Insulin Resistance and Diabetic Autonomic Neuropathy

Autonomna dijabetička neuropatija važna je kronična komplikacija šećerne bolesti koja se očituje u više organskih sustava, a udružena je s padom kvalitete života te povećanim mortalitetom i morbiditetom osoba oboljelih od šećerne bolesti. Točan patološki mehanizam odgovoran za ovo oštećenje nije poznat. Epidemiološka ispitivanja upozorila su na povezanost hiperinzulinemije i povećane aktivnosti simpatičkog dijela autonomnoga živčanog sustava. Na temelju rezultata više ispitivanja potomaka osoba oboljelih od tipa 2 šećerne bolesti (koji su često rezistentni na inzulin uz još uvijek urednu toleranciju glukoze) smatra se da su inzulinska rezistencija i kompenzatorna hiperinzulinemija rane patofi ziološke promjene vezane uz razvoj autonomne disfunkcije koja pak kasnije utječe na razvoj arterijske hipertenzije i tipa 2 šećerne bolesti. U ispitivanjima srčane autonomne regulacije na istome modelu uočeno je statistički značajno povišenje srčane frekvencije uz povišenje omjera simpato-vagalnog kardijalnog tonusa. Rezultati navedenih ispitivanja govore u prilog ranijem pojavljivanju autonomne disfunkcije nego što se do sada smatralo, vežući ju uz parenteralni tip 2 šećerne bolesti. Pokušaji liječenja autonomne dijabetičke neuropatije nisu zadovoljili. Inzistiranje na poboljšanju glukoregulacije najčešće nije praćeno poboljšanjem simptoma dijabetičke neuropatije. Osnovu liječenja ovog poremećaja čine izbjegavanje neurotoksina (alkohola), primjena antioksidansa i simptomatska terapija, a opisan je i mogući povoljan učinak liječenja metforminom.Diabetic autonomic neuropathy is an important chronic complication of diabetes that affects many physiological systems and is associated with a signifi cant deterioration in the quality of life and increased morbidity and mortality. The exact pathological mechanism responsible for this damage is unknown. Epidemiological studies have shown that insulin resistance and hyperinsulinism are associated with an increased sympathetic nervous system activity. Based on the results of research in children of type 2 diabetic patients (who are often insulin resistant despite normal glucose tolerance), it is considered that insulin resistance and compensatory hyperinsulinemia represent early pathophysiological changes related to the development of autonomic dysfunction. The latter is responsible for the subsequent development of hypertension and/or type 2 diabetes. In autonomic cardiac regulation studies performed on the same model, a statistically signifi cant increase in heart rate and sympatho-vagal cardiac tone ratio was observed. The results of these studies suggest that autonomic dysfunction develops earlier than previously thought, connecting it to parenteral type 2 diabetes. The treatment of diabetic neuropathy is less than satisfactory. Most often, the improved glycemic control is not accompanied with the improvement in diabetic neuropathy symptoms. The mainstays of therapy are avoidance of neurotoxins (alcohol), administration of antioxidants and symptomatic treatment. Possible favorable effects of metformin were also described

Lifestyle habits of Croatian diabetic population: observations from the Croatian Adult Health Survey [Životne navike osoba sa šećernom bolepću u Republici Hrvatskoj: zapažanja iz Hrvatske zdravstvene ankete]

The aim of this study was to assess the behavioural risk factors in Croatian diabetic population and to compare them with the lifestyle habits of individuals with no known history of diabetes. The study was a part of the Croatian Adult Health Survey (CAHS), a cross-sectional survey that provided comprehensive health assessment of the Croatian adult population. Risk factors were defined as an unhealthy nutritional regimen, excessive alcohol consumption, smoking and lack of physical activity. Physical inactivity was the most prevalent risk factor observed in a significant number of both diabetic and non-diabetic subjects (44.8% and 29.1%). It was also the only behavioural risk factor that was more prevalent in the diabetic individuals as compared to those without diabetes. Alcohol consumption did not vary significantly between the two groups (5.8% vs. 6.3%), while unhealthy dietary pattern and smoking were less frequent in respondents with diabetes (10.0% vs. 16.5% and 14.3% vs. 23.2%, respectively). Among diabetic patients, a significantly larger proportion of men than women reported smoking (19.2% vs. 10.0%), whereas no such sex-related differences were observed in other behavioural risk factors. Although the most prominent risk factor in diabetic patients was physical inactivity, a significant proportion of respondents with diabetes also reported the presence of other risk factors investigated in this survey. Since the majority of diabetic patients do not reach their treatment goals, there is a substantial need for curative and preventive interventions. Given the importance of physical activity in the treatment and prevention of diabetes and the high proportion of inactive diabetic patients, any future preventive programme in Croatia should address that risk as well

