Evaluación de la realización del cribado del pie diabético en Atención Primaria

AimTo ascertain whether patients with type 2 diabetes are screened for diabetic foot, and to analyze the factors related to patients and centers associated to performance of such screening.Material and methodsA multicenter, epidemiological, cross-sectional study was conducted. The clinical records of 443 patients with type 2 diabetes monitored at Primary Care for at least 12 months were reviewed. Demographic and healthcare variables and characteristics of the primary care center were recorded.ResultsIn the previous year, 51.2% of patients had been trained on foot self-care, 56.4% had undergone foot inspection, 39.5% had been examined with a monofilament, and palpation of peripheral pulses and measurement of the ankle-brachial index were performed in 45.8 and 10.1% of patients, respectively. Diabetic foot screening (inspection, monofilament testing, and palpation of peripheral pulses) was performed in 37% of study patients. Ulcer risk stratification was done in 12.4% of patients. A significant association was found between diabetic foot screening and presence of foot deformities (P < .001), history of neuropathy (P = .005), and history of peripheral artery disease (P < .05). Screening was also associated to some characteristics of the center, such as reception of information about goal achievement (P < .001) and economic incentives for goal attainment (P < .001).ConclusionsCompliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor.     

Unidades de pie diabético en España: conociendo la realidad mediante el uso de un cuestionario

ObjectiveTo ascertain the number of diabetic foot units (DFUs) in Spain, the specialists working in them, and the population covered by them.Material and methodsThe Spanish Group on the Diabetic Foot (SGDF) prepared and agreed a questionnaire based on the recommendations of the 2011 International Consensus on the Diabetic Foot (ICDF). From October to December 2012, the questionnaire was sent to members of three scientific societies formed by professionals involved in the care of patients with diabetes mellitus. Population coverage of the responding centers and DFUs was estimated using the 2012 population census.ResultsSeventy five questionnaires were received, 64 of them from general hospitals, which accounted for 13% of the general hospitals of the National Health System. It was calculated that they provided coverage to 43% of the population. Thirty four centers answered that they had a DFU. Specialized diabetic foot care was only provided to 25% of the population. The number of different professionals working at diabetic foot units was 6.3 ± 2.7. Classification of DFUs based on their complexity was as follows: 5 basic units (14.7%), 20 intermediate units (58.8%), and 9 excellence units (26.5%).ConclusionsThe number of DFUs reported in this study in Spain is low, and allow for foot care of only one out of every four patients with diabetes. Spanish health system needs to improve diabetic foot care by creating new DFUs and improving the existing ones.     

Ischémie myocardique du diabétique : apports de la scintigraphie myocardique de perfusion

Diabetes is an important risk factor of myocardial ischemia. Myocardial perfusion imaging (MPI) is used for diagnostic, prognostic assessment and for post-therapeutic follow-up of coronary artery disease (CAD). Its usefulness has been documented extensively in the general population. However, in diabetic population, little studies have been published. CAD is more severe and more frequent among diabetic patients. The goal of this work was to assess usefulness of MPI among diabetic patients. This work includes 44 diabetic patients (22 women, 22 men), investigated by stress MPI in nuclear medicine department of Ibn Rochd UH of Casablanca. The studied parameters concerned: age, antecedents of CAD, risk factors of CAD associated to diabetes, duration of the diabetes, diabetes complications, diabetes treatment, indication of MPI, presence or not of anomaly on the ECG performed at rest, existence or not of typical or atypical clinical signs of CAD, investigations and therapy prescribed as well as the occurrence or not of cardiac event during monitoring after MPI. Results of MPI have been compared to clinical, therapeutic and monitoring data of patients. Mean age of patients was 55 years (39 to 75 years), mean diabetes duration was 8.6 years (1 to 30 years), at least one diabetes complication has been noted in 18 patients. The most frequent complication was diabetic retinopathy. MPI has been achieved for diagnosis of ischemia in 37 patients and assessment of anti-ischemic treatment in 7 cases. Treadmill exercise has been achieved in 34 cases and a pharmacological stress in 10 others. During follow-up, which was between 1 and 36 months (mean: 14.9 months), 6 cardiac events occurred among the 44 patients. Patients with abnormal findings at stress MPI had two cardiovascular risk factors or more associated to diabetes (91.3% vs. 9.5% among patients having normal findings, P < 0.001) and had diabetic retinopathy more often (56.5% vs. 9.5% among patients with normal findings, P < 0.001). Cardiac events were more frequent among men (100% vs. 43.2% of patients who did not have a coronary event, P < 0.01). Patients with stress MPI showing ischemia in 3/17 segments or more have presented a cardiac event more often during the follow-up (4/12 Vs 2/32 among patients with normal MPI or defect in less than 3/17 segments, P < 0.01). In this series, coronary artery disease was found more frequently among patients having more than 2 cardiovascular risk factors. In addition, risk of cardiac event seems related to extent of uptake decrease.     

