Metabolic diseases such as hypertension, obesity, diabetes, and vascular diseases have reached epidemic proportions worldwide. In the past four decades, childhood and adolescent obesity has increased four-fold worldwide. During the same period, obesity in adults has doubled and diabetes has increased by four-fold. In China, India, and the USA, the number of prediabetes is more than diabetics. This population is at considerable risk for developing diabetes, its clinical complications, and acute vascular events. The management of modifiable risks for cardiometabolic risks has improved considerably. Several major studies have demonstrated, that robust management of modifiable risks for cardiovascular diseases (CVDs), significantly reduces premature mortality from CVDs. Considering the progress made in the risk assessment, risk management, we feel strongly, that not much progress is made in the areas of primary prevention and early risk assessment, for clinical complications associated with metabolic diseases, in particular, diabetes. The majority of the clinical complications associated with diabetes are due to dysfunction of the vascular system or nervous system. Complications include vasculopathy leading to subclinical atherosclerosis, heart attacks, and stroke.
Partial Exchange Transfussion In Polycythemia Secondary To Complex Cyanotic H...AR Muhamad Na'im
This patient is a 12-year-old girl with pulmonary atresia and ventricular septal defect who presents with symptoms of hyperviscosity due to polycythemia. She has undergone partial exchange transfusions every 4 months to manage her polycythemia. Examination revealed central cyanosis, clubbing, and a heart murmur. Laboratory tests showed hemoglobin of 21.9 g/dL and hematocrit of 68.7%. She underwent a successful partial exchange transfusion of 400 mL to reduce her hematocrit and symptoms. Partial exchange transfusion is an established treatment for polycythemia in cyanotic heart disease patients to reduce viscosity and improve oxygen delivery.
This document discusses myocarditis, including its clinical presentation and findings on cardiac MRI. Regarding clinical presentation, it notes that symptoms can range from subclinical to fulminant heart failure, with the most common symptoms being chest pain, dyspnea, and arrhythmias. Cardiac MRI is useful for identifying myocarditis and can detect tissue edema, hyperemia, and fibrosis. Findings on MRI include increased T2 signal from edema, early contrast enhancement indicating hyperemia, and late gadolinium enhancement of replaced fibrotic tissue. Morphological abnormalities seen include transient increases in wall thickness and LV volumes during active myocarditis.
This document discusses updates in supporting respiratory failure and extracorporeal membrane oxygenation (ECMO). It summarizes evolving concepts in ventilator support, including non-invasive positive pressure ventilation (NIPPV), low tidal volume ventilation for acute respiratory distress syndrome (ARDS), and use of esophageal pressure monitoring. The document also discusses the evolving roles of ECMO in various types of respiratory and cardiac failure, as well as initiatives to promote ICU liberation and reduce delirium and deconditioning in ventilated patients.
This document summarizes a case report of a 14-year-old female patient presenting with cyanosis, dyspnea, palpitations, and hemoptysis. Tests revealed a pulmonary arteriovenous (PAV) fistula connecting her pulmonary artery and vein. PAV fistulas are abnormal direct connections that allow blood to bypass the lungs, sometimes mimicking cardiac conditions. The patient's PAV fistula was located in her left lower lobe and confirmed by pulmonary angiography. She was referred for coil embolization to treat the fistula. PAV fistulas are usually congenital but can also be acquired due to conditions like mitral stenosis or infections. They may cause hypoxemia and paradoxical embol
This document provides an overview of Hodgkin lymphoma (HL), including:
- HL is a malignancy of mature B lymphocytes that represents 10% of lymphomas diagnosed annually.
- Classical HL has high cure rates of over 85% with radiation and chemotherapy. However, late therapy-related toxicities are a new challenge.
- Staging is important for selecting appropriate therapy intensity, with early stage patients having a better prognosis than advanced stage.
- Treatment depends on stage and risk factors, and may involve chemotherapy alone or with radiation for early stage disease. Advanced stage is treated with chemotherapy only.
- Late effects of therapy include secondary cancers and heart disease, so reducing radiation exposure is a focus of research.
Myocarditis is an inflammatory disease of the heart muscle that is usually caused by viral infections. It can present in many ways from mild symptoms to life-threatening cardiogenic shock. Diagnosis is challenging as there is no single confirmatory test, but endomyocardial biopsy is the gold standard. Treatment focuses on managing heart failure and arrhythmias with medications. The course of myocarditis involves an acute viral phase, a subacute immune mediated phase that can lead to dilated cardiomyopathy, and a chronic phase with possible complications of heart failure, arrhythmias or sudden death.
This document provides an edited book on the diagnosis and treatment of myocarditis. It contains several sections and chapters contributed by international experts on various aspects of myocarditis. The book covers clinical presentations of myocarditis, pathogenesis of the condition, diagnostic methods including endomyocardial biopsy and cardiac MRI, special populations affected by myocarditis such as children, peripartum and chronic Chagas patients, and new trends in treatment of viral myocarditis. Overall, the book serves as a comprehensive reference for both clinical aspects and pathophysiology of myocarditis, and reviews causes, classification, diagnosis and management strategies for the disease.
Partial Exchange Transfussion In Polycythemia Secondary To Complex Cyanotic H...AR Muhamad Na'im
This patient is a 12-year-old girl with pulmonary atresia and ventricular septal defect who presents with symptoms of hyperviscosity due to polycythemia. She has undergone partial exchange transfusions every 4 months to manage her polycythemia. Examination revealed central cyanosis, clubbing, and a heart murmur. Laboratory tests showed hemoglobin of 21.9 g/dL and hematocrit of 68.7%. She underwent a successful partial exchange transfusion of 400 mL to reduce her hematocrit and symptoms. Partial exchange transfusion is an established treatment for polycythemia in cyanotic heart disease patients to reduce viscosity and improve oxygen delivery.
This document discusses myocarditis, including its clinical presentation and findings on cardiac MRI. Regarding clinical presentation, it notes that symptoms can range from subclinical to fulminant heart failure, with the most common symptoms being chest pain, dyspnea, and arrhythmias. Cardiac MRI is useful for identifying myocarditis and can detect tissue edema, hyperemia, and fibrosis. Findings on MRI include increased T2 signal from edema, early contrast enhancement indicating hyperemia, and late gadolinium enhancement of replaced fibrotic tissue. Morphological abnormalities seen include transient increases in wall thickness and LV volumes during active myocarditis.
This document discusses updates in supporting respiratory failure and extracorporeal membrane oxygenation (ECMO). It summarizes evolving concepts in ventilator support, including non-invasive positive pressure ventilation (NIPPV), low tidal volume ventilation for acute respiratory distress syndrome (ARDS), and use of esophageal pressure monitoring. The document also discusses the evolving roles of ECMO in various types of respiratory and cardiac failure, as well as initiatives to promote ICU liberation and reduce delirium and deconditioning in ventilated patients.
This document summarizes a case report of a 14-year-old female patient presenting with cyanosis, dyspnea, palpitations, and hemoptysis. Tests revealed a pulmonary arteriovenous (PAV) fistula connecting her pulmonary artery and vein. PAV fistulas are abnormal direct connections that allow blood to bypass the lungs, sometimes mimicking cardiac conditions. The patient's PAV fistula was located in her left lower lobe and confirmed by pulmonary angiography. She was referred for coil embolization to treat the fistula. PAV fistulas are usually congenital but can also be acquired due to conditions like mitral stenosis or infections. They may cause hypoxemia and paradoxical embol
This document provides an overview of Hodgkin lymphoma (HL), including:
- HL is a malignancy of mature B lymphocytes that represents 10% of lymphomas diagnosed annually.
- Classical HL has high cure rates of over 85% with radiation and chemotherapy. However, late therapy-related toxicities are a new challenge.
- Staging is important for selecting appropriate therapy intensity, with early stage patients having a better prognosis than advanced stage.
- Treatment depends on stage and risk factors, and may involve chemotherapy alone or with radiation for early stage disease. Advanced stage is treated with chemotherapy only.
- Late effects of therapy include secondary cancers and heart disease, so reducing radiation exposure is a focus of research.
Myocarditis is an inflammatory disease of the heart muscle that is usually caused by viral infections. It can present in many ways from mild symptoms to life-threatening cardiogenic shock. Diagnosis is challenging as there is no single confirmatory test, but endomyocardial biopsy is the gold standard. Treatment focuses on managing heart failure and arrhythmias with medications. The course of myocarditis involves an acute viral phase, a subacute immune mediated phase that can lead to dilated cardiomyopathy, and a chronic phase with possible complications of heart failure, arrhythmias or sudden death.
This document provides an edited book on the diagnosis and treatment of myocarditis. It contains several sections and chapters contributed by international experts on various aspects of myocarditis. The book covers clinical presentations of myocarditis, pathogenesis of the condition, diagnostic methods including endomyocardial biopsy and cardiac MRI, special populations affected by myocarditis such as children, peripartum and chronic Chagas patients, and new trends in treatment of viral myocarditis. Overall, the book serves as a comprehensive reference for both clinical aspects and pathophysiology of myocarditis, and reviews causes, classification, diagnosis and management strategies for the disease.
This document discusses myocarditis in children. It defines myocarditis and describes the epidemiology, etiology, pathophysiology, clinical presentation, diagnosis and treatment. Myocarditis has many potential causes including viruses like adenovirus and enterovirus. Clinically it presents variably depending on age from nonspecific symptoms to heart failure. Diagnosis involves blood tests, ECG, imaging like echocardiogram and cardiac MRI, and endomyocardial biopsy. Treatment is supportive with heart failure medications, antivirals may help, and immunosuppressants can reduce inflammation and improve function.
1) Myocarditis is an inflammation of the heart muscle that can progress to dilated cardiomyopathy and heart failure. Viruses are the most common cause, with adenovirus and enterovirus being the most frequently detected viruses.
2) Myocarditis causes chest pain, arrhythmias, shortness of breath, and fever. ECG findings can include tachycardia, conduction abnormalities, and T-wave inversions. Biomarkers like troponins are elevated but nonspecific.
3) Endomyocardial biopsy remains the gold standard for diagnosis but cardiac MRI is becoming more important for diagnosis and follow-up of acute myocarditis patients.
