Aim.
To present results of combined surgical treatment of the ischemic form of diabetic foot syndrome complicated by pyonecrotic process. To show thatthe use of modern diagnostic tools and the choice of adequate treatment strategy permits to substantially reduce the number of above-the-knee amputations.
Materials and methods.
A total of 140 patients with diabetes mellitus and critical ischemia of lower extremities were under observation during 2004-2008.All of them had purulent and/or necrotic foot lesions. The patients were examined by X-ray, computed and magneto-resonance tomography of the feet,duplex scanning of lower leg vasculature, transcutaneous measurement of PO2, pelvic and lower leg arterial angiography.
Results.
A strategy of surgical treatment was developed to be used depending on the patients health status, clinical features and severity of pyonecroticprocesses in the foot, and the degree of involvement of the main blood vessels of lower extremities.
Conclusion.
Combination of endovascular surgery with various methods for plastic wound closure permits to extend the range of possibilities for the treatmentof high-risk patients, such as those with pyonecrotic lesions and neuroischemic form of diabetic foot syndrome. This approach opens up prospects fora significant decrease of percentage of above-the-knee amputations and improves the quality of life in these patients.

Aim.
To compare efficiency, safety, and cost of different treatment modalities.
Materials and methods.
The study included 40 patients with type 1 and 2 diabetes, foot and lower leg trophic ulcers at granulation stage I-II (Wagners classification)free from wound infection. The patients were randomized for the treatment during 2 months with a Biatain dressing (Coloplast, Denmark)(group1) and for conventional treatment with the use of an atraumatic mesh dressing (group 2). Biatain dressings were changed every 2-4 (up to 5) daysand conventional dressings once daily. Patients in the two groups were adjusted for age, sex, ulcer type, size and duration, length of antibiotic therapy beforeand during treatment, blood glucose level, and other characteristics (p>0.05).
Results.
Ulcers healed within 2 months in 70% of the patients in group 1 and in 53.3% in group 2 (insignificant difference, p = 0.48). Other efficiency (medianhealing time, survival curves) and safety parameters were not significantly different either. The cost of treatment by the two methods was comparabledespite a higher cost of Biatain dressings due to their rarer change and economy of material for secondary dressing. When dressings were changed by medicalprofessionals rather than by the patient or his (her) relatives at home, treatment with the use of Biatain dressings proved 1.75 times cheaper.
Conclusion.
Efficiency and safety of high-tech and conventional dressing materials is comparable. The real difference between the costs of treatment byeither method is significantly smaller than the difference between retail prices of the two materials. Cost effectiveness of high-tech dressings is higher if thetreatment is accomplished in a medical facility.

Aim.
To study the OPG/RANKL system in patients with diabetes mellitus, mediacalcinosis and obliterating atherosclerosis of lower leg arteries.
Materials and methods.
The study enrolled 70 patients including 20 with manifest diabetic neuropathy (DN) and mediacalcinosis of lower leg arteries(group 1). 29 patients with diabetes mellitus (DM) and clinical manifestations of obliterating atherosclerosis of lower leg arteries comprised group 2. Thecontrol group 3 consisted of 30 subjects without disturbances of carbohydrate metabolism. Immunoassays with Alkphase-B (Metra biosystems, USA),Osteoprotegrin (Biomedica, Austria), and sRANKL(Biomedica, Austria) kits were used to detect serum markers of bone formation (alkaline phosphatase(AP), OPG, and RANKL respectively). The patients underwent examination by digital X-ray of affected joints in frontal and lateral projections using anAxiom Iconos R 200 apparatus (Siemens, Germany). Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (Expert 1188,Lunar, USA). Ultrasound duplex scanning of lower leg arteries was performed with Sonoc-5500 (Agilent, USA).
Results.
OPG levels in diabetic patients were significantly higher than in controls (p<0.0001). In group 1, they negatively correlated with RANKL (r = 0.68;p<0.001). Total cholesterol (TC) in diabetic patients was higher than in controls (p<0.05). In the former, TH and TG levels correlated with OPG concentration(r = 0.3; p<0.0003 and r = 0.2; p<0.001 respectively). Inverse correlation between BMD and OPG (r= -0.61; p<0.002) was documented in group 1.AP in diabetic patients correlated with OPG (r = 0.1; p<0.01) and RANKL (r = 0.21; p<0.01).
Conclusion.
The OPG/RANKL system participates in the development of mediacalcinosis and calcification of arterial intima in the lower extremities.

Aim.
To measure endothelial factors (nitric oxide (NOx) metabolites, endothelin-1 (ET-1), and basic fibroblast growth factor (bFGF)) in children and adolescentswith diabetes mellitus (DM) during development of diabetic peripheral polyneuropathy (DPNP).
Materials and methods.
A total of 130 children and adolescents with diabetes mellitus were examined. Duration of DM varied from 3 months to 14 years. Thecontrol group comprised 20 children and adolescents without DM or neurologic pathology. Subjective manifestations of DPNP were assessed based on thedata of a standardized Neuropathy Symptom Score (NSS) questionnaire. Neuropathy Disability Score (NDS) questionnaire was used to monitor objectivechanges of DPNP. NOx metabolites were detected with Griess reagent (Aldrich Chemical Co, USA). Serum ET-1 and bFGF were measured using solid-phaseimmunoenzyme assay (DRG, USA) and CYTIMMINE (USA) kits respectively.
Results.
All children and adolescents with DM1 had lower NOx and bFGF levels than controls. ET-1 level in DM patients was 3.5 times that in controls. DMpatients with DPNP had more pronounced endothelial dysfunction than DM patients without DPNP and control subjects. Patients with hyperproduction ofNOx had DM for more than 10 years and their total NDS score was significantly higher than in two other groups.
Conclusion.
Endothelial dysfunction in children and adolescents with type 1 diabetes mellitus progresses with the development of DPNP. Depletion of endothelialfunctional reserve is responsible for the unfavourable course of DPNP.

