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The worldwide prevalence of diabetes mellitus is projected to reach 5.4% (300 million individuals) by 2025, and the evolving pandemic of childhood obesity in Western countries has caused a significant increase in insulin resistance and type 2 diabetes. The potential societal impact is enormous, and growing appreciation of the scale of the problem is reflected in increasingly frequent public pronouncements...
Failure of the thyroid gland requires thyroid hormone replacement therapy, which is relatively easily adjusted to replicate the normal physiological state by monitoring plasma levels of thyroxine and/or thyroid-stimulating hormone. In contrast, failure of pancreatic β-cells requires insulin therapy, and optimal replacement requires monitoring, not of the absent hormone (insulin), but of its major...
The acute onset of type 1 diabetes and the fact that almost all cases rapidly reach medical attention means that registers of new cases can be relatively easily established. Provided ascertainment can be verified, these data can be combined with population denominator data to give age-specific and sex-specific rates.
Hypertension occurs more often in patients with diabetes than in individuals without diabetes. This 1.5-2-fold excess of hypertension can be accounted for by several clinical and pathophysiological factors including diabetic nephropathy, altered neuroendocrine and sodium-volume determinants of blood pressure, disturbed vascular tone and altered blood pressure regulation (Figure 1). Hypertension is...
Type 2 diabetes is the most common clinical form of diabetes, accounting for about 90% of all cases. It is currently undergoing a worldwide epidemic; the prevalence has tripled during the last 30 years. The most recent surveys in Europe indicate a prevalence of almost 5% in the middle-aged and older population. In the USA, the prevalence is about 8%. The disease typically affects adults over the age...
The aetiology and pathogenesis of type 2 diabetes remain unclear. Most patients exhibit a combination of two major metabolic defects: • reduced sensitivity of target tissues to insulin (insulin resistance) (see page 6) • a relative deficiency of endogenous insulin secretion (see page 7). The clinical picture is heterogeneous, ranging from (less commonly) non-obese, predominantly insulin-deficient...
Most of the excess mortality and much morbidity in diabetes (and in impaired glucose tolerance) is caused by cardiovascular disease; type 2 diabetes may be regarded as a condition of accelerated atherosclerosis with associated metabolic derangements. Means of countering cardiovascular risk include scrupulous control of blood pressure and lipid profile. In recent years, large-scale trial evidence has...
Diabetes mellitus is a largely self-managed disease. If the patient is unwilling or unable to self-manage his or her diabetes on a day-to-day basis, the outcome will be poor, regardless of how advanced the treatment technology is. As Glasgow et al. recently noted: ‘Diabetes is at heart a behavioural issue’. Psychological and social factors have a vital role in diabetes management.
Type 1 diabetes is characterized by immune-mediated destruction of pancreatic β-cells resulting in insulin deficiency. This results in a common biochemical end-point of hyperglycaemia and risk of ketoacidosis, but the clinical presentation varies widely depending on the rate and degree of β-cell failure. As a consequence, there has been increasing recognition of type 1 diabetes presenting in adulthood,...
Most cases of clinical hypoglycaemia are insulin-induced episodes in patients with diabetes. Hypoglycaemia is probably the major factor preventing insulin-treated patients from achieving the glucose targets needed to prevent diabetic complications. The incidence of hypoglycaemia reflects the inadequacy of current methods of insulin delivery, which lead to inappropriately high insulin concentrations,...
Diabetes presents several special problems during surgery. Fasting causes particular problems in type 1 diabetes. Such patients need basal insulin to prevent ketosis, and develop hypoglycaemia without additional carbohydrate intake. Fasting is of little significance in type 2 diabetes, unless the patient has received oral hypoglycaemic agents. Metabolic changes include the following. • Increases...
Diabetic nephropathy is a major cause of premature death in patients with diabetes, principally from cardiovascular disease, the incidence of which is about 15-fold greater in patients with diabetic nephropathy. By convention, diabetic nephropathy is defined as the appearance of persistent ‘clinical’ albuminuria (albumin excretion rate > 300 mg/24 hours) in an individual who has had diabetes for...
Foot problems account for more hospital admissions of diabetic patients than any of the other long-term complications. An understanding of the causes of these problems enables early recognition of patients at high risk. It has been shown that up to 50% of amputations and foot ulcers in diabetic patients can be prevented by effective identification and education. In this contribution, the term ‘diabetic...
Diabetic ketoacidosis (Figure 1) is a life-threatening condition requiring immediate hospitalization and treatment. Recognition of this condition is of utmost importance, because even small delays can have an impact on survival. The overall mortality is about 5-10%, but is higher in the elderly.
Diabetes in the young (Figure 1) is a multifaceted disease encompassing severe, life-threatening metabolic derangement, psychosocial aspects of the management of chronic ill health, and the antecedents of long-term health complications; 90-95% of patients present with type 1 disease.
Diabetic retinopathy is a microvascular disease that leads to capillary occlusion. It affects the retinal precapillary arterioles, capillaries and venules. Early pathological features include thickening of the basement membrane, loss of pericytes and the development of microaneurysms. Persistent hyperglycaemia is considered to be the primary cause of changes in the vascular endothelium. Capillary...
Macrovascular disease is atherosclerotic disease affecting medium and large blood vessels. It manifests clinically as acute or progressive ischaemia, affecting most commonly the coronary, cerebral, renal and lower limb vessels.
Erectile failure is particularly common in men with diabetes; it affects up to 30%, and the prevalence increases further with age, duration of diabetes, and the presence of microvascular and macrovascular complications. It can be distressing for both the man and his partner. There is now increasing awareness of the importance of the problem, and the increased efficacy and availability of treatment...
Pregnancy profoundly affects carbohydrate metabolism. These changes are important in women with diabetes (typically type 1, but more young type 2 patients are being encountered) who are planning pregnancy, and in women who develop gestational diabetes mellitus (GDM–;glucose intolerance first recognized during pregnancy). In all cases, a comprehensive approach involving expertise in obstetrics, diabetology,...
Examination of the heart is an important clinical skill. Despite advances in non-invasive imaging, no other investigation (ECG, radiology, echocardiography or radioisotope scanning) has supplanted clinical examination as a means of: • making an initial anatomical diagnosis • rapidly assessing cardiac function and progress at the bedside. The skill of examination is best learned at the bedside...
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