Avances en Diabetología最新文献

Objective

When used with continuous glucose monitoring (CGM) and bolus estimation algorithms, many patients on insulin pump therapy achieve near-euglycemia. We evaluated the usage patterns of integrated pump/CGM technology that are associated with A1C levels < 7%.

Methods

Data from 217 patients (age > 11 years, 53.5% male, 91.7% with type 1 diabetes, all with > 3 months pump experience) receiving care at a teaching hospital in Bogotá, Colombia, were analyzed. Data included insulin delivery, A1C levels, severe hypoglycemic events, use of CGM, completion of diabetes education courses, and the frequency of blood glucose checks. All patients received training on the use of the pump, and most (73.7%) received additional training on carbohydrate counting, basal rate adjustments, and use of CGM data.

Results

Initiation of pump therapy was associated with decreases in A1C, insulin use, and severe hypoglycemic events (all P < .001). Pump and CGM-specific behaviors associated with lower A1C included the use of a dose estimation algorithm for > 80% of bolus doses and use of CGM sensors > 80% of the time (both P < .005). Lower A1C was also associated with the completion of additional training, age > 18, use of the Paradigm 722 pump with an integrated CGM device, use of CGM-based alarms, A1c >7% before pump therapy, and more frequent blood glucose checks (all P < .05). Many (45.6%) patients reached A1c ≤ 7% with pump therapy.

Conclusions

Patient education, with an A1c below 7% before sensor-augmented pump therapy, when combined with consistent use of CGM sensors and bolus estimation algorithms, leads to favorable reductions in A1C beyond those achieved with pump therapy alone

Objectives

To evaluate the epidemiological, clinical and healthy lifestyle adherence variables that are associated with HbA1c ≤ 7% in patients with type 1 diabetes (DM-1).

Methods

A descriptive observational study was conducted in 130 patients with DM-1 of 33.7 ± 11.7 years old. Various clinical, anthropometric and analytical variables were analysed, together with the results of the “Minnesota Leisure Time Physical Activity Questionnaire” and “Adherence to the Mediterranean Diet Questionnaire”.

Results

Patients with HbA1c ≤ 7% (n = 39) spent more time on physical activity (PA) (999.7 ± 538.6 versus 719.5 ± 386.0 versus 834.2 ± 512.7 minutes/PA/week, P = .010) and intense PA (180.6 ± 80.4 versus 259.3 ± 125.5 versus 104.3 ± 139.9 minutes/PA intense/week, P = .037), compared with patients with HbA1c between 7-8% (n = 41) and higher than 8% (n = 50). Patients with HbA1c ≤ 7% were more likely to be college graduates (77%) than patients of other groups. There were no significant differences in HbA1c levels according to age, sex, diabetes evolution, body mass index, number of hypoglycaemia, presence of chronic complications, or adherence to the Mediterranean diet. In the multivariate analysis, the independent variables “college graduate” and “spent more than 150 minutes of intense physical activity a week” showed a significant association with the dependent variable “HbA1c ≤ 7%”.

Conclusions

In our study, patients with DM-1 and HbA1c ≤ 7% were most often college graduates and spent more time practicing intense physical activity than patients with poor metabolic control.

Objectives

To assess the reasons for referral of type 2 diabetes (T2DM) patients from primary care (PC) to specialized care (SC) in Spain. To assess the level of compliance with referral criteria established in national recommendations.

Methods

Observational, cross-sectional, multi-centre national study, in PC and SC. Each physician provided, using a structured case report form, data on usual practice for T2DM patient referral and data about referral of 6 patients. Recommendations of the Spanish Society for Endocrinology and Nutrition (SEEN) and the National Health System (NHS) were used as reference documents to assess compliance. Data from clinical practice of 143 professionals of SC/641 general practitioners (GPs) and from referrals of 805 patients to PC/3,624 to SC are presented.

Results

Almost one-third (31.8%) of GPs and 46.2% of SC professionals reported the existence of a coordination protocol with the other healthcare level. The most frequent communication tool for referrals to SC was a Consultation Report (89.2%), and the Medical History for referrals to PC. The referral criterion to SC most frequently declared was Metabolic Instability (80.5%) and to PC was Goal Achievement (96.5%). The most frequent cause for referral to SC among the patients studied was Reassessment (48.4%) and to PC Goal Achievement (91.6%). Almost half (46.8%) of GPs applied all NHS criteria in usual practice, and 3.9% all SEEN referral criteria.

Conclusions

The number of reported coordination protocols is low, and the compliance with national guidelines is poor.

Type 1 diabetes mellitus is a chronic, autoimmune disease, where specific pancreatic β-cell destruction leads to complete insulin deficiency.

Management of the patient at diagnosis includes patient education (training in insulin self-injection, self-monitoring of glucose and ketone levels, prevention and management of hypoglycaemia…) and intensive insulin treatment, aimed at achieving glucose concentrations as close to normal as safely possible and avoiding hypoglycaemia. Screening for associated thyroid and coeliac diseases is recommended at the onset of type 1 diabetes. Pancreatic auto-antibody measurement, however, is only recommended in case of diagnostic uncertainly. The measurement of stimulated C-peptide after a mixed meal is the reference method to assess endogenous insulin production, although its use is currently limited to intervention trials.

