Ngda.gr

2nd Balkandiab Meeting
Chronic diabetic
complications
INTRODUCTION
(or the status of Diabetes Care) will be presented.
Dr Christos Manes
In the second half we will discuss with the advisory President of Northern Greece, Diabetes association board the plan of our activities in the future. So it’stime to start.
I would like to ask Dr. I. Kalo and Pr. M.
On behalf of Northern Greece Diabetes Asso- Alevizos to take their seats as chairpersons in the ciation I would like to welcome you in the 2nd Bal- kandiab Meeting. This network was established 2(two) years ago to stimulate local implementation SOME EPIDEMIOLOGICAL AND CLI-
to achieve Saint Vincent Declaration’s targets.
NICAL DATA ON DIABETES MELLITUS
AND ITS CHRONIC COMPLICATIONS
convinced that the implementation of our decisions IN TIRANA DISTRICT
will contribute in a better quality of diabetes care in Dr F. Mete, Dr M. Minga, Dr V. Lila, Dr L.
our region and therefore supports this meeting.
Branka,
Taken this account the executive board of our Dr Gj. Gjonçaj, Dr XH. Xhemali, Pr. F. Agaçi MD
network decided to organize our 2nd meeting in Thessaloniki in this friendly and hospitable am-phitheater.
Abstract
supports these activities and it is my duty to thank In this article are discussed some main epi- once again Dr. I. Kalo for his contribution.
demiological and clinical data on diabetes mellitus In the first half of the meeting some data re- and its chronic complications of diabetic patients garding the field of chronic diabetic complications of 3 outpatient diabetic clinics of Tirana district 113
114
EÏÏËÓÈο ¢È·‚ËÙÔÏÔÁÈο XÚÔÓÈο 14, 1 (6562 patients). The highest annual incidence of 27,47% of type 2 diabetes. HbA was below 8% in this disease is in the period of time from 1995 to 28,27% of type 1 and in 30,36% of type 2 diabetes.
Cholesterol levels above 5,0 mmol/l have 53% of On the other hand, the highest frequency of type 1 and 76% of type 2 diabetics. Triglycerides diabetes, in total, is in patients over 50 years old, above 2,0 mmol/l have 20% of type 1 and 40% of (69%), which suffer from diabetes type 2.
In majority of diabetics (54%), the diagnosis of diabetes was made 3—6 months after onset of dia- 9,42% of type 1 diabetes and in 8,14% of type 2 diabetes. Diabetic neuropathy is the most common The majority of diabetic patient (51%) with complication — 30% in type 1 and 63% in type 2 diabetes type 2 are treated with sulfÔnylurea and diabetes. Arterial hypertension is very often asso- biguanide drugs or in combination between them.
ciated with diabetes mellitus. Type 1 diabetics have The frequency of blinding, leg’s amputations hypertension in 19,8% and type 2 — in 63,2%. Per- and end-stage kidney failure is higher in the period haps this is the reason of very common ischemic heart disease among type 2 diabetic patients — Microvascular complications (diabetic retino- 35,38% of type 2 patients suffer of this complica- pathy and nephropathy), neuropathy and diabetic foot are more frequent in diabetes type 1 (33.2%, Three years’ programm of diabetic patients 23%), 39% and 20% respectively than in diabetes ty- education in Bulgaria resulted in more than 20,000 pe 2 (13.9%, 10.1%), 20.8% and 13% respectively, patients educated through 5–days long educational while macro vascular complications (coronary heart courses. The evaluation of metabolic control 6 disease and stroke) are more frequent in diabetes months later showed out significant lowering of type 2 (15.4% and 13.1% respectively), than in fasting glycaemia and HbA in the educated group diabetes type 1 (8.1% and 2.2% respectively).
in comparison with the control group. Lipid levels The diagnosis, treatment and prevention of also decreased significantly in the educated group.
diabetes mellitus and its chronic complications are There was noted a dramatic decrease in the absolu- connected with many medical, economic and social te number of patients admitted into the surveyed 25 problems that must resolve gradually.
hospitals where education was practised because ofketoacidosis or because of severe hypoglycaemia.
METABOLIC CONTROL AND CHRO-
We conclude that systematic and well-structured NIC COMPLICATIONS IN DIABETIC
education of patients may improve the metabolic PATIENTS IN BULGARIA
control and hopefully the chronic complications.
