Type 1 diabetes and cardiovascular disease

The presence of cardiovascular disease (CVD) in Type 1 diabetes largely impairs life expectancy. Hyperglycemia leading to an increase in oxidative stress is considered to be the key pathophysiological factor of both micro- and macrovascular complications. In Type 1 diabetes, the presence of coronary calcifications is also related to coronary artery disease. Cardiac autonomic neuropathy, which significantly impairs myocardial function and blood flow, also enhances cardiac abnormalities. Also hypoglycemic episodes are considered to adversely influence cardiac performance. Intensive insulin therapy has been demonstrated to reduce the occurrence and progression of both micro- and macrovascular complications. This has been evidenced by the Diabetes Control and Complications Trial (DCCT) / Epidemiology of Diabetes Interventions and Complications (EDIC) study. The concept of a metabolic memory emerged based on the results of the study, which established that intensified insulin therapy is the standard of treatment of Type 1 diabetes. Future therapies may also include glucagon-like peptide (GLP)-based treatment therapies. Pilot studies with GLP-1-analogues have been shown to reduce insulin requirements

From Surviving to Thriving: Evaluation of the International Diabetes Federation Life for a Child Program

IDF-LFAC aims to provide: (1) insulin and syringes; (2) blood glucose monitoring (BGM) equipment; (3) appropriate clinical care; (4) HbA1c testing; (5) diabetes education; and (6) technical support and training for health professionals, as well as 7) facilitating relevant clinical research, and where possible 8) assisting with capacity building. IDF-LFAC receives financial and in-kind support from private foundations, individuals, and corporations. Insulin and blood glucose monitoring equipment distribution is made possible by donations of insulin and the purchase of blood glucose monitors and strips at a reduced price from large pharmaceutical companies.The goal of this evaluation is to assess IDF-LFAC's organizational structure, strategic framework, processes, program impact, and potential to catalyze longterm sustainable improvements to T1D care delivery systems in its partner countries. LSHTM were commissioned to undertake the evaluation in 2014 when IDF-LFAC had active programs in 45 countries

Presentation and management of diabetic ketoacidosis in adults in Malta

Aim: The aim of this audit was to assess adherence to local guideline in the management of Diabetic Ketoacidosis (DKA). Method: Patients admitted with DKA between April 2013 and March 2015 were identified and data was retrospectively collected from patients’ confidential files and Isoft®. Data collected included initial parameters recorded and biochemical investigations taken (initial and subsequent assessment of pH, HCO3-, blood glucose, potassium levels and urinary ketones), insulin regime started and intravenous fluid administered. Results: During the established time period 40 cases of DKA were identified in 18 patients. Median age was 33 years with a female preponderance of 60%. Six patients had newly diagnosed diabetes mellitus while 8 patients had more than one admission of DKA. All cases had capillary blood glucose monitoring (BGM) and/or venous random blood (plasma) glucose (RBG) checked and pH and HCO3- recorded on admission. 0.9% sodium chloride was the intravenous fluid started in all cases (as recommended by the guideline) and a median of 6.75L was prescribed during the first 24 hours. The median time spent on intravenous insulin infusion was 42.7 hours while the median time to pH >7.30, HCO3- >15mmol/L and negligible urinary ketones were 6.88, 12.83 and 34.5 hours respectively. Subcutaneous insulin was started at a median time of 48.21 hours from initiation of DKA protocol. Conclusion: This audit showed good adherence to local guideline. The great discrepancy between the time to pH >7.3 and the time to negligible urinary ketones highlights the need to introduce tools to measure systemic ketone production in the management of DKA with an update in the current local clinical practice guideline.peer-reviewe

Minimizing hypoglycemia while maintaining glycemic control in diabetes

In the accompanying Perspective, Cryer identifies a number of different areas where therapeutic interventions have the potential to reduce hypoglycemia without compromising glycemic control. Some approaches provide well defined clinical benefits, a few offer dramatic reductions in hypoglycemia but remain out of reach for most people while others, although promising have yet to be properly evaluated. (Table 1) In this Perspective, I examine the evidence which underpins these interventions. It is beyond the scope of this article to review the data for each potential intervention in detail but the reader is directed to the appropriate source where appropriate. The Perspective focuses on treatment of Type 1 diabetes as most of the potential specific therapies have been evaluated in this group although I have commented in relation to recent trials of intensive therapy in Type 2 diabetes

Pediatric Type II Diabetes Mellitus: Examining the Upward Trend

In recent years, there has been a significant increase in pediatric onset of type II diabetes. This paper will examine elements contributing to this trend. Type II diabetes will be discussed, including related pathophysiology, manifestations, diagnosis, and complications, with differentiation between adult and pediatric onset. Possible prevention and treatment methods appropriate for pediatric patients will also be discussed, along with possible outcomes in pediatric patients that could result from this disease. Overall, this paper will provide insight on the causes of this growing trend, and ways to improve the risks imposed on pediatric patients

Diabetic Ketoacidosis (DKA) Insulin Infusion Protocol Update Using Evidence-Based Practice: A Quality Improvement Project

Diabetic Ketoacidosis is a life-threatening side effect to Diabetes Mellitus. Standards of treatment and recommendations are made by the American Diabetes Association. The project was to evaluate and provide the latest evidence-based practice to update the hospital policy for the treatment of DKA in the Intensive Care Unit and Emergency Department. Retrospective chart reviews were conducted to review the number of patients admitted with diabetic ketoacidosis and treated on the DKA Insulin Infusion Protocol before and after the update. Rapid correction of blood glucose levels proved to be an issue at this facility both before and after the updates were made to the DKA Insulin Infusion Protocol. The data supports the need for change in protocol, staff development in the use of the protocol and the need for change in the emergency department as well as the intensive care unit

Diabetes in Malta : current findings and future trends

Diabetes is a considerable global problem. Recent projections suggest that at least 194 million people suffer from diabetes worldwide. The World Health Organization suggests this number will increase to 333 million by 2025. Approximately four million deaths each year are caused by diabetes-related complications totaling an astounding 9% of deaths worldwide. Currently, epidemiological studies indicate that 1% of the Maltese population suffer from Type I Diabetes Mellitus and 9% from Type II Diabetes Mellitus. Following global predictions, it is probable that the incidence of Type I diabetes will increase also. This article evaluates the current Maltese diabetic care system and conducts a strategic analysis of diabetic practices. Recommendations for a cost-effective standard of care, legislative support for comprehensive diabetic care, and a national policy are proposed.peer-reviewe