SSS medical 2

Students’ Scientific Society - Kasr El-Ainy Issue 2, 2nd edition Spring 2007 ©

SSS is an independent, non profit association; run by volunteered medical students & aiming at producing active contributing physicians of a global society

General Overview on Diabetic Complications.

Prof. Sherif Hafez

Renal Involvement: Diabetic Nephropathy.

Dr. Tarek Fayyad

Empowering People To Cope With Diabetes.

Laila El Sioufi

Awareness of Diabetic Complications The SSS medical© Editorial Team Diabetes & Blindness: A Breakable Bond.

Diabetes Through Time...

Ahmed Nour Eldin

Dr. M. Sameh H. El Agha Vascular Complications: The Road to Perdition

My “Diabetes” Friend…!!!

The SSS medical Editorial Team

Neuropathies: When nerves get involved

d n co e S

n ti io Ed

Table of Contents Editorials

SSS Supervisor Prof. Mohamed Elsada 1st Edition Editorial Team Ayman Wafik Ahmad Belal Samar Moharram Reem Ayman Reham Samir Omar Weshahy 2nd Edition Additional Team Yomna Zaghloul Hebatallah Ibrahim Hanaa Galal Fundraising Team Karim Aly Yahia Hashish All rights reserved to the Students’ Scientific Society “SSS” Kasr El Ainy - Cairo University April 2007 For additional information and sponsorship please visit our website at

www.ssscairo.org Silver Sponsor

Prof. Mohamed Elsada Ayman Wafik Diabetes Mellitus Complications: General Overview Prof. Sherif Hafez

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Diabetic Complications Awareness Among Medical Students The SSS medical editorial team

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Diabetes Through Time The SSS medical editorial team

10-11

Diabetes and Blindness: A breakable bond Dr. M. Sameh H. El-Agha

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Vascular Complications: The Road to Perdition The SSS medical editorial team

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Neuropathies: When nerves get involved The SSS medical editorial team

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Renal Involvement: Diabetic Nephropathy Dr. Tarek Fayyad

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Empowering People to Cope With Diabetes M.Laila El Sioufi

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My “Diabetes Friend…!!!

Ahmed Nour-Eldin

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We are the SSS members

ic et ab i D

...Elvis Presley…

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hroughout the pages of this issue, the reader would find pictures of celebrities of different nationalities, fields and generations.

They all have one thing in common: Diabetes. Yet, they excelled in their fields like no one did.

ic et ab i D

.Elizabeth Taylor.

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ic et ab i D

...Anwar El Sadat…

Prof. Mohamed Elsada, SSS Supervisor

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ear “SSS medical” readers. It is my pleasure that I have been involved with the activities of the SSS since October 2004. I admit that I did not know much about the society, nor the participants although member of the faculty staff.

I was surprised to encounter a group of motivated highly active students, working together in a harmonized fashion, forming a superb team. The activities of the society are diverse covering more than one scope, among which is the “SSS medical” journal. The first issue, which was about Breast Cancer Awareness was the perfect example of what medical students are capable of achieving.

They proved that such a scientific work can be presented in an all new different way: the SSS way.

The second issue as well so very well received that a second issue was to see the light of day. I’m sure this second edition won’t fail to accomplish the same goal as the first in the most unique way. The journal “SSS medical”, is by far an accomplishment for SSS. Every page, every word of the journal you’re holding in your hands is yet another proof that SSS members aren’t only medical students, they are practically anything they want to be.

The achievement of this important project shall be reflected on the medical community, final year students and young graduates.

I sincerely hope that members of the society proceed more and more in their activities and hope that I can help them whenever they need it.

Ayman Wafik, SSS President

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edical students.

“An unprecedented flow of motivation, productivity and creative imagination”. This is neither a slogan nor a theory. We are here to prove it.

This journal is here to prove it. Every inch of this publication you’re holding in your hands is the outcome of extensive preparation and work. From material to fundraising, from concept to design, from management to team dynamics. The Students’ Scientific Society - Kasr El Ainy rests on those fundamentals, proving that medical students can do anything they put their mind into.

After an extremely successful second issue of the SSS medical, the need to issue a second edition of the journal became obvious to all.

In addition

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we’re currently racing a very tight timeline to issue the very promising third issue entitled “Nine Months” and tackling the issue of maternal and fetal health.

The ingredients? Seven cups of SSS mega-members, a spoonful of infrastructure, two drops of motivation, a touch of coordination and creativity in abundance.

I would like to thank all our supporters and contributors for enabling us to present this issue in the way we would be proud of. And the specialists thanks for my SSS family, who made my faculty days that magical.

