Coronary Artery disease as the major health problem: CAD and other cardiovascular disease occur earlier and with greater frequency in patients with NIDDM than in the general population. Several mechanisms contribute to this excess. First CAD and NIDDM frequently occur together in families. For example : patients with NIDDM are more likely to have a parent with CAD or controls without diabetes. Second, hyperinsulinemia and insulin resistence which precede by many years the development of NIDDM also are predictors of the development of elevated blood pressure and lipid abnormalities. Several studies have demonstrated that an elevated serum insulin level in the fasting is an independent predictor of CAD. After NIDDM develops, risk factors for CAD become more prevalent and more intense.

Hypertension: Hypertension is more prevalent both among persons with IDDM and those with NIDDM  than in the general population. The role of hypertension as a risk factor for atheroscrosis is at least as strong for diabetic as for non diabetic person. Hypertersion can be the result of diabetic nephropathy, although the frequency of hypertension appears to be higher in the diabetic population. In NIDDM, hypertension occur as part of a syndrome in which it can co-exist with central obesity, insulin resistance, and dyslipidemia.

Microvascular complications of diabetes represent one of the most serious consequences of the disease. It is likely that all blood vessels both large and small, are abnormal in patients with diabetes of long duration. The changes involve both the vascular cells making up the capillaries and arterioles and their basements membranes.

The main function of the vasculature is to provide a conduit for the delivery of the nutrients required by the individual tissues and for the removal of materials from specific tissues. To achieve this important goal, the cells of the vascular need to monitor the needs of the tissue continuously and either increase or decrease functional capacity appropriately.

The classic morphologic finding in diabetic is the thickening of basement membranes in capillaries. The basement membranes of mammary duets, testes, and sweat glands are thickened. Once there changes have occurred, the blood vessels lose their ability to regulate blood flow, and the capillaries in turn lose their ability to receive blood, a deficit that leads to the formation of ghost capillaries. With the formation of ghost vessels areas of anoxia are formed which can lead to serious stage of diabetic retinopathy called proliferative retinopathy. These new blood vessels do not form the usual retinal blood barrier. There properties increase the risk of bleeding and as a consequence can cause blindness.

The prevalence of macro vascular disease is markedly increased among individuals with diabetes mellitus. Antopy studies have reportedly demonstrated that atherosclerosis in diabetic individuals is more extensive and accelerated than in individuals without diabetes.

Smoking: There is strong evidence that smoking markedly increases the risk of heart ailments and vascular diseases particularly myocardial infarction. Smoking is believed to be associated with adverse changes in plasma lipids especially with the levels of cholesterol.

Aging processes. Both IDDM and NIDDM are characterized by the periods of hyperglycemia. Proteins with long-half lives are likely to undergo more extensive monenzymatic glycation in those with diabetes than in those without diabetes. Since protein glycation has been linked to the aging process, the diabetic state might be considered a state of accelerated aging. One life-threatening complication is keto-acidosis in diabetic mellitus. This is a condition characterized by the blood sugar level of more than 250 ml with blood PH of less than 7.3 presence of ketones in urine and elevated serum ketones of above 5 ml. General in young diabetic patients treated with insulin this complication can be due to some infection such as pneumonia, urinary tract infection or by acute emotional stress and depression. This complication demands immediate effective insulin therapy.

Diabetes and the Disease of the skin: The skin is a fabroelastic membrane which may be called the living envelope of the human body. It is complex in structure and endowed with active and passive functions so that it affords covering and protection to the deeper tissues and receives impressions from the external world to which it is continually exposed. It is closely related to the structures beneath through its connective tissue, blood vessels, nerves and lymphatics.

Many different agents may cause a dermatitis which eventually becomes gangrenous. Among these may be mentioned excessive cold or heat, external application of chemical agents, ingestion of drugs, disease of the nervous system, other diseased conditions of the blood vessels and diabetes.

1 Multiple Gangrene: This condition has developed independently of any disease but usually follows or developed independently of any disease but usually follows or complicates such infectious as scarlatina, variola, typhoid, fever. Although persistent recovery usually takes place. When children are affected, the result may be fatal.

2 Hysterical Gangrene : This type of gangrene is noticed in hysterical and anaemic young women suffering from diabetes. This condition may be an imposture or possible due to some central nerve lesion. It occurs first as a raised reddened spot, varying in size accompanied by burning sensation.

3 Diabetic Gangrene: No doubt the chief cause of this form is the diminished tissue resistance which diabetes occasions. Hence micro organisms can give gain easy access. In some primary forms, The origin is purely neurotic. It may be unilateral or bilateral and is opt to affect the middle of the extremities rather than the finger or toes although rarely it may affect any portion. Cases of spontaneous origin may heal but complication of a most serious underlying condition.

4 Symmetric Gangrene: It is of rare affection occurring at the periphery of the circulation and characterized by local Ischemia and asphyxia and usually ending in gangrene of the skin and deeper tissues which is often symmetrically distributed. Extremities such as the fingers and toes or less often the nose, ears and brows may be attacked. The first indications are the coldness and paleness of the parts affected. Numbness, loss of sensation, pain and pallor may precede or follow the initial symptoms. Unless the disease be arrested at this or at earlier period, the second stage develops with sensations of prickling, crawling, stinging and pain with a swollen dark, red livid or bluish appearance. Unless the disease be arrested at this or an earlier period, the third stage that of superficial dry gangrene is developed. At this time, the skin may be cold, firm and dark in colour. This condition usually follows directly firm cold but has been observed after the exanthemata, diphtheria, malaria, gout, and diabetes.