Molecular genetic studies in Saudi population; identified variants from GWAS and meta-analysis in stroke

IntroductionStroke is a multifactorial and heterogeneous disorder, correlates with heritability and considered as one of the major diseases. The prior reports performed the variable models such as genome-wide association studies (GWAS), replication, case-control, cross-sectional and meta-analysis studies and still, we lack diagnostic marker in the global world. There are limited studies were carried out in Saudi population, and we aim to investigate the molecular association of single nucleotide polymorphisms (SNPs) identified through GWAS and meta-analysis studies in stroke patients in the Saudi population.MethodsIn this case-control study, we have opted gender equality of 207 cases and 207 controls from the capital city of Saudi Arabia in King Saud University Hospital. The peripheral blood (5 ml) sample will be collected in two different vacutainers, and three mL of the coagulated blood will be used for lipid analysis (biochemical tests) and two mL will be used for DNA analysis (molecular tests). Genomic DNA will be extracted with the collected blood samples, and specific primers will be designed for the opted SNPs (SORT1-rs646218 and OLR1-rs11053646 polymorphisms) and PCR-RFLP will be performed and randomly DNA sequencing will be carried out to cross check the results.ResultsThe rs646218 and rs11053646 polymorphisms were significantly associated with allele, genotype and dominant models with and without crude odds ratios (OR’s) and Multiple logistic regression analysis (p < 0.05). Correlation between lipid profile and genotypes has confirmed the significant relation between triglycerides and rs646218 and rs1105364 6polymorphisms. However, rs11053646 polymorphism was correlated with HDLC (p = 0.04). Genotypes were examined in both males' vs. males and females' vs. females in cases and control and we concluded that in rs11053646 polymorphisms with male subjects compared between cases and controls found to be associated with dominant model heterozygote genotypes (p < 0.05).ConclusionThe results of the current study confirmed the SORT1 and OLR1 SNPs were associated in the Saudi population. The current results were in the association with the prior study results documented through GWAS and meta-analysis association. However, other ethnic population studies should be performed to rule out in the human hereditary diseases.     

Assessment of gender-related differences in vitamin D levels and cardiovascular risk factors in Saudi patients with type 2 diabetes mellitus

Diabetes is a major risk factor for cardiovascular disease (CVD) including stroke, coronary heart disease, and peripheral artery disease. It remains a leading cause of mortality throughout the world, affecting both women and men. This investigation was aimed to study gender based differences in cardiovascular risk factors of adult population with type-2 diabetes mellitus (T2DM) and to check the correlation between serum HbA1C, lipid profile and serum vitamin D levels, in T2DM patients of Riyadh, Saudi Arabia. This hospital-based cross-sectional study involving subjects was divided into two gender based groups; normal male (800), diabetic male (800) and normal female (800) and T2DM females (800). Blood samples were analyzed for fasting glucose (FBG), HbA1c, total cholesterol (TC), triglycerides (Tg), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and serum levels of 25(OH)-vitamin D in all groups. All the glycemic control parameters and lipid profile parameters were found to be significantly different in diabetic vs non-diabetic group (p < 0.001) in both genders. The results also show that vitamin D concentration decreased significantly (p < 0.001) in diabetic patients than the healthy individuals in both the genders. Vitamin-D and HbA1C were negatively correlated in both males and females in T2DM patients and significant at P < 0.05. Our study reveals that dyslipidemia remains one of the major risk factors of CVD in T2DM. In addition to dyslipidemia, decreased levels of vitamin-D associated with increased HbA1C alarms the early diagnosis of Type 2 Diabetes.     