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iabetes mellitus is a group of metabolic disorders characterized by inappropriate hyperglycemia, due to either an absolute deficiency of insulin secretion or a reduction in the biological effectiveness of insulin or both and is associated frequently with specific lesions of the microcirculation, neuropathic disorders , and a predisposition to atherosclerosis.

If not controlled properly, diabetes mellitus may have lots of complications which develop in all the systems of the body; for example, people with diabetes have extra reason to worry from heart and blood vessel diseases.

Diabetes carries an increased risk for heart attack, stroke, and complications related to poor circulation. Diabetic complications related to heart diseases are so common that 2 out of 3 people with diabetes die from heart disease and stroke! Heart diseases are much more dangerous with diabetes, as diabetes can affect the nerves and therefore, make heart attacks painless or ic “silent� (with no t e ab i warning signs).

D Diabetes also can damage the kidneys, which can make them lose their ability to filter out waste products. This is called diabetic nephropathy.

When kidney disease is caught late, end...George Lucas... stage renal disease (ESRD) usually follows. A person with ESRD needs to have a kidney transplant or to have dialysis.

Diabetes can also cause eye problems and may lead to blindness. People with diabetes are 40% more likely to suffer from glaucoma than people without diabetes.

Classification of Diabetes Mellitus Type 1 Diabetes - Immuno-mediated - Idiopathic Type 2 Diabetes May range from predominately insulin resistant to predominately insulin -deficient.

Gestational Diabetes Other specific types - Genetic Diabetes of ǃ-cell function - Genetic defects in insulin action - Endocrinopathies - Drug or chemically induced - Infections - Uncommon forms of immuno-mediated diabetes - Other genetic syndromes sometimes associated with diabetes.

From American Diabetes Association 2004

Many people without diabetes get cataracts, but people with diabetes are 60% more likely to develop this eye condition.

Non-proliferative diabetic retinopathy is the common, mild form. It usually has no effect on vision and needs no treatment. In other people, retinopathy progresses after several years to a more serious form called proliferative diabetic retinopathy. People sometimes have no symptoms until it is too late to treat them.

For this reason, diabetics should have their eyes checked at least yearly.

Diabetic neuropathy can occur in one of two forms. The first is sensorimotor neuropathy, also known as peripheral neuropathy. This can cause tingling, pain, numbness, or weakness in feet and hands.

The second is called autonomic neuropathy.

This type can lead to digestive problems, vomiting, diarrhea, or constipation, sexual problems, dizziness, loss of the typical warning signs of a heart attack & changes in eye reflexes.

People with diabetes can also develop many different foot problems.

Foot problems most often happen when there is

neuropathy, which results in loss of feeling in feet. Diabetes can cause changes in the foot skin. The skin may peel and crack causing ulcers. Pathogenesis of this condition is that the nerves controlling the skin moisture are not functional. Neglecting ulcers can result in infections, which in turn can lead to gangrene and septicemia.

Gastroparesis is a disorder, where the stomach takes too long to empty its contents. It happens when the nerves to the stomach are damaged or stop working. Signs and symptoms of gastroparesis (delayed gastric emptying) are heartburn, nausea, vomiting of undigested food, early feeling of fullness, loss of appetite, weight loss, spasms of the stomach wall & gastroesophageal reflux.

Diabetes can affect every part of the body, including the skin. As many as one third of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if diagnosed early.

...The Pump Girls 2004...

...The Pump Girls 2003...

At any given time, most people with diabetes do not have depression. But studies show that people with diabetes have a greater risk of depression than people without diabetes.

There are no easy answers about why this is true. The stress of daily diabetes management can build. The diabetic person may feel alone or set apart from his friends and family because of all this extra work. Even tension between the patient and the physician may make him feel frustrated and sad.

In the end, it is important to emphasize that all of these complications can be avoided just by controlling blood sugar level, taming diabetes and by following the

...The Pump Girls 2002...

Criteria for diagnosis of Diabetes Mellitus 1. Symptoms of diabetes plus casual plasma glucose concentration >200mg/d Or 2. FPG >126mg/dl: fasting is defined as no calorie intake for at least 8 hours.

Or 3. Two hours plasma glucose >200mg/dl during an oral glucose tolerance test : The test should be performed as described by the world health organization with a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water.

Criteria B and C should be confirmed by repeated testing on separate days.

...The Pump Girls 2001...

