Macrovascular complications and Diabetic Neuropathy of the Foot

Question 1

what are the diseases associated in macrovascular disease?

Answer 1

• early widespread atherosclerosis
• IHD
• cerebrovascular disease
• peripheral vascular disease

Question 2

stages of atheroma formation

Answer 2

• initial lesion with macrophages creating foam cells
• fatty streak with intracellular lipids
• intermediate with extracellular lipids
• atheroma where a core of lipids has formed (clinically significant from this point on)
• fibroatheroma, the atheroma is fibrotic with calcific layers
• complication stage with surface defect and thrombosis

Question 3

what is associated with significantly reduced life expectancy?

Answer 3

hyperglycaemia (the earlier the presentation, the shorter the life ex)

Question 4

how do women and men with diabetes compare in atheroma formation?

Answer 4

women lose the protection of being a woman when they have diabetes when developing atheroma

they suffer more than men so the relative risk is much worse for them than men

Question 5

difference in effects of microvascular and macrovascular disease

Answer 5

micro causes morbidity

macro causes morbidity and mortality

Question 6

what is the biggest cause of mortality in diabetics?

Answer 6

IHD

more than in the general population

Question 7

why does malignancy reduce as a cause of death in diabetics?

Answer 7

many diabetes die before cancer can manifest

Question 8

what is the MI risk in diabetics compared to non-diabetics?

Answer 8

diabetes who have never had an MI have a greater chance of an MI than non-diabetics who have had an MI before

Question 9

what do diabetics who look well tend to have?

Answer 9

IHD

Question 10

what is the Framingham risk score?

Answer 10

Framingham risk score

– gender-specific algorithm to estimate 10-year cardiovascular event risk.

Question 11

which ethnicity have a worse mortality for CHD?

Answer 11

South Asians

Question 12

cerebrovasc disease in diabetics?

Answer 12

present earlier
more widespread
uncommon in people younger than 60

Question 13

what does peripheral vasc disease in diabetics lead to?

Answer 13

leads to diabetic foot problems

Question 14

what does renal artery stenosis contribute to?

Answer 14

contributes to hypertension

Question 15

is treatment of hyperglycaemia effective in reducing CVD risk?

Answer 15

hyperglycaemia treatment alone is not enough and has a minor effect on reducing risk of CVD

intensive glucose control improves CHD but does not change mortality much

Question 16

risk factors of macrovascular disease (non-modifiable)

Answer 16

age
sex
birth weight
FH
genes

Question 17

risk factors of macrovascular disease (modifiable)

Answer 17

dyslipidaemia
hypertension
smoking
diabetes

Question 18

what two factors need management to prevent complications in T2DM

Answer 18

BP and cholesterol

Question 19

what drug can help significantly reduce macrovascular disease risk?

Answer 19

statins

Question 20

examples of treatment for reducing blood glucose

Answer 20

metformin
sulphonylureas
insulin

Question 21

what is the blood pressure management target?

Answer 21

<130/80 when there is damage to kidneys, eyes or cerebrovasculature

otherwise <140/80

needs constant monitoring

Question 22

how is lipids management monitored?

Answer 22

CV risk analysed annually

Question 23

risk factors of IHD

Answer 23

• fasting glucose > 6mmol/L
• waist circumference (men >102, women >88)
• insulin resistance
• hypertension
• low HDL

Question 24

what increase is proportional to the risk of retinopathy?

Answer 24

increasing HbA1c

Question 25

what is canakinumab?

Answer 25

reduces inflammation decreased lipids for damaged arteries targets IL-1beta

Question 26

what complications of diabetes predispose you to diabetic foot disease?

Answer 26

neuropathy (sensory, motor and autonomic) peripheral vascular disease

Question 27

prevalence - of DFN in diabetics - current/past foot ulcerations

Answer 27

2-3% | 5-7%

Question 28

risk of amputation in foot ulcerations

Answer 28

60x higher in diabetics 10% of NHS bed occupancy due to diabetes related foot problems (50% with foot disease)

Question 29

how can sensory function be tested?

Answer 29

monofilament | 10g pressure applied when monofilament bends

Question 30

what are the 8 ways that can lead to foot ulceration?

Answer 30

1) Sensory neuropathy – cannot feel monofilament – ulcers due to abnormal pressures. 2) Motor neuropathy – imbalance of extensors/flexors so foot is abnormal shape – ulcers due to abnormal pressures. 3) Limited join mobility – causes joint immobility and cannot put hands flat against each other. 4) Autonomic neuropathy – no sweating so skin dries out and you get ulcers. 5) Peripheral vascular disease – blood flow is compromised to the lower limbs. 6) Trauma – repeated or minor episodes. 7) Reduced resistance to infection. 8) Other – diabetic complications (e.g. retinopathy).

Question 31

how is a neuropathic foot described after examination?

Answer 31

``` numb warm dry palpable foot pulses ulcers at points of pressure ```

Question 32

how is an ischaemic foot described after examination?

Answer 32

cold pulseless ulcers at foot margins

Question 33

what are the features of a neuropathic foot?

Answer 33

``` numb warm dry pulseless ulcers at points of pressures and foot margins ```

Question 34

what factors must be assessed in foot examination?

Answer 34

- appearance (callus, deformity) - touch/feel (hot, dry) - foot pulses (dorsalis pedis, posterior tibial) - neuropathy (vibration, fine touch) - vibration, temperature, ankle jerk, fine touch

Question 35

where on the foot can pressure often increase?

Answer 35

great toe metatarsal head (50% of foot lacerations occur here)

Question 36

what must be managed in diabetics?

Answer 36

``` o Hyperglycaemia. o Hypertension. o Dyslipidaemia. o Stop smoking. o Education. ```

Question 37

what are the preventive measures against diabetic neuropathy of the foot?

Answer 37

o Controlling diabetes: Inspecting feet daily. o Have feet measured for shoes :Buying shoes with laces and square toe box. o Attend chiropodist: Cut nails straight across. o Take care when feet get hot: Never walk barefoot.

Question 38

how is foot ulceration managed?

Answer 38

 Relief of pressure – bed rest and redistribution of pressure.  Antibiotics – possibly long-term.  Debridement.  Re-vascularisation – angioplasty or arterial bypass surgery.  Amputation.

Question 39

what causes dryness in feet?

Answer 39

autonomic control of sweat glands lost

Question 40

what causes hand disorders in T2DM?

Answer 40

inability to flatten the palm due to glycosylated tendons limiting joint motility

Question 41

why do ischaemic feet feel cold?

Answer 41

poor blood supply

Question 42

what is Charcot Foot?

Answer 42

abnormal disorientation of bones in feet which is painful to a non-diabetic but not painful to a diabetic due to sensory neuropathy there is a destruction of joints

Question 43

what causes the deformity of Charcot ?

Answer 43

due to loss of joint-position sense this abnormal shape predisposes the foot to ulceration which then further predisposes the foot to osteomyelitis

Question 44

what is osteomyelitis?

Answer 44

bone infection

Question 45

osteomyelitis vs charcot

Answer 45

osteomyelitis: infection - hot red foot with ulceration - forefoot and hind foot issues Charcot:bone issue - hot red foot without ulceration - mid foot issues