Different expression of Fibrinopeptide A and related fragments in serum of type 1 diabetic patients with nephropathy

Type 1 diabetes (insulin-dependent diabetes mellitus, IDDM) is an autoimmune disease affecting about 0.12% of the world's population. Diabetic nephropathy (DN) is a major long-term complication of both types of diabetes and retains a high human, social and economic cost. Thus, the identification of markers for the early detection of DN represents a relevant target of diabetic research.The present work is a pilot study focused on proteomic analysis of serum of controls (n = 9), IDDM patients (n = 10) and DN patients (n = 4) by the ClinProt profiling technology based on mass spectrometry. This approach allowed to identify a pattern of peptides able to differentiate the studied populations with sensitivity and specificity close to 100%. Variance of the results allowed to estimate the sample size needed to keep the expected False Discovery Rate low. Moreover, three peptides differentially expressed in the serum of patients as compared to controls were identified by LC-ESI MS/MS as the whole fibrinopeptide A peptide and two of its fragments, respectively. The two fragments were under-expressed in diabetic patients, while Fibrinopeptide A was over-expressed, suggesting that anomalous turnover of Fibrinopeptide A could be involved in the pathogenesis of DN.     

Associations between diet quality, health status and diabetic complications in patients with type 2 diabetes and comorbid obesity

ObjectivePatients with type 2 diabetes (T2DM) demonstrate low dietary adherence and this is further aggravated with comorbid obesity. The aim of the present study was to assess diet quality in patients with T2DM and comorbid obesity compared to patients with T2DM alone and to examine the associations between comorbidities and diet quality.MethodsThe sample consisted of 59 adult patients with diabesity (T2DM and comorbid obesity) and 94 patients with T2DM alone. All diabetes comorbidities and complications were recorded and diet quality was assessed with the Healthy Eating Index (HEI).ResultsMean raw HEI of the diabese subjects was 81.9 ± 7.1 and the diabetic subjects was 80.2 ± 6.9. When HEI was adjusted to the sex, age and weight status, the diabese demonstrated a higher HEI. Among comorbidities, only renal disease decreased HEI. According to the principal component analysis of the total sample, adequate diet quality was explained by cardiovascular disease, cigarette smoking, alcohol consumption, peptic ulcer, sex, diabesity and diabetic foot syndrome. In the diabese, adequate HEI was explained by diabetic foot syndrome, smoking, drinking alcohol and having a family history of diabetes.ConclusionsAdult patients with T2DM demonstrate adequate diet quality. Different factors are associated with the adoption of a high quality diet between the diabese and the T2DM alone.     

Metabolic control and chronic complications during a 3-year follow-up period in a cohort of type 2 diabetic patients attended in primary care in the Community of Madrid (Spain)

BackgroundOur aim was to analyze both metabolic control and chronic complications of type 2 diabetes mellitus (T2D) patients regularly attended in primary care during a 3 years of follow-up in the Community of Madrid (Spain).MethodsFrom 2007 to 2010 we prospectively included 3268 patients with T2D attended by 153 primary care physicians from 51 family health centers. An prospective cohort study with annual evaluation over 3 years to the same population was performed. We measured the goals of control in diabetic patients and the incidence of chronic complications of diabetes during the study period.ResultsA significant decrease in serum glucose levels (143 ± 42 mg/dl vs 137 ± 43 mg/dl, p < 0.00), HbA1c (7.09 ± 1.2% vs 7.02 ± 1.2%, p < 0.00), total cholesterol (191.4 ± 38 mg/dl vs 181.5 ± 36 mg/dl, p < 0.00), LDL cholesterol (114.7 ± 31 mg/dl vs 105.5 ± 30 mg/dl, p < 0.00) and triglyceride levels (144.5 ± 93 mg/dl vs 138 ± 84 mg/dl, p < 0.00) during study period was documented. On the contrary, a significant elevation in HDL cholesterol levels was observed (49.2 ± 14 mg/dl vs 49.9 ± 16 mg/dl, p < 0.00). The incidence of diabetic complications throughout the study period was low, with a incidence of coronary heart disease of 6.2%, peripheral arterial disease 3%, ischemic stroke 2.8%, diabetic foot 11.2%, nephropathy 5.9%, retinopathy 4.5%, and neuropathy 3%.ConclusionMetabolic control in T2D patients attended in primary care in the Community of Madrid throughout 3 years is adequate and is accompanied by low percent of chronic diabetic complications during this period of follow-up.     

