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Archived Comments for: Type 1 diabetes and cardiovascular disease

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  1. We need new terms to better explore emergent clinical settings

    Carlos Musso, Nephrology Division. Hospital Italiano de Buenos Aires. Argentina

    24 February 2014

    The names we use to designate diseases in fact reduce them to just a handful of links (segment) belonging to what actually is a huge chain of patho-physiological processes (continuum), but this interpretative approach makes possible to analyze this segments and later develop strategies (treatments) which tend to solve or slow down them. Nevertheless, the extension of life expectancy, together with the development of various kinds of therapeutic treatments (antibiotics, dialysis, transplants, etc.) has given way to a singular phenomenon: the appearance of new clinical scenarios whose evolutionary course and response to conventional therapeutics are different from the previous ones, so the classical labels turn out to be insufficient for them (1-4).                                                                                      As Schnell et al. describe in their excellent review article regarding “type 1diabetes and cardiovascular disease” (5), there are many factors that can contribute to induce vascular damage, and consequently to increase cardiovascular mortality, secondary to long-term hyperglycemia. However, some of these factors (chronic inflammation, oxidative stress, etc.) are more pronounced in those diabetic patients who are also on dialysis or transplant treatment, than in those who just suffer from diabetes mellitus without renal disease (6-8). Such is the case of chronic dialysis patients whose clinical evolution depends on the etiology of their nephropathy: dialysis patients have usually worse cardio vascular prognostic when they suffer from a systemic disease as cause of their nephropathy (eg: diabetes mellitus) than when they suffer from a primarily kidney disease (eg: polycystic kidney disease, etc.)(9). In the same sense, pharmacological treatment of dyslipidemia in chronic dialysis patients, opposed to what happens to patients not suffering from nephropathy, has not proved to modify their mortality rates (10,11). Therefore, our intervention on several patho-physiological processes (infection, hormonal deficit, endothelial disease, etc.) has paved the way to new clinical scenarios that are no longer represented properly by our classic medical vocabulary; there is even the risk of reducing them since they could not be adequately represented by the old terms. Thus arises the need for a new vocabulary that describes these new entities which are product of the combination of classic ones (diabetes mellitus or dyslipidemia) and chronic treatments (dialysis or transplantation). Naming these entities would make it easier to identify them and separate them from the mere sum of its entities put together, as well as to focus the attention on them for their analysis (protocols of investigation) so as to favor its resolution through new therapeutic perspectives where the conventional ones have failed.                      In order to create a name convention which designates these new entities product of the juxtaposition with others, but with consequences which transcend the mere sum of these illnesses, we could use a resource that natural languages have and that great writers (Carroll, Joyce) have already used to be able to describe concepts which did not have a word to represent them. This resource consists of the terms portmanteaux, meaning the words which arise from the fusion of others and whose objective is to break the linearity of formal thought and create new concepts (12).Thus, taking into consideration the mechanism of formation of a portmanteaux words, each term designates a classic illness to an entity which mixes with others to originate a new one, it could be subdivided in a first segment (main word) and a second one (suffix), so in order to designate a new clinical situation which is a product of the interaction between a classical entity (eg: dislypidemia) and a particular clinical situation (eg: dialysis), the “main word” could be constituted by the former, and the “suffix by the latter: So, for instance, taking the clinical situation mentioned above: dyslipidemia of a patient on chronic dialysis, could be called dislypidemia-D (D:dialysis); or in the case of a person suffering from diabetes mellitus in chronic dialysis, could be called diabetes mellitus-D (dialysis).                     Obviously, this is not about creating neologisms for all kinds of classic entities combination, but only for those where the combination gives as a result a new clinical situation which is different to the mere sum of its entities defined by their intersection, it may be because of its worst evolution (eg: diabetes mellitus + chronic dialysis) or its lack of response to treatments which are successful for the isolated version of them (eg: dislypidemia + chronic dialysis). As we have already mentioned, given the way in which human beings interpret phenomena, being able to remark these new pathological processes by providing them with their own name, upgrades them as entities, making their analysis easier and favoring the rise of new and effective therapeutics to solve them.

    References

    1) Wittgenstein L. Philosophical investigations. Barcelona. Editorial Crítica. 2004

    2) Eco U. Semiotics and philosophy of the language. Barcelona. Editorial Lumen. 1990

    3) Musso CG. The forgotten organ. Humane Health Care. 2003; 3(2): 1

    4) Musso CG, Enz P. Medical semiotics. Buenos Aires. Delhospital Ediciones. 2007

    5) Schnell O, Cappuccio F, Genovese S, Standi E, Ceriello A. Type 1 diabetes and cardiovascular disease. Cardiovascular Diabetology. 2013; 12:156

    6) Ren H, Zhou X, Lou Z, Han S, Cai Q, Rui W, Li Y. The relationship between carotid atherosclerosis, inflammatory cytokines, and oxidative stress in middle-aged and elderly hemodialysis patients. Int J Nephrol. 2013; 2013: 835465

    7) Velloso MS, Otoni A, de Paula Sabino A, de Castro WV, Pinto SW, Marinho MA, Rios DR. Peritoneal dialysis and inflemmation. Clin Chim Acta. 2013, 11; 430 C: 109-114

    8) Israni AK, Leduc R, Jacobson PA, Wilddebush W, Schladt D. Matas AJ, Oetting WS; DeKAF genomics investigators. Inflammation in the setting of chronic allograft dysfunction post-kidney trasplant: phenotype and genotype. Clin Transplant. 2013; 27(3): 348-58

    9) Tzamaloukas A, Friedman E, Diabetes. In Daugirdas J, Blake P, Ing T (Eds). Handbook of dialysis. Philadelphia. Lippincott Williams & Wilkins. 2001: 453-465

    10) Wanner C, Krane V, März W, Olsschewski M, Mann J, Ruf G, Ritz E. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. The New England Journal of Medicine. 2005; 353(3): 238-248

    11) Fellström B, Jardine A, Schmieder R, at al. Rosuvastatin and cardiovascular events in patients undergoing hemodialysis. The New England Journal of Medine. 2009; 360(14): 1395-1407

    12) Tindall W. A reader¨s guide to Finnegans wake. New York. Syracuse University Press. 1996 

    Competing interests

    I declair to have no competing interests.

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