The Pump Girls is a Girls’ music band all formed of diabetic teenagers

From American Diabetes Association 2004

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hat do Elvis Presley, Anwar El Sadat, Miss America 1998 and Thomas Edison have in common? They all have the “condition”. A "condition" that around 200 million people suffer from worldwide, a number that is expected to rise drastically to reach 300 million cases worldwide by the year 2025. A “condition” that initiated thousands of support groups, associations and care centers around the globe.

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Diabetes has more than what the word “disease” can define, some people even describe it as their personal “life planning assistant”. Most diabetics see diabetes and insulin injections as a condition similar to errors of refraction that requires wearing glasses. Hence, most of them prefer the term “condition” rather than “disease”. ...Andrew Lloyd Weber...

This journal isn’t about international figures and rates; we conducted a survey study to measure the awareness of medical students in THE biggest and most renowned medical school in the middle-east. Three hundred awareness questionnaires were collected from medical students of the different years of study and from a non-medical sample for comparison.

Incidence of Diabetes...

Students’ Awareness about the Normal Blood Glucose Level

The first impression we got from the students is that they were expecting a much higher incidence in Egypt than the actual figure: 64.1% of them accused diabetes of affecting the life of more than 25% of the Egyptian population, while only 14% knew that the actual average incidence in Egypt is between 10 and 20%. It is important to note that, according to WHO figures, unlike many diseases, diabetes is not a “disease of the poor”. On the contrary, recent studies revealed that the incidence of diabetes in rural areas in Egypt was 4.9%, 13.5% in lower socioeconomic urban areas and reaching an unprecedented 20% incidence in higher socioeconomic urban areas; reflecting the effect of sedentary life style on the incidence of diabetes.

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Students’ answers about “What is the commonest type of diabetes?”

Basic Diabetes Knowledge

Prevention of Complications

Medical students’ awareness of diabetes basic knowledge has shown a great discrepancy. Although 71.8% had quite an accurate idea about the commonest diabetic symptoms and 67.1% of them were aware of the insulin administration frequency for type 1 patients, yet, medical students’ awareness about normal fasting blood glucose level was even lower than the public awareness by more than 10%! In other words, the common man knows about normal blood glucose level more than the medical student. Some of them even commented by saying “I’ve just had a biochemistry lecture ic et about diabetes, but I ab i D don’t recall the figure”.

It is rather encouraging to find that 61.3% of the students knew that the suitable frequency for ophthalmologic examination in diabetics is at least once every year. Also, it has been noticed that students’ awareness about this recommendation gets a considerable boost after the faculty’s ophthalmology course.

Regarding diabetes predisposing factors, 71% of students though t excessive weight loss was one of these factors, while 41% of the public sample was convinced that smoking had absolutely no effect on diabetes.

...Sharon Stone...

Blood Sugar Monitoring Concerning blood sugar level monitoring and control, the results were rather deceiving; the public sample showed higher results than the students sample when asked about the best management for a diabetic patient having coma of unknown type: 60% of the public knew it is better to give glucose in such case while only 44.6% of students were aware of this.

And finally, when asked about the commonest route for daily insulin injections in IDDM patients, 45.9% of

students knew it was the subcutaneous route while 50% of the public chose this answer, although most of them did need assistance in the meaning of the word "subcutaneous".

This leaves us with a question mark about the students’ clinical sense and basic knowledge about the most common and w i d e s p r e a d condition in the world.

Results of “From these factors, which doesn’t predispose to diabetes?”

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Ebers Papyrus

Ebers Papyrus written in Egypt. First document referring to something that could be diabetes.

Aretaeus writes first clinical description of diabetes, saying “Diabetes is a dreadful affliction, not very frequent among men, being a melting down of the flesh and limbs into urine. The patients never stop making water and the flow is incessant, like the opening of aqueducts. Life is short, unpleasant and painful, thirst unquenchable, drinking excessive, and disproportionate to the large quantity of urine, for yet more urine is passed…”

The Greek scientist "Celsus" writes an encyclopedia on medicine that includes a description of a condition likely to be diabetes, calls it "excessive pouring out of urine and causing emaciation and danger” .

Celsus

Aretaeus

Diabetes through

The SSS me

T. Willis

The British physician Thomas Willis discovered that the urine of diabetics was "very much sweet, loaded with sugar or honey ", because he put his finger in the chamber pot and tasted the urine!

Hermann von Fehling invented the "Fehling's solution" which is an aqueous solution of copper sulfate, sodium hydroxide, and potassium sodium tartrate used to test for the presence of sugars and aldehydes in any substance, such as urine.