Dragomir Koev
PREVALENCE OF DIABETIC NEURO-
PATHY AND FOOT ULCERATION- PO-
Diabetes mellitus in Bulgaria is constantly in- PULATION BASED STUDY. IDENTIFI-
creasing. In 1963 the percentage of diabetic pa- CATION OF RISK FACTORS
tients was 0,19% of the total population, in 1985 — Ch. Manes, N. Papazoglou, E. Sossidou, K. Soulis,
1,01% and in 1999 it reached 2,07%. Type 1 dia- D. Milarakis, A. Satsoglou, A. Sakallerou
betes mellitus have 13,74% of all diabetic patients “PAPAGEORGIOU” General Hospital, Diabetes and type 2–86,26%. Obesity is a major metabolic problem in type 2 diabetics: 45,17% are overweight(BMI 25–30) and 28,27% are obese 5 BMI 30.
Population based studies reflecting the true The treatment is free of charge and 65,7% are prevalence of a disease need to include a large sam- on oral drugs, 24,3% on insulin and 10,0% on diet ple size and to obtain a high response rate in order only. All available insulins are human insulins. Pens to truly represent the disease in the community.
are readily available and 67% of insulin–treated The aim of this population study was to evaluate patients use different kind of insulin pens.
the prevalence of peripheral diabetic neuropathy Data from 1,028 type 1 and 1,003 type 2 diabe- (DN) and the potential risk factors. Eight hundred tic patients showed out that excellent glycaemic and twenty one diabetic patients, 304 male, 781 control was achieved in 32,57% of type 1 and type 2, (80% of the known diabetic population in a EÏÏËÓÈο ¢È·‚ËÙÔÏÔÁÈο XÚÔÓÈο 14, 1 115
county, aged 18-70 yrs) were studied. Mean age of test, Wald-Wolfowitz Runs test. Spearman Rank the patients and known diabetes duration were 59.5±7.46 and 7.6±6.9 yrs respectively. Neuro- Results: 858 diabetic patients were examined
pathy was defined clinically by a standardised exa- (345 males and 513 females). 295 (34%) had CD, 40 mination as the presence of abnormalities of at (5%) CS, 75 (9%) PVD and 501 (58%) Hypertension.
least two of the following criteria: Symptoms, sen- 289 (34%) had one, 59 (7%) two and 1 (0,1%) three sory and motor signs (using score techniques). Vi- complications present. Prevalence of CD and CS was bration perception thresholds (VPT) were estima- the same in males and females, however the ted in all the patient. The prevalence of neuropathy prevalence of PVD and MI was greater in men was 33.5% (95% confidence limits 30.3 - 36.7%) (p<0,03 and p<0,000003 respectively) and in women and of foot ulcerations 4.75% (95% confidence li- the prevalence of hypertension (p<0,000001). The mits 3.3 - 6.2%). Patients with foot ulcers had more existence of macrovascular complications correlated severe neuropathy (NDS 11.6±5.26) and higher positively with Systolic Blood Pressure (SBP), duration of diabetes, age, total Cholesterol / HDL 6.92±2.83. VPT 30±13.8) (t-test, a=0.001). Age, index and negatively with BMI, Diastolic Blood height, fasting glucose and diabetes duration were found to be significant risk factors in univariate Conclusions: These observations support the
analyses for DN (t-test, x2-test). Further investi- evidence that diabetes exerts a deleterious effect on gation by multiple logistic regression analysis of the general risk factors of atherosclerosis and increases above variables showed that all of them remain the susceptibility to cardiovascular disease (CVD).
significant risk factors for DN. Statistical tests were Because the adverse “independent” effect of diabe- performed at the significant level a=0.05. Conclu- tes on the risk factors of CVD, these data empha- sion: These findings indicate that a large propor- size the need for the vigorous treatment of stan- tion of diabetic people (neuropathic) are at risk of dard risk factors in order to reduce the progress of foot ulceration or have current ulceration. So there is a substantial need for propper footcare to furtherreduce the amputations rate according to St DIABETES: RISK FACTORS AND
COMPLICATIONS IN TURKEY
I. Satman, K. Karsidañ, N. Dinççañ, S. Salman,
PREVALENCE OF CARDIOVASCULAR
F. Salman, Y. Yilmaz, E. Özer, S. Gedik,
COMPLICATIONS IN DIABETIC
≤. Karadeniz, Yilmaz MT.