Dengue Fever-Related Cardiac manifestation in Ibn-Sina Hospital Mukalla, Hadh...asclepiuspdfs
This document summarizes a study on cardiac manifestations in patients hospitalized with dengue fever in Mukalla, Yemen. The study found that the most common cardiac manifestations were sinus tachycardia (39.4% of patients) and hypotension (18.37% of patients). Other less common findings included pulmonary congestion, bradycardia, and pericardial effusion. There was a close correlation between the severity of cardiac manifestations and the severity of dengue based on WHO classifications, with more severe cardiac issues seen in those with severe dengue. The most common causes of death in the study (10 patients) were refractory shock and other complications associated with severe dengue disease.
Central Nervous System Histoplasmosis Related to Bioprosthetic Endocarditisasclepiuspdfs
Endocarditis caused by Histoplasma capsulatum is a rare occurrence. Involvement of the central nervous system by Histoplasma is also relatively uncommon. This paper reports a case of a 62-year-old woman with a past medical history significant for a myocardial infarct 5 years prior which necessitated coronary artery bypass graft surgery, prosthetic aortic valve replacement 4 years prior, and sarcoidosis, diagnosed 1 year prior, which was treated with methotrexate. She presented with fevers, generalized weakness, night sweats, and chest and throat pain. An echocardiogram done as part of her evaluation showed a vegetation on her prosthetic aortic valve. H. capsulatum was identified on blood cultures, and she was started on antibiotics. She expired shortly thereafter. At autopsy, a diagnosis of Histoplasma endocarditis was confirmed with evidence of embolic disease involving kidneys and digits of the hand. Hilar lymph nodes showed evidence of the fungus. Examination of the brain showed multiple widespread microscopic foci of macrophages, lymphocytes, and microglial cells with associated Histoplasma organisms, highlighted on Gomori methenamine silver staining. This paper will discuss central nervous system involvement by Histoplasma.
This document discusses the use of anticoagulants in COVID patients and raises several questions about their usage. It questions whether anticoagulants are being overused in COVID patients and discusses when, which medications, and for how long they should be used. It also questions whether the use of anticoagulants is important and whether guidelines exist around their use, as there are controversies regarding anticoagulation in COVID patients. A second section discusses venous thromboembolism risk and treatment in cirrhosis patients.
Complicated Tubercular Pericarditis Presenting as Ventricular Apical Aneurysm...Crimsonpublisherssmoaj
This case report describes a 27-year-old female who presented with symptoms of breathlessness, fever, and fatigue. She had a history of treated pulmonary tuberculosis. Imaging revealed chronic calcific pericarditis with a narrow-necked left ventricular apical aneurysm. This ventricular aneurysm is a rare complication of tubercular pericarditis. The patient was counseled for surgical treatment but declined due to financial constraints. Ventricular aneurysms are uncommon in tuberculosis and result from contained rupture of infected myocardial tuberculomas under strain of thickened pericardium. Recognition by radiologists is important for timely surgical management of this life-threatening complication.
Cardiac Manifestation in Dengue InfectionSoroy Lardo
Dengue Infection and Cardiac Manifestations How Important? Certainly greatly affect the clinical course of dengue patients with viremia phase - critical phase and recovery phase. Cardiac Manifestations, as an important organ that determines stable hemodynamics. What if our heart is disturbed? of course there is influence in management and prognosis. Please refer to this power point.
1) The document discusses the relationship between carotid artery disease and coronary artery disease. Studies have found an association between carotid artery plaques and stenosis and adverse cardiac outcomes.
2) Measuring intima-media thickness (IMT) of the carotid arteries has been used as a surrogate for coronary artery atherosclerosis. However, atherosclerosis is non-uniform and different risk factors are associated with IMT increases in different carotid artery segments.
3) A recent study in young adults found that multiple coronary risk factors cause different morphological changes in carotid artery segments. Systolic blood pressure was most associated with common carotid IMT while age was most associated with carotid bulb IMT.
The document discusses the relationship between carotid artery disease and coronary artery disease. It notes that asymptomatic patients with carotid bruits have high rates of cardiac death, and that ultrasonographically measured carotid intima-media thickness (IMT) is used as a surrogate for coronary artery disease risk. However, atherosclerosis is non-uniform, and individual carotid segments may be differently associated with risk factors and cardiac outcomes. A recent study found that multiple risk factors cause different morphological changes in carotid segments, with systolic blood pressure most associated with common carotid IMT and age most associated with bulb IMT. The relationship between individual carotid segments and prognosis requires further study.
This document discusses thromboprophylaxis in ICU patients. It provides information on:
- The risk of venous thromboembolism (VTE) in hospitalized patients and the potential for prophylaxis to reduce this risk
- Common prophylactic options like enoxaparin, fondaparinux, and unfractionated heparin
- Tools to assess patient risk like the PADUA and IMPROVE scores
- Factors to consider when selecting a prophylactic method, including duration of prophylaxis
The document aims to review best practices for preventing VTE in high-risk hospitalized populations through appropriate thromboprophylaxis.
Comparison of Infection Episodes in CKD Patients with or without Hemodialysis...ijtsrd
This study compared infection episodes in chronic kidney disease (CKD) patients with and without hemodialysis. A cross-sectional study of 56 CKD patients found that those undergoing hemodialysis had higher rates of chills, increased white blood cell count, and elevated erythrocyte sedimentation rate compared to non-hemodialysis patients. The study concluded that CKD patients on long-term hemodialysis were more prone to developing infections than those not on hemodialysis, likely due to factors such as catheter insertion for hemodialysis. Better infection prevention strategies are needed for CKD patients undergoing hemodialysis.
Perspective of Cardiac Troponin and Membrane Potential in People Living with ...asclepiuspdfs
Background: Hypertension is an event in which the force of the blood against the artery walls is too high leading to severe health complications and increases the risk of heart disease, stroke, and sometimes death. Aim: This study was carried out to determine the levels of cardiac troponin 1 and membrane potential in hypertensive subjects in Owerri, Imo state. Materials and Methods: A total of 120 subjects within the age 30–70 years were recruited for this study. The study consists of 60 subjects who were diagnosed of hypertension and 60 were apparently healthy individuals who served as controls subjects of the same age bracket. The levels of cardiac troponin 1 and membrane potential were analyzed using enzyme-linked immunosorbent assay technique. Data were assessed using SPSS version 20, the mean value with P ˂ 0.05 was considered statistically significant. Results: The result revealed that the levels of cardiac troponin 1 in hypertension were significantly increased when compared with control subjects while the levels of membrane potential were significantly decreased when compared to control at P < 0.05. Conclusion: The increased serum level of cardiac troponin 1 and decreased membrane potential in hypertensive subjects may contribute some risk factors in patients with hypertension.
This document discusses venous thrombosis and pulmonary embolism. It covers risk factors, pathophysiology, diagnostic evaluation, and treatment options. The main points are:
1. Venous thrombosis and pulmonary embolism are concerns in postoperative and ICU patients. Thrombi often form silently in leg veins and can break off and travel to the lungs.
2. Diagnostic evaluations include D-dimer, ventilation-perfusion scans, echocardiograms, angiograms. Imaging shows defects from clots blocking blood flow.
3. Treatment involves anticoagulation initially with heparin or low molecular weight heparin. Warfarin is used long-term. Thrombolytics or inferior v
Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia.
Several distinct types of DM are caused by a complex interaction of genetics and environmental factors.
Depending on the etiology of the DM, factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose utilization, and increased glucose production.
The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system.
This document discusses diabetes and cardiovascular disease. It defines diabetes and describes its increasing worldwide prevalence. It notes that diabetes significantly increases the risk of cardiovascular diseases like coronary artery disease and stroke. The pathophysiology of diabetic vascular disease is described, including how hyperglycemia, dyslipidemia, inflammation, and oxidative stress damage blood vessels and promote atherosclerosis. The document also outlines criteria for diagnosing diabetes and the role diabetes plays in various cardiovascular conditions.
There has been an increase in the predominance of diabetes mellitus over the past 40 years worldwide. The worldwide occurrence of diabetes in 2000 was approximately 2.8% and is estimated to grow to 4.4% by 2030. This data interprets a projected rise of diabetes from 171 million in 2000 to well over 350 million in 2030. The presence of hypertension in diabetic patients substantially increases the risks of coronary heart disease, stroke, nephropathy and retinopathy. Indeed, when hypertension coexists with diabetes, the risk of CVD is increased by 75%, which further contributes to the overall morbidity and mortality of an already high risk population. Patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality, and are disproportionately affected by cardiovascular disease. Most of this excess risk is associated with high prevalence of well-established risk factors such as hypertension, dyslipidaemia and obesity in these patients. Hypertension plays a major role in the development and progression of microvascular and macrovascular disease in people with diabetes. Lifestyle Modifications and pharmacotherapy are the choice for the Management of Hypertension in Patients with Diabetes.
This study examined the prevalence of vascular complications among patients with type 2 diabetes at Aden Abdulle Hospital in Somalia. A cross-sectional study was conducted with 69 patients. The majority were male, over age 60, and married. Most common complications were heart and leg issues. Over half did not have kidney disease, but 18% did, with 11 receiving dialysis 1-3 times per week. About a quarter reported numbness in their legs. The study provides insight into the burden of vascular complications of type 2 diabetes in Somalia.
Diabetes is a group of metabolic disorders characterized by hyperglycemia. The prevalence of diabetes has risen dramatically worldwide over the past few decades. Diabetes greatly increases the risk of cardiovascular disease like coronary artery disease. Patients with diabetes have a 2-4 times higher risk of cardiovascular disease and it often develops decades earlier than in non-diabetic patients. Diabetes contributes to both microvascular complications like nephropathy and retinopathy as well as macrovascular complications from atherosclerosis.
Running head illness and disease managementillness and disearyan532920
Chronic kidney disease is a debilitating disease that affects many organ systems and is associated with high risks of cardiovascular disease and early death. It has numerous comorbidities such as diabetes, hypertension, heart disease, and impacts patients' quality of life through disability and high medical costs. About 10% of the global population is affected by CKD, and it is a leading cause of death worldwide. Goals for improving CKD include reducing the disease burden through early detection and treatment of risk factors like diabetes and hypertension.