H. Fehling

M. Chevreul Diabetes recognized in Hindu medicine during what is called the Brahman period. First descriptions of sugar in the urine and occurrence in obese individuals (type 2).

Dr. M. Chevreul confirmed that the sugar giving urine a sweet taste was glucose, hence the name "Diabetes Mellitus".

Mellitus is a Latin word which means honey or very sweet.

First human proof that the administration of GLP-1 to type 2 diabetic subjects stimulates endogenous insulin secretion and effectively lowers blood glucose levels.

time...

edical editorial team Minkowski and von Mering (University of Strasbourg) find that removing the pancreas from dogs results in diabetes.

Paul Langerhans, a German medical student, announces in a dissertation that the pancreas contains two systems of cells. One set secretes the normal pancreatic juice; the function of the other was unknown. Several years later, these cells are known as the “Islets of Langerhans”.

First successful transplantation of islets without immunosuppression.

Jean de Meyer (Belgium) proposes the name insulin (Latin: insula, island) for the unknown substance in the pancreas.

Discovery and isolation of pluripotential stem cells within the pancreatic islets of Langerhans which can be grown in culture and differentiated into insulin producing cells.

Normal glucose level was identified as 110gm/dl.

George Ludwig Zuelzer extracts a pancreatic substance that he then injects into five patients.

Sugar is reduced or disappears but the patients experience unacceptable side-effects.

G. L. Zuelzer

P. Langerhans

Roger Himsworth divided diabetes into two categories: "insulin sensitive" (today's Type 1) and "insulin resistant" (the modern Type 2).

A new hormone, Glucagon-Like Peptide (GLP-1), was discovered and proved that it stimulates insulin secretion and enhances the transcriptional expression of the insulin gene.

First biosynthetic human insulin is introduced.

Fredrik Banting & Charles Best were able to publish their first paper describing the successful lowering of glucose in a pancreatectomized dog injected with pancreatic extract.

F. Banting

Phase III clinical trials for inhaled insulin was completed, an insulin powder is delivered deep into the lungs where it is easily absorbed into the blood.

The world witnesses the birth of a new scientific breakthrough; FreeStyle® Blood Glucose Monitoring System is a virtually pain-free testing device, providing accurate measurement of blood glucose from the smallest blood samples (0.3 micro liter).

C. Best 11

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iabetes mellitus is one of the most prevalent diseases in Egypt. There are at least 16 million Egyptians afflicted with the disease. That's why we need to explain to our diabetic patients that strict blood sugar control reduces the risk of blindness from diabetes.

Diabetic Retinopathy

The prevalence of diabetic retinopathy increases with the duration of diabetes and the patient’s age. After 20 years of diabetes, nearly 99% of those with IDDM and 60% of those with NIDDM have some degree of diabetic retinopathy.

Generally, any patient who is diagnosed as having diabetes mellitus should have dilated fundus examination once per year.

Other causes of visual disturbance in Diabetes

x Blood sugar fluctuation causes transient

refractive errors.

Therefore, diabetic patients should be well controlled for at least 2-3 weeks before they can get a prescription for glasses. x C a t a r a c t s : Hyperglycemia may cause transient lens There are several ways that diabetic opacification. retinopathy can cause vision loss:x Retinal vascular xRetinal edema from increased occlusion (arterial or capillary permeability and leakage venous, central or from retinal capillary branch). microaneurysms. x Anterior ischemic xRetinal ischemia from occlusion of optic neuropathy, retinal capillaries.

Laser marks as they which is an infarction xVitreous hemorrhage from abnormal appear in a fluorescein of the prelaminar angiography. vessels growing on the optic disc or portion of the optic the retinal surface. nerve. xTractional retinal detachment due to the x Cranial nerve palsies affecting the proliferation of fibrovascular membranes on extraocular muscles, may be associated the retinal surface. with diplopia. xT r a c t i o n a l / r h e g m a t o g e n o u s retinal x Acute iridocyclitis may cause blurred vision detachments, where these membranes with headache. actually cause the retina to tear. x Recurrent chalazia and styes are often one xNeovascular glaucoma, which involves the of the first ocular manifestations of abnormal growth of blood vessels on the undiagnosed diabetes. iris & the angle of the anterior chamber.

Pregnancy is associated with worsening of retinopathy.

When should a diabetic patient have an initial eye exam?

Age of onset of diabetes

Recommended time of first eye exam

Routine minimum follow-up

0-30

Within 5 years of diagnosis

Annually

31 and older

Upon diagnosis

Annually

Pregnancy

Before conception or early in first trimester

Every 3 months or at discretion of ophthalmologist

Diabetics with IDDM rarely have retinopathy during the first five y ea r s after diagnosis. In contrast, a significant percentage of patients with NIDDM have established retinopathy at the time of initial diagnosis. The table to the left summarizes the guidelines for initial ophthalmic examination in diabetic patients.

