Vol 20, No 2 (2017)

Epidemiology
Epidemiological characteristics and organisation of care for patients with diabetic foot syndrome in Khanty-Mansiysk autonomous okrug–Yugra
Girsh Y.V., Davidenko O.P.
Abstract

Background. Epidemiological studies in regions of Russia have revealed significant differences in the prevalence of diabetic foot syndrome (DFS).

Aims. To determine the epidemiological characteristics and associated complications of DFS in Khanty-Mansi Autonomous Okrug (KHMAO)-Yugra

Materials and methods. The epidemiological indicators and complications of diabetes were determined in diabetic patients in KHMAO-Yugra. The statistical reporting form №12 was used. Data from patients diagnosed with type 1 or type 2 diabetes and DFS were gathered from the service area of hospitals, the state registry (2007–2014) and outpatient clinics in the city of Surgut (2009–2014). A prospective observational study with active screening and characterisation of DFS was conducted.

Results. Of all patients, 43% were at high/very high risk of developing DFS. DFS was diagnosed in 4.1% of patients with diabetes and was characterised as neuropathic (57.3%), neuroischaemic (35.1%) and ischaemic (7.6%).

Conclusions. Prevention and early diagnosis of DFS is crucial in the prevention and reduction of amputations in patients with diabetes. Given that DFS can present in various forms, programmes aimed at promoting DFS awareness are required to increase the identification and treatment of this syndrome. Additionally, improvements in the statistical tests used and better organisation of the flow patients referred to general physicians, endocrinologists, podiatrists and surgeons, are also important in the prevention and early diagnosis of DFS and its associated complications.

Diabetes mellitus. 2017;20(2):99-107
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Economic aspects
Is it beneficial to the state to provide insulin-treated diabetic patients with public funds for self-monitoring blood glucose?
Popovich L.D., Shestakova M.V., Potapchik E.G., Mayorov A.Y., Vikulova O.K.
Abstract

Background. In Russia, the prevalence of diabetes continues to increase with the growing diabetes epidemic. In recent years, the paradigm of diabetes treatment has been changing, with patients increasingly becoming equal participants in the treatment process, through the introduction of self-monitoring blood glucose (SMBG). Several clinical studies have demonstrated a positive relationship between SMBG and the decline of the epidemiological and economic burden of diabetes. At present, the procurement of public funds for SMBG is below the specified level in Russia.

Aims. To investigate the potential macroeconomic benefits of public health resource allocation and the use of planned state investments to fund SMBG in insulin-treated diabetic patients.

Materials and methods. This study was conducted with data from insulin-treated diabetic patients. The epidemiological burden of this cohort was determined by the following indicators: the number of patients and the incidence of complications resulting from diabetes, disability, mortality, age and sex. The economic benefits were evaluated by the implementation of two measures: (1) procurement of public funds for the purchase of means for SMBG in patients with insulin-treated diabetes and (2) the use of highly accurate blood glucose metres. To evaluate economic burden, the epidemiological burden was translated into monetary terms using cost-of-illness. Economic benefits were defined as reductions in economic burden.

Results. The economic benefits of public-funded blood glucose test strips for insulin-treated diabetic patients exceeded the required additional investments for their purchase by 1.5 fold. A significant reduction in the inaccuracy of blood glucose metres from 20% to 10% may reduce the economic burden by 9.36 billion RUB. The combined state benefits from the implementation of both measures would significantly decrease the economic burden of diabetes to 29.2 billion RUB.

Conclusions. Increased procurement of public funds for SMBG in insulin-treated diabetic patients would bring economic benefits that far exceed the required investments.

Diabetes mellitus. 2017;20(2):108-118
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Pathogenesis
Post-operative insulin resistance
Tarasova I.A., Shestakov A.L., Nikoda V.V.
Abstract

Post-operative insulin resistance (IR) is a recognised marker of surgical stress. However, the reasons underlying post-operative IR and its clinical value are still unclear. IR has been described as a pathological condition, in which organs and tissues fail to respond to the hormone insulin, resulting in acute hyperglycaemia. Post-operative IR in patients without type 2 diabetes has been identified as an independent, negative predictor of post-operative outcome. Studies have shown a direct relationship between post-operative morbidity (including complications from infection) and total mortality in patients with acute hyperglycaemia compared with diabetic patients. IR and stress-induced hyperglycaemia in the early post-operative period may be corrected by insulin infusion; however, this has often been associated with hypoglycaemia. Detection and modification of risk factors in the pre- and intra-operative periods may decrease the frequency of IR and hyperglycaemia and eliminate the use of insulin. In this literature review, the mechanisms underlying the development and prevention of post-operative IR, and its clinical value are discussed. This study demonstrates the relationship between IR and post-operative morbidity, highlighting the benefits of a complex approach to prevent the adverse events of post-operative IR and stress-induced hyperglycaemia.

