RESUMO
Insulin treatment in type 2 diabetes mellitus patients is still essential and its usage has increased during recent years. Despite this, the level of control continues to be very poor. Insulin treatment is initiated with control levels above the recommendations set by the Clinical Practice Guidelines (CPG) and patients are exposed to very high blood glucose levels during long periods of time. This paper reviews the role of insulin in the different CPG, the criteria for therapy initiation and intensification, the beginning of the intensification and the different types of insulin which are commercialized in our country. Moreover, we discuss insulinization in special situations such as corticosteroid treatment, fragile elderly patients, palliative care situations, chronic kidney disease or during Ramadan. Finally, the problem of therapeutic inertia in insulinization is also addressed.
Assuntos
Diabetes Mellitus Tipo 2 , Insulinas , Médicos de Atenção Primária , Idoso , Glicemia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hemoglobinas Glicadas/análise , Humanos , Hipoglicemiantes , InsulinaRESUMO
OBJECTIVES: To estimate the prevalence of known and undiagnosed depression in patients with type 2 diabetes attended in primary care setting in Spain, and to determine the factors associated with the presence of depression. METHODS: This was a cross-sectional and multicenter study performed in a random sample of patients with type 2 diabetes attended in 21 primary care centers. Depressive symptoms were measured with the self-administered Patient Health Questionnaire (PHQ-9). RESULTS: A total of 411 patients were analyzed (mean age 70.8 (SD 10.3) years; 53.8% women). 29.2% of patients met the diagnostic criteria of depression, of whom 17% had known depression and 12.2% undiagnosed depression (PHQ-9 score ≥10, without a previous diagnosis of depression). Depression was more common in women (43.4%; 95% confidence interval [CI] 34.5-52.3%), widow (33.3%; 95% CI 27.9-38.7%), and hypothyroidism (12.5%; 95% CI 8.7-16.3%). Cardiovascular risk factors, the degree of control, complications related to diabetes, antidiabetic therapy and the number of drugs were not associated with the presence of depression. CONCLUSIONS: The prevalence of depression was high in patients with type 2 diabetes. However, in approximately 40% of patients depression was undiagnosed. The complications related to diabetes and antidiabetic therapy were not associated with the presence of depression.
Assuntos
Depressão/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Depressão/diagnóstico , Depressão/psicologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Questionário de Saúde do Paciente , Prevalência , Atenção Primária à Saúde , Fatores de Risco , Espanha/epidemiologiaRESUMO
AIMS: To evaluate the degree of glycemic control and its relationship with disease characteristics and antidiabetic treatment in patients with type 2 diabetes mellitus (DM), as well as the frequency of A1c use. METHODS: For this purpose, an observational, cross-sectorial, and multicenter study was performed. A total of 443 patients were monitored in 17 Spanish primary healthcare centers. Demographic and clinical variables were recorded from the clinical history of patients. RESULTS: Mean age was 68.9±12.0 years. Time of evolution of DM was 9.2±6.4 years. Mean A1c was 7.38±1.34% and 45% of patients achieved A1c <7%. There was a no significant relationship between the degree of control and time of evolution of DM. In 16% of patients no A1c determination was performed in the previous twelve months. In those patients in whom A1c was determined, 95% received pharmacologic treatment, and 31% insulin therapy. 66% of patients on monotherapy attained A1C <7%, compared with 39% and 23% of those receiving double- and triple-oral therapy, respectively (p<0.001). Only 21% of patients on insulin therapy achieved A1c <7%. The worst-controlled patients were those receiving oral antidiabetic agents and insulin (24% had A1c levels ≥9%). CONCLUSIONS: A large proportion of patients are poorly controlled. Poor control increases according to complexity of treatment. A1c is underdetermined in many patients, likely related to clinical inertia.
Assuntos
Glicemia/efeitos dos fármacos , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hemoglobinas Glicadas/metabolismo , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Atenção Primária à Saúde , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Glicemia/metabolismo , Estudos Transversais , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/diagnóstico , Quimioterapia Combinada , Feminino , Humanos , Hipoglicemiantes/administração & dosagem , Insulina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Espanha , Resultado do TratamentoRESUMO
AIM: To 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 METHODS: A 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. RESULTS: In 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). CONCLUSIONS: Compliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor.