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ascular complications are the main cause of morbidity in diabetes mellitus. It is considered the major cause of all other complications paving the way for their occurrence & progression. A diagnosis of diabetes immediately increases the risk of developing various clinical complications that are largely irreversible and are due to microvascular or macrovascular disease. It was believed that the development of these complications depends greatly on the hyperglycemic state of the diabetic, but actually the role of postprandial glycemia was overestimated as disturbed blood pressure & lipid profile play an important role as well in the development of atherosclerosis in diabetics. Diabetes affects the entire cardiovascular system: the heart, large & small vessels, resulting in what's so called macroangiopathy (atherosclerosis & hypertension) & microangiopathy (retinopathy, nephropathy & neuropathy).

Though the risk factors for vascular disease remain incompletely elucidated, it has been previously suggested that factors other than glycemia may contribute to the development of vasculopathy. The prevalence of phospholipid-binding antibodies in uncomplicated and complicated diabetes was determined in many studies. Other risk factors for macroangiopathy were analyzed.

Uncomplicated diabetes was not associated with phospholipid-binding antibodies. A higher prevalence ic et of these antibodies in diabetics ab i D with macro-angiopathy or nephropathy was found. These results suggest a potential role of phospholipid-binding antibodies in the progression of vascular complications in diabetes mellitus.

Hypertension is a major factor that contri butes to the development of the vascular

complications of diabetes mellitus. The mechanism of the pathophysiological effects of hypertension lies at the cellular level in the blood vessel wall, which intimately involves the function and interaction of the endothelial and vascular smooth muscle cells. Both hypertension and diabetes mellitus alter endothelial cell structure and function. Thus, the endothelium emerges as a key target organ of damage in diabetes mellitus; this damage is enhanced in the presence of hypertension.

The problem with diabetes is not only the so many vascular complications that develops nearly in all patients but also the patient may be having a serious problem without being aware of having such a problem, because of the neuropathy. They may develop painless myocardial infarctions & other coronary heart diseases that pass unnoticed.

Atherosclerosis involving coronaries, lower limbs & brain is the major cause of death in Diabetes. Atherosclerotic process begins earlier & is more severe & occurs equally in both sexes unlike non diabetics. Many type 2 diabetics show higher prevalence of subclinical atherosclerosis & may progress to occlusive disease, but if these patients were treated in the early stage of their cardiovascular disease the risk of future cardiovascular events is markedly reduced. Cerebrovascular disease is more prevalent in diabetics than in non-diabetics and the mortality of stroke in DM patients is two-fold higher than that of non-diabetics.

Miss America 1998

Since a continuous relation exists between glycemic control and the progression of microangiopathy in both patients with type 1 & type 2 diabetes, reduction in glycated hemoglobin [Hb.sub.A1c] concentration reduce greatly the incidence of microvascular disease.

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alking or thinking about long-term complications can be scary. Let's be realistic, it can be hard for anyone to make changes in how they live today to decrease the risk of health problems that may not show up for decades. However, it's important to be at least aware of diabetic complications.

Many of the complications of diabetes don't show up until after many years - even decades - of having the disease. They usually develop silently and gradually over time, so even if people with diabetes aren't having any signs of complications, they may still eventually develop them. One of the most common complications of diabetes is the diabetic neuropathy. Over time, high blood sugar levels from diabetes can damage nerves throughout the body.

Types of diabetic neuropathy Peripheral neuropathy is from damage to the peripheral nervous system. It reduces the ability to feel pain, touch, temperature, & vibration in certain parts of the body & may sometimes affect movement and muscle strength. It most often affects the feet and lower legs and may contribute to serious foot problems, such as ulcers, infection, bone and joint deformities. It is the most common form of diabetic neuropathy.

Digestive System Problems Temperature Regulation Problems Urinary System Problems Sexual Problems Heart and Blood Vessels Problems

ic et ab i D

Autonomic neuropathy is from damage to the autonomic nervous system. These nerves control the involuntary functions of the body, such as heartbeat, blood pressure, sweating, digestion, urination, and some aspects of sexual function. This is also a common form of diabetic neuropathy.

Focal neuropathy affects a single nerve, most often in the wrist, thigh, or foot. It may also affect the nerves of the back and chest and those that control the eye muscles. Focal neuropathy usually develops suddenly.