PATIENTS
Diabetes and Metabolism Unit, Institute for Exp. K. Soulis1, C. Manes2, S. Koukourikos1, N.
Medical Research, Istanbul University - TURKEY Papazoglou2
1
According to the Turkish Diabetes Epidemio- B′ Department of Internal Medicine, Gen. Hosp. logy (TURDEP) study which was recently comple- ted with randomly assigned 24788 subjects (age B′ Department of Internal Medicine and Diabetes +19 yrs, F/M 13708/11080) from 540 centers (ur- Center, Gen. Hosp. “Papageorgiou” ban 63 and rural 37%), overall crude prevalence ofdiabetes was 7.2% (new 32 and known 68%), and Background: To examine the relationship of
impaired glucose tolerance (IGT) was 6.7%. Age- diabetes mellitus with the prevalence of macrova- adjusted prevalence was 7.9% for diabetes and 7% scular complications in a population sample of for IGT. Both were more frequent among female than male (diabetes and IGT, F: 8 and 8.4%; M: 6.2 Design: We examined 52% of registered dia-
and 4.6%, p<.0001) and in urban than rural (urban betics living in Kilkis perfecture during the period 8.1 and 7%; rural 5.8 and 6.2%, p<0.001). Total between 9/1993-9/1997. Criteria: Coronary Disease glucose intolerance (diabetes + IGT) increased (CD): angina or myocardial infarction (MI) or ab- with aging, approaching to 37% at 8th decade.
normal ECG (Minnesota code). Cerebral Stroke Frequency of diabetes was highest in the most (CS): history, Peripheral Vascular Disease (PVD): industrialized north and lowest in the least civilized history or symptoms or Ankle/Brachial Index 0,9.
east region of the country (8.2 and 6.2%, Statistical analysis: Pearson x2, Mann-Whitney U 116
EÏÏËÓÈο ¢È·‚ËÙÔÏÔÁÈο XÚÔÓÈο 14, 1 p<0.0001). Hypertension (HT) and obesity were nomic burdens, diabetes is seemed to persist as one found in 28.3 and 22.3% of the attendees, both of the major public health concerns of the 21st cen- were more remarkable among female than male (F: 31 and 29.9%, M: 25 and 12.9%, p<.0001 for both).
Similar regional differences were observed for THE PREVALENCE OF DIABETES
IGT, HT and obesity (p<0.001 for all). Risk of dia- CHRONIC COMPLICATIONS IN
betes and IGT increased clearly across tertiles of BMI, and W/H. HT and positive family history for Prof. Constantin Ionescu
diabetes were strong predictors of abnormal gluco- Tirgoviste, Institute of Diabetes, Nutrition and se homeostasis (HT and NT: diabetes 32.9 and 4.1%; IGT 25.7 and 5.4%, p<0.00001, and with andwithout family history: diabetes 8.7 and 4.2%; IGT Prof. N.C. Paulescu
9.2 and 7.4%, p<0.0001). Both risks were inversely associated with income and education.
The diabetic patient is susceptibil to a series of Based on Outpatient population of Diabetes complications that cause morbidity and premature and Metabolism Unit, Institute for Exp. Medical mortality. While some patiens may never develop these Research, Istanbul University, 18.4% of patients problems and others note their onset early, on average, are being followed with type1 diabetes (mean age symptoms develop 15 to 20 years following the 32.9 yr, mean duration 4.9 yr, BMI 24.3 kg.sqm-2, appearance of overt hyperglycemia. A given patient HbA1c 8.3%), 73.6% with type2 diabetes (mean may experience several complications simultaneously, age 56.1 yr, mean duration 7.4 yr, BMI 29.9 kg.sqm- or a single problem may dominate the picture.