Pojavnost dijabetičkog stopala u jedinici intenzivne skrbi sveučilišne klinike Vuk vrhovac u periodu od 2001.-2005.

Cilj je rada utvrditi učestalost akutnog dijabetičkog stopala u Jedinici intenzivne skrbi Klinike Vuk Vrhovac, najčešće razloge amputacije te obilježja bolesnika obzirom na dob, spol, trajanje dijabetesa i utvrditi karakteristike bolesnika obzirom na čimbenike rizika hipertenziju, pušenje i HbA1c. Pregledana je dokumentacija svih bolesnika koji su hospitalizirani s dijagnozom dijabetičkog stopala unazad 5 godina (N=252). Dijabetičko je stopalo kao kasna komplikacija šećerne bolesti prisutno u 29,3% svih hospitalizacija bolesnika u Jedinici intenzivne skrbi. Prosječna starost bolesnika je 65,6 godina, zastupljenost žena je 40,5%, a muškaraca 59,5%. Prosječno trajanje dijabetesa je 15,7 godina. Prosječna razina HbA1c iznosi 8,6%. Hipertenzija je prisutna u 81,4% bolesnika, a 18,7% ima uredne vrijednosti krvnog tlaka. Zastupljenost pušača je 16,3% i nepušača 83,7%. Od svih je zaprimljenih bolesnika kritičnu ishemiju imalo 2,8%, trofički ulkus 35,3%, gangrenu 35,7% i flegmonu 26,2%. Udio amputacija iznosi 50%, od toga je amputacija prsta 11,5%, amputacija stopala 2,8%, potkoljeničnih amputacija 18,7% i natkoljeničnih amputacija 17,1%. Najčešći je razlog potkoljenične amputacije bio flegmona 46,8%, gangrena 42,6%, trofički ulkus 8,5%, te kritična ishemija 2,1%. Najčešći razlog natkoljenične amputacije je flegmona u 20,9% slučajeva, kritična ishemija 11,6% te trofički ulkus 2,3%. Prosječno je trajanje hospitalizacije bolesnika iznosilo 13,4 dana. Dijabetičko stopalo zauzima značajan udio svih hospitalizacija u Jedinici intenzivne skrbi Klinike Vuk Vrhovac (29,3%). Značajan je i udio amputiranih bolesnika s akutnim dijabetičkim stopalom (50%). Rizični čimbenici koji su praćeni ukazuju na neadekvatnu regulaciju glikemije (HbA1c8,56%.), visoki udio bolesnika s povišenim krvnim tlakom te dugogodišnju šećernu bolest

Diabetes and Coronary Heart Disease

Šećerna bolest (ŠB) sve više poprima pandemijske razmjere. Osim porasta novootkrivenih bolesnika zabrinjava porast šećerne bolesti tipa 2 u mlađoj dobnoj skupini. Vodeći uzrok smrtnosti u osoba sa ŠB su kardiovaskularne bolesti (KVB) u koje ubrajamo koronarnu bolest srca (KBS), cerebrovaskularnu bolest i perifernu vaskularnu bolest. Aterosklerotske promjene u osoba sa ŠB su teže, difuzno rasprostranjene i obično nepogodne za dilataciju. Kliničkom slikom KBS-a dominira ishemijska bol, često prisutna samo s dispnejom (ekvivalent angine), nijemom ishemijom ili nijemim infarktom miokarda. S obzirom na navedeno preporuke za dijagnostički postupak nešto su drugačije nego u osoba bez ŠB. Cilj liječenja je smanjenje rizika obolijevanja od KBS (primarna prevencija), odnosno usporavanje razvoja ateroskleroze u bolesnika kod kojih je već ustanovljena koronarna bolest (sekundarna prevencija). Liječenje KBS bitno se ne razlikuje u osoba sa ŠB i bez nje.Diabetes mellitus (DM) is increasingly gaining pandemic dimensions. Along with the growing number of the newly detected patients, the increase of diabetes type II in younger age deserves special attention. The leading cause of mortality in patients with diabetes are cardiovascular diseases (CVD) including coronary heart disease (CHD), cerebrovascular disease and peripheral vascular disease. Atherosclerotic changes in patients with diabetes are more severe, diffusely distributed and usually inadequate for dilatation. Clinical features of coronary heart disease are dominated by ischemic pain, often accompanied only by dispnea (an equivalent to angina), mute ischemia or mute myocardial infarction. Having this in mind, the recommendations for diagnostic procedures are somewhat different than in persons without diabetes. The aim of treatment is the reduction of risks for coronary heart disease (primary prevention), i.e. slowing down atherosclerotic processes in patients with already established coronary disease (secondary prevention). The treatment of coronary heart disease does not differ in patients with or without diabetes