The best way to prevent neuropathy is to keep the blood glucose level as close to the normal range as possible. Maintaining safe blood glucose level protects nerves throughout the body. Blood glucose monitoring, meal planning, exercise, and oral drugs or insulin injections are needed to control blood glucose level. Although symptoms may get worse when blood glucose is first brought under control, over time, maintaining lower blood glucose level helps lessen neuropathic symptoms. Importantly, good blood glucose control may also help prevent or delay the onset of further problems.

...Larry King...

There's probably not much time in our life for wondering what's happening next weekend, let alone time to consider how having diabetes affects our future. But thinking about diabetes a little bit now — and taking some steps to prevent problems — may make things easier down the road.

Frequent bloating, constipations, nausea, vomiting, diarrhea and abdominal pain Sweating of the torso, face and neck at night.

Alternatively, some may have reduced sweating, especially in their feet and legs Difficulty sensing when the bladder is full or difficulty emptying the bladder completely Erection problems in men and vaginal dryness in women Low blood pressure, causing dizziness, weakness

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iabetic Nephropathy is the single most common cause of end stage renal disease (ESRD) in Europe & the USA, accounting for 25% to 45% of patients on dialysis. The mortality rate of patients with diabetic nephropathy is high, particularly from cardiovascular diseases.

Persistent albuminuria (>300mg/24hr) is the hallmark of diabetic nephropathy, the presence of diabetic nephropathy and the absence of clinical or laboratory evidence of any other kidney disease confirms the diagnosis. Microalbuminuria is defined as urinary albumin excretion greater than 30mg/24hr and less than or equal to 300mg/24hr.

Macroalbuminuria:Persistent albuminuria (>300mg/24hr) characterizes this stage accompanied by decline in GFR and hypertension. Fluid retention is early observed and manifested by peripheral edema. The rate of decline in GFR ranges from 2 – 20 ml/min/year. Systemic hypertension accelerates the progression of nephropathy. Glomerular hypertension due to increased glomerular pressure, secondary to impaired renal auto regulation of renal plasma flow, also occurs. Proteinuria contributes to renal damage, therefore diabetics with nephrotic proteinuria > 3 g/24hr have the worst prognosis.

Prevalence

Pathogenesis

The overall prevalence of micro and macroalbuminuria is around 30% to 35% in both type 1 & type 2 diabetes. Diabetic nephropathy rarely develops before 10 years duration of type 1 diabetes, whereas 3% of patients with newly diagnosed type 2 diabetes have overt diabetic nephropathy.

Natural course Normoalbuminuria:In this stage the GFR is above the upper normal range, the degree of hyperfiltration is less in type 2 diabetic patients. Intensified insulin treatment and blood glucose control reduce GFR towards normal levels in both type 1 and type 2 diabetic patients. Hyperfiltration is a risk factor for increasing urinary albumin excretion and development of diabetic nephropathy in type 1 diabetic patients, but the prognostic significance of hyperfiltration in type 2 is unclear.

Microalbuminuria:It means subclinical albumin excretion.

Other factors can induce microalbuminuria in diabetic patients such as hypertension, cardiac failure & severe obesity. The prevalence of hypertension is increased in both type 1 and type 2 diabetic patients with progressive proteinuria.

Kidney lesions of diabetic nephropathy appear to be related to ECM (Extra Cellular Matrix) accumulation, this ECM accumulation is secondary to an imbalance between synthesis and degradation of ECM components. Increased levels of growth factors (particularly TGF-ǃ) ic are associated with inet ab i D creased production of ECM molecules.

Advanced glycation end products, aldose reductase enzyme, oxidation stress, glomerular mononuclear cell infiltration, insulin resistance, abnormalities of the endothelin and prostaglandin pathways all play ...Halle Berry... a role in the pathogenesis of diabetic nephropathy.

Treatment - Glycemic control - Blood pressure control: particularly using ACE I (Angiotensin Converting Enzyme I) Inhibitors or ARBs (Angiotensin Receptor Blockers).

- Lipid lowering agents: particularly HMGCoA reductase inhibitors.

- Dietary protein restriction.

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"According to W.H.O., the number of people worldwide with diabetes is projected to rise from 171 million in 2000 to 366 million by 2030. The burden will fall heavily and disproportionately on the developing countries. Countries such as Indonesia, Pakistan, Bangladesh and Brazil will remain in the top-10 countries with the highest numbers of people with the condition, joined by the Philippines and Egypt."