1, HbA1c 9.4%), and the remaining 8% with Diabetic nephropathy is a leading cause of
death and disability in diabetes. It develops in about Distribution of complications in the Outpa- one third of type I DM patients and in a smaller tient population revealed that of type 1 diabetes percentage of type II DM patients. The incidence of patients; prevalence for HT is 47%, Hyperlipide- diabetic nephropathy has a particular pattern. This mia 46.5%, Retinopathy 12.2% (proliferative pattern shows that the renal disease is clinically 4.9%), and Amputation 3.4% (all below knee manifested after 5 years of diabetes progression.
level). Among type 2 diabetes patients: prevalence Then we notice a sudden increase in the number of for HT is 13.3%, Hyperlipidemia 54%, Retino- newly diagnosed cases. After 10 years there are 25 pathy 18.3% (proliferative 3.4%), and Amputation newly diagnosed cases/year/ 1000 diabetes. The 0%. In the overall group, frequency of blindness is annual number of newly diagnosed cases decreased 1%, Myocardial infarction 3.7%, and Stroke 1.3%.
then progressively. The percentage of patients with Nearly all patients attended diabetes educationcourse for nutrition, foot care, hypoglycemia, andlong-term complications. Of type 1 patients in the Table 1. The prevalence of diabetic nephropathy
outpatient clinic, 63% have self-monitoring facili-ties, 44.8% of whom enabled for self-adjustment of Percentage of patients
Duration of diabetes
with diabetic nephropathy
Extrapolation of the results of TURDEP to data of recent census held in October 2000 pointed out that there are about 2.6 million of people with diabetes living in Turkey. Every third of whom isunaware of diabetes. Moreover, people with IGTare nearly 2.5 million, and made up a considerable Table 2. The prevalence of proliferative retinopathy
candidate population for diabetes. On the other Prevalence of proliferative
Duration of diabetes
hand, the two main risk factors, HT and obesity are retinopathy
very common in Turkey. Of 11.5 million with HT, nearly half have undiagnosed HT. Obese popula- In conclusion, with increasing social and eco- EÏÏËÓÈο ¢È·‚ËÙÔÏÔÁÈο XÚÔÓÈο 14, 1 117
Table 3. The prevalence of diabetic neuropathy
Diabetes duration
Prevalence of diabetic
Prevalence of diabetic
neuropathy in type I DM
neuropathy in type II DM
Fig. 2. Incidence of lower limb amputations in diabetic pa-
Fig. 1. The prevalence of diabetic neuropathy (white – type II
DM, black – type I DM) in relation with diabetes duration. bodies such as needles, tacks and glass. Deep ulcersand particularly ulcers associated with any detectable this disease reached 20% after 15 years, 25% after 20 cellulitis require immediate hospitalisation, since years, 30% after 25 years and 35% after 40 years.
systemic toxicity and permanent disability may Diabetic retinopathy. Retinopathic lesions are
develop. Early surgical debridment is an essential part divided into two large categories simple (back- of management, but amputation is sometimes ground) and proliferative. Proliferative retinopathy necessary. The incidence of lower limb amputations in (which has a high risk for blindness), has an inci- diabetic patients in Romania has decreased from dence and an evolution particular in comparison 7,8%/1000/year (in 1989) to 43/1000/year in present.
with «background» retinopathy. Background retino-pathy has an annual incidence wich increases from DIABETES CARE IN THE FORMER YU-
2% year (after 3 years from the onset of diabetes) to5% year (after 5 years) and 10% year (after 10 GOSLAV REPUBLIC OF MACEDONIA
years). After 15 years of diabetes evolution, 90% of M. Bogoev, S. Delinikolov, B. Bogoeva
the patients have background retinopathy.
Clinic of endocrinology, Fac.of Medicine, Skopje Diabetic neuropathy. Diabetic neuropathy is a
The number of people with Diabetes in the major cause of morbidity. Several different types of Former Yugoslav Republic of Macedonia is aprox.
neuropathy may be present in the same patient. It 60000 - The prevalence of Diabetes is 3%.The inci- is present in 5% in type I DM patients and in 15% dence of type 1 is 6,7/10000, type 2:250/100000. The in type II diabetic patients under 5 years from the diabetic population is controlled and educated in diagnosis of DM; after 10 years, in 10% in type I 38 diabetic centers in the country. The first level of DM and 20% in type II DM, after 20 years in 15% diab.car is performed by g.p. in the regional cen- in type I and in 45% in type II and after 25 years, ters, the second of specialists in diabetes and endo- crinology and the third of professors at the Clinic of Diabetic foot ulcers. A special problem in the
endocrinology. We have an educational program diabetic patient is the development of ulcers of the for type 1 and type 2, which is designed according feet and lower extremities. The ulcers may be initiated to the educational program of Düsseldorf (prof.