Pojavnost dijabetičkog stopala u jedinici intenzivne skrbi sveučilišne klinike Vuk vrhovac u periodu od 2001.-2005.

Cilj je rada utvrditi učestalost akutnog dijabetičkog stopala u Jedinici intenzivne skrbi Klinike Vuk Vrhovac, najčešće razloge amputacije te obilježja bolesnika obzirom na dob, spol, trajanje dijabetesa i utvrditi karakteristike bolesnika obzirom na čimbenike rizika hipertenziju, pušenje i HbA1c. Pregledana je dokumentacija svih bolesnika koji su hospitalizirani s dijagnozom dijabetičkog stopala unazad 5 godina (N=252). Dijabetičko je stopalo kao kasna komplikacija šećerne bolesti prisutno u 29,3% svih hospitalizacija bolesnika u Jedinici intenzivne skrbi. Prosječna starost bolesnika je 65,6 godina, zastupljenost žena je 40,5%, a muškaraca 59,5%. Prosječno trajanje dijabetesa je 15,7 godina. Prosječna razina HbA1c iznosi 8,6%. Hipertenzija je prisutna u 81,4% bolesnika, a 18,7% ima uredne vrijednosti krvnog tlaka. Zastupljenost pušača je 16,3% i nepušača 83,7%. Od svih je zaprimljenih bolesnika kritičnu ishemiju imalo 2,8%, trofički ulkus 35,3%, gangrenu 35,7% i flegmonu 26,2%. Udio amputacija iznosi 50%, od toga je amputacija prsta 11,5%, amputacija stopala 2,8%, potkoljeničnih amputacija 18,7% i natkoljeničnih amputacija 17,1%. Najčešći je razlog potkoljenične amputacije bio flegmona 46,8%, gangrena 42,6%, trofički ulkus 8,5%, te kritična ishemija 2,1%. Najčešći razlog natkoljenične amputacije je flegmona u 20,9% slučajeva, kritična ishemija 11,6% te trofički ulkus 2,3%. Prosječno je trajanje hospitalizacije bolesnika iznosilo 13,4 dana. Dijabetičko stopalo zauzima značajan udio svih hospitalizacija u Jedinici intenzivne skrbi Klinike Vuk Vrhovac (29,3%). Značajan je i udio amputiranih bolesnika s akutnim dijabetičkim stopalom (50%). Rizični čimbenici koji su praćeni ukazuju na neadekvatnu regulaciju glikemije (HbA1c8,56%.), visoki udio bolesnika s povišenim krvnim tlakom te dugogodišnju šećernu bolest

Utjecaj psa vodiča na regulaciju glikemije u slijepih/slabovidnih osoba sa šećernom bolešću

