macrovascular complications

Question 1

List the steps of development of artheroma?

Answer 1

Starts by looking normal but accumulation of lipids (slight)-even at 20 have fatty streaks (intracellular)
Beginning of extracellular accumulation of lipid, until artheroma-intracellular lipid accumulation and core of extracellular lipids
Then fibroartheroma-one or more lipid cores and fibrious cap+calcium-takes more and more space in arteries
then last is complication lesions-surface defect-when the lipid leaks-blockage-thrombis, hemmorghage

Question 2

What are the 5 factors that are important to artheroma?

Answer 2

Blood glucose, Hypertension, low HDL, high LDL, large waist circumference (very good), drawn together by generally insulin resistance, high CRP, adipocytokines, urine microalbumin

Question 3

What stages of artheroma are associated with Insulin resistance?

Answer 3

the first 3 ones for sure + lipids and blood pressure
later stages also-smooth msucle hypertrophy has IR associations
Thrombosis is also associated with insulin resistance

Question 4

Why is hyperglycemia associated with significantly lower life expenctancy?

Answer 4

mainly because of macrovascular complications-if you have it longer-more harm

the higher the insulin resistance, the higher the risk of CHD
with or without diabetes

micro is associated with morbidity, macro with morbidity and death

Question 5

Is T2DM a progressive disease or not? can early treatment reduce HbA1c? can that fix all?

Answer 5

Progressive, and with intense treatment can reduce hba1c-but it still progresses-and therefore complications would happen

Question 6

How could you describe the risk of micro and macro vascular complication in relation to sugar (how does the curve look)

Answer 6

With micro-the risk shoots up (like an exponential) with higher sugars
Meanwhile the CHD curve rises quite linearly with sugar-but the proportional increase is a lot higher
Having had a heart attack before increases MI chances-but diabetic w/o prior MI have same chance as non diabetic with prior MI

Question 7

What is the leading cause of deaths in diabetes?

Answer 7

under 70-normal people-artheroma kills about 50% of the people
over 70-diabetic people-artheroma kills about 75% of the (and about 3x more death)

Question 8

How does diabetes affected chances of having MI?

Answer 8

greatly increase-Having had a heart attack before increases MI chances-but diabetic w/o prior MI have same chance as non diabetic with prior MI
also overall recovery from MI is lower in diabetes

Question 9

Is there an ethnic variance for CHD chances?

Answer 9

Yes-UK south asians are much more likely than white caucasians

Question 10

Is macrovascular disease local or systemic?

Answer 10

Systemic-occurs in multiple arterial beds at the same time-
In the heart-MI, or cerebrovascular, peripheral vascular disease, kidney artery artheroma (contribute to hypertension + renal failure

Question 11

How does diabetes affect chances of cerebrovascular diseases? and peripheral vascaular disease?

Answer 11

cerebro-happens more often and earlier than without DM. and will be more widespread in brain
peripheral also increased greatly-contributes to diabetic foot with neuropathy

Question 12

How effective is the treatment of blood glucose is on the CHD chances/

Answer 12

Still important. will reduce the risk of CHD by quite a lot-BUT DOESNT REDUCE MORTALITY
want to treat it, but to stop death also have to do lipids and blood pressure and more risk factors

Question 13

What are the risk factors for vascular deaths? which ones are best to treat?

Answer 13

non modif: age, gender, ethnic, being lighter at birth (lower better), genes
modifyable: Dyslipedemia, high blood pressure, smoking, then treat sugar –statins work very very well (if only treat cholesterol, likeness to survive is much higher 37% less likely)
treating them all-a lot to ask but also very effective reduction of death

Question 14

What is the overall goal of diabetes treatment?

Answer 14

Cant treat cause so risk all the risk factors associated with it-and that cause death
dyslipidemia, glucose, BP,

Question 15

What is new and different about Canakinumab?

Answer 15

Its a monoclonal AB-reduces Inflammation (IL1B), but doesnt impact lipids
caused lower HbA1c, and significantly lower CHD-

Question 16

What are the 2 factors of diabetic foot?

Answer 16

main: Neuropathy (sensory, motor, ANS), and then peripheral artery disease

Question 17

What is the prevalence of diabetic foot? How much of the NHS is taken up by it? Whats the prognosis?

Answer 17

2-3% of the UK (5-7% current/past ulcers)
10% of UK beds taken by diabetes (50% of those are diabetic foot)
risk of amputation x60-do poorly afterwards

Question 18

What is the pathway to foot ulceration?

Answer 18

In terms of importance

1) Sensory neuropathy (assess light touch with nylon)-a lot of people with diabetes cannot sense
2) Motor neuropathy-clubbed toes/feet-loss shape of feet (direct cause harm and can cause bad balance)-often cause increase pressure on big toe-where 50% ulcers start
3) Limited joint mobility-sugar sticks to many proteins-like collagen-stops bending-in hands nuisance, in feet dangerous
4) Autonomic neuropathy-loss of sweat glands-dry skin-lose integrity of skin
5) peripheral vascular disease-often the dreadfull last step-can try to go around surgically
extra: Trauma, retinopathy, reduced infection resistance

Question 19

What are the 2 main forms of diabetic foot disease?

Answer 19

Neuropathic foot-no sense-can be dangerous
Warm, dry, numb-but has foot pulses-ulcers at place of heavy pressure

ischemic foot-cold, pulseless, ulcers at the extremities (where arteries are done)

can also have both-v bad

Question 20

How would you assess a foot ulcer>

Answer 20

Describe what is in front of you-
apprearance-deformity-callus-
Feel-warm, cold, sweaty
foot pulses-in foot and in leg
neuropathy-vibration, temperature, reflex, fine touch

Question 21

how do you prevent a diabetic foot?

Answer 21

stop sugar, lipids, smoking, bp
and educate patients to take care of their feet

prevent-control diabetes
use sneakers-inspect feet-inspect feel, dont cut nails too short,care with hear-never walk bear foot

Question 22

How do you treat a diabetic foot?

Answer 22

Relief of pressure-bed rest + redistribution of pressure with casts
Abx-probably long term-bad for resistance
Debridement-dead tissue needs to go
Revascularisation-angioplasty (balloon in artery and blow it), bypass
And sometimes accept amputation and moving on