by ill-fitting shoes, cuts and puncters from foreign Berger). The educational program is composed of 118
EÏÏËÓÈο ¢È·‚ËÙÔÏÔÁÈο XÚÔÓÈο 14, 1 five days of education and a final control test. We foot risk factors, foot care education, diagnosis of have also an educational program for educators foot lesions based on clinical assessment and de- with a duration of 3 days and books for educators.
tailed local status, team approach in ulcer treat- The journal for diabetic patients is issued every ment, prophylactics of developing new lesions in three months. Patients inject insulin by Novo Nor- disk pen devices (more than 95%). We use gliben- The applied therapeutical schedule was based clamide, Repaglinide and Acarbose as oral antidia- on consecutive assessment of diabetic foot risk betics. The number of ketoacidosis is aprox. 20 per factors, classifying the diabetic foot and the grade year. Retinopathy: 40% (for both types), nephro- of foot ulcerations, management of foot ulcera- pathy type 1:30%,type 2:9,8%. Diabetic gangrene tions. The assessment of diabetic foot risk factors type1:3,7%, type2:5,7% (data from the Clinic). We included assessment of foot deformity, diabetic are introducing a national diabetes register. Inclu- polyneuropathy and macroangiopathy. The feet we- ding data from all diabetic centers in our country.
re examined for foot deformities – pes cavus, haluxrigidus, Charcot foot, hammer toes, status post am- SPECIALIZED CARE IN DIABETIC
putation, etc. To assess the presence of diabetic FOOT CENTER
polyneuropathy vibration perception threshold, L. Koeva
pressure sensation with 5.07/10 g monofilament and Department of endocrinology, Medical University, knee and Achilic jerks were investigated. To assess the state of diabetic macroangiopathy foot pulseswere investigated by palpation and Doppler ultra- Diabetic foot is a major complication of diabe- sound, ankle-brachial pressure index was measured.
tes. It leads to diabetic foot deformities, ulcera- The diabetic foot was classified as neuropathic, tions, cellulitis, osteomyelitis. Early treatment of diabetic foot provides prevention of foot amputa- Bacterial cultures were investigated, X-Ray tions. In order to increase quality of diabetic foot study, bone scan and angiography were carried out.
care a Diabetic foot center was created in Varna’s After classifying of foot ulcerations according to Wagner’s system patients were subjected to treat- The aim of the study was to implement the St.
ment. Out-patient treatment was carried out in cases Vincent Declaration targets for diabetic foot of lesions 1-st and 2-nd grade and in – patient treat- management in practice – by prophylactics and ment – in case of lesions 3-rd, 4-th and 5-th grade.
treatment of diabetic foot lesions in diabetic pa- Management of diabetic foot lesions was based on the following principles: good control of diabetes,control of the infection, regular chiropody, mecha- Patients and methods
Patients
Object of investigation were 198 patients (25 – type 1 diabetics, 173 – type 2 diabetics) treated in The majority of patients (92.3%) were suc- Varna’s clinic of endocrinplogy and diabetic foot cessfully treated by non–surgical methods – 68.8% of foot ulcers were effectively healed; 23.5% of footulcers are in a process of healing. Surgically were Methods
treated – 7.7% of the patients – 6.7% of patients were subjected to minor amputation; 1% of patients approaches were applied: screening for diabetic Table 1. Patients treated in the Diabetic foot center of Varna’s clinic of endocrinology
Distribution
Grade of ulceration / Wagner system
of patients
EÏÏËÓÈο ¢È·‚ËÙÔÏÔÁÈο XÚÔÓÈο 14, 1 119
Discussion
converting enzyme inhibition to ameliorate definite Diabetic foot is a serious complication of dia- diabetic autonomic neuropathy (DAN), as defined betes. It is the cause for foot deformities, inflamma- by standard cardiovascular reflex tests (CRT) of
tions, foot amputations. Early treatment of diabetic autonomic function, has not yet been studied in foot is the best prevention of foot amputations. In order to implement in practice the principles of Methods: Forty three consecutive patients (19
effective foot care a Diabetic foot center was created men and 24 women of mean age 52 years), with in Varna’s clinic of endocrinology. The work of this definite DAN were studied over a period of 18 center contributes for better quality of diabetic foot months, with repeated measurements of CRT at care and helps the early and effective treatment of three month intervals. Definite DAN was establi- shed if the values of two or more of CRT were ab- We estimate the applied screening and the- normal. The Monitor ONE NDX devise was used rapeutical schedule as effective. It allows early iden- for the assessment of CRT. Patients were ran- tification of high risk patients and treatment of domized to quinapril (n=21) or placebo (n=22). diabetic foot lesions in an earlier stage. The major Results: In the placebo group all measured
principles of the applied therapeutical approach are indices, except the Valsalva index, deteriorated sig- screening for diabetic foot risk factors and prophy- nificantly (p<0.05) in all 22 patients on placebo lactics, education of patients, multidisciplinary team during the 18 month follow-up. Deterioration be- approach. The permanent implementation of these came significant at month 15 in most variables.
principles would be the basis for future reduction of Seven out of 22 patients developed DAN related symptoms. Quinapril, by 18th month, improvedsignificantly the expiration-inspiration ratio (1.2± In conclusion
0.08 vs 1±0.06), Standard Deviation (34±2.4 vs 1. The applied screening and therapeutical sche- 25±2.2) and Mean Circular Resultant (24±2.2 vs 14±1.6) of R-R intervals as well as the 30:15 index — early identification of high risk patients; (1.2±0.08 vs 1±0.07) and postural hypotension — treatment of diabetic foot lesions in an earlier (13±2.1 vs 21±2.4 mmHg). These changes were significant in comparison to baseline (p<0.05) and 2. The initial basis for future reduction of diabetic placebo (p<0.01). Quinapril had no significant foot complications and improvement of life effect on the Valsalva index (1.4± 0.07 vs 1.3± 0.06).
Conclusion: Quinapril improved autonomic
— screening for foot risk factors and prophy- nervous system function in patients with definite DAN, in comparison to baseline and placebo. Since autonomic function is an important contributor in — multidisciplinary team approach in treatment the pathogenesis of acute coronary events, malig- nant arrhythmias and sudden cardiac death, impro-vement of indices related to autonomic function in LONG-TERM EFFECT OF CONVERT-
DAN patients by an angiotensin converting enzyme ING ENZYME INHIBITION ON DIABE-
inhibitor, may prove beneficial in clinical practice.
TIC AUTONOMIC NEUROPATHY AS
Key words: Diabetic autonomic neuropathy,
ESTIMATED BY CARDIOVASCULAR
Cardiovascular Reflex Tests, Quinapril.
REFLEX TESTS
T.P. Didangelos, MD1 V.G. Athyros, MD,2
SIDENAFILE CITRATE FOR TREAT-
A.A. Papageorgiou, MD3 G.A. Kourtoglou, MD1
MENT OF ERECTILE DYSFUNCTION
D.T. Karamitsos, MD1
IN MEN WITH DIABETES MELLITUS
1Diabetes Center and 2Division of Cardiology, 32nd Predrag B. Djordjevic
Propedeutic Department of Internal Medicine, Aristotelian Institute for Endocrinology, Diabetes & Metabolic Diseases, Clinical Center of Serbia, Belgrade Yugo-slavia Abstract
Background: The potential of angiotensin
Multicentric non-comparative study to evalua- 120
EÏÏËÓÈο ¢È·‚ËÙÔÏÔÁÈο XÚÔÓÈο 14, 1 te the impact of Viagra (Sildenafil citrate) on treat- more, There were no significant differerences ment satisfaction in diabetic men with erectile dys- between two groups in IIF and questionnaire after function (ED) was performed with flexible dose of Viagra treatment (in two main questions; Ability to 50mg (duration two months, twice weekly). There maintain an erection and Ability to achieve an were 20 patients (average age 45±3.2, duration of erection). Patients with gradus I and II of PgT had diabetes l2-6±6-2 yrs, 14 type 1 and 6 type 2), better results in achieving and maintaining of Authors used: Prostaglandine test (PgT), measure- erections using Viagra, then those with gradus in ment of Peno-brachial index (PBI) and verifica- and IV (Our experience is that fhis test is more tions of chronical explications, measurement of reliable in diagnosing ED especially in diabetic residual wine. None of them had associated risk patients). 68% of diabetic patients receiving Viagra factors for treatment with Viagra: use of organic reported improved erections. Viagra was registra- nitrate, age >65 year, hepatic impairment (cirrho- ted in Yugoslavia for treatment of erectile dysfun- sis), severe renal impairment (creatinine clearence ction in 1998. Before the registration and beginning <30ml/imn), Concomitant use of potent cytohrome of the clinical use of Viagra a suitable set of medical P450 344 inhibitors (erythromycine), hypersensiti- data referring to the use of this drug was prepared vity to any component of the