Effects of Canarium odontophyllum leaves on plasma glucose and T lymphocyte population in streptozotocin-induced diabetic rats

Type 1 diabetes mellitus is a chronic disease characterized by lack of insulin production. Immune mechanisms are implicated in the pathogenesis of Type 1 diabetes. Canarium odontophyllum (CO) fruits and leaves have been shown to possess high antioxidant activity. This study was conducted to evaluate the effects of CO leaves aqueous extract on the blood glucose and T lymphocyte population in the spleen of streptozotocin (STZ)-induced diabetic rats. Nineteen male Sprague–Dawley rats were randomly divided into three groups: normal, diabetic control and CO treated diabetic groups. Diabetes was induced by a single intraperitoneal injection of 65 mg STZ/kg body weight. The extract of CO leaves was administered orally by force feeding daily at the dose of 300 mg/kg for 28 days. The rats were sacrificed at the end of the study and the spleen was harvested for flow cytometry analysis. The results showed a significant decrease in body weight of diabetic and CO treated diabetic groups compared with the normal group (p < 0.05). The fasting blood glucose level of CO treated diabetic group was significantly lower than the diabetic group (p < 0.05). Diabetic and CO treated diabetic groups showed a significant increase in the percentage of spleen CD3⁺ CD4⁺ T lymphocytes (p < 0.05) when compared with the normal group. However, there was no significant difference in the percentage of spleen CD3⁺ CD8⁺ T lymphocytes among all experimental groups. The finding suggested that an aqueous extract of CO leaves has the ability to reduce blood glucose levels in diabetic rats.     

Diabetes and Hyperglycemia Quality Improvement Efforts in Hospitals in the United States: Current Status,Practice Variation,and Barriers to Implementation

ObjectiveTo determine the status of diabetes and hyperglycemia quality improvement efforts in hospitals in the United States.MethodsWe designed and administered a survey to a convenience sample of hospitals, and the responses were analyzed statistically.ResultsWe received 269 responses from 1,151 requested surveys. The sample was similar to hospitals in the United States on the basis of hospital type and geographic region (P = no significant difference) but not on the basis of number of beds (P < .001). Among responding hospitals, 39%, 21%, and 15% had fully implemented inpatient diabetes and hyperglycemia quality improvement programs for critically ill, non-critically ill, and perioperative patients, respectively. Moreover, 77%, 44%, and 49% had fully implemented protocols for hypoglycemia, hyperglycemic crises, and diabetic ketoacidosis, respectively. Variations in glucose target ranges were noted. The responding hospitals had no standard biochemical definition of hypoglycemia; 47% defined hypoglycemia as a glucose level ≤ 70 mg/dL, but 29%, 8%, 6%, and 4% used < 60, ≤ce:hsp sp="0.10"/>50, < 40, and < 80 mg/dL, respectively. Almost a third of reporting hospitals had no metric to track the quality of inpatient diabetes and hyperglycemia care. More than half (59%) indicated that they did not have an automated capability to extract and analyze glucose data. The most frequent barrier to implementing a glycemic control program was concern regarding hypoglycemia (61%).ConclusionHospitals are addressing the issue of inpatient diabetes and glycemic control but face obstacles to implementation of quality improvement programs and vary in their approach to management. Improving the consistency of glucose control practices within hospitals in the United States should help enhance patient care and safety. Future efforts to help hospitals overcome barriers to introducing glucose control programs could include developing standardized glycemic control metrics, improving data collection and reporting methods, and providing improved tools that enable clinicians to control glucose safely. (Endocr Pract. 2010;16:219-230)     

Cancer with Diabetes: Prevalence,Metabolic Control,and Survival in an Academic Oncology Practice