The growing epidemic of type 2 diabetes is one of the leading causes of premature morbidity and mortality worldwide, mainly due to the micro- and macrovascular complications associated with the disease. A growing body of evidence suggests that although the risk of developing complications is greater with glucose levels beyond the established
This document provides information about diabetes and diabetic retinopathy for medical students. It outlines learning objectives related to understanding diabetes demographics, diagnosis, complications, and treatments. Key points include that diabetes affects over 29 million Americans and has significant medical costs. Diabetic retinopathy is a leading cause of blindness and its progression can be slowed by controlling blood sugar and blood pressure. The document also defines the stages of diabetic retinopathy and diabetic macular edema.
This document discusses myocarditis in children. It defines myocarditis and describes the epidemiology, etiology, pathophysiology, clinical presentation, diagnosis and treatment. Myocarditis has many potential causes including viruses like adenovirus and enterovirus. Clinically it presents variably depending on age from nonspecific symptoms to heart failure. Diagnosis involves blood tests, ECG, imaging like echocardiogram and cardiac MRI, and endomyocardial biopsy. Treatment is supportive with heart failure medications, antivirals may help, and immunosuppressants can reduce inflammation and improve function.
1) Myocarditis is an inflammation of the heart muscle that can progress to dilated cardiomyopathy and heart failure. Viruses are the most common cause, with adenovirus and enterovirus being the most frequently detected viruses.
2) Myocarditis causes chest pain, arrhythmias, shortness of breath, and fever. ECG findings can include tachycardia, conduction abnormalities, and T-wave inversions. Biomarkers like troponins are elevated but nonspecific.
3) Endomyocardial biopsy remains the gold standard for diagnosis but cardiac MRI is becoming more important for diagnosis and follow-up of acute myocarditis patients.
Dengue Fever-Related Cardiac manifestation in Ibn-Sina Hospital Mukalla, Hadh...asclepiuspdfs
This document summarizes a study on cardiac manifestations in patients hospitalized with dengue fever in Mukalla, Yemen. The study found that the most common cardiac manifestations were sinus tachycardia (39.4% of patients) and hypotension (18.37% of patients). Other less common findings included pulmonary congestion, bradycardia, and pericardial effusion. There was a close correlation between the severity of cardiac manifestations and the severity of dengue based on WHO classifications, with more severe cardiac issues seen in those with severe dengue. The most common causes of death in the study (10 patients) were refractory shock and other complications associated with severe dengue disease.
Central Nervous System Histoplasmosis Related to Bioprosthetic Endocarditisasclepiuspdfs
Endocarditis caused by Histoplasma capsulatum is a rare occurrence. Involvement of the central nervous system by Histoplasma is also relatively uncommon. This paper reports a case of a 62-year-old woman with a past medical history significant for a myocardial infarct 5 years prior which necessitated coronary artery bypass graft surgery, prosthetic aortic valve replacement 4 years prior, and sarcoidosis, diagnosed 1 year prior, which was treated with methotrexate. She presented with fevers, generalized weakness, night sweats, and chest and throat pain. An echocardiogram done as part of her evaluation showed a vegetation on her prosthetic aortic valve. H. capsulatum was identified on blood cultures, and she was started on antibiotics. She expired shortly thereafter. At autopsy, a diagnosis of Histoplasma endocarditis was confirmed with evidence of embolic disease involving kidneys and digits of the hand. Hilar lymph nodes showed evidence of the fungus. Examination of the brain showed multiple widespread microscopic foci of macrophages, lymphocytes, and microglial cells with associated Histoplasma organisms, highlighted on Gomori methenamine silver staining. This paper will discuss central nervous system involvement by Histoplasma.
This document discusses the use of anticoagulants in COVID patients and raises several questions about their usage. It questions whether anticoagulants are being overused in COVID patients and discusses when, which medications, and for how long they should be used. It also questions whether the use of anticoagulants is important and whether guidelines exist around their use, as there are controversies regarding anticoagulation in COVID patients. A second section discusses venous thromboembolism risk and treatment in cirrhosis patients.
Complicated Tubercular Pericarditis Presenting as Ventricular Apical Aneurysm...Crimsonpublisherssmoaj
This case report describes a 27-year-old female who presented with symptoms of breathlessness, fever, and fatigue. She had a history of treated pulmonary tuberculosis. Imaging revealed chronic calcific pericarditis with a narrow-necked left ventricular apical aneurysm. This ventricular aneurysm is a rare complication of tubercular pericarditis. The patient was counseled for surgical treatment but declined due to financial constraints. Ventricular aneurysms are uncommon in tuberculosis and result from contained rupture of infected myocardial tuberculomas under strain of thickened pericardium. Recognition by radiologists is important for timely surgical management of this life-threatening complication.
Cardiac Manifestation in Dengue InfectionSoroy Lardo
Dengue Infection and Cardiac Manifestations How Important? Certainly greatly affect the clinical course of dengue patients with viremia phase - critical phase and recovery phase. Cardiac Manifestations, as an important organ that determines stable hemodynamics. What if our heart is disturbed? of course there is influence in management and prognosis. Please refer to this power point.
1) The document discusses the relationship between carotid artery disease and coronary artery disease. Studies have found an association between carotid artery plaques and stenosis and adverse cardiac outcomes.
2) Measuring intima-media thickness (IMT) of the carotid arteries has been used as a surrogate for coronary artery atherosclerosis. However, atherosclerosis is non-uniform and different risk factors are associated with IMT increases in different carotid artery segments.
3) A recent study in young adults found that multiple coronary risk factors cause different morphological changes in carotid artery segments. Systolic blood pressure was most associated with common carotid IMT while age was most associated with carotid bulb IMT.
The document discusses the relationship between carotid artery disease and coronary artery disease. It notes that asymptomatic patients with carotid bruits have high rates of cardiac death, and that ultrasonographically measured carotid intima-media thickness (IMT) is used as a surrogate for coronary artery disease risk. However, atherosclerosis is non-uniform, and individual carotid segments may be differently associated with risk factors and cardiac outcomes. A recent study found that multiple risk factors cause different morphological changes in carotid segments, with systolic blood pressure most associated with common carotid IMT and age most associated with bulb IMT. The relationship between individual carotid segments and prognosis requires further study.
This document discusses thromboprophylaxis in ICU patients. It provides information on:
- The risk of venous thromboembolism (VTE) in hospitalized patients and the potential for prophylaxis to reduce this risk
- Common prophylactic options like enoxaparin, fondaparinux, and unfractionated heparin
- Tools to assess patient risk like the PADUA and IMPROVE scores
- Factors to consider when selecting a prophylactic method, including duration of prophylaxis
The document aims to review best practices for preventing VTE in high-risk hospitalized populations through appropriate thromboprophylaxis.
Comparison of Infection Episodes in CKD Patients with or without Hemodialysis...ijtsrd
This study compared infection episodes in chronic kidney disease (CKD) patients with and without hemodialysis. A cross-sectional study of 56 CKD patients found that those undergoing hemodialysis had higher rates of chills, increased white blood cell count, and elevated erythrocyte sedimentation rate compared to non-hemodialysis patients. The study concluded that CKD patients on long-term hemodialysis were more prone to developing infections than those not on hemodialysis, likely due to factors such as catheter insertion for hemodialysis. Better infection prevention strategies are needed for CKD patients undergoing hemodialysis.
Perspective of Cardiac Troponin and Membrane Potential in People Living with ...asclepiuspdfs
Background: Hypertension is an event in which the force of the blood against the artery walls is too high leading to severe health complications and increases the risk of heart disease, stroke, and sometimes death. Aim: This study was carried out to determine the levels of cardiac troponin 1 and membrane potential in hypertensive subjects in Owerri, Imo state. Materials and Methods: A total of 120 subjects within the age 30–70 years were recruited for this study. The study consists of 60 subjects who were diagnosed of hypertension and 60 were apparently healthy individuals who served as controls subjects of the same age bracket. The levels of cardiac troponin 1 and membrane potential were analyzed using enzyme-linked immunosorbent assay technique. Data were assessed using SPSS version 20, the mean value with P ˂ 0.05 was considered statistically significant. Results: The result revealed that the levels of cardiac troponin 1 in hypertension were significantly increased when compared with control subjects while the levels of membrane potential were significantly decreased when compared to control at P < 0.05. Conclusion: The increased serum level of cardiac troponin 1 and decreased membrane potential in hypertensive subjects may contribute some risk factors in patients with hypertension.
This document discusses venous thrombosis and pulmonary embolism. It covers risk factors, pathophysiology, diagnostic evaluation, and treatment options. The main points are:
1. Venous thrombosis and pulmonary embolism are concerns in postoperative and ICU patients. Thrombi often form silently in leg veins and can break off and travel to the lungs.
2. Diagnostic evaluations include D-dimer, ventilation-perfusion scans, echocardiograms, angiograms. Imaging shows defects from clots blocking blood flow.
3. Treatment involves anticoagulation initially with heparin or low molecular weight heparin. Warfarin is used long-term. Thrombolytics or inferior v
Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia.
Several distinct types of DM are caused by a complex interaction of genetics and environmental factors.
Depending on the etiology of the DM, factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose utilization, and increased glucose production.
The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system.
This document discusses diabetes and cardiovascular disease. It defines diabetes and describes its increasing worldwide prevalence. It notes that diabetes significantly increases the risk of cardiovascular diseases like coronary artery disease and stroke. The pathophysiology of diabetic vascular disease is described, including how hyperglycemia, dyslipidemia, inflammation, and oxidative stress damage blood vessels and promote atherosclerosis. The document also outlines criteria for diagnosing diabetes and the role diabetes plays in various cardiovascular conditions.