The aim was to assess glycemia regulation in a blind diabetic patient after getting a guide dog. Glycosylated hemoglobin (HbA1c) results of a blind patient before and after getting the guide dog were retrospectively collected. The paired t-test results yielded a two-tailed P value of 0.0925, a difference considered not statistically significant; the 95% confidence interval of this difference varied from -0.2494 to 1.889. An improvement of glycemia regulation was observed with the guide dog compared to previous glycemia regulation, however, the difference was not statistically significant. The moderate improvement could probably be attributed to the mobility of the blind person having a guide dog. Standard quality of life tests should be included in the evaluation of diabetic blind persons, especially the impact of a guide dog on glycemic control or other chronic complications of diabetes.Cilj je bio procijeniti regulaciju glikemije kod slijepe osobe sa šećernom bolešću nakon što je ta osoba dobila psa vodiča. Retrospektivno su se prikupljali rezultati HbA1c u slijepe osobe prije i nakon dobivanja psa vodiča. Primjenom rezultata parnog t-testa dobivena je dvosmjerna vrijednost P od 0,0925. Razlika nije bila statistički značajna, dok se 95% interval pouzdanosti te razlike kretao od -0,2494 do 1,889. Zabilježeno je poboljšanje regulacije glikemije uz psa vodiča u usporedbi s vrijednostima prije dobivanja psa vodiča, ali razlika nije bila statistički značajna. Smatramo da bi to umjereno poboljšanje moglo biti povezano s pokretljivošću slijepe osobe uz psa vodiča. U procjenu slijepe osobe sa šećernom bolešću treba uključiti standardne testove za kvalitetu života, osobito utjecaj psa na regulaciju glikemije ili na druge kronične komplikacije šećerne bolesti

Scintigrafija z indij-111-DTPA-oktreotidom pri bolnikih s karcinoidom

Background. The aim of the study was the evaluation of clinical utility and comparison of 111 In-DTPA- octreotide receptor scintigraphy (SRS) with conventional imaging modalities (CIM) in the detection of carcinoid tumor. Patients and methods. Fourteen patients with pathohistologically proven diagnosis of carcinoid tumor and one patient with clinical suspicion of carcinoid tumor were investigated by SRS. SRS was performed for localization of primary tumor, recurrence or estimation of spread of the disease after CIM had been completed. Whole body scans and single photon emission computed tomography (SPECT) were acquired 6 and 24 h after the application of radiopharmaceutical. The intensity of nonspecific radiopharmaceutical uptake in the bowel was assessed semiquantitatively by a score using whole body scans. Results. The evaluation was done for patients and for tumor sites. The sensitivity, specificity, and positive and negative predictive values for patient evaluation were 89 %,100 %,100 % and 80 %, respectively for both CIM and SRS, whereas for tumor sites, these parameters were 69 % 100 %,100 % and 82 % for CIM, and 88%,100%,100% and 92 % for SRS. Intensity score of nonspecific 111In-octreotide bowel accumulation was 0.92 and 2.01 for 6 and 24h scans respectively (p < 0.01). Conclusion. 111In-octreotide scintigraphy should be included in the diagnostic algorithm for the patients with clinical suspicion of carcinoid and for the assessment of patients with proven carcinoid tumor.Izhodišča. Študijo smo izvedli z namenom, da ocenimo klinično uporabnost scintigrafije somatostatinskih receptorjev z indij-111-DTPA-oktreotidom (SRS) ter jo primerjamo s konvencionalnimi načini slikovne preiskave pri bolnikih s karcinoidom. Bolniki in metode. Štirinajst bolnikov s patohistološko potrjenimkarcinoidom in enega bolnika s klinično ugotovljenim karcinoidom smo preiskali s SRS. Preiskavo SRS smo izvedli po konvencionalni slikovni preiskavi in z njo poskušali lokalizirati primarni tumor in ugotoviti ponovitev ali razsoj bolezni. Scintigrafijo celotnega telesa in računalniško tomografijo z emisijo posameznih elektronov (SPECT) smo opravili 6 in 24 ur povbrizganem radiofarmacevtskem sredstvu. Intenzivnost nespecifičnega kopičenja radiofarmacevtskega sredstva v črevesu smo ocenili semikvantitativnos scintigrafijo celotnega telesa. Rezultati. Intenzivnost kopičenja smo ocenili glede na bolnike in glede na lokalizacijo tumorja. Pri bolnikih je občutljivost znašala 89%, specifičnost 100%, pozitivne in negativne napovedne vrednosti pa so bile 100% in 80% tako pri konvencionalnem načinu slikovne preiskave kot pri SRS. Pri ocenjevanju lokalizacije tumorja sobili zgornji parametri naslednji: slikanje celotnega telesa: občutljivost 69%, specifičnost 100%, pozitivne in negativne napovedne vrednosti 100% in 82%SRS: občutljivost 88%, specifičnost 100%, pozitivne in negativne napovedne vrednosti 100% in 92%. Intenzivnost nespecifičnega kopičenja 111-indija-oktreotida v črevesju je bila pri slikah, posnetih po 6. urah 0,92 in pri slikah, posnetih po 24 urah, 2,01 (p < 0,01). Zaključki. SRS bi morala biti vključena v diagnostični algoritem pri bolnikih, pri katerih je bil karcionoid ugotovljen le klinično in tudi pri bolnikih s potrjeno diagnozo karcionoida