5 Carbunculus: It is an acute circumscribed, cutaneous, inflammation characterized by multiple foci of necrosis and sloughing of the superficial tissues. Carbunculosis is a condition where the lesions occur singly or in crops. Mild prodromata usually precede the carbunde, such as chill, fever, and malaise but when the lesions are extensive, numerous or situated on the head, the prostration may be alarming.

A burning, tense pain is felt at the site of the beginning lesion which appears as a deep, flat hard swelling at first covered by reddened skin which soon becomes more darkly tinted. From the size of a boil or large, the infitltration may spread until it reaches the size of the palm. At the end of a week or ten days, the carbuncle appears as a flatly convex, hard tumor, livid in colour, gradually merging into the surrounding skin.

Prognosis of carbuncle depends entirely upon the influence of pre-disposing factors. In conditions like nephritis and diabetes or in the aged, debilitated or alcoholic or in such locations as the scalp, face or abdomen.

6 Acne: Acne is a common inflammatory skin disease that mainly affects the face, neck, chest and upper back. It is caused by an interaction between hormones, bacteria and sebum produced by the sebaceous glands in the skin, symptoms show as comedones, pustiles and occasionally cysts with diabetes patients. Acne is traditionally thought to develop at puberty but many women suffering from diabetes have acne throughout life. It can develop permanently or may be associated with taking or stopping of oral contraceptive pills. This is possibly caused by changing harmonic levels. In diabetes very sever cases can be treated using a derivative of Vitamin A .

7 Diffused symmetrical soleroderma : Soleroderma is a chronic disease characterized by diffused tinted in durations, fixation, rigidity, stiffness and sometimes atrophy. Two forms which are widely different in appearance, distribution and extent, although they sometimes co-exist are described a. diffused symmetrical soleroderma b. circumscribed soleroderma.

Diffused symmetrical soleroderma often follows exposure to cold and wet, with antecedent rheumatic pains and stiffness in the limbs or joints. The onset may be insidious and not clearly noted by the patients. The initial lesion is non-inflammatory with or without edema. If with Edema, the surface may pit on hard pressure but owing to the density of the part there is none of the doughty feeling of ordinary odema. More often edema is absent. After sometime progressive hardness and rigidity develop. While it always attacks the upper segment of the body first. The sites of preference in their order are the upper extremities, trunk, face, head and hands. The parts affected appear frozen but are without coldness. Dilated capillaries may appear in contrast with the abnormally pale surface and brown or black pigmentation may be seen in lines or spots generally diffused.

The disease pursues a symmetrical course changing its situation with periods of aggravation lasting for years. Restoration may follow when the maximum involvement is reached or treatment arrests the process. In such cases elasticity, mobility and function of the skin are partially restored. If this happy condition does not take place, atrophy begins with reduction of the parts involved to such an extent that the muscles may disappear.

This disease is more prevalent in early adult life. Two out of every three cases occur in women. Possible causes are exposure of cold and heat, rheumatism, thyroid, mental and nervous emotions and diabetes.

The Diabetic Foot: Our patients with diabetes no longer die from acute conditions stemming from hyperglycemia. Rather it is the chronic complications of the disease that dominate. Chief among these complications is pathology of the diabetic foot which is the most common reason for hospital admission among people with diabetes. Over the past generation, care of the diabetic foot has so much advanced that many lower-extremity complications of diabetes are preventable. Foot ulceration is a disturbing complication of diabetes that often results in a diminishing quality of life.

In diabetic patients, the foot is the cross road of several pathological processes. Almost all components of the lower extremity are involved; skin, subcutaneous tissue, muscles, bones, joints and blood vessels. Because each of these components can contribute to foot ulcers, a multidisciplinary approach is needed. A diabetic foot ulcer is defined as any full thickness lesion of the skin-that is, a wound penetrating through the dermis. If patients have loss of sensation, limited mobility, and poor vision, they may not even be aware that they have a foot ulcer. The location of an ulcer can give clues to its cause and will help to determine if and how pressure relief should be applied. Neuropathic ulcers are usually located on areas with elevated pressure, such as the planter side of the foot, ischemic ulcers are more common on the tips of the toes. Injection of the diabetic foot is one of the major reason for lower extremity amputation. Unfortunately no standard exists for diagnosing an infection. A superficial infection without systematic signs can be diagnosed based on local swelling, purulent discharge, erythema, foul smell, or local tenderness or pain. Polyneuropathy is a major factor in foot ulceration, resulting in loss of protective sensation, muscle paralysis with subsequent deformities, abnormal walking pattern, and abnormal loading of the foot. callus and foot deformities- such as hallux valgus, grominent metatarsal heads, or clawing of the toes are usually recognized during inspection of the feet. Both of the shoes and socks should be examined. The fit of the footwear is important to evaluate, as most ulcers are caused by poorly fitting shoes and insoles.

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