Luminiţa Vanghelie

Hand abnormalities, represented by Dupuytren's contracture, limited joint mobility, carpal tunnel syndrome, flexor tenosynovitis,occur in approximately 50% of the diabetic patients, affecting their activity and decreasing the quality of their life. Using specific methods, these can by detected long before they are observed by the patients. These disturbances have a high prevalence inthe persons with long diabetes mellitus duration, the prevalence increasing with the age. Smoking, usual hard activities, bad metabolic control and so on, can increase the severity of these disturbances. It is compulsory a careful examination of the patients' hands, because more abnormalities can be surgically rightened.

The vascular chronic complications are the main cause of morbidity and mortality in patients with diabetes mellitus. Nowadays it is well known the fact that the arteriosclerosis is initiated by the injury of the vascular endothelium and that the normal endothelial cells are producing a number of vasoactive factors. Thus, the vascular endothelium was considered an inert "lining" layer, but today is seen as a complex organ, with paracrin and autocrin function, which provides a "first line" physiological defence against atherosclerosis. Impaired endothelial function occurs in people with diabetes as a result of associated conditions (e.g. hyperglycemia, hypertension, dyslipidemia), or as an effect of hyperglycemia itself (e.g. cytokines, free fatty acids, AGES). The presence of endothelial dysfunction in non diabetic insulin resistant subjects suggests that metabolic and vascular abnormalities are tightly related at a fundamental level. Recent evidence suggests that insulin signalling for glucose transport in classical target tissues (muscle and adipose tissue) and upregulation of NO production in the endothelium utilises the same postreceptor pathway. This pathway involves the enzyme P13 kinase. Knowledge of the molecular mechanisms involved in the pathogenesis of endothelial dysfunction may ultimately result in novel approaches to the treatment and prevention of cardiovascular disease in people with diabetes mellitus.

The diabetic peripheral neuropathy is present in approximately 50% of the diabetic patients, being a major health problem, frequently associated with physical, psychological and social “sequelae”. Its presence leads to a significant raise of the risk for the lower limbs ulcer and, consequently, of the amputation risk, which, in their turn, imply supplementary costs for treatment, disruption in employment and decrease the quality of life.1,2On the other hand, clinical studies have emphasized the fact that the diabetic patients present a high risk of depressive disorder, the stress of daily care, the social isolation feeling, the difficulties in the obtaining of an optimum glycemic control and in the management of complications and comorbidity (when they are present) being only a part of the factors that contribute to the decrease in the quality of life and to the appearance of the depressive symptoms.3,4In literature we find contradictory data regarding the association between diabetic neuropathy and depression, data that may be partially explained by the fact that in different studies different tests have been used in order to establish the diagnosis of peripheral nerves damage or to evaluate the relationship between the presence of the symptoms characteristic to neuropathy and to depression.Based on the current information regarding the pathogenetic mechanisms of the diabetic peripheral neuropathy, the research has focused on the development of drugs which would interfere in the perception of pain and modulate descending inhibitory pain pathways. Duloxetine is used both in the treatment of painful diabetic neuropathy and of major depressive disorder (it is a selective serotonin and nor epinephrine reuptake inhibitor at the synaptic level).