acidosis.27
If control is inadequate, insulin may be needed.
Insulin can be required in the postoperative phase temporarily.
On the day of surgery keep ‘nil by mouth’ as usual and omit short-acting sulphonylurea.
Monitor blood glucose as for type 1 diabetes above. If blood glucose is >13 mmol/L, use insulin to control (small doses of soluble insulin).
For major surgery or where there is prolonged postoperative starvation, use glucose and insulin infusions as set out above.
Emergency situations
In general, emergency or non-elective cases must have blood glucose controlled with insulin, glucose and potassium infusions as above with special attention being given to rehydration before surgery.

Pitfalls
Diabetic ketoacidosis. This can present as abdominal pain and vomiting, with the vomiting usually preceding the pain (unlike in the acute abdomen when pain usually precedes vomiting). If diabetic ketoacidosis does not respond to treatment, it should be remembered that the acute abdomen may have triggered diabetic ketoacidosis.
Anaesthesia and surgery in diabetic ketoacidosis is hazardous but is occasionally required (e.g. for perforated diverticular abscess). For example, there is a risk of cerebral oedema (resulting from swings in serum osmolarity) and the effects of acidosis on ventilation can cause problems.
Hyperosmolar non-ketotic diabetic coma. These patients rarely require surgery but, if required, it is high-risk. Heparinisation is usually required.
Lactic acidosis should be suspected when there is acidosis but no ketosis. It can be caused by the effects of biguanides but occurs also in septicaemia, pancreatitis, and hepatic and renal failure

 

        

[Drsumitra]

Dentists and patients agree that blood sugar testing in dental offices is useful and should be done routinely, according to a new study in the Journal of the American Dental Association.

Type 2 diabetes mellitus (DM) has been increasing at epidemic rates, the study authors noted. More than 12% of the U.S. population suffers from DM, making it one of the most common and costly chronic conditions in the country. In addition, prediabetes affects about 54 million Americans, meaning a quarter of the U.S. population has impaired glucose metabolism.

Detecting these conditions and treating them adequately are major public health objectives, according to lead researcher Andrei Barasch, DMD, formerly associate professor at the University of Alabama at Birmingham School of Dentistry and now chairman of the Department of Dental Medicine at Winthrop University Hospital.

The dental office is uniquely suited for screening patients for specific conditions, and study results have demonstrated that it can be used for preventive health interventions, such as smoking cessation, the study authors noted. However, most dental practitioners regard blood glucose testing as outside their scope of practice, and only a few dental offices own and use a glucometer, the researchers wrote.

Multicenter international study

The JADA study (March 2012, Vol. 143:3, pp. 262-269) was conducted through the Dental Practice-Based Research Network using responses from dentists and staff members in community practices in Sweden and five U.S. regions: Alabama/Mississippi, Florida/Georgia, Minnesota, and Permanente Dental Associates in Oregon and Washington state.

The goal was to test the feasibility of screening patients for abnormal random blood glucose levels using glucometers and finger-stick testing. Practitioners and staffers were trained to use a glucometer, and they then screened adult patients ages 19 years and older during routine dental exams.

Dental practitioners offered BGT to patients with a body mass index (BMI) greater than 25 kilograms per square meter who had a self-reported history of hypertension or hypercholesterolemia or who had been diagnosed with DM or prediabetes.

Each patient received a card with the results of their tests and instructions on how to interpret the results. If a patient’s blood glucose level was abnormal, the dentist told the patient they might benefit from a formal evaluation and should discuss the results with their physician.

Patients then completed questionnaires, as did the dentist and staff members who performed the tests.

Dentists and staff members from 28 dental practices (24 general practices, one practice specializing in oral surgery, one practice specializing in periodontics, and two practices specializing in endodontics) from the five U.S. regions were included in the survey.

Twenty-eight dentists and 44 staff members participated, and 67 (93%) returned questionnaires. Twenty-two respondents (33%) were from the Alabama/Mississippi region, 31% were from the Florida/Georgia region, 17% were from Minnesota, 8% were from Permanente Dental Associates in Oregon and Washington state, and 11% were from Sweden.

Study findings positive

Among the respondents, 56 (84%) said that BGT benefits patients, and 46 (68%) said the tests may lead to better control of blood glucose levels if patients are tested in the dental office. Forty (60%) thought test results could help determine the timing of invasive procedures, and five (8%) did not.

Fifty respondents (74%) said the test results can help identify patients at risk of developing periodontal disease, while seven (11%) disagreed. A total of 59 (88%) respondents thought the test would promote the perception that dentists are interested in patients’ general health and increase patients’ confidence in the practice.