ObjectiveTo determine the prevalence of diabetes mellitus, glycemic control, and impact of diabetes on over all survival in an academic oncology practice.MethodsData on cancer patients (1999 to 2008) were retrieved from the institutional cancer registry and linked to electronic files to obtain diabetes status and hemoglobin A1c (A1C) values within the first 6 months of cancer diagnosis. Overall survival by cancer type with and without diabetes was compared using Cox regression.ResultsExcluding skin and hematologic malignancies, 15,951 cancer cases were identified. Overall diabe tes prevalence was 6.8% (n = 1,090), declining over time (P < 0.001). Diabetes was common among patients with pancreatic (9.8% [61 of 624]), colorectal (7.7% [89 of 1,151]), or bladder cancers (7.6% [68 of 899]). Patients with diabetes were older (mean age, 70 versus 66 years; P < 0.001) and more likely to be male (66.3% [723 of 1,090] versus 60.2% [8,949 of 14,858]; P < 0.001). The mean A1C among diabetic cancer patients was 6.8% and did not dif fer across cancer types (P = 0.80). Only 58.6% (331 of 565) of diabetic cancer patients had all A1C < 7.0% during the first 6 months following cancer diagnosis. Pancreatic cancer patients with coexisting diabetes had better overall survival than pancreatic cancer patients without diabetes (hazard ratio, 0.60; 95% confidence interval 0.44 to 0.80; P < 0.001). Conversely, diabetic prostate cancer patients had worse overall survival than prostate cancer patients without diabetes (hazard ratio, 1.36; 95% confidence interval 1.05 to 1.76; P = 0.02).ConclusionIn this academic oncology practice, diabetes was common, glycemic control often was subopti mal, and survival varied by cancer type. Additional study is needed to optimize glucose management and investigate mechanisms underlying age, sex, and survival differences. (Endocr Pract. 2012;18:898-905)     

Astragaloside IV ameliorates renal injury in streptozotocin-induced diabetic rats through inhibiting NF-κB-mediated inflammatory genes expression

Accumulating evidence suggests that inflammatory processes are involved in the development of diabetic nephropathy (DN). However, there are no effective interventions for inflammation in the diabetic kidneys. Here, we tested the hypothesis that Astragaloside IV(AS-IV), a novel saponin purified from Astragalus membranaceus (Fisch) Bge, ameliorates DN in streptozotocin (STZ)-induced diabetic rats through anti-inflammatory mechanisms. Diabetes was induced with STZ (65 mg/kg) by intraperitoneal injection in rats. Two weeks after STZ injection, rats were divided into three groups (n = 8/each group), namely, diabetic rats, diabetic rats treated with AS-IV at 5 and 10 mg kg^?1 d^?1, p.o., for 8 weeks. The normal rats were chosen as nondiabetic control group (n = 8). The rats were sacrificed 10 weeks after induction of diabetes. AS-IV ameliorated albuminuria, renal histopathology and podocyte foot process effacement in diabetic rats. Renal NF-κB activity, as wells as protein and mRNA expression were increased in diabetic kidneys, accompanied by an increase in mRNA expression and protein content of TNF-α, MCP-1 and ICAM-1 in kidney tissues. The α₁-chain type IV collagen mRNA was elevated in the kidneys of diabetic rats. All of these abnormalities were partially restored by AS-IV. AS-IV also decreased the serum levels of TNF-α, MCP-1 and ICAM-1 in diabetic rats. These findings suggest that AS-IV, a novel anti-inflammatory agent, attenuated DN in rats through inhibiting NF-κB mediated inflammatory genes expression.     

Distribución de la circunferencia de la cintura y de la relación circunferencia de la cintura con respecto a la talla según la categoría del índice de masa corporal en los pacientes atendidos en consultas de endocrinología y nutrición