Diabetes Voice, September 2005

iabetes, which is linked both directly and indirectly to behavioural, nutritional and environmental factors, has emerged in recent years as the leading cause of illness, disability and death. Estimates demonstrate that in 2002 there were 4 million people in Egypt with diabetes including 40,000 children and adolescents. If current trends continue, then within the next 20 years a quarter of Egyptian people (approx. 20 million) will be living with diabetes. To prevent incapacitating disabilities linked to diabetes such as blindness, heart disease, amputations, kidney failure and severe psychosocial problems, assistance to young diabetics (A.Y.D) has developed & successfully applied an educational therapeutic program that enables youngsters and their families to control & live successfully with diabetes.

The Egyptian Society for Child Care “E.S.C.C” is an N.G.O. established in November 2000 and registered in the Ministry of Social Affairs under reference 436/2000. The president of the board is M. Laila El Sioufi and its members include the most eminent Paediatric Endocrinologists in Egypt.

"A.Y.D" is an E.S.C.C. program currently dealing with the therapeutic education of youngsters with diabetes and their families, development plans are underway to include an educational program for all insulin dependent diabetics. In 2005, A.Y.D was awarded the International DAWN (Diabetes Attitudes Wishes and Needs) prize for its successful program as well as the cooperation established with the French Association A.J.D. Aide aux Jeunes Diabetiques.

In Egypt, the first school of diabetes started to operate in 2002. By December 2005, records demonstrated that trainings and awareness projects for over 2000 youngsters and their families was achieved.

One team of four trained diabetes educators is responsible for Agouza Center and a mo-

bile team offers an intensive, indispensable course to "in–patients" in Cairo University Hospitals such as Aboul Reesh and Demerdash .

Why do we need to expand A.Y.D's program in other parts of Egypt?

Based on a conservative estimation, there are 40,000 youngsters with diabetes in Egypt. A.Y.D sets itself the target to reach out and train 13,000 youngsters over a fiveyear period empowering them to know, handle and control their diabetes, enjoying better lives, devoid of health complications.

Objectives of the program - To offer the A.Y.D program in 8 Egyptian governorates (out of 27) training and educating 13000 youngsters with diabetes and their families over a 5 year period.

- To provide education for health-care teams aiming at the development of specialized diabetes educators (medical, nutritionists, psychology and social).

- Thorough therapeutic education to allow youngsters to deal efficiently with their illness so that they know, handle and control their diabetes.

- To integrate the " Sukar Mazboot " diabetes therapeutic education program in the primary health care network.

Currently A.Y.D. operates exclusively in the Cairo Agouza Center which will continue to be the main focal point of A.Y.D’s activities.

The strategy for development and expansion of the A.Y.D. program will be through the Primary Health Care network.

Knowledge is Power 17

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et me tell you my story tailing a good experience with Mr. or Ms. Diabetes!

It is your choice whether to call my ‘Diabetes’ friend a “he” or a “she”, or even an “it” if you like. You might have been confused once you’ve read the title of my story.

I am sure a query like “Is Diabetes a friend or a foe?!” or “What is this man talking about?!” has popped up in your mind. But, I can consistently assure you that after having this long relationship with Diabetes that I entirely believe that Diabetes was and will remain my lifetime best friend.

When this friend first knocked my door and that was at my early teenage stage when I was 17 years old, my family and I were extremely shocked, worried, and afraid! We miserably started shooting anxious questions like “Why?” and “How?” It was definitely not impressive receiving this ‘Diabetes’ stranger who has just landed without any prior notice or even without any alert. By time I found myself getting into very successful relationship with that ‘Diabetes’ stranger who was always turning to be a good long lasting friend! And I really started to figure out the great values that I can acquire while learning about my new friend’s thoughts, believes, and emotions.

My ‘Diabetes’ friend likes my day to day life to be always organized and scheduled.

He adores my good shape & health, he/she gets very delighted when I disagree to smoke, to drink, or to act in a way which would waste my well being by any means.

Walking or jogging, swimming or running, aerobics or gymnastics training, practicing any type of sports in general makes my ‘Diabetes’ friend vigorously wanting to live, to breathe, & to openly fly in the sky like free emigrating birds. I do my best to eat moderately, to avoid junk or fast food, & to have vegetables & fruits in all my meals because this helps me to consist with my ‘Diabetes’ friend. Both of us always cheer each other for a long lasting healthier lifestyle. Who hates to live healthy? Certainly not me, nor my ‘Diabetes’ friend..! I love my ‘Diabetes’ friend, & I will always protect him or her against any wrong beliefs, against any

public misunderstandings, & also against surrounding rumors and hearsays. They say that my ‘Diabetes’ friend is categorized as a disability or as an infirmity. I believe my ‘Diabetes’ friend should be categorized as a condition: a condition which only needs some attention, some care, & some tuning.