tablet. Prior to pre- and distributed to each of 17000 physicians in Yu- scribing Viagra physician should carefully consider goslavia. According to the data of National Centre whether their patients with underlying cardiova- for Monitoring Side-Effect of Drugs, not a single scular disease could be affected by such vasodila- death was recorded till the end of November 2000 tatory effects, especially in combination with cau- connected with taking of Viagra since indications, tion: patients who have suffered a myocardial infra- contraindications and warnings was strictly obser- ction, stroke or the life-threatening arrythmia ved both when prescribing this drug and when ta- within the last 6 months, with resting hypotension king it. There were no statistical significant change (BP <90/50mmHg) or hypertension (BP >170/ 110mmHg), within cardiac failure or coronaryartery disease causing unstable angina with retinitis PROGRESSION OF DIABETIC RETINO-
pigmentosa. Study included index of Erectile PATHY IN LASER TREATED PATIENTS
Function (IIEF) Questionnaire and Questionnaire Dr Triantafyllou Georgios
after treatment All of these patients with ED had Ophthalmological Diabetic department of Hippo- no experience with similar medications for ED be- kration Hospital Thessaloniki Greece fore. According to PgT 21% had El (gradus oferection), 47% E2 and 32% E3 (with standard 1580 Laser treated patients ˇ 1998 & 1999 dosage of Prostine VR), 8 patients of 14 (measu- rement of PBI) had PBI less than 1 and 6 had 1 or Progression of Diabetic Retinopathy in Laser treated patients (the total series)
same or better
visual loss
condition
<2 lines
visual loss
Macular edema
and less severe
retinopathy:
Macular edema
and more severe
retinopathy:
Macular edema
and high-risk
proliferative:
EÏÏËÓÈο ¢È·‚ËÙÔÏÔÁÈο XÚÔÓÈο 14, 1 121
Defuse macular edema in the total series
Among patients without Rubeoses Iridis
1. 7 had neovascularization regression.
2. 6 had partial neovascalarization regression,
– visual loss <2 lines 169 pat, 34,9% which was maintained during follow-up time.
3. 5 developed neovascular glaucoma.
Proliferative Diabetic Retinopathy:
same or better
visual loss
condition
<2 lines
visual loss
DECENTRALIZATION OF THE ST VIN-
sions and strategies. People with diabetes, their fami- CENT PROGRAMME MANAGEMENT
lies, diabetes associations, health professionals, and AT COUNTRY LEVEL - IN THE FRAME
industry are working together much more closely OF THE NEW QUALITY OF HEALTH
now than a decade ago and country capacity and ca- SYSTEM DEVELOPMENT APPROACH
pability for improving diabetes care is much moreadvanced.
Dr Isuf Kalo, Regional Adviser
As a result of lessons learned, achievements to Quality of Health Systems, WHO Euro date and challenges to be faced a new SVD strategy After 10 years of successful experience, several for the next millennium is being proposed. This is factors and changes are dictating the development of looking mainly to decentralise the management of a new strategy for the management of the St Vincent the St Vincent programme to country level, giving Declaration Action Programme in the new millen- each Member State the opportunity to design and nium. These include social and political changes in manage their own St Vincent programme according Europe as a whole, and in the countries individually, to their specific priorities and circumstances and to and new challenges in diabetes care. WHO and IDF, look for improvement in the quality of diabetes care the two SVD parent organizations, and EASD, have in a broader scope within the frame of health care also evolved and have developed new concepts, vi-

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