Diabetes mellitus. 2017;20(2):119-125
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The role of «metabolic memory» mechanisms in the development and progression of vascular complications of diabetes mellitus
Chernikov A.A., Severina A.S., Shamhalova M.S., Shestakova M.V.
Abstract

The study of diabetes mellitus (DM), its complications and related pathologies has been continuously performed for many years; however, despite the substantial work and outstanding achievements in studying the mechanisms of DM development and the success of new medicinal products for controlling glycaemia, the problems associated with the late complications of DM continue to increase. The importance of glycaemic control in the early stages of DM for the development of complications is seen only after a sufficiently long period of observation. Such a delayed effect of primary good or unsatisfactory metabolic control, which shapes the patient’s clinical fate to a greater extent, is termed ‘metabolic memory’. The disorders developed under the influence of hyperglycaemia persist for long periods after the normalisation of carbohydrate metabolism; moreover, the effect of previous hyperglycaemia extends over the next 20 and even 30 years. Current research is focused on the possible mechanisms of metabolic memory development, including oxidative stress, advanced glycation end products and epigenetic mechanisms. This research will provide insight into potential markers for the early development and progression of vascular complications and new therapeutic possibilities for the future. However, determining the probable ‘point of no return’ is more important, which implies that a point exists; after this point is crossed, the progression of vascular complications associated with DM cannot be prevented or reversed. The results of numerous experimental studies demonstrate that the prerequisite components of metabolic memory can be used as potential markers of the progression of DM complications, and may be potential therapeutic targets.

Diabetes mellitus. 2017;20(2):126-134
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Diabetic foot
Clinical and morphological characteristics of wound healing in diabetic foot syndrome
Komelyagina E.Y., Kogan E.A., Antsiferov M.B.
Abstract

Aim. To assess the clinical and morphological characteristics of neuropathic diabetic foot ulcers (DFUn)

Materials and Methods. Forty-three specimens of DFUn were analysed. Depending on the outcome, samples were divided into 2 groups: group 1—healed ulcers (30 samples), group 2—unhealed ulcers (13 samples). The following characteristics were analysed: age, sex, glycated haemoglobin (HbA1c), ulcer duration, time of admission to the specialised clinic, severity of neuropathy, presence of late complications, plantar localisation, percentage of necrotic tissue, granulation and fibrotic tissue and, Ki-67expression.

Results. Patients were similar in age, HbA1c, severity of late complications and plantar localisation. There was a significant difference in the time of admission to the specialised clinic [50 vs 132 days, p = 0.03], percentage of granulation [61 ± 25 vs 32 ± 21 %, р = 0.001] and fibrotic tissue [24 ± 24 vs 49 ± 22 %, р = 0.002], the granulation/fibrosis coefficient [7.5 ± 8.1 vs 1.9 ± 4.6 (%), р = 0,02] and expression of Ki-67 [15 ± 8 vs ± 21 (%), р = 0.001] between groups. A multidimensional model revealed granulation tissue as the main parameter influencing healing. The probability of healing was 1.0 if the percentage of granulation tissue was <50%. If the percentage of granulation tissue was <50%, the prognosis of healing was determined by the expression of Ki-67. When Ki-67 levels were >7%, the probability of healing was 0.75. For Ki-67 levels ≤7%, the probability of healing was 0.17 and the probability of not healing was 0.83.

Conclusion. The time at which a patient was admitted to the specialised clinic and the percentage of granulation tissue were key factors affecting the prognosis of wound healing in DFUn.

Diabetes mellitus. 2017;20(2):135-141
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Diagnosis, control, treatment
Combined insulin detemir and liraglutide therapy in type 2 diabetic patients: a base for an alliance
Ruyatkina L.A., Sorokin M.
Abstract

Combined glucose-lowering therapy, comprising of basal insulin with glucagon-like peptide-1 (GLP-1) analogues, has become central to the treatment of type 2 diabetes both at the start of insulin therapy, and as an alternative to basal-bolus insulin. The combination of insulin detemir (insulin analogue) with liraglutide (GLP-1 analogue) reduces fasting and postprandial glycaemia, lowers the risk of hypoglycaemia and does not have a negative impact on body weight. In this literature review, the pharmacodynamic and pharmacokinetic profiles, as well as the potential benefits of combined insulin detemir and liraglutide therapy on diabetic nephropathy and high cardiovascular disease risk were determined. Data from randomised clinical trials and the National Registry were used to assess the clinical efficacy of combined insulin detemir and liraglutide therapy. The different mechanistic actions of insulin detemir and liraglutide resulted in an additive glucose-lowering effect, which did not affect the pharmacodynamic and pharmacokinetic profiles of each therapeutic agent.

Diabetes mellitus. 2017;20(2):142-150
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Clinical Guidelines
Guidelines for the diagnosis and treatment of testosterone deficiency (hypogonadism) in male patients with diabetes mellitus (Draft)
Melnichenko G.A., Shestakova M.V., Rozhivanov R.V., Terehova A.L., Zilov A.V., Ladygina D.O., Kurbatov D.G.
Abstract

Hypogonadism in male patients is defined as a decrease in the serum testosterone level; it is associated with specific symptoms and/or signs (see the detailed description below). It is a common complication in diabetes mellitus. The guidelines do not review all disorders leading to the development of hypogonadism but focus on options for the treatment of hypogonadism, which is generally observed in male patients with diabetes. In the literature, data on the prevalence of hypogonadism in patients with diabetes are available. In the section on diagnostics, the medical history of patients with hypogonadism and diabetes, including the necessary methods for physical and laboratory inspection. Risk factors for and the clinical consequences of hypogonadism are separately considered. In the section on treatment options, variations in treatment using various androgenic therapeutic agents based on patients’ requirements, conservation of their reproductive function, and their risk factors are provided. Special attention is given to indications of, contraindications of and risk factors for androgenic therapy in male patients with diabetes, particularly those in their advanced age. The principles of the clinical monitoring are developed. The favourable effects of androgenic therapy for hypogonadism in male patients with diabetes are shown.

Diabetes mellitus. 2017;20(2):151-160
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