There has been an increase in the predominance of diabetes mellitus over the past 40 years worldwide. The worldwide occurrence of diabetes in 2000 was approximately 2.8% and is estimated to grow to 4.4% by 2030. This data interprets a projected rise of diabetes from 171 million in 2000 to well over 350 million in 2030. The presence of hypertension in diabetic patients substantially increases the risks of coronary heart disease, stroke, nephropathy and retinopathy. Indeed, when hypertension coexists with diabetes, the risk of CVD is increased by 75%, which further contributes to the overall morbidity and mortality of an already high risk population. Patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality, and are disproportionately affected by cardiovascular disease. Most of this excess risk is associated with high prevalence of well-established risk factors such as hypertension, dyslipidaemia and obesity in these patients. Hypertension plays a major role in the development and progression of microvascular and macrovascular disease in people with diabetes. Lifestyle Modifications and pharmacotherapy are the choice for the Management of Hypertension in Patients with Diabetes.
This study examined the prevalence of vascular complications among patients with type 2 diabetes at Aden Abdulle Hospital in Somalia. A cross-sectional study was conducted with 69 patients. The majority were male, over age 60, and married. Most common complications were heart and leg issues. Over half did not have kidney disease, but 18% did, with 11 receiving dialysis 1-3 times per week. About a quarter reported numbness in their legs. The study provides insight into the burden of vascular complications of type 2 diabetes in Somalia.
Diabetes is a group of metabolic disorders characterized by hyperglycemia. The prevalence of diabetes has risen dramatically worldwide over the past few decades. Diabetes greatly increases the risk of cardiovascular disease like coronary artery disease. Patients with diabetes have a 2-4 times higher risk of cardiovascular disease and it often develops decades earlier than in non-diabetic patients. Diabetes contributes to both microvascular complications like nephropathy and retinopathy as well as macrovascular complications from atherosclerosis.
Running head illness and disease managementillness and disearyan532920
Chronic kidney disease is a debilitating disease that affects many organ systems and is associated with high risks of cardiovascular disease and early death. It has numerous comorbidities such as diabetes, hypertension, heart disease, and impacts patients' quality of life through disability and high medical costs. About 10% of the global population is affected by CKD, and it is a leading cause of death worldwide. Goals for improving CKD include reducing the disease burden through early detection and treatment of risk factors like diabetes and hypertension.
The growing epidemic of type 2 diabetes is one of the leading causes of premature morbidity and mortality worldwide, mainly due to the micro- and macrovascular complications associated with the disease. A growing body of evidence suggests that although the risk of developing complications is greater with glucose levels beyond the established
This document provides information about diabetes and diabetic retinopathy for medical students. It outlines learning objectives related to understanding diabetes demographics, diagnosis, complications, and treatments. Key points include that diabetes affects over 29 million Americans and has significant medical costs. Diabetic retinopathy is a leading cause of blindness and its progression can be slowed by controlling blood sugar and blood pressure. The document also defines the stages of diabetic retinopathy and diabetic macular edema.
This document discusses programs for preventing non-communicable diseases. It first describes an integrated community-based program that aims to prevent the four main non-communicable diseases (cardiovascular diseases, cancer, chronic obstructive pulmonary disease, and diabetes) through promoting a healthy lifestyle to reduce risk factors like unhealthy diet, physical inactivity, and smoking. It then discusses other programs to prevent non-communicable diseases like mental disorders, blindness, kidney disease, and support people with disabilities.
This document discusses programs for preventing non-communicable diseases. It focuses on an integrated community-based program to prevent the major non-communicable diseases (cardiovascular disease, cancer, COPD, diabetes) through promoting a healthy lifestyle to reduce risk factors like unhealthy diet, physical inactivity, and smoking. It also discusses programs for preventing other non-communicable diseases like mental disorders, blindness, kidney disease, and supporting people with disabilities. The majority of the document provides details on cardiovascular diseases, including common types like congenital heart disease, rheumatic heart disease, hypertension, and associated risk factors.
Diabetes mellitus type 2: One monster eating allApollo Hospitals
Type 2 diabetes mellitus (T2DM) has become one of the most prevalent non-communicable diseases worldwide. If left uncontrolled, T2DM can damage almost every organ system in the body and lead to numerous serious complications. The main complications discussed in the document are cardiovascular disease, diabetic retinopathy (damage to the retina), diabetic nephropathy (kidney damage), pulmonary dysfunction, diabetic neuropathy, and hepatic dysfunction. Uncontrolled hyperglycemia increases the risks of all these complications through mechanisms like increased advanced glycation end products, oxidative stress, and inflammation. Studies have shown T2DM poses a major threat in India as well, with Indians at high risk of related cardiovascular and metabolic issues.
This document discusses diabetic nephropathy, one of the most serious long-term complications of diabetes. Diabetic nephropathy usually manifests after 10 years of type 1 diabetes or at diagnosis of type 2 diabetes. It is the most common cause of end-stage renal disease in developed countries. Screening for microalbuminuria through urine tests should begin 5 years after diagnosis of type 1 diabetes or at diagnosis of type 2 diabetes to detect early stages of nephropathy. Risk factors that can lead to the development of microalbuminuria include high blood pressure, high blood glucose, dyslipidemia, and smoking. The document provides guidelines on screening, risk factors, and when to refer patients for diabetic
Diabetes occurs when the body does not produce enough insulin or the body does not properly respond to insulin. There are two main types of diabetes: type 1 where the body does not produce enough insulin and type 2 where the body does not properly respond to insulin. If uncontrolled, diabetes can lead to complications that affect blood vessels and blood supply to organs, increasing risks of heart attack, kidney failure, and vision loss. The risk of developing diabetes is higher with obesity, family history of diabetes, older age, and among certain ethnic groups. Managing diabetes involves identifying those with diabetes or pre-diabetes, maintaining tight control of blood sugar levels, enabling self-management of the condition, and addressing lifestyle risk factors.
1. Type 2 diabetes is a common chronic disease characterized by progressively rising blood glucose levels and worsening insulin resistance, which are major causes of morbidity and mortality. It is estimated that over 16 million people suffering from diabetes live in the Eastern Mediterranean Region alone.
2. The document discusses the different types of diabetes, including type 1, type 2, and gestational diabetes. It provides details on the causes and complications of diabetes, noting that uncontrolled diabetes can cause numerous serious complications affecting many organs and tissues over time.
3. The goal of diabetes treatment is to control blood sugar levels, but the methods vary depending on the type of diabetes. Current therapies have problems with compliance, effectiveness, and side effects, highlighting the need
Type 2 Diabetes Mellitus: The Concerned Complications and Target OrgansApollo Hospitals
Diabetes has been considered as the most dreaded non-communicable disease consuming the mankind rapidly. WHO has predicted the number of diabetics to be approximately 366 millions by 2030. The disease is characterized by hyperglycemia and the basic symptoms are polyphagia, polydipsia and polyuria. The autoimmune type 1 diabetes represent almost 1% of the total diabetic population, the rest being that of type 2 diabetes (T2D). Type 2 diabetes has been linked to a variety of factors such as heredity, environmental factors, unhealthy eating habits, sedentary lifestyle, stress etc. The uncontrolled hyperglycemia has profound deleterious effects on almost all the organs and results in various cardiovascular disorders, retinopathy, neuropathy, and nephropathy. Recent studies have revealed an array of pulmonary dysfunctions related with T2D ranging from respiratory defects to tuberculosis. Diabetes also predisposes the person to hepatic dysfunctions like NAFLD and HCC and a range of infections at various sites which are difficult to manage. Post-surgical infections are of special interest for subjects with uncontrolled hyperglycemia prior to surgery. Scientists all over the world are revealing different pathways and associated therapies for type 2 diabetes in order to control the pathological effects covering almost whole body physiology.
This document discusses health education intervention strategies for preventing and managing diabetes. It describes the different types of diabetes, including type 1, type 2, gestational diabetes, metabolic syndrome, and pre-diabetes. The causes of diabetes are discussed, including genetics and lifestyle factors like obesity and lack of exercise. Health education strategies are recommended to increase awareness of diabetes symptoms and management through programs run by health agencies.
Diabetes mellitus - britannica online encyclopediaRohinikumar T
This document summarizes diabetes mellitus, including the two major types (Type I and Type II). Type I diabetes is caused by an autoimmune destruction of the pancreas resulting in a lack of insulin production. Type II diabetes is caused by insulin resistance and deficiency and is strongly associated with obesity. Both types can be treated through diet, exercise, insulin therapy, and other drugs that help control blood glucose levels. Long-term complications of uncontrolled diabetes include damage to blood vessels and organs.
Germany has a high burden of disease due to diabetes. About 7.4 million adults in Germany have diabetes, which is 12% of the total population. This is projected to increase to 8 million adults by 2030. Diabetes is the 4th leading cause of death in Europe. Risk factors for diabetes in Germany include age, family history of diabetes, physical inactivity, overweight/obesity, and diet. Obesity rates are also high, with over 50% of adults overweight or obese. Diabetes increases the risk of cardiovascular diseases, kidney disease, lower limb amputation, blindness, and early death. It is estimated that diabetes costs the German healthcare system €43.2 billion annually.
This document provides an overview of diabetes, including:
- Diabetes is a metabolic disease where the body does not properly process glucose due to not producing or responding to the hormone insulin.
- There are three main types of diabetes: type 1, type 2, and gestational diabetes.
- Risk factors include family history, age, lifestyle, and ethnicity. Symptoms include frequent urination, thirst, and weight changes.
- Complications can include kidney damage, heart disease, eye problems, and limb amputation if not properly managed.
- Diagnosis involves blood glucose testing and management involves monitoring levels and lifestyle changes like diet and exercise.
This case study presents information on an 80-year-old female patient diagnosed with Coronary Artery Disease, Hypertensive Cardiovascular Disease, and Type 2 Diabetes Mellitus. The patient has a history of high blood pressure and chest pain. She was admitted to the hospital in February 2019 for increased blood pressure and chest discomfort. The case study objectives are to present information on the patient's conditions, gather data through assessment, and provide comprehensive nursing care. Student nurses conducted interviews, examinations, and reviewed medical records to understand the patient's history, diagnoses, symptoms, and plan appropriate interventions.
Similar to Diabetes-related Clinical Complications: Novel Approaches for Diagnosis and Management (20)
Convalescent Plasma and COVID-19: Ancient Therapy Re-emergedasclepiuspdfs
Convalescent plasma has been used as a treatment for infectious diseases for over a century. It involves transfusing plasma from patients who have recovered from an infection into patients who are currently ill with that same infection. Clinical trials are now investigating its use for COVID-19. While some early studies showed promising results, larger randomized controlled trials found no significant benefit of convalescent plasma for severe COVID-19. Further research is still needed to determine whether certain patient populations or plasma dosages may be more effective.
The Negative Clinical Consequences Due to the Lack of the Elaboration of a Sc...asclepiuspdfs
Until a few years ago, the immune system was considered as responsible for the only defense against microbial infections and other external agents. On the contrary, the immune cells have been proven to be linked not only through cell-cell contact but also by releasing proteins capable of influencing the immune-inflammatory response, the so-called cytokines or interleukins. Moreover, the cytokines have appeared to play not only immune activities but also metabolic and systemic effects influencing the overall biological systems, including the nervous, the endocrine, and the cardiovascular systems, by representing the main endogenous molecules responsible for the maintenance of the unity of the biological life. Therefore, only the systematic clinical consideration of cytokine effects may allow the generation of real future holistic medicine.
The great benefit of blood/blood constitutes therapy is the ability to provide transfusion support for patients with many unique hematologic conditions. For some patients, such as patients with sickle cell disease, thalassemia major, immune hemolytic anemia, anemia of kidney disease, and aplastic anemia may need for this consolidation extends throughout their life. By knowing the alteration mechanisms of these conditions, we can appreciate the stationary, urgency, and the value of the transfused red blood cell (RBC).
Decreasing or Increasing Role of Autologous Stem Cell Transplantation in Mult...asclepiuspdfs
During the past four decades, autologous stem cell transplantation (ASCT) has been the first choice and the standard option for the treatment of newly diagnosed patients with multiple myeloma. The introduction of new agents such as thalidomide, lenalidomide, and bortezomib has led to a clear improvement in basic approach and those agents became the standard of care in the induction phase; however, they were not able to play the role of ASCT in term of progression-free survival and overall survival. Debate continues about the best induction, consolidation, and maintenance taking into account the toxicities of these new agents. The new monoclonal antibody (anti CD38) starts to take its place in the induction setting and it seems to be a promising agent in the high-risk group. Until recently, ASCT is the standard treatment for newly diagnosed patients.
Comparison of the Hypocalcemic Effects of Erythropoietin and U-74389Gasclepiuspdfs
Aim: This study calculated the effects on serum calcium (Ca) levels, after treatment with either of two drugs: The erythropoietin (Epo) and the antioxidant lazaroid (L) drug U-74389G. The calculation was based on the results of two preliminary studies, each one of which estimated the certain influence, after the respective drug usage in an induced ischemia-reperfusion animal experiment. Materials and Methods: The two main experimental endpoints at which the serum Ca levels were evaluated were the 60th reperfusion min (for the Groups A, C, and E) and the 120th reperfusion min (for the Groups B, D, and F). Especially, the Groups A and B were processed without drugs, Groups C and D after Epo administration, whereas Groups E and F after the L administration. Results: The first preliminary study of Epo presented a non-significant hypocalcemic effect by 0.34% ± 0.68% (P = 0.6095). However, the second preliminary study of U-74389G presented a non-significant hypercalcemic effect by 0.14% ± 0.66% (P = 0.8245). These two studies were coevaluated since they came from the same experimental setting. The outcome of the coevaluation was that L is 2.3623042-fold (2.3482723–2.3764196) more hypercalcemic than Epo (P = 0.0000). Conclusions: The antioxidant capacities of U-74389G ascribe 2.3623042-fold more hypercalcemic effects than Epo (P = 0.0000).
The term refractory anemia (RA) may be confusing to those who are not hematologists. RA should be well defined because it means more than what it says. RA is defined as anemia that is not responsive to therapy except transfusion.[1] The term RA is used to rule out those types of anemia with a known cause such as anemia of systemic diseases (liver and kidney) and anemia of inflammation even though they are considered refractory to therapy.[2] RA with cellular or hypercellular bone marrow was formerly used to exclude aplastic anemia.
Management of Immunogenic Heparin-induced Thrombocytopeniaasclepiuspdfs
Immunogenic heparin-induced thrombocytopenia (HIT) is an immune response to heparin associated with significant morbidity and mortality in hospitalized patients if unidentified as soon as possible, due to thromboembolic complications involving both arterial and venous systems. Early diagnoses based on a comprehensive interpretation of clinical and laboratory information improve clinical outcomes. Management principles of strongly suspected HIT should not be delayed for laboratory result confirmation. Treatment strategies have been introduced including new, safe, and effective agents. This review summarizes the clinical therapeutic options for HIT addressing the use of parenteral direct thrombin inhibitors and indirect factor Xa inhibitors as well as the potential non-Vitamin K antagonist oral anticoagulants.
A 73-year-old woman presented with fever and linearly arranged erythema on her chest, back, and abdomen. She was initially diagnosed with drug-related scratch dermatitis due to antibiotic use. However, her fever persisted and lab work showed abnormal liver enzymes and very high ferritin levels. Biopsies ruled out infection and malignancy. She was ultimately diagnosed with adult Still's disease (ASD) based on her symptoms and lab results. Treatment with prednisolone resolved her symptoms within a week. This case demonstrates that ASD can present with various skin lesions, and a high index of suspicion is needed for diagnosis.
Bone Marrow Histology is a Pathognomonic Clue to Each of the JAK2V617F, MPL,5...asclepiuspdfs
According to the World Health Organization and Clinical Laboratory Molecular and Pathological criteria bone marrow pathology in JAK2V617F mutated trilinear myeloproliferative neoplasm (MPN) patients essential thrombocythemia (ET) and polycythemia vera are indistinguishably featured by clustered medium to large pleomorphic megakaryocytes and increased cellularity (60–90%) due to increased erythropoiesis and megakaryopoiesis. MPL515 mutated ET is the second distinct clonal MPN characterized by thrombocythemia in a normocellular bone marrow showing clustered increased large to giant mature megakaryocytes with staghorn-like hyperlobulated nuclei. Calreticulin (CALR) mutated hypercellular thrombocythemia associated with prefibrotic megakaryocytic, granulocytic myeloproliferation (MGM) recently became the third distinct MPN featured by dense clusters of immature megakaryocytes with cloud-like nuclei. Bone marrow pathology in newly diagnosed MPN patients appears to be a pathognomonic clue for diagnostic differentiation between JAK2V617F mutated trilinear MPN, MPL515 normocellular thrombocythemia, and CALR thrombocythemia with MGM characteristics followed by secondary reticulin fibrosis. Their natural histories clearly differ featured by an increase of erythro/granulopoiesis and cellularity in JAK2V617F, decrease of erythropoiesis and cellularity in MPL515 and increase of dual megakaryo/granulopoiesis and cellularity in CALR mutated MPN.
Helicobacter pylori Frequency in Polycythemia Vera Patients without Dyspeptic...asclepiuspdfs
Introduction: In polycythemia vera (PV) patients, peptic ulcer and gastroduodenal erosions are more common than the general population, but there are insufficient data on the frequency of Helicobacter pylori (HP) and its role in etiopathogenesis. In this study, we aimed to compare the prevalence of HP infection in PV patients without dyspeptic complaints with a healthy control group without dyspeptic complaints. Materials and Methods: Fifty patients with PV without dyspeptic complaints and 50 controls without dyspeptic complaints were enrolled in this study after informed consent obtained. Stool samples of selected patients were analyzed using HP stool antigen test (True Line®). Results: There was surprisingly striking difference between HP prevalence in PV patients without dyspeptic complaints and asymptomatic healthy controls (64% vs. 2%) (P < 0.05). There was no significant relationship found between HP presence and age, gender, treatment modalities, complete blood count, positivity of JAK2 V617F, serum erythropoietin level, and splenomegaly in PV patients (P > 0.05). Conclusion: As the susceptibility of HP infections in PV patients are higher, it is recommended to have close surveillance of these patients by screening HP presence. In addition, when HP positivity is determined, the eradication of HP is essential to prevent possible future gastrointestinal lesions in patients with PV.
Lymphoma of the Tonsil in a Developing Communityasclepiuspdfs
The lymphoma of the tonsil is a rarity. Single case reports have appeared in countries as disparate as China, Greece, India, Japan, and Turkey. Therefore, this paper presents cases found in Nigeria among the Ibo ethnic group. The epidemiological comparisons are deemed to be worthy of documentation such as age ranges and sides of involvement.
Should Metformin Be Continued after Hospital Admission in Patients with Coron...asclepiuspdfs
Background: In most patients with diabetes, guidelines recommend discontinuation of oral anti-diabetic agents. Preliminary data suggest that pre-admission metformin use may have a mortality benefit in patients with coronavirus disease (COVID)-19 admitted to the hospital. Objective: The objective of the study was to review the impact of metformin on morbidity and mortality among hospitalized patients with COVID-19. Methods: Review of English literature by PUBMED search until November 10, 2020. Search terms included diabetes, COVID-19, metformin, retrospective studies, meta-analyses, pertinent reviews, pre-print articles, and consensus guidelines are reviewed.
Clinical Significance of Hypocalcemia in COVID-19asclepiuspdfs
- Several retrospective studies found that hypocalcemia is common in hospitalized patients with COVID-19, occurring in 62-78% of patients.
- Hypocalcemia is associated with more severe disease and worse outcomes, including increased risk of hospitalization, longer hospital stays, multi-organ failure, acute respiratory distress syndrome, and death.
- The cause of hypocalcemia in COVID-19 patients is unclear but may involve consumption of calcium for viral entry into cells or reflect severity of illness. Further study is needed.