Lifestyle Habits of Croatian Diabetic Population: Observations from the Croatian Adult Health Survey

The aim of this study was to assess the behavioural risk factors in Croatian diabetic population and to compare them with the lifestyle habits of individuals with no known history of diabetes. The study was a part of the Croatian Adult Health Survey (CAHS), a cross-sectional survey that provided comprehensive health assessment of the Croatian adult population. Risk factors were defined as an unhealthy nutritional regimen, excessive alcohol consumption, smoking and lack of physical activity. Physical inactivity was the most prevalent risk factor observed in a significant number of both diabetic and non-diabetic subjects (44.8% and 29.1%). It was also the only behavioural risk factor that was more prevalent in the diabetic individuals as compared to those without diabetes. Alcohol consumption did not vary significantly between the two groups (5.8% vs. 6.3%), while unhealthy dietary pattern and smoking were less frequent in respondents with diabetes (10.0% vs. 16.5% and 14.3% vs. 23.2%, respectively). Among diabetic patients, a significantly larger proportion of men than women reported smoking (19.2% vs. 10.0%), whereas no such sex-related differences were observed in other behavioural risk factors. Although the most prominent risk factor in diabetic patients was physical inactivity, a significant proportion of respondents with diabetes also reported the presence of other risk factors investigated in this survey. Since the majority of diabetic patients do not reach their treatment goals, there is a substantial need for curative and preventive interventions. Given the importance of physical activity in the treatment and prevention of diabetes and the high proportion of inactive diabetic patients, any future preventive programme in Croatia should address that risk as well

CROATIAN GUIDELINES FOR THE PHARMACOTHERAPY OF TYPE 2 DIABETES

Uvod: Hrvatsko društvo za dijabetes i bolesti metabolizma Hrvatskoga liječničkog zbora izradilo je 2011. godine prve nacionalne smjernice o prehrani, edukaciji i samokontroli te farmakološkom liječenju šećerne bolesti tipa 2. Sukladno povećanom broju dostupnih lijekova te novim spoznajama o učinkovitosti i sigurnosti primjene već uključenih lijekova, pokazala se potreba za obnovom postojećih smjernica za farmakološko liječenje šećerne bolesti tipa 2 u Republici ­Hrvatskoj. Sudionici: Kao koautori Smjernica navedeni su svi članovi Hrvatskog društva za dijabetes i bolesti metabolizma Hrvatskoga liječničkog zbora, kao i ostalih uključenih stručnih društava, koji su svojim komentarima i prijedlozima pridonijeli izradi Smjernica. Dokazi: Ove su Smjernice utemeljene na dokazima, prema sustavu GRADE (engl. Grading of Recommendations, Assessment, Development and Evaluation) koji uz razinu dokaza opisuje i snagu preporuke. Zaključci: Individualan pristup temeljen na fiziološkim principima regulacije glikemije nuždan je u liječenju osoba sa šećernom bolesti. Ciljeve liječenja i odabir medikamentne terapije treba prilagoditi oboljeloj osobi, uzimajući u obzir životnu dob, trajanje bolesti, očekivano trajanje života, rizik od hipoglikemije, komorbiditete, razvijene vaskularne i ostale komplikacije, kao i ostale čimbenike. Zbog svega navedenoga od nacionalnog je interesa imati praktične, racionalne i provedive smjernice za farmakološko liječenje šećerne bolesti tipa 2.Introduction: The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of ­diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the ­pharmacotherapy of type 2 diabetes in the Republic of Croatia. Participants: as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines. Evidence: These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations. Conclusions: An individual patient approach based on physiological principles in blood glucose control is essential for diabetes’ patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglycemia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes