Secondary diabetes

Secondary diabetes can be defined as a diabetic condition that develops after the destruction of the beta-cells in the pancreatic islets and/or the induction of insulin resistance by an acquired disease (e.g. endocrinopathies) or others. Recently, diabetes mellitus has divided into four distinct types (type 1 diabetes, type 2 diabetes, other specific types of diabetes and gestational diabetes) in the Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus in USA. The categories between secondary diabetes and the other specific types of diabetes might be different a little, some of the latter being described here. The details of the genetic defects in insulin action has been presented elsewhere (see Chapter V-3).     

Secondary stroke prevention

Stroke is the most common life-threatening neurological disorder. Based on limited acute therapies, clinicians have opted to focus on preventive strategies to limit its recurrence. Targets for prevention include modifiable risk factors such as hypertension, diabetes mellitus, dyslipidemia, cigarette smoking, obesity, alcohol use, and physical inactivity among others. The American Stroke Association and American Heart Association guideline for the secondary prevention of stroke published in 2006 provides comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of stroke or transient ischemic attack. This guideline helps healthcare providers who have arrived at a potential explanation of the cause of stroke in an individual patient to select therapies that reduce the risk of recurrent events and other vascular events. The purpose of this review is to highlight the recently published American Stroke Association/American Heart Association guidelines for the secondary prevention of stroke.     

Secondary prevention of stroke

Stroke and transient ischemic attacks result from a range of mechanisms. Secondary prevention includes both conventional approaches to vascular risk-factor management (blood pressure lowering, cholesterol reduction with statins, smoking cessation and antiplatelet therapy) and more specific interventions, such as carotid endarterectomy or anticoagulation for atrial fibrillation. The relative importance of even conventional risk factors in stroke differs from coronary artery disease. Large clinical trials produce information on most aspects of stroke prevention. Stroke and transient ischemic attacks are now recognized as medical emergencies, with a high early risk of recurrence, and evidence is accumulating to support the importance of immediate institution of secondary preventative treatments. We review current literature on the secondary prevention of stroke.     

Secondary prevention of stroke

Patients suffering a transient ischaemic attack (TIA) or ischaemic stroke (IS) have a high recurrence risk. Secondary prevention aims to prevent not only further strokes but also cardiac events. Important parts of secondary prevention regimens are the modification of vascular risk factors and the inhibition of platelet function or anticoagulation if indicated. The inhibition of platelet function is effective in the reduction of secondary vascular events in patients with TIA or stroke. This is true for acetylsalicylic acid (ASA), clopidogrel, and the combination of ASA plus slow-release dipyridamole. A prediction model which allows to identify patients in whom clopidogrel or dipyridamol plus ASA is superior to ASA for the secondary prevention of stroke is presented.     

Secondary prevention of cancer

OBJECTIVES: To review criteria for mass cancer screening among asymptomatic populations and barriers to secondary prevention of breast, cervical, and colorectal cancers. To describe challenges to implementing theoretically based interventions to increase appropriate cancer screening, follow-up, and surveillance. DATA SOURCES: Published journal articles, text books, and epidemiologic reports. CONCLUSION: Interventions to increase breast, cervical, and colorectal cancer screening participation must be approached from a systems perspective that includes patient, health care provider, and health care system variables. IMPLICATIONS FOR NURSING PRACTICE: Understanding the array of factors that impede progress in the secondary prevention of cancer is necessary to improve care. Nurses have an important role in decreasing morbidity and mortality from breast, cervical, and colorectal cancers.     

Secondary prevention of cardiovascular disease in type 2 diabetes and prediabetes: a cardiologist's perspective

Patients with type 2 diabetes mellitus (T2DM) and prediabetes have a substantially greater risk of developing cardiovascular (CV) disease than the general population. This increased risk of CV disease is due to a complex cluster of risk factors including insulin resistance, hyperglycaemia, diabetic dyslipidaemia, hypertension and systemic inflammation. As a result of this cluster of risk factors, life expectancy is reduced by up to 10 years upon diagnosis of T2DM, principally because of fatal CV events. Patients with T2DM are not only more likely to sustain a CV event, but also have a higher risk of a fatal outcome from this event. Therefore, whilst primary prevention is critical in determining the prognosis of patients newly diagnosed with T2DM, many will go on to suffer CV events and represent a high-risk group requiring intensive secondary prevention techniques. Recent data demonstrate that contemporary prevention therapies do not afford equal benefits to T2DM sufferers after acute myocardial infarction compared with their non-diabetic counterparts. This finding highlights the need for more effective secondary preventative strategies to prevent recurrent CV events in patients with T2DM and prediabetes. The cardiologist's role in the multidisciplinary management of T2DM is to improve patient outcomes by optimising use of evidence-based strategies for the prevention of recurrent CV events.     

Secondary prevention of ischemic heart disease

Thirty-three coronary patients received preventive therapy in unfavorable for the disease seasons (late autumn, early winter). Chemotherapy included three treatment combinations: acetylsalicylic acid plus nicotinic acid, curantyl plus nicotinic acid and intercordin plus potassium salts. The preventive measures reduced the frequency of anginal attacks and meteoropathic reactions. The hemostasis, fibrinolysis and microcirculation exhibited a positive trend.     

Primary prevention of diabetes mellitus

Two-thirds of all deaths in developed countries are caused by the major noncommunicable diseases, e.g., cardiovascular disease, cancer, and non-insulin-dependent diabetes mellitus (NIDDM). There is increasing evidence that these diseases are a consequence of life-style change, and they have a number of risk factors in common. Primary prevention of both insulin-dependent diabetes mellitus (IDDM) and NIDDM has become increasingly important because of their significant morbidity and mortality and the human and economic costs associated with diabetes and its complications. Prevention of the two major forms of diabetes, IDDM and NIDDM, are quite separate issues. The former appears to be an autoimmune disorder, whereas the latter should be considered along with other life-style-related noncommunicable diseases. The primary prevention of NIDDM appears to offer the greatest promise of success. The uncertainty that still exists as to the role of obesity and other risk factors in the development of NIDDM gives support to a multiple-risk-factor intervention approach (through a healthy life-style strategy) for NIDDM prevention.     

The economics of diabetes prevention

In the United States, the costs associated with diabetes mellitus are increasing. Although people with diabetes comprise less than 6% of the US population, approximately 1 in 5 health care dollars is spent caring for people with diabetes. Healthy lifestyle interventions for the general population and intensive lifestyle and medication interventions for high-risk individuals present opportunities for diabetes prevention. This article describes the costs associated with glucose intolerance and diabetes, the effect of glucose intolerance and diabetes on the quality of life, and the cost-effectiveness of screening and primary prevention interventions for diabetes prevention.     

Primary prevention of diabetes mellitus

Diabetes mellitus is one of the chronic noncommunicable diseases that have increased markedly in this century. The discovery of insulin and other drugs for lowering hyperglycemia have certainly reduced mortality from acute complications of diabetes and improved the quality of life of many diabetic patients. Recent advances in research into the etiology and natural history of diabetes have increased our knowledge about different types of diabetes to such an extent that primary prevention of diabetes mellitus is becoming a reality. Until now, few studies have attempted to test measures for primary prevention of diabetes. Therefore, the data supporting the possibility for primary prevention are largely indirect and need to be tested in preventive trials or in community-based prevention programs. We believe, however, that the time is right to start action in populations in which the prevalence of diabetes is known to have clearly increased recently. We summarize the evidence that can be used as the scientific basis of primary prevention of diabetes mellitus.     

Secondary prevention in elderly survivors of heart attacks

More than 200,000 elderly patients survive myocardial infarctions each year. Thus, the achievement of even minimal decreases in reinfarction and mortality rates will benefit large numbers of patients. Secondary prevention strategies include smoking cessation; the control of hyperlipidemia, obesity and diabetes; the management of hypertension and stress; exercise; the use of drugs such as beta blockers and aspirin, and increased attention to general health.     

Secondary prevention of stroke and transient ischaemic attack

Transient ischaemic attack (TIA) and stroke are clinical syndromes characterised by acute neurological deficits with vascular causes. People experiencing TIA or a first stroke are at significant risk of subsequent stroke. Risk factors have been identified and include factors associated with lifestyle such as tobacco use, diet, obesity, alcohol consumption, physical activity and stress. Targeted therapeutic interventions have the potential to reduce the burden of stroke substantially. The aim of this article is to provide an overview of the evidence relating to lifestyle risk factors for stroke. Health promotion theories and intervention techniques that nurses can use to address lifestyle behaviour change following stroke will also be discussed.     

Costs associated with the primary prevention of type 2 diabetes mellitus in the diabetes prevention program

OBJECTIVE: To describe the costs of the Diabetes Prevention Program (DPP) interventions to prevent or delay type 2 diabetes. RESEARCH DESIGN AND METHODS: We describe the direct medical costs, direct nonmedical costs, and indirect costs of the placebo, metformin, and intensive lifestyle interventions over the 3-year study period of the DPP. Resource use and cost are summarized from the perspective of a large health system and society. Research costs are excluded. RESULTS: The direct medical cost of laboratory tests to identify one subject with impaired glucose tolerance (IGT) was $139. Over 3 years, the direct medical costs of the interventions were $79 per participant in the placebo group, $2,542 in the metformin group, and $2,780 in the lifestyle group. The direct medical costs of care outside the DPP were $272 less per participant in the metformin group and $432 less in the lifestyle group compared with the placebo group. Direct nonmedical costs were $9 less per participant in the metformin group and $1,445 greater in the lifestyle group compared with the placebo group. Indirect costs were $230 greater per participant in the metformin group and $174 less in the lifestyle group compared with the placebo group. From the perspective of a health system, the cost of the metformin intervention relative to the placebo intervention was $2,191 per participant and the cost of the lifestyle intervention was $2,269 per participant over 3 years. From the perspective of society, the cost of the metformin intervention relative to the placebo intervention was $2,412 per participant and the cost of the lifestyle intervention was $3,540 per participant over 3 years. CONCLUSIONS: The metformin and lifestyle interventions are associated with modest incremental costs compared with the placebo intervention. The evaluation of costs relative to health benefits will determine the value of these interventions to health systems and society.     

Stroke prevention in diabetes and obesity

Stroke is an important cause of morbidity and mortality, and is an economic burden. Diabetes and obesity are two important modifiable risk factors for stroke. Patients with diabetes have a higher incidence of stroke and a poorer prognosis after stroke. Risk-factor modification is the most important aspect of prevention of stroke in diabetes and obesity. This includes lifestyle modifications and different therapeutic modalities to control conditions, such as diabetes, hypertension, dyslipidemia and arrhythmia. Recent landmark studies have shown the beneficial effects of statins in diabetic patients even with close to normal or normal low-density lipoprotein cholesterol. Obesity, which is a risk factor for diabetes, hypertension and hyperlipidemia has been shown to be an independent risk factor for stroke. Increased leptin, dysregulation of adipocyte proteins, increased insulin resistance and C-reactive protein may be factors involved in the increased incidence of cardiovascular morbidity and mortality directly related to obesity. Visceral fat is a much bigger health risk than subcutaneous fat. Lifestyle interventions and pharmacotherapeutic agents have been used to manage obesity. In morbidly obese patients, surgical intervention seems to be the best method of treatment with a long-lasting favorable metabolic outcome. In the 21st Century, with the advanced medical knowledge and the therapeutic modalities available, it should be possible to reduce the incidence of stroke associated with diabetes and obesity.