Aim.
To assess results of realization of the regional Diabetes Mellitus Program in the Tyumen region.
Materials and methods.
Materials of the regional Diabetes Mellitus Registry for 1999-2007 were analysed.
Results.
DM1 and DM2 morbidity increased from 6.6 to 8.16 and from 97.3 to 216.96 per100,000 population respectively. Primary disability rate among DM1 and DM2 patientsdecreased by a factor of 2. The fraction of patients with severe diabetic complications also decreased (1.3 times for blindness, 1.8 times for amputations). The frequency of diabeticcoma decreased by a factor of 2. Thirty five Diabetes School were organized. Mean life expectancy of DM1 and DM2 subjects increased from 49.55?5.43 to 50.11?2.96 years(p = 0.0001) and from 68.00?1.79 to 71.52?0.39 years (r = 0.0001) respectively. Mortality rate in DM1 and DM2 patients dropped by a factor of 5 and 3. All DM patients use onlymodern insulin formulations, with analogs accounting for 39.5% and human recombinant insulins for the rest of the total. Therapeutic use of secretagogues for the managementof DM2 decreased from 84.8 to 49.1% (p = 0.0001) and that of metformin increased form 6.8 to 28% (p = 0.0001); the need in insulin therapy also increased.
Conclusion.
Elaboration and implementation of the program contributed to the decreased occurrence of diabetic coma, blindness, and amputations in DM1 and DM2 patients,their longer life expectancy, and improved availability of high-quality oral hypoglycemic agents.

Aim.
To elucidate sonographic characteristics of common carotid arteries in adolescents with type1 diabetes mellitus (DM1) depending on the duration of the disease and thepresence of chronic complications.
Materials and methods.
A total of 56 adolescents having DM1 of different duration were examined to evaluate conditions of common carotid arteries (CA) in the systole anddiastole during at least 3 cardiac cycles. The following parameters were measured: CA diameter, intima-media thickness (IMT), estimated stretch and stiffness coefficients, Youngsmodulus. The control group comprised 16 healthy adolescents.
Results.
Bilateral increase of IMT was recorded in patients with DM duration over 5 years. Youngs modulus, stretch and stiffness coefficients were virtually unrelated to diseaseduration. In patients having DM for more than 10 years, stretch coefficient was 5.38 (95% DI 4.82-5.8) compared with 5.82 (95% DI 5.63-7.38) in those with DM for less than 3years (p = 0.04). The level of albuminuria correlated with IMT (r=0.32, p=0.03), stiffness coefficient (r = 0.43, p=0.001), stretch coefficient (r= -0.48, p<0.001), and Young modulus(r=0.32, p=0.002). Dyslipidemia occurred almost in half of the patients with DM duration over 5 years. In patients with hyperlipidemia, IMT was significantly higher than inpatients with normolipidemia (0.58 and 0.5 mm respectively, p=0.013). IMT also increased in case of distal neuropathy.
Conclusion.
Examination of CA revealed enhanced IMT in adolescents with DM1 over 5 years, dyslipidemia, proteinuric nephropathy, and distal neuropathy. Calculated indicesof vascular resistance and arterial wall elasticity were related to the level of albuminuria.

Aim.
To assess the frequency and character of non-compliance with medicamentous therapy of type 2 diabetes mellitus based on the results of a questionnaire study.
Materials and methods.
A special qiuestionnaire form was filled by 745 patients (232 men) of mean age 60.3?10.4 years, duration of the disease 6.4?5.5 years and mean HbA_1c level 7.7?1.1%.
Results.
52.8% of the patients reported non-compliance with medication. The most frequent profile of non-compliance was the change of time and occasional omission of therapeuticdoses (42.7 and 42.2% respectively), the main cause being mere forgetfulness (71.2%). Other factors (30.8%) included poor understanding of medication schedule andfears of health hazard from the following of medical advice. Patients to whom monotherapy with glibomet was prescribed (n=277) showed a lower non-compliance rate and lowerHbA_1c level despite the intake of fewer daily doses than patients taking other oral hypoglycemic agents (7.0?1.0 vs 7.3?1.3%, p<0.05).
Conclusion.
Most patients with DM2 report non-compliance with recommended therapeutic regime. This suggests the necessity of greater efforts by attending doctors to educatetheir patients and provide compliance assistance. The use of combined agents may improve adherence to prescribed therapy.

Aim.
To consider homocysteinemia in children and adolescents with diabetes mellitus (DM1) as an independent risk factor of diabetic nephro- and retinopathy (DN and DR).
Materials and methods.
Twenty nine adolescents (19 girls and 10 boys) with DM1 were examined. DN and DR were diagnosed in conformity with medical aid standards for DM1patients. Plasma homocysteine level was measured by IEA.
Results.
Plasma homocysteine level in DN patients was higher (6.4?1.6, n=10) than in DR group (5.3?1.7, n=9) and controls (5.6?1.8, n=10). Patients of all study groups werecomparable in terms of age, DM duration, and HbA_1c level.
Conclusion.
Plasma homocysteine level in DN patients was higher than in DR and control groups. It gives reason to consider this parameter as an independent risk factor alongwith some others in pathogenesis of diabetic microangiopathies (in the first place, nephropathy). Adolescents with DM1 and elevated plasma homocysteine level need additionalcorrection by specific medicines.