Excess of Maternal Transmission of Type 2 Diabetes: Is there a Role of Bioche...asclepiuspdfs
Objective: An excess of maternal transmission of Type 2 diabetes (T2D) has been reported in some populations but not confirmed in other studies. Mitochondrial inheritance has been proposed to explain such excess. In the present paper, we have considered the presence of T2D in the mother and/or in the father in relation to the risk of T2D and to age at onset of the disease in the offspring. The distribution of two genetic polymorphisms involved in glucose metabolism in relation to the presence of T2D in the mother has been also considered. Materials and Methods: Two hundred and seventy-nine participants with T2D were studied in the population of Penne, a small rural town in the eastern side of central Italy. Adenosine deaminase locus 1 (ADA1) and phosphoglucomutase locus 1 (PGM1) phenotypes were determined by starch gel electrophoresis. Statistical analyses were carried out using commercial software (SPSS). Results: The proportion of patients from T2D mothers is much greater as compared to the proportion of the patients from T2D fathers (P < 0.0001). Age at onset of the disease in patients in whom one or both parents are T2D is lower as compared to other patients. The distribution of ADA1 and PGM1 phenotypes in participants with T2D depends on the presence of diabetes in the mother. Conclusions: About the transmission of T2D, our data confirm the high proportion of maternal T2D and show the role of two common biochemical polymorphisms involved in glucose metabolism.
The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...asclepiuspdfs
Objective: Diabetes mellitus, the most common cause of non-traumatic foot amputations, is a life-threatening condition due to its high mortality and morbidity. In our study, we retrospectively evaluated our patients with diabetic foot syndrome in our clinic. Materials and Methods: The demographic data, duration of diabetes, Wagner classification, haemoglobin A 1c (HbA1c) levels, white blood cell, C-reactive protein sedimentation levels, hospital stay, and treatment results were evaluated retrospectively in 14 patients with diabetic foot between January 2017 and December 2018. Results: The mean age of the patients was 62.43 ± 7.7 years. Of the 14 patients, 3 were females and 11 were males. All 14 patients were type 2 diabetes mellitus. When diabetic foot Wagner classification was performed, 6 patients were evaluated as Wagner 2, five patients were Wagner 3, and three patients were evaluated as Wagner 4. Nine patients had complete amputation and 3 had vascular surgery. Conclusion: Although the level of HbA1c is below the target level, the risk of diabetic foot is increased when there is no adequate diabetes mellitus foot training. Inadequate diabetic patient education and hospitalization of patients after infection progress the amputation rate.
Self-efficacy Impact Adherence in Diabetes Mellitusasclepiuspdfs
The aim of the paper is to explore how self-efficacy (SE) is associated with adherence among adults with diabetes mellitus (DM). Methods: The search of electronic databases identified 564 records from 2007 to 2017 on SE and adherence from different perspectives and its effect on adults with DM. Discussions: SE increases the confidence in adults in their self-care behaviors. Non-adherence continues to be a significant barrier to SE. SE and adherence should be informed by an understanding of theoretical frameworks and the individual characteristics. Conclusion: Adherence is likely among adults with better SE to empower them to make valid decisions about their health. Interventions to improve SE should be tailored based on different types of non-adherence such as intentional and unintentional non-adherence. Implications: An intercollaborative professional practice approach is crucial to improve SE and adherence for sound judgment and valid decision-making.
Uncoiling the Tightening Obesity Spiralasclepiuspdfs
While an underweight prevalence was once more than twice that of obesity, now more people are obese than underweight. Obesity is one of the leading causes of preventable death in the world. There are an estimated 2,100,000,000 obese people worldwide and that number is forecast to grow to 51% of the world’s population by 2030. Escalating obesity-related disease costs threaten to bankrupt the world’s health-care systems.
Prevalence of Chronic Kidney disease in Patients with Metabolic Syndrome in S...asclepiuspdfs
Background and Objective: Chronic kidney disease (CKD) which is an increasingly important clinical and public health issue is associated with cardiovascular disease. Epidemiologic studies have also linked metabolic syndrome (MetS) with an increased risk of incident CKD. Therefore, the present study was designed retrospectively to find the prevalence and potential risk factors of CKD in patients with MetS in Saudi Arabia.
Management Of Hypoglycemia In Patients With Type 2 Diabetesasclepiuspdfs
Hypoglycemia is the rate-limiting step of intensive management in patients with diabetes. Lowering one’s A1C to a prescribed target is expected to mitigate one’s risk of developing long- and short-term diabetes-related complications. Several of the less expensive and commonly prescribed glucose lowering agents favored by practitioners result in weight gain, hypoglycemia, and even an increased risk of cardiovascular (CV) mortality. Although achieving a targeted A1C of <7 % is the standard of care, clinicians often fail to evaluate patients for glycemic variability which can increase oxidative stress driving long-term diabetes-related complications including CV death. The use of concentrated insulins and glucagon-like peptide-1 receptor agonists separately or in combination with each other reduces glycemic variability and one’s risk of hypoglycemia. Pharmaceutical agents which allow patients to safely achieve their targeted A1C without weight gain and hypoglycemia should be preferred in patients with type 2 diabetes.
Predictive and Preventive Care: Metabolic Diseasesasclepiuspdfs
South Asians have a very high incidence of ischemic heart disease and stroke. In addition, they also have a very high incidence of metabolic diseases such as prehypertension, hypertension, visceral obesity, metabolic syndrome, prediabetes, type-2 diabetes, and its clinical complications. Currently, there are over 75 million diabetic subjects in India and an equal number of prediabetics. Republic of China has taken over India as the diabetes capital of the world, with over 115 million diabetics. Modern medicine is disease focused and has failed to address the prevention of these chronic diseases. According to the reports from the United Nations (Millennium Development Goals [MDGs], the World Health Organization, Global Health Initiatives, and the non-communicable disease risk task force), obesity has increased by 2-fold and type-2 diabetes by 4-fold worldwide. Experts in this field predict that chances of meeting the MDGs set by the UN members of reducing the incidence of these diseases at 2025 to the level of 2020 are very little. Western medicine has failed to reduce or reverse the trend in the incidence of these diseases. We feel that an integrated approach to health care may be a better option, to reduce the disease burden in developing and resource-poor countries. Having said that, one cannot prevent something that one is not aware of, as such it is the need of the hour for us, to develop a robust predictive and preventive health-care platform. In an earlier article, we presented our views on reducing or reversing cardiometabolic diseases. There is great enthusiasm among the health-care providers and professional bodies that integration of emerging technologies will help develop personalized, precision medicine, as well as reduce the cost of health-care worldwide.
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One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. Choda and Rao: Diabetes-related complications
2 Journal of Clinical Cardiology and Diagnostics • Vol 2 • Issue 2 • 2019
obese, with at a greater risk of diseases, like diabetes.” Apart
from the known symptoms like increased thirst or urination,
by and large, the disease is recognized clinically by increased
blood sugar levels. According to the International Federation
of Diabetes (IDF), and the WHO, diagnostic criteria for
diabetes are fasting sugar 7.0 mmol/l (126 mg/dl) or 2 h
post-prandial glucose 11 mmol/l (200 mg/dl).
Complications associated with diabetes may include;
vasculopathy and neuropathy. Heart attacks and stroke are
2–4 times more common in people with diabetes. High blood
pressure affects two out of three individuals with diabetes. It
greatly raises the risk of diabetes-related complications, heart
attack, stroke, kidney failure, and blindness. Periodontal
disease occurs more often in people with diabetes. Diabetes
is the leading cause of blindness (retinopathy or glaucoma).
Diabetes is one of the major contributors to end-stage renal
disease (ESRD). More than half of individuals with diabetes
have some form of nerve damage (neuropathy). In Type-1
diabetes, ketoacidosis is quite common. Vascular diseases
are one of the main causes of erectile dysfunction in men
with diabetes. Diabetes is a group of metabolic disorders
characterized by hyperglycemia. All awareness programs
should emphasize the importance of protecting the body from
hyperglycemia. The direct and indirect effects of the human
vascular tree are the major source of morbidity and mortality
in both Type-1 and Type-2 diabetes.[2]
The injurious effects
of hyperglycemia manifest as macrovascular complications
(coronary artery disease, peripheral arterial disease,
and stroke) and microvascular complications (diabetic
nephropathy, neuropathy, and retinopathy).
Diabetic retinopathy (DR) may be the most common
microvascular complication, which depends on both duration
and the severity of hyperglycemia. Development of DR
was associated with both the severity of hyperglycemia and
hypertension in the UK Prospective Diabetes Study.[11-13]
DR
is the most common microvascular complication, responsible
for over 10,000 new cases of blindness every year in the USA
alone. Diabetes retinopathy may begin to develop as early as
7 years before the diagnosis of diabetes in individuals with
diabetes. Therefore, this condition may go unnoticed for
several years. As to the mechanism of cell injury by excess
sugar, high glucose level seems to increase the flux of sugar
molecules through the polyol pathway, increasing sorbitol
levels. Increased osmotic stress from accumulated sorbitol
seems to be the major contributor to diabetic microvascular
complications. Furthermore, high glucose concentrations
can promote the formation of advanced glycation end
products. Oxidative stress may also play an important role
in hyperglycemia mediated cell injury. Besides, growth
factors (endothelial growth factor) and transforming growth
factors also have been implicated in the pathogenesis of
diabetes-related retinopathy. Small vascular dilation occurs
in the retina as an early sign of retinopathy. In addition to
microaneurysms, which induce such vascular dilation,
small spot hemorrhages occur, which are described as “dot
hemorrhages.”
Diabetes nephropathy is a leading cause of chronic kidney
disease and renal failure worldwide.[14]
Diabetic nephropathy
is kidney damage that results from having uncontrolled
diabetes for a long duration. High blood sugar damages
that part of the kidneys that filter the blood. The damaged
filter becomes “leaky” and lets protein into the urine. It
is diagnosed in clinics by the presence of microalbumin,
leading to “microalbuminuria.” Like the retinopathy, this
condition also seems to manifest several years before the
diagnosis of diabetes. However, experts predict that peak
incidence usually occurs in persons having diabetes for
10–20 years. The overall prevalence of microalbuminuria
and macroalbuminuria in Type-2 diabetics is 30–35%. ESRD
is the major cause of death. Patient education seems to be the
key to prevent nephropathy. There is a great need to identify
and clarify the role of biomarkers in clinical practice.
Diabetes peripheral neuropathy (PN) is accompanied by the
presenceofsymptomsorsignsofperipheralnervedysfunction
in people with diabetes. Clinical diagnosis includes a test to
determine loss of touch, vibration, and temperature sensitivity.