Assuntos
Diabetes Mellitus Tipo 2/complicações , Pé Diabético/diagnóstico , Exame Físico/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Idoso , Índice Tornozelo-Braço , Comorbidade , Estudos Transversais , Angiopatias Diabéticas/epidemiologia , Neuropatias Diabéticas/epidemiologia , Retinopatia Diabética/epidemiologia , Feminino , Deformidades Adquiridas do Pé/epidemiologia , Objetivos , Instalações de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Palpação , Educação de Pacientes como Assunto , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Reflexo Anormal , Medição de Risco , Fatores de Risco , Autocuidado , Autoexame , Fumar/epidemiologia , Espanha , Percepção do Tato , VibraçãoRESUMO
In the last few years, the publication of new studies in diabetes, together with the development of new classes of blood glucose-lowering medications, have led to updates of the most prestigious clinical practice guidelines for the treatment of diabetes. Thus, a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes on the management of hyperglycemia in type 2 diabetes was published in April 2012. An update of one of the evidence-based guidelines issued by the Canadian Diabetes Association appeared in 2013 and this year, 2014, saw the publication of the consensus document of the redGDPS, whose guidelines are those most closely followed by primary care physicians in Spain. The three guidelines highlight the need for an individualized approach to type 2 diabetes mellitus, outlining both target glycemic goals and distinct treatment regimens based on patient characteristics, disease stage and the presence of comorbidities or complications. In the treatment of the disease, the three guidelines also stress the importance of considering patients' opinions and of recommending lifestyle modifications to achieve good disease control. Metformin is identified as the first-line drug, with the addition of other glucose-lowering agents if necessary.
Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Guias de Prática Clínica como Assunto , Glicemia/efeitos dos fármacos , Diabetes Mellitus Tipo 2/terapia , Desenho de Fármacos , Quimioterapia Combinada , Humanos , Hipoglicemiantes/administração & dosagem , Estilo de Vida , Metformina/administração & dosagem , Metformina/uso terapêuticoRESUMO
PURPOSE: To analyse the course of burnout and develop an explanatory model. DESIGN: Prospective cohort dynamics. SITE: All primary health care centres in Burgos. SUBJECTS: All physicians except medical emergencies, paediatrics and residents. MAIN MEASUREMENTS: Anonymous self-report questionnaire: Maslach Burnout Inventory (MBI) and related variables. An analysis was performed using the Student-t, X(2) test and logistic regression. RESULTS: The response rate was 47.76% in 2007, which was lower than that of 2005. There were significant differences between 2005 and 2007, for increases in the percentage of physicians who smoked, postgraduate training, residency, and those who believe that coordination with nursing and specialist care and institutional communication is appropriate. There was an increase in the prevalence of burnout by almost one point compared with 2005, a decrease in maximum burnout and emotional exhaustion (EC), and an increase in depersonalisation (DP) and personal accomplishment (RP). The incidence density of burnout was 1/113. 5 primary care physicians per year. The existence of burnout is associated with the use of chronic medication and inadequate coordination between nursing and EC, and also with the high workload. CONCLUSIONS: The increase in the prevalence found is consistent with the idea of burnout as a dynamic development and the theoretical model described. Stable and quality employment is one way to indirectly mitigate (by encouraging internal communication) professional burnout. In the multivariate analysis, the most critical variable in the onset of burnout is the inadequate coordination with nursing.
Assuntos
Esgotamento Profissional/epidemiologia , Médicos de Atenção Primária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
The present document intends to adapt the general recommendations set up in a consensus to elaborate the hospital discharge report in medical specialties to the specific needs of the hospitalized diabetic population. Diabetes is an illness with a very high health cost, being the global risk of death in people with diabetes almost double than in non-diabetes people, justifying the fact that diabetes constitutes one of the most frequent diagnoses in hospitalized patients and the growing interest upon hyperglycaemia management during hospitalization and at discharge. To set up an adequate treatment plan at discharge suitable for each patient, the most important elements to take into account are the etiology and prior hyperglycaemia treatment, the patient's clinical situation and the degree of glycaemia control. Due to instability of glycaemia control, it is also needed to anticipate the educational needs for each patient, as well as to set up the monitoring schedule and follow-up at discharge, and an adequate treatment plan at discharge.