IntroductionWaist circumference (WC) and the waist-to-height ratio (WHtR) are anthropometric measures widely used in clinical practice to evaluate visceral fat and the consequent cardiovascular risk. However, risk thresholds should be standardized according to body mass index (BMI).ObjectiveTo determine the distribution of WC and WHtR according to the BMI cut-points currently used to describe overweight and obesity.Materials and methodsWC, WHtR and BMI were measured in 3521 adult patients (>18 years) attended in Endocrinology and Nutrition units.ResultsA total of 20.8% (734 patients) were diabetic. Obesity was found in 82.1% of diabetic patients and in 75% of non-diabetic patients. The WC thresholds proposed by the National Institute of Health (102 cm in men, 88 cm in women), Bray (100 cm in men, 90 cm in women) and the International Diabetes Federation (94 cm in men, 80 cm in women) were exceeded by 92.9%, 94.8% and 98.4% of obese men, 96.8%, 95.5% and 99.7% of obese women, 79.1%, 83.1% and 90% of diabetic men and 95.5%, 81.5% and 97.4% of diabetic women, respectively. Thresholds adapted to the degree of obesity (90, 100, 110 and 125 cm in men and 80, 90, 105 and 115 cm in women for normal BMI, overweight, obesity I and obesity greater than I) were exceeded by 58.4% of obese men, 54.2% of obese women, 57.5% of diabetic men and 60.7% of diabetic women. WC was higher in men, and BMI and the WHtR were higher in women. The WC of diabetic women equalled that of men, and WC, WHtR and BMI were higher in diabetic than in non-diabetic women (p<0.001). WC (p<0.005), WHtR (p<0.001) and BMI (p<0.5) were also higher in diabetic than in non-diabetic men.ConclusionWC and WHtR thresholds by BMI discriminated diabetic and obese patients better than single thresholds, and can be represented graphically by the distribution of percentile ranks of WC and WHtR by BMI.ik     

Neurotensin-loaded collagen dressings reduce inflammation and improve wound healing in diabetic mice

Impaired wound healing is an important clinical problem in diabetes mellitus and results in failure to completely heal diabetic foot ulcers (DFUs), which may lead to lower extremity amputations. In the present study, collagen based dressings were prepared to be applied as support for the delivery of neurotensin (NT), a neuropeptide that acts as an inflammatory modulator in wound healing. The performance of NT alone and NT–loaded collagen matrices to treat wounds in streptozotocin (STZ) diabetic induced mice was evaluated. Results showed that the prepared dressings were not-cytotoxic up to 72 h after contact with macrophages (Raw 264.7) and human keratinocyte (HaCaT) cell lines. Moreover, those cells were shown to adhere to the collagen matrices without noticeable change in their morphology. NT–loaded collagen dressings induced faster healing (17% wound area reduction) in the early phases of wound healing in diabetic wounded mice. In addition, they also significantly reduced inflammatory cytokine expression namely, TNF-α (p < 0.01) and IL-1β (p < 0.01) and decreased the inflammatory infiltrate at day 3 post-wounding (inflammatory phase). After complete healing, metalloproteinase 9 (MMP-9) is reduced in diabetic skin (p < 0.05) which significantly increased fibroblast migration and collagen (collagen type I, alpha 2 (COL1A2) and collagen type III, alpha 1 (COL3A1)) expression and deposition. These results suggest that collagen-based dressings can be an effective support for NT release into diabetic wound enhancing the healing process. Nevertheless, a more prominent scar is observed in diabetic wounds treated with collagen when compared to the treatment with NT alone.     

Multichannel EMG-based estimation of fiber conduction velocity during isometric contraction of patients with different stages of diabetic neuropathy

This study compares muscle fiber conduction velocities estimated using surface electromyography during isometric maximal voluntary contraction in different stages of diabetic neuropathy. Eighty-five adults were studied: 16 non-diabetic individuals and 69 diabetic patients classified into four neuropathy stages, defined by a fuzzy expert system: absent (n = 26), mild (n = 21), moderate (n = 11) and severe (n = 11). Average muscle fiber conduction velocities of gastrocnemius medialis, tibialis anterior, vastus lateralis and biceps femoris were assessed using linear array electrodes, and were compared by ANOVA. Conduction velocities were significantly decreased in the moderate neuropathy group for the vastus lateralis compared to other groups (from 18% to 21% decrease), and were also decreased in all diabetic groups for the tibialis anterior (from 15% to 20% from control group). Not only the distal anatomical localization of the muscle affects the conduction velocity, but also the proportion of muscle fiber type, where the tibialis anterior with greater type I fiber proportion is affected earlier while the vastus lateralis with greater type II fiber proportion is affected in later stages of the disease. Generally, the muscles of the lower limb have different responsiveness to the effects of diabetes mellitus and show a reduction in the conduction velocity as neuropathy progresses.     