If I am always going to be serious about caring well for my ‘Diabetes’ friend, he or she will let me live very pleasantly & quietly without causing any problems or hazards for tic be a me or my family. On the other Di hand, if I will lose interest about caring well for my ‘Diabetes’ friend, he or she will hit back! Ofcourse I do not, and will not, want for myself and my ‘Diabetes’ friend to ever reach such phase of life where we are only fighting to survive!

Greetings & blessings are ...Hafez El Assad... extremely needed for our life lasting journey; we do need support from the surrounding community, fellow brothers & sisters, professionals & care givers, fathers & mothers, relatives & friends! It is a long exhausting journey, but once you get a grip on it, you will not feel the pain anymore. Instead you will always feel the great values of a successful long lasting relationship that is between me & my or anyone’s ‘Diabetes’ friend. Salute, is the word we always greet each other by. In the morning when we are just awake, or at night when we are getting ready to sleep.

Same case between me & my ‘Diabetes’ friend, I wake up to check whether his/her condition is high or low or hopefully moderate. Accordingly, I plan my morning, my day, & my night. How lovely? How pleasantly? Isn’t it great to plan your whole life day by day, week by week, month by month, & lastly year by year?

If it was not for my ‘Diabetes’ friend, I believe I would have never thought of organizing my life, nor of living healthily.

We are those who chose to take responsibility for life, for community, for our medical colleagues and for ourselves.

We are those who want to be worthy of demanding a brighter tomorrow that we can be proud to share with future generations…

We are the SSS members…

As our constitution would read - the Students' Scientific Society is an independent, non-profit association, run by volunteered Kasr El Ainy medical students and represents the local level of the International Federation of Medical Students' Association "IFMSA".

The SSS opens for future physicians a gateway to understanding global health issues; become culture sensitive medical students capable of appreciating, criticizing, and improving the community constructively.

The fuel? The members. We do EVERYTHING ourselves, from human resources to public relations, from management to finances, from fundraising to publications. Our members learn everything by doing everything, proving once more that medical students can do everything they put their minds into doing.

Kindly give us a bit more of your time and let's navigate through what we have to offer and make a vow to bring more…

Our approach varies greatly from common traditional tools of the learning process.

Projects and activities are developed and periodically reviewed to guarantee a place for every taste!

Professional and Research Exchange: You must be knowing already that the SSS is highly recognized for its exchange program. On an annual basis dozens of Egyptian Medical Students are given the chance to experience a different medical atmosphere abroad. We also receive foreign students of Medical Education different backgrounds interested in the SSS members prepared trainings and social events - who come for a winter or summer school.

Reproductive Health

Public Health

Medical Education - like medi- A real major concern in all over the world & cine itself - evolutes from day in Egypt specifically for us is Public health. to day. Amid this revolution to Health education, direct supportive projects provide the best line of medi- and campaigns associated with projects as Hepatitis Awareness, TB Advocacy, and cal education there's an inDiabetic Complications Awareness are part creasing demand at our facof the committee's trials to ensure ulty, for a sensible, feasible knowledge of the disease & treatment to change in the near future & a major one in the long run. At both the medical & the non-medical person. the SSS we totally appreciate that change demands the adChild Happiness ministration & the students The very first, the very new, the one & working hand in hand. Via only committee to pay particular attenresearch methodology tion to children. Believing that a doctor courses, participation in facmust be a human doctor, we decided to ulty's accreditation protocol, place a child's interests as the priority of competitions such as DM Comthis committee, to understand a child's petition and more to come we feelings, struggles & needs. This is where believe we are on the way... your inner child comes into action!!!

Even we, medical students, do have some problems at appreciating & developing awareness towards an important issue as reproductive health. This committee has been specially developed to tackle the problem. Awareness campaign, peer-education programs & workshops are conducted on an annual basis, usually in relation to internationally recognized days as with the World Aids Day since that we work on local, national Last but not least…Our Publications & The SSS Medical – an SSS ripe fruit that you are holding now! With each issue, there's a topic of internamedical interest to be tackled. The Buzz... Not really scientific in the sense of experimental and tional applied data. Like our member centered social activities, the buzz is how we tell our fellow collevels. leagues that “all work and no play” guarantees to make the promising physician “a dull” one. This is a science in itself! It's our fresh, new, lively, page-turner booklet. Our Buzz!

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