Patients, who have lost 10-g monofilament sensation, are
at considerable risk for developing foot ulceration. About
60–70% of all people with diabetes will eventually develop
PN, although not all suffer pain. Numbness is the most
common symptom of nerve damage due to diabetes. People
who lose sensation are the ones most likely to get ulcers on
their feet and end up needing amputations.[15-17]
Diabetic
PN has been defined by the Toronto Consensus Panel on
Diabetic Neuropathy, as a “symmetrical, length-dependent
sensorimotor polyneuropathy, attributable to metabolic and
microvessel alterations, as result of chronic hyperglycemia
exposure and cardiovascular risk covariates.”[16]
Since
the loss of sensation is a subtle change that occurs over a
long period, there is a great need for the development of
novel noninvasive methodologies to follow microvascular
dysfunction.
DISCUSSION
In spite of the fact, diabetes is managed worldwide by
monitoring glycemic load, some experts feel that diabetes is
a disorder of lipid metabolism. Abnormal lipid environment
seems to be responsible for the devastating vascular
complications associated with uncontrolled diabetes,
including chronic inflammation that promotes vascular
disease. Hyperglycemia and insulin abnormality seems to
be the underlying causes for all vascular disease in diabetes
although the exact molecular mechanisms responsible for
this vascular injury are poorly understood. Endothelial
and vascular smooth muscle cell dysfunction contributes
3. Choda and Rao: Diabetes-related complications
Journal of Clinical Cardiology and Diagnostics • Vol 2 • Issue 2 • 2019 3
significantly to atherosclerosis and its complications. Several
studies have shown that endothelium-dependent vasodilation
is abnormal in patients with diabetes.
Monitoring glucose for management of diabetes
The concentration of glucose is highest in the arterial
blood. Laboratory analysis of blood glucose is done usually
in venous blood samples. Glucose concentration may be
determined in whole blood, plasma, or serum. Although
clinical diagnostic laboratories still use venous blood
samples for glucose analysis, introduction three decades ago,
self-monitoring of blood glucose using finger stick blood
samples, test strips, and portable meters, has significantly
aided diabetes management. The WHO has approved the use
of point-of-care-testing devices for hemoglobinA1c (HbA1c)
diagnostic tests traceable to the International Federation of
Clinical Chemistry reference method. The Quo-Test analyzer
by Entwicklung, Konstruktion und Fertigung Diagnostics,
directly measures HbA1c in minutes using a 4 ul sample of
blood from a simple finger stick.
The use of this method in resource-poor countries is limited.
We have been working on the development of a portable
non-invasive method for monitoring blood glucose for quite
some time. Senior author, Gundu H.R. Rao was funded
by the Indian Council of Medical Research, India, for
developing prototypes of non-invasive glucometers (NIGM).
We used near infrared (NIR) sensors for the detection of
blood glucose (Antony Aneel Joseph and Gundu H.R. Rao:
Indian Patent number 2756/CHE/2012 A). The NIR emitter
used was a 940 nm IR light-emitting diode and the detector
was a photodiode chip, with 1100 nm wavelength (https://
www.diabiqik.com). The NIGM is currently undergoing
productization and clinical validation. Continuous glucose
monitoring (CGM) from the interstitial fluid is a new
technology that is used by the Abbott Diabetes Care as well
as Dexcom G-6 (www.dexcom.com). The Food and Drug
Administration (FDA) of the USA has approved both these
systems. We and others have validated the FreeStyle Libre Pro
in India, for Type-1 as well as Type-2 diabetes management.
None of the existing home monitoring devices directly
determine HbA1c. Since it is very important to know the
HbA1c values to manage glycemic load effectively, we
prefer the use of FreeStyle Libre Pro or Dexcom-G6 devices.
Figure 1 shows a plot for fasting glucose done by Abbott
(Courtesy Abbott Diabetes Care) device, compared to a
commercially available device using the fingerstick method.
The data show a strong linear relationship between blood
glucose and interstitial fluid glucose values.
Since HbA1c values are more reliable for robust management
of blood glucose, we did a population-based study of over
10,000 individuals in a hospital setting. Data presented as a
dot-plot in Figure 2 show a wide scatter of values at HbA1c
7.0, ranging between 100 and 200 mg/dl. Because of this
Figure 2: Glucose profile of a diabetic patient on medication for over 20 years. Source: Personal data
Figure 1: (a) Fasting glucose: CMG versus fingerstick (b) Fasting glucose versus hemoglobin A1c (n = 10,000)
a b
4. Choda and Rao: Diabetes-related complications
4 Journal of Clinical Cardiology and Diagnostics • Vol 2 • Issue 2 • 2019
observation, we feel strongly that one should not go by the
HbA1c values alone, but conduct additional tests to diagnose
early signs of diabetes-related clinical complications. Given
the fact, that CGM devices are available.
Individuals should be encouraged to use such devices.
Figures 2 and 3 show the glucose profiles of a diabetic
individual, who is on medication. Despite having diabetes
for over 20 years, the patient seems to have a well-controlled
glucose profile, with mean glucose of 156 and HbA1c of 7.2.
However, in the absence of a further test, it will not be possible
to predict, whether or not any diabetes-related complications
are already in the early stages of development. The trend in
glucose profile makes it easy to detect ups, downs, night-time
lows as well as postprandial peaks and recovery times.
Early diagnosis of risk factors for vascular
diseases
The ability to scan many times, as well as the accumulation
of data frequently over several days, allows one to better
understand the impact of actions such as food intake, exercise,
and lifestyle changes. These devices can be customized to
send reminders, alerts and add your notes, thus, it empowers
the users for improving their health.
Primary prevention of cardiovascular disease (CVDs) has
been aimed at early risk factor identification and robust
management of the modifiable risks (American College
of Cardiology/American Heart Association Guidelines:
J Am Coll. Cardiol 17: epub. 2019). At the University of
Minnesota, a center was established for comprehensive
screening of an asymptomatic population with ten tests
designed to detect early vascular and cardiac abnormalities
using a scoring system from 0 to 20, 48% of the population
screened exhibited scores 5, indicative of early vascular
disease. One of the tests used for monitoring endothelial
dysfunction was pulse wave analysis using Cardiovascular
Profiling Instrument developed by Hypertension Diagnostics
of Minneapolis, Minnesota [Figure 4].
Hypertension diagnostics of Minneapolis, Minnesota, has
developedamethodfornoninvasivelymeasuringtheelasticity
of large and small arteries, providing an early assessment of
CVDs. According to experts including Professor Jay Cohn
of the University of Minnesota, alterations in the small
artery elasticity are the earliest and most sensitive marker of
CVDs. For use at the population level, we need a simple cost-
effective hand-held monitor to detect vascular dysfunction or
hardening of the arteries. We are trying to develop a wearable
device using flexible piezoelectric pressure sensors.
Imaging of carotid intima-media thickness is widely used for
monitoring subclinical atherosclerosis. However, an Imaging
Research Laboratory in Ontario, Canada, has developed a
three-dimensional (3D) imaging of the carotid arteries. On
the left side [Figure 5] is a relatively healthy artery with no
visible signs of plaque buildup, whereas, in the photo on the
right side, clear atherosclerotic plaque is seen. Proprietary
software and analytics will provide plaque volume and other
characteristicsneededforfollowingprogression,orregression
Figure 3: Mean daily glucose values for the same patient shown in Figure 2, plotted as a graph. Source: Personal data
Figure 4: Cardiovascular - Profiler. (Courtesy: Hypertension Diagnostics, Minneapolis, USA)
5. Choda and Rao: Diabetes-related complications
Journal of Clinical Cardiology and Diagnostics • Vol 2 • Issue 2 • 2019 5
of plaque before and after treatment. In collaboration with the
Medical Electronics Group at Bengaluru, India, we are trying
to develop a cost-effective carotid 3D scanning device.
Early diagnosis of risk for DR
There is a great need for the development of cost-effective,
reliable, easy-to-use, portable fundus cameras for evaluating
retinopathies, responsible for childhood, and adult vision
loss. The Pictor Plus (Volk Optical, Mentor, OH) is an FDA
approved, commercially available portable system that shows
utility for determining optic disc edema and DR.[18,19]
Retinal
fundus photography is the most common DR detection
method globally. Forus Health Technology, Bengaluru, has
developed “The 3nethra classic,” a compact, portable, easy to
use nonmydriatic digital imaging device to acquire, display,
store, and transmit images of the posterior and anterior
surface of the human eye. Photographs indicating retinal
hemorrhages, hard exudate, and microaneurysms can be
obtained easily by non-clinician healthcare workers. Fundus
photographs serve as a reference standard in early detection
and for following the progression of DR.
Shown in the Figure 6 are the color photographs of an eye of a
normal individual (left side), and that of a smoker (right side).
The inventors claim that their state-of-the-art imaging and
telemedicine system is fully equipped to improve diagnostic
accuracy and minimize screening time. Furthermore, once
images are captured, the system grades, in real-time, and
identifies images have DR. Then patients are advised to consult
the specialists, for further clinical tests and management.
Fundus autofluorescence imaging has been effectively used
as a non-invasive tool for the detection of calcium emboli, as
well as atherosclerotic plaques in the retinal artery. NIR imaging
modality is being widely used for the detection of lipid content
in coronary plaques. These two simple non-invasive techniques,
fundus autofluorescence, and infrared fundus imaging have
been used for detecting asymptomatic or atypical emboli, even
before vascular occlusion occurs.[19]
We are very much interested
in developing devices that can follow the flow dynamics in the
blood vessels of the eye using IR imaging systems. We also
are interested in using confocal microscopy as well as optical
coherence tomography, non-invasive imaging techniques, to
follow the morphology of blood vessels of the eye as a means to
study subclinical atherosclerosis and its progression.