Alteraciones del metabolismo glucídico en el estudio de control de factores de riesgo de Extremadura (estudio COFRE)

AimsTo assess the prevalence and control of glucose metabolism disorders in a population of Extremadura (Spain) with at least one cardiovascular risk factor and to compare the characteristics of these patients with those who were normoglycemic in the risk factor control in Extremadura (COFRE study).Patients and methodsThe prevalence and control of cardiovascular risk factors were recorded in a sample of 1,022 patients with at least one cardiovascular risk factor consecutively visiting a primary care office. Of these, 951 patients were included in the analysis. In all patients, fasting glycemia was recorded. Glycated hemoglobin was recorded in diabetic patients.ResultsA total of 320 patients (33.6%) were previously known to be diabetic (DM) and 84 (8.8%) had glycemia ≥126 mg/dl without a previous diagnosis of diabetes (12 with glycemia above 200 mg/dl). Impaired fasting glycemia (IFG) was found in 211 (22.2%) and normoglycemia (NG) in 336 (35.3%). Within the DM group, glycemia <126 mg/dl was found in only 31.4% but glycated hemoglobin lower than 7% was found in 46.8%. Triglyceride concentrations were higher in the IFG group than in the NG group (137±65 mg/dL vs 124±65 mg/dL, p=0,041). Pulse pressure was also higher, but no differences were found in diastolic blood pressure (DBP) or heart rate. Differences in systolic blood pressure (SBP) were at the limit of significance (DM 139.5±17 vs NG 136.5±16 mmHg; p=0.056). No significant differences were found in any of these parameters between the DM and IFG groups.ConclusionsThe prevalence of glucose metabolism disorders was very high in the recruited sample. Patients with IFG showed higher pulse pressure and triglyceride concentrations than those with NG but there were no differences in comparison with DM patients. Diabetic control was poor when assessed by fasting glycemia but glycated hemoglobin showed better control.     

Trace elements,oxidative stress and glycemic control in young people with type 1 diabetes mellitus

Trace elements and oxidative stress are associated with glycemic control and diabetic complications in type 1 diabetes mellitus. In this study, we analyzed the levels of serum copper, zinc, superoxide dismutase (SOD) activity, and malondialdehyde (MDA) and urinary MDA and 8-hydroxy-2′-deoxyguanosine (8-OHdG) in 33 type 1 diabetic patients with optimal and suboptimal glycemic control (HbA_1C < 9.0%) and 40 patients with poor glycemic control (HbA_1C ≥ 9%) and 27 age- and sex-matched non-diabetic controls to evaluate the differences between these markers in different glycemic control states. Diabetic patients, especially poor-glycemic-control subjects (HbA_1C ≥ 9%), exhibited significantly lower levels of serum zinc and increased levels of serum copper (and, therefore, increased serum copper-to-zinc ratios), serum SOD, blood MDA, and urinary MDA and 8-OHdG, relative to non-diabetic subjects. Furthermore, significant correlations existed in these patients between the serum copper, serum copper-to-zinc ratio, and urinary MDA (all p < 0.001) and the levels of urinary 8-OHdG (p = 0.007) and HbA_1C. Our results suggest that high serum copper levels and oxidative stress correlate with glycemic control. Therefore, strict glycemic control, decreased oxidative stress, and a lower copper concentration might prevent diabetic complications in patients with type 1 diabetes mellitus.     

Achievement of therapeutic targets in Mexican patients with diabetes mellitus

Background and aimComplications of diabetes comprise the leading cause of death in Mexico. We aimed to describe the characteristics of management and achievement of therapeutic targets in Mexican patients with diabetes mellitus.MethodsWe analyzed data from 2642 Mexican patients with type 1 (T1D, n = 203, 7.7%) and type 2 diabetes (T2D, n = 2439, 92.3%) included in the third wave of the International Diabetes Management Practices Study.ResultsOf T2D patients, 63% were on oral glucose-lowering drugs (OGLD) exclusively (mostly metformin), 11% on insulin, 22% on OGLD plus insulin, and 4% on diet and exercise exclusively. T2D patients on insulin were more likely to be trained on diabetes, but they were older, had worse control, longer disease duration and more chronic complications than patients on OGLD only. Glycated hemoglobin (HbA1c) < 7% was achieved by 21% and 37% of T1D and T2D patients, respectively. Only 5% of T1D and 3% of T2D attained the composite target of HbA1c < 7%, blood pressure < 130/80 mmHg and low-density lipoprotein cholesterol < 100 mg/dl. T1D patients had less macrovascular but more microvascular complications, compared with T2D patients. Late complications increased with disease duration, so that about 80% of patients after 20 years of diagnosis have at least one late complication. Reaching the target HbA1c < 7% was associated with a reduced number of microvascular but not with less macrovascular complications.ConclusionA great proportion of these Mexican patients with diabetes did not reach therapeutic targets. Insulin was used mostly in complicated cases with advanced disease.     