Under low oxygen pressure (hypoxia), cells activate a specific genetic program, modulating genes involved in anaerobic metabolism and cellular energy metabolism. The transcriptional hypoxia inducible factors (HIFs) are central to this response. HIF activity is regulated by the von Hippel-Lindau tumour suppressor protein (pVHL). In the presence of oxygen, pVHL targets HIF for ubiquitination and subsequent proteasomal degradation. Several recent reports have revealed a critical role of the hypoxia response mediated by HIF on glucose homeostasis. Changes in HIF pathway activity in beta-cells impair insulin secretion. Furthermore, the HIF pathway regulates the metabolic function in organs involved in the pathogenesis of diabetes and metabolic syndrome such as liver, fat and muscle. These observations raise the question of whether changes in HIF levels might contribute to the progression of type 2 diabetes.

Type 2 diabetes mellitus (T2DM) in the pediatric age is defined as the impaired balance between insulin sensitivity and insulin secretion, obesity and the absence of pancreatic antibodies. The worldwide epidemic of childhood obesity has been accompanied by an increase of T2DM, but not in Spain. Significant risk factors for T2DM include ethnicity, family history, obesity, low (or high) birth weight and gestational DM.

Its outcome includes the early development of acute and chronic diabetic complications and secondary comorbidities as hypertension and hyperlipidaemia.

Treatment goals include lifestyle changes (nutrition and exercise) to achieve glycemic control. Metformin and insulin are the only agents approved for pediatric T2DM.

Children at substantial risk for T2DM should be considered for screening by fasting plasma glucose or oral glucose tolerance test.

Objective

To assess the characteristics of autoimmune diseases (AD) in patients with type 1 diabetes mellitus (T1DM).

Patients and methods

A cross-sectional, multicentre study on adult patients with T1DM seen in outpatient endocrinology clinics over a 12 month period. Sociodemographic and clinical variables and the presence of AD [autoimmune thyroid disease (ATD), chronic gastritis, coeliac disease (CD), vitiligo, primary adrenal insufficiency, and other AD in this cohort] were investigated.

Results

The study included a total of 1,465 patients (51.5% male) with a median age of 38.2 years (interquartile range 28,5-48,3) and a median diabetes duration of 17.3 years (11.1-25.6). Just under one-third (29.2%) had AD, with ATD being the most frequent (22% with normal thyroid function or hypothyroidism, and 3.4% with hyperthyroidism). ATD was most frequent in females [70.5% (P < .001)] and the prevalence increased with age [41.7 ± 14.5 vs 38.6 ± 13.1 years in patients with and without ATD respectively (P < .001)]. ATD with normal thyroid function or hypothyroidism increased also with longer duration of T1DM [17.1% with < 10 years, 21% with 10-20 years, 24.6% with 20-30 years and 26.3 with > 30 years (P < .05)]. Other AD were chronic gastritis (3.6%), vitiligo (1.6%), CD (1.1%), primary adrenal insufficiency (0.3%) and others (3.4%).

Conclusions

ATD was the most prevalent AD. CD and chronic gastritis were probably underdiagnosed in our study as there is no consensus for screening. Screening for AD may be necessary in patients with T1DM.

Introduction

Premixed insulins are a common treatment for type 2 diabetes mellitus (DM). However, their limitations and the lack of achieving glycaemic control in some patients reinforce the need to find therapeutic alternatives.

Objectives

To assess whether basal–prandial therapy (basal insulin, and additional pre-prandial rapid insulin boluses, when required) improves glycaemic control in patients with type 2 DM and glycosylated haemoglobin (HbA1c) >53 mmol/mol (7%) treated with premixed insulin in the primary care setting.

Material and methods

A retrospective observational study in which 116 patients with type 2 DM switched from premixed insulin to basal–prandial therapy. Data on demographics, anthropometrics, laboratory results, and antidiabetic treatment were collected from the medical charts of the patients, prior to switching the treatment (baseline) and 4 months thereafter.

Results

HbA1c significantly decreased from baseline to month 4 (65.1 ± 5.7 mmol/mol [8.1 ± 0.5%] versus 51.9 ± 7.2 mmol/mol [6.9 ± 0.7%]; p < .005), and 70 patients (60.9%) had an HbA1c ≤53 mmol/mol (7%). Additionally, fasting blood glucose (FBG) significantly decreased (9.7 ± 1.7 mmol/l [175.4 ± 31.2 mg/dl] versus 6.9 ± 1.4 mmol/l [124.4 ± 25.8 mg/dl]; p < .005), and the number of patients with FBG < 5.6 mmol/l (100 mg/dl) (2 patients [1.7%] versus 21 patients [18.3%]; p < .005), and with post-prandial blood glucose ≤10 mmol/l (180 mg/dl) (14 patients, [12.1%] versus 87 patients [76.3%]; p < .05) significantly increased. There were also significant decreases in body weight (76.3 ± 12.9 kg versus 74.8 ± 12.5 kg; p < .001) and waist circumference (96.1 ± 16.0 cm versus 94.4 ± 14.5 cm; p < .005). Only 4 patients (3.5%) had hypoglycaemia.

Conclusions

Basal–prandial therapy improved glycaemic control in patients with type 2 DM, with a low incidence of hypoglycaemia, and decreased body weight.