Looking at a graph that shows the sharp increase in new cases of diabetes is a bit like catching sight of an iceberg from the deck of the Titanic. The challenge of dealing with the immediate effects of the disease in such numbers is daunting. Even more chilling is the thought of the yet-to-emerge impact on related health problems in an aging population. Diabetes uses the bloodstream as a direct path of attack on virtually every part of the body, causing heart and kidney disease, increasing risk of Alzheimer's and dementia, and potentially causing loss of vision and limbs. Fortunately, Birmingham-area medical facilities are using a number of new strategies to help diabetics steer clear of complications. A Sweeter Start in Life: Protecting Mothers and Infants Even with perfect blood sugar numbers going into pregnancy, women can develop gestational diabetes, or the greater demands on the body can bring a developing case to light. For women who have been coping with the disease since their own childhood, there are additional issues of concern. "We've come a long way since the days when diabetics were advised to avoid pregnancy," said high-risk pregnancy specialist Dr. Antonio González-Ruíz of Brookwood Maternal Fetal Medicine. "Now women whose diabetes has been well controlled can usually expect to have outcomes similar to nondiabetic women. The question we'd have to look at is whether there has been previous damage to the kidneys and other organs. Generally, we suggest that women have good control of their blood sugar with their A1C within target range for six months before becoming pregnant." All expectant mothers should be monitored for gestational diabetes, which can cause serious complications for both mother and child. "For the mother, the risks can range from bladder infections to hypertension, preeclampsia and greater odds they will need a caesarean delivery. The fetus is at higher risk of spontaneous death, and the baby may be born with jaundice, electrolyte problems and a sudden drop in blood sugar. Babies are also usually larger, which can lead to a difficult delivery that may result in shoulder dystocia or Erb's palsy of the arm. Doctor's have often found themselves in legal difficulty because the palsy doesn't always go away." At the first sign of gestational diabetes, intervention should begin with a combination of nutrition, activity, medication and monitoring. Gestational diabetes usually goes away after delivery but may recur in future pregnancies, and those who experience it may be at greater risk of developing Type 2 diabetes later in life. Better Outcomes: Managing Blood Sugar in Heart Surgery Patients Something odd happens when the body responds to injury. Whether from a surgeon's scalpel or trauma from an automobile accident, when the body senses damage, it frequently releases a surge of glucose into the bloodstream. While this response may have evolved as a survival mechanism, it can lead to complications and delay recovery even in nondiabetics. Hospitals are seeing improved outcomes by aggressively managing blood sugar levels in patients who have open-heart surgery. Princeton Baptist Medical Center is already seeing better outcomes from this approach. "It has reduced the length of stay in the ICU and the overall length of hospital stay for our heart surgery patients," said Shannon Price, assistant director of pharmacy and clinical services. "We're thinking of expanding the protocol to other patients who might benefit from better glycemic control." The new approach, which is based on the Atlanta Protocol, is also saving nursing time, relieving doctors of the need to continually update orders, and allowing a faster response to the patient's needs. "At first, it requires more intensive monitoring, but it saves nursing time overall. We can usually get patients within the blood sugar goal range of 90 to 110 quickly, then monitor them every hour, then every two hours," Price said. "As diabetics recover, we transition them from drips to subcutaneous insulin using a combination of basal long-acting insulin combined with a bolus of short-acting insulin at each meal and for correction. If no diabetes is indicated in the A1C, we transition the patient to corrective doses as needed." Healing the Wounds of Time As diabetes takes its toll, damaging vascular and nerve tissue, the problem of non-healing wounds becomes all too common, particularly in aging diabetics. With advancing neuropathy, patients are at risk of amputation because they may not be able feel serious wounds in their feet. To help patients deal with slow-healing and non-healing wounds, some area hospitals are establishing wound healing centers that focus advanced treatment strategies. The Advanced Wound Care Clinic at Shelby Baptist will open December 10, 2008, with Ron Pinkerton, RN, as program director. "First we determine why the wound isn't healing, whether from arterial or venous insufficiency or other diabetes-related issues," Pinkerton said. "We also work to get compliance from the patient with diet and insulin to improve blood sugar levels." "The wound may simply require removal of necrotic tissue and a specialized dressing and compression, or surgical intervention may be necessary to improve circulation," he said. "For deep, serious wounds, where testing shows that oxygen therapy can improve blood oxygen levels in the area, we also offer hyperbaric oxygen therapy. The patient receives compressed 100 percent oxygen daily for five days a week, typically for an hour or two a day for up to 60 days as we monitor their progress." Other high-tech treatment options include bioengineered skin substitute. The clinic will also be working with patients who have other types of problem wounds, including brown recluse spider bites, burns, and skin and bone infections. The Comprehensive Approach: Connecting Patients to Multiple Resources The war against diabetes is fought on many fronts. In the course of managing the disease, a patient and physician may have to rely on the support of many allies, including endocrinologists, nutritionists, diabetes educators and a broad range of specialists when different organs are under attack. Seeking out so many sources of help in so many places can be difficult. That's why UAB's new Multidisciplinary Comprehensive Diabetes Clinic brings the full spectrum of resources together to give patients easy access to the care they need. "In one day we may be working with teenagers who are taking on more responsibility for managing their insulin and diet, or older patients who have more complex issues, or newly diagnosed patients who come and spend a full day thinking and talking about their diabetes and asking questions," said director Fernando Ovalle, MD. A week before a patient comes to the clinic, continuous glucose monitoring equipment can be set up to record shifts in blood sugar. When the patient arrives at the clinic, the monitor is downloaded and fasting blood and urine levels are tested. Newly diagnosed patients attend classes to learn about managing their blood sugar with diet, exercise and medication. They also have breakfast and lunch with a nutritionist to practice as they learn. The program is partnering with the YMCA to assess patients for exercise and help them plan an activity program. Ovalle said, "The patient meets with an adult or pediatric endocrinologist and other specialists such as an ophthalmologist, a foot specialist from orthopedics, and if the assessment indicates a need, we can bring in a nephrologist, cardiologist, neurologist or other specialists." Ovalle also hopes to make the clinic a continuing education resource for healthcare providers. He added, "In the future, we'd like to offer mini-courses on focused topics related to diabetes and on new treatment and research to help health professionals update and refine their skills."