The majority (54, 79%) did not find the test too time consuming, and most (37, 56%) said it was not too expensive. A majority of the practices (18, 64%) reported the average test duration was two to five minutes, eight practices (29%) said it was less than two minutes, and two practices (7%) said it was longer than five minutes. A majority of the respondents (17, 61%) did not find it disruptive, and most (23, 82%) thought it was beneficial to the practice.

Most (51, 77%) said that blood glucose levels are relevant to dental practice, and two (2%) disagreed. Most (62, 93%) said patients were happy with the screening, and three (5%) disagreed. Three respondents (5%) thought the test opens the practice to liability, while the majority (48, 72%) did not.

Regarding barriers to implementation of routine BGT, 16 of the practices (57%) named lack of insurance coverage and seven (25%) thought there was insufficient patient demand. Twenty-six of the practices (93%) thought routine testing for at-risk patients should be done in dental practice, and all respondents said it was well received by patients and was easy to perform.

Patient perceptions

In addition to the practitioner questionnaires, researchers screened 498 patients. Most had dental insurance (83%) and qualified for BGT (84%).

Most (413, 83%) said testing in a dental office was a good idea and that the test showed a high level of care. Most said they would likely refer friends and family to the practice because BGT was offered; 28 (6%) patients disagreed.

A majority (422, 86%) found the test easy, and 397 (79%) said test results were useful.

Due to the cost of and the lack of robust evidence in support of earlier treatment, neither the U.S. Preventive Services Task Force nor the American Diabetes Association support community screening. Rather, the American Diabetes Association recommends opportunistic screening in the healthcare setting.

"Dental offices are healthcare settings, and, therefore, the feasibility of obtaining blood glucose measurements in dental offices is worthy of scrutiny," the study authors wrote.

Elevated blood glucose levels in people with DM and prediabetes may trigger dentists’ referral of patients to their physicians for evaluation of their treatment and help dentists determine the correct timing for these patients to undergo invasive dental procedures, the survey found.

In addition, the bidirectional relationship of DM with periodontal disease suggests a potential benefit of screening for DM and prediabetes for both patients and dental practitioners.

"Our findings suggest that most providers and their patients regard BGT as beneficial and easy after becoming familiar with the process," researchers concluded.

 

        

[drsushant]

Periodontal disease is an early complication of diabetes, and about 70 percent of U.S. adults see a dentist at least once a year," says Dr. Ira Lamster, dean of the College of Dental Medicine, and senior author on the paper. "Prior research focused on identification strategies relevant to medical settings. Oral healthcare settings have not been evaluated before, nor have the contributions of oral findings ever been tested prospectively."
For this study, researchers recruited approximately 600 individuals visiting a dental clinic in Northern Manhattan who were 40-years-old or older (if non-Hispanic white) and 30-years-old or older (if Hispanic or non-white), and had never been told they have diabetes or pre-diabetes.
Approximately 530 patients with at least one additional self-reported diabetes risk factor (family history of diabetes, high cholesterol, hypertension, or overweight/obesity) received a periodontal examination and a fingerstick, point-of-care hemoglobin A1c test. In order for the investigators to assess and compare the performance of several potential identification protocols, patients returned for a fasting plasma glucose test, which indicates whether an individual has diabetes or pre-diabetes.
Researchers found that, in this at-risk dental population, a simple algorithm composed of only two dental parameters (number of missing teeth and percentage of deep periodontal pockets) was effective in identifying patients with unrecognized pre-diabetes or diabetes. The addition of the point-of-care A1c test was of significant value, further improving the performance of this algorithm.
"Early recognition of diabetes has been the focus of efforts from medical and public health colleagues for years, as early treatment of affected individuals can limit the development of many serious complications," says Dr. Evanthia Lalla, an associate professor at the College of Dental Medicine, and the lead author on the paper. "Relatively simple lifestyle changes in pre-diabetic individuals can prevent progression to frank diabetes, so identifying this group of individuals is also important," she adds. "Our findings provide a simple approach that can be easily used in all dental-care settings."
Other authors who contributed are: Dr. Carol Kunzel, associate clinical professor at the College of Dental Medicine and at Columbia’s Mailman School of Public Health; Dr. Sandra Burkett, at the College of Dental Medicine; and Dr. Bin Cheng, an assistant professor in the Department of Biostatistics at the Mailman School of Public Health.
According to the Centers for Disease Control and Prevention, one in four people affected with type 2 diabetes in the United States remains undiagnosed. And those with pre-diabetes are at an increased risk for type 2 diabetes and also for heart disease, stroke and other vascular conditions typical of individuals with diabetes.

 

        

[Drsumitra]

 American adults of normal weight with new-onset diabetes are more likely to die than overweight and obese adults with the same disease, according to a new study.

The study, published in the August 7 issue of JAMA, finds that normal-weight participants experienced both significantly higher total and noncardiovascular mortality than overweight or obese participants.