Early diagnosis of peripheral vasculopathy (PV)
and neuropathy
Lower extremity diseases, including PN and peripheral vascular
disease, are leading causes of disability worldwide.[20]
The early
detection of PN and PV, with appropriate counseling, seems
to be the best strategy for preventing dysfunction of the two
lower extremities. We and others (SUDOSCAN) have used
monitoring Sudo Path System to monitor sudomotor function
for the detection of diabetic neuropathy.[21,22]
Apart from the
measurement of c-fiber response to stimuli, there are many
other methods available for early detection of PN/PV. Corneal
nerve fiber density, cold perception threshold, intraepidermal
nerve fiber density, peroneal motor nerve conduction velocity,
sural nerve action potential, sural nerve conduction velocity,
vibration perception threshold, and warm perception threshold
can be followed using appropriate devices. Corneal nerve fiber
densitydeterminedbycornealconfocalmicroscopy(no/mm20).
The non-invasive vascular screening device, -VP 1000 plus
(Omron Healthcare), is capable of detecting ankle-brachial
index, toe-brachial index, pulse wave velocity, and vascular age
in 5 min. It also can detect R-R interval heart rate variability.
On the other hand, IR thermal imagers are useful for recording
thermograms, which provide temperature variation in subjects
with multicolor graphs. When connected to software, the
software helps to generate multiple patient report charts.
Forward-looking infrared radar (FLIR) - E6-XT 43.2 (240 ×
180) pixel infrared detector, with built-in Wi-Fi, allows to
quickly connect with the FLIR - tools Mobile app, for sharing
images and sending reports easily from any location. FLIR
systems (Wilsonville, Oregon) are the leading manufacturers
of IR imaging systems for a variety of applications. FLIR TG
165 Spot Thermal Camera with image storage capabilities
features innovative lepton IR imaging engine with 80 × 60
resolution, 150mK sensitivity, and 9 hz refresh rate 4800 IR
pixel resolution. At Aranca Research Laboratory, Bengaluru,
India, we use FLIR-E85 series thermal imaging camera to
obtain thermal scans of body surfaces for monitoring thermal
variations [Figure 7].
For population-based screenings, we may use a portable
smartphone camera (Therm-App), similar to the one, as
shown in Figure 7. In a routine thermal imaging process,
Figure 5: (a) Carotid scans (Carotid artery by three-
dimensional ultrasound. Courtesy: Dr. Fenster). (b) Imaging
Research Laboratories, London. Ont. Canada
b
a
Figure 6:Thecolorfundusimages(Normalandthatofasmoker.
Courtesy: Shaym Vasudev Rao, Forus Health, Bengaluru)
b
a
6. Choda and Rao: Diabetes-related complications
6 Journal of Clinical Cardiology and Diagnostics • Vol 2 • Issue 2 • 2019
we shoot the video at 30 frames/s for 1 min and capture
1800 frames of data. The data thus collected are computed
and processed further, using proprietary software to obtain
patterns of thermal variation, and graded for risk with 1–10,
one being no risk and increases in the numbers indicating
higher risk. Figure 8 shows a thermal scan of a low-risk
individual with an even distribution of temperature. The
subject is an 83-year old, male individual with 20-years
of diabetes, under medication: Metformin (2 g), Glipizide
(10 mg), Januvia (100 mg), Carvedilol (6.25 mg), Lisinopril
(20 mg), and Atorvastatin (10 mg). Shown in the Figure 8 are
thermal scans of the hands of a low risk individual (left side),
and that of a high risk individual (right side) with uncontrolled
diabetes. The scan shows thermal asymmetry for both hands.
Figure 9showsthermalscansofthefootofalow-riskindividual
and a high-risk individual. In the low-risk individual with
20 years of diabetes, the thermal activity is evenly distributed,
but for a slight difference in the left foot, compared to the right
foot. In the high-risk individual (shown on the right side), the
thermal activity is quite uneven and shows some unusual focal
pattern (light yellow) on the right heel.
Earlier in the article, we described observations made by
experts that diabetes-related complications may develop even
before the disease is diagnosed. Because of such observations,
it is essential to scan individuals often enough, to observe
early signs of vasculopathy. For instance, in the case we
have discussed above, despite well-controlled diabetes, and a
reasonably acceptable HbA1c of 7.2 [Figure 2], the individual
shows early signs of vascular dysfunction as evidenced by
regional thermal variations in the foot (Figure 9 left side). In
the preliminary clinical studies, we have done the technique
of thermal imaging with appropriate software analytics
seems to be of great value to follow thermal variations in the
two lower extremities, which are the body parts most liable
to develop vascular dysfunction and PN in individuals with
diabetes. We are developing other non-invasive technologies
as well, to follow the blood flow dynamics of regional
vascular beds. The results of our clinical validation of these
emerging technologies will be reported in the near future.
CONCLUSIONS
Metabolic diseases have increased in the incidence and
prevalence, to epidemic proportions worldwide in the past
four decades. Hypertension, excess weight, obesity contribute
significantly to the comorbidities of diabetes, and vascular
diseases. It has been very well established that the coexistence
of diabetes and hypertension worsens clinical outcomes. The
interdependency of metabolic diseases is so complicated that
having hypertension appears to increase the risk for Type-2
diabetes, and having Type-2 diabetes increases the risk of
hypertension. Having both conditions increase the risk of
various complications such as heart attack, stroke, kidney
disease, neuropathy, and retinopathy. Close to 70% of deaths
occur in diabetes due to macrovascular complications, such
as myocardial infarction and stroke. Being overweight or
obese, increases the chances of developing Type-2 diabetes.
The number of obese adults is forecasted by the experts,
to rise by 73% over the next two decades. The relationship
between obesity and diabetes is again interdependent and as
a result, a new term, “diabesity” has been coined by experts
to describe this condition. Major factors that contribute to
this condition include overconsumption of energy-dense
food, altered lifestyle, genetic predisposal, and altered fat
metabolism, leading to adipose tissue dysfunction. Visceral
fat content seems to serve as an independent predictor of
insulin resistance. According to experts, 80% of diabetics are
obese. Having said that, we should inform the readers about
the Asian phenotype, which is characterized by an increase
in visceral fat (central abdominal obesity). Therefore, in
this population, waist/ratio is a better indicator of metabolic
syndrome, than body mass index, the gold standard for
obesity.
Aswehavedescribedinthispreliminarystudy,diabetes-related
clinicalcomplicationsare far less common in people who have
well-controlled blood sugar levels. Therefore, maintaining
glycemic control in patients with diabetes prevents many
Figure 7: (a) Forward-looking infrared radar-E85 thermal
image camera. (b) portable thermal camera for smartphone
b
a
Figure 8: (a) Low risk (even thermal symmetry). (b) High risk
(Uneven asymmetry)
a b
Figure 9: (a) Low risk (Even thermal activity). (b) High risk
(Thermal asymmetry)
b
a
7. Choda and Rao: Diabetes-related complications
Journal of Clinical Cardiology and Diagnostics • Vol 2 • Issue 2 • 2019 7
of the microvascular and macrovascular complications
associated with diabetes. Macrovascular complications
of diabetes are primarily diseases of the coronary arteries,
peripheral arteries, and cerebrovascular arteries. Early-onset
of vasculopathy begins with the hardening of the artery or with
altered blood flow, resulting in endothelial dysfunction, the
earliest signs of vascular dysfunction. Early macrovascular
disease is associated with the development of subclinical
atherosclerosis. Earlier studies have demonstrated the
presence of subclinical atherosclerosis even in asymptomatic
individuals. DR, on the other hand, presents as two different
types: Non-proliferative retinopathy with venous loops,
retinal hemorrhages, hard exudates, and soft exudates.
Whereas, proliferative retinopathy is marked by the presence
of new blood vessels, with or without vitreous hemorrhage.
Diabetic nephropathy is defined as persistent proteinuria,
which can progress to kidney dysfunction and, ultimately
ESRD. Diabetic neuropathy is quite heterogeneous and is
associated with vasculopathy as well as nerve pathology.
In view of the fact, that diabetes-related clinical complications
are far less common in patients who have well-controlled
blood sugar levels, we have discussed the importance of using
emerging technologies to monitor blood or interstitial fluid
glucose levels. We also have emphasized, that we should not
be dependent on fasting blood glucose values or the HbA1c
values alone for the success of interventions, but conduct tests
for early markers of various know clinical conditions. We
have described available methods for monitoring endothelial
dysfunction or hardening of the arteries. We also are trying
to develop simple, easy to use cost-effective mobile devices,
to monitor endothelial dysfunction, which is considered to
be the earliest sign of vascular disease. We have described
emerging technologies to monitor atherosclerosis in carotid
arteries. Currently used diagnostic methods for monitoring
altered vascular pathology of the carotid artery are; ultrasound
scanning for measuring intimal media thickness (IMT), and
the use of Doppler Ultrasound for visualising bloodvolume
flow dynamics. Its two-dimensional grayscale can be used
for measuring intimal-media thickness. However, the method
that we have described being 3D gives a better idea about
plaque volume as well as plaque morphology.
For early diagnosis of DR, we have described portable fundus
cameras that are available with modern software analytics,
for the detection of eye conditions such as glaucoma, non-
proliferative as well as proliferative conditions. Furthermore,
these platforms can collect, analyze the data real-time, and
send reports to the clients as well as health providers. We also
have described that fundus autofluorescence imaging has
been effectively used as a non-invasive tool for the detection
of calcium emboli, as well as atherosclerotic plaques in
the retinal artery. NIR imaging modality is being widely
used for the detection of lipid content in coronary plaques.
Continuing in the same lines of thinking, we have described a
newer application, thermal imaging for monitoring diabetes-
mediated vasculopathy and PN. At present, we are testing
the new technology under clinical conditions, to validate
the superiority of this method, to other methods in use for
the detection of vascular insufficiency and resulting body
surface temperature variations. We will present the results of
our studies using thermal imaging, in some important clinical
cases, in our future articles.
Finally, we would like to inform the readers that we have
no clue whatsoever, at this time of writing, as to how the
molecular mechanisms (altered lipid and carbohydrate
metabolism, gene expressions, and micro RNAs), drive the
progress of the disease to any of the complications we have
discussed in this article. It is a great topic of interest for us,
for our future exploratory studies.
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How to cite this article: Choda G, Rao CHR. Diabetes-
related Clinical Complications: Novel Approaches
for Diagnosis and Management. J Clin Cardiol Diagn
2019;2(2):1-8.