When should ultrasonography be used to detect asymptomatic carotid atheroma in diabetic patients?

INTRODUCTION: While guidelines for detection of silent myocardial and lower limb ischemia are established, data on screening asymptomatic carotid lesions remain scarce. However, such screening would be costly. Since the prevalence of diabetes increases constantly, it is necessary to keep screening costs low by setting up criteria for the selection of patients at risk of ischemic cerebral attack and those who will need medical or surgical attention. Diabetic patients, particularly type 2, often have many reasons to take anti-platelet agents and lipid-lowering therapy. Therefore, carotid ultrasonography screening would have little effect on treatment modification or on glycaemia and blood pressure objectives, but could improve the prognosis of operable lesions. IN THE GENERAL POPULATION: A one-time screening program was considered worthwhile if the prevalence of severe asymptomatic stenosis was over 20%. The presence of another arterial occlusive disease or other cardio-vascular risk factors could be a major argument for screening. IN DIABETIC PATIENTS: Carotid intima-media thickness (IMT) was recognized as a reliable prognostic indicator of heart attack and stroke. It worsens with duration of diabetes, renal failure, cardiac neuropathy and poor long term glycaemic control. CONCLUSION: Our review suggests that a one-time carotid ultrasonography screening could be recommended for diabetic patients with coronary disease or lower limb atherosclerosis (secondary prevention), all diabetic patients above 60 years of age, smokers, hypertensive and with hypercholesterolemia; type 1 diabetic patients with poor long term glycaemic control; all type 2 diabetic patients with renal failure, a long duration of ill-controlled diabetes or with a carotid bruit. This literature review should be analyzed with caution. It would be helpful to organize a prospective long term study on all types of diabetic patients, including a carotid ultrasonography screening program by experienced radiologists.     

When to start dialysis in diabetic patients?

Diabetic nephropathy and diabetes related nephropathies represents one of the most common causes of end-stage renal disease (ESRD), and diabetic patients with chronic renal failure represent the most important high risk cohort of uraemic patients requiring renal replacement therapy. Interventions to slow progression of kidney disease and measures to reduce the risk of cardiovascular disease are highly effective in early renal damage and should be the main task of nephrologists, but diabetic patients are more frequently referred late to the nephrologist. Factors involved in the rate of mortality of diabetic patients with ESRD are multiple, including nutritional status, co-morbidity, age, etc, but the duration and quality of pre-dialysis nephrological care constitute a key for improving outcomes of diabetic patients with ESRD.     

When rheumatoid arthritis is mentioned,should only dryness come to mind?

Clinical Rheumatology - To evaluate corneal parameters of rheumatoid arthritis (RA) patients by corneal topography. One hundred two RA patients and 60 control subjects were enrolled. Corneal...     

When should immunosuppressants be prescribed to treat systemic vasculitides?

Steroids and immunosuppressants are indicated to treat systemic vasculitides. However, the therapeutic strategy is different from one disease to the other. Treatment choice should be adapted to the predictable outcome, severity, pathogenic mechanisms and patient's general condition. In polyarteritis nodosa, Churg Strauss syndrome, and microscopic polyangiitis we have demonstrated that immunosuppressants should not be systematically prescribed. Immunosuppressants should be only prescribed in the most severe patients, when factors of poor prognosis are present. In Wegener's granulomatosis, immunosuppressants should be systematically prescribed together with steroids. The optimal treatment duration is of 12 months for polyarteritis nodosa and Churg-Strauss syndrome. A more prolonged treatment is mandatory in Wegener's granulomatosis, at least 18 months. The new therapeutic strategies comprise also new immunosuppressants and new immunomodulating agents which could replace or be associated to the "older drugs".     

When should patients with chest pain be referred for coronary angiography?

When evaluating patients with possible coronary artery disease, it is necessary to combine physiologic assessment (measurements of ischemia) with anatomic pathologic assessment (coronary angiography). Coronary angiography currently is the only way to assess the anatomic pathology of the coronary circulation with precision. When it is combined with ventriculography and tests for myocardial ischemia, one can make clinical decisions related to the significance of the coronary artery disease observed. Common sense really demands that coronary angiography is only indicated when the information derived from this diagnostic procedure will facilitate therapeutic decisions in the individual patient.     

Is there a rationale to using leflunomide in early rheumatoid arthritis?

The efficacy of leflunomide in the treatment of early rheumatoid arthritis (RA) patients might be attributed to the fact that it acts at several levels, including the anti-inflammatory and anti-destructive pathways. This is in addition to its inhibition of the L-dihydro-orotate dehydrogenase (DHOH) enzyme and pyrimidine de novo synthesis which decreases cell proliferation and more specifically early activated CD4+ T cells, as well as monocyte interaction with T cells leading to cytokine and anticytokine production. Recent studies clearly indicate the rationale of an early administration of leflunomide in RA patients, particularly in the light of the results of previously reported clinical studies showing its rapid onset of action when compared to other DMARDs. The early efficacy and safety of leflunomide in patients with early RA is sustained over a long period, and the long-term safety profile of leflunomide does not seem to be different from that observed in phase III trials.