Normal-weight adults with type 2 diabetes have been understudied because those who typically develop the disease are overweight or obese. In this study, about 10 percent of those with new-onset diabetes were at a normal weight when they found out they had the disease.

Being overweight is a risk factor for developing this disease, but other risk factors such as family history, ethnicity, and age may play a role.

        

[drmithila]

Assessing the relationship between blood glucose levels and clinical parameters of periodontal disease in diabetic patients, this recent study involved 65 diabetic and 81 nondiabetic individuals. The study was published online by Dr. J. E. Botero et al in the Journal of Periodontology. A full-mouth periodontal examination and prepandrial fasting glycemia values were recorded in each subject. Glycosylated hemoglobin was only measured in diabetic patients. A comparative analysis between groups (Mann-Whitney U-test) and a correlation analysis between glycemia and periodontal parameters were performed (Spearman test). The study found that nondiabetic patients presented more teeth than diabetic patients (P < .05). Diabetic patients with periodontitis displayed loss of periodontal clinical attachment compared to nondiabetics, but the highest value was observed in periodontitis patients who reported having a smoking habit. Furthermore, diabetic subjects with periodontitis presented higher glycemia and glycosylated hemoglobin values in contrast to gingivitis subjects. Diabetic patients with hyperglycemia had higher risk to develop periodontitis. A positive correlation was observed between glycemia and clinical attachment loss, while a negative correlation between glycemia and the number of teeth present was found. The study concluded that tooth and periodontal clinical attachment loss were increased by hyperglycemia in diabetic subjects. This study contributes to further evidence that diabetes could aggravate periodontal disease and affect the systemic health of individuals.

 

        

[Drsumitra]

Diabetic nephropathy is one of the most serious complications related to diabetes, often leading to end-stage kidney disease. Purple corn grown in Peru and Chile is a relative of blue corn, which is readily available in the U.S. The maize is rich in anthocyanins (also known as flavonoids), which are reported to have anti-diabetic properties.
Scientists from the Department of Food and Nutrition and Department of Biochemistry at Hallym University in Korea investigated the cellular and molecular activity of purple corn anthocyanins (PCA) to determine whether and how it affects the development of diabetic nephropathy (DN). Their findings suggest that PCA inhibits multiple pathways involved in the development of DN, which may help in developing therapies aimed at type 2 diabetes and kidney disease.
The study is entitled "Purple corn anthocyanins inhibit diabetes-associated glomerular monocyte activation and macrophage infiltration." It appears in the online edition of the American Journal of Physiology — Renal Physiology, published by the American Physiological Society.
Methodology
Researcher Min-Kyung Kang and colleagues performed a two-part study, an in vitro experiment investigating the effects of PCA on human endothelial cells cultured under hyperglycemic kidney conditions and an in vivo study that investigated the effects of PCA on kidney tissue in diabetic mice. In the in vitro experiment, cultured cells were exposed to 1-20 µg/ml of PCA for six hours (control cells were not exposed), then assessed for level of monocyte-endothelial cell adhesion, a major factor in the development of diabetic glomerulosclerosis. In the in vivo experiment, diabetic and control mice were dosed with PCA for eight weeks, then changes in kidney tissue were assessed and immunohistological analyses were performed. Kidney tissue was further analyzed for levels of inflammatory chemokines, which are key components in DN.
Results
Researchers found that in human endothelial cells cultured in hyperglycemic kidney conditions, induction of endothelial cell adhesion molecules decreased in a dose-dependent manner with PCA exposure, meaning that the PCA likely interfered with cell-cell adhesion in glomeruli. PCA also appeared to interfere with leukocyte recruitment and adhesion to glomerular endothelial cells. In diabetic mice, PCA exposure slowed mesangial expansion and interrupted the cellular signaling pathway that may instigate glomerular adhesion and infiltration of inflammatory cells responsible for diabetic glomerulosclerosis. Finally, PCA inhibited levels of macrophage inflammatory protein-2 and monocyte chemotactic protein-1 in kidney tissue, demonstrating that it may inhibit macrophage infiltration, which is closely related to renal inflammation.
Importance of the Findings
The research suggests that anthocyanins may be the main biofunctional compound in purple corn and could protect against mesangial activation of monocytes and infiltration of macrophages in glomeruli — the two major contributors to DN. The research further suggests that renoprotection by PCA against mesangial activation may be specific therapies targeting diabetes-associated diabetic glomerulosclerosis and renal inflammation. Finally, PCA supplementation may be an important strategy in preventing renal vascular disease in type 2 diabetes.
"PCA may be a potential renoprotective agent treating diabetes-associated glomerulosclerosis," wrote the researchers.

 

        

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