Inpatient Management of Diabets Mellitus Among Noncritically Ill Patients at the University Hospital of Puerto Rico

ObjectiveTo describe the state of glycemic control in noncritically ill diabetic patients admitted to the Puerto Rico University Hospital and adherence to current standard of care guidelines for the treatment of diabetes.MethodsThis was a retrospective study of patients admitted to a general medicine ward with diabetes mellitus as a secondary diagnosis. Clinical data for the first 5 days and the last 24 hours of hospitalization were analyzed.ResultsA total of 147 noncritically ill diabetic patients were evaluated. The rates of hyperglycemia (blood glucose ≥ 180 mg/dL) and hypoglycemia (blood glucose < 70 mg/dL) were 56.7 and 2.8%, respectively. Nearly 60% of patients were hyperglycemic during the first 24 hours of hospitalization (mean random blood glucose, 226.5 mg/dL), and 54.2% were hyperglycemic during the last 24 hours of hospitalization (mean random blood glucose, 196.51 mg/dL). The mean random last glucose value before discharge was 189.6 mg/dL. Most patients were treated with subcutaneous insulin, with basal insulin alone (60%) used as the most common regimen. The proportion of patients classified as uncontrolled receiving basal-bolus therapy increased from 54.3% on day 1 to 60% on day 5, with 40% continuing to receive only basal insulin. Most of the uncontrolled patients had their insulin dose increased (70.1%); however, a substantial proportion had no change (23.7%) or even a decrease (6.2%) in their insulin dose.ConclusionThe management of hospitalized diabetic patients is suboptimal, probably due to clinical inertia, manifested by absence of appropriate modification of insulin regimen and intensification of dose in uncontrolled diabetic patients. A comprehensive educational diabetes management program, along with standardized insulin orders, should be implemented to improve the care of these patients. (Endocr Pract. 2014;20:452-460)     

Economic and Clinical Impact of Inpatient Diabetic Hypoglycemia

ObjectiveTo assess the clinical and economic impact of hypoglycemia that develops during hospitalization of patients with diabetes.MethodsIn this retrospective cohort study, data from 70 hospitals were used to identify the first inpatient encounter for adult patients with diabetes. Patients were included if all blood glucose measurements were 70 mg/dL or higher during the first 24 hours and their primary discharge diagnosis was for a condition other than hypoglycemia. Those who developed laboratory evidence of hypoglycemia (blood glucose < 70 mg/dL after 24 hours) were compared with patients whose blood glucose values were all 70 mg/dL or higher. An alternative definition of hypoglycemia (blood glucose < 50 mg/dL after 24 hours) was also evaluated. We adjusted for potential confounders with multivariate models.ResultsHypoglycemia had an adverse effect on all outcomes among more than 100 000 diabetic patients. After adjustment, patients with diabetes who developed hypoglycemia had higher charges (38.9%), longer lengths of stay (3.0 days), higher mortality (odds ratio, 1.07; 95% confidence interval, 1.02-1.11), and higher odds of being discharged to a skilled nursing facility (odds ratio, 1.58; 95% confidence interval, 1.48-1.69) than diabetic patients without hypoglycemia (P < .01 for all). In all cases, using the lower threshold (< 50 mg/dL) to define hypoglycemia resulted in similar findings with a larger magnitude of differences.ConclusionsAlthough a direct causal relationship cannot be inferred, these study findings suggest the importance of carefully maintaining euglycemia during hospitalizations. Whether the observed worse outcomes were due to hypoglycemia itself or whether they were a marker of worse outcomes due to other causes requires further research. (Endocr Pract. 2009;15:302-312)