Cardiorenal outcomes with dapagliflozin by baseline glucose-lowering agents: Post hoc analyses from DECLARE-TIMI 58.

AIM: To assess the associations between baseline glucose-lowering agents (GLAs) and cardiorenal outcomes with dapagliflozin versus placebo in the DECLARE-TIMI 58 study. MATERIALS AND METHODS: DECLARE-TIMI 58 assessed the cardiorenal outcomes of dapagliflozin versus placebo in patients with type 2 diabetes. This post hoc analysis elaborates the efficacy and safety outcomes by baseline GLA for treatment effect and GLA-based treatment interaction. RESULTS: At baseline, 14 068 patients (82.0%) used metformin, 7322 (42.7%) sulphonylureas, 2888 (16.8%) dipeptidyl peptidase-4 inhibitors, 750 (4.4%) glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and 7013 (40.9%) insulin. Dapagliflozin reduced the composite of cardiovascular death (CVD) and hospitalization for heart failure (HHF) versus placebo regardless of baseline GLA, with greater benefit in the small group of patients with baseline use of GLP-1 RAs (HR [95% CI] 0.37 [0.18, 0.78] vs. 0.86 [0.75, 0.98] in GLP-1 RA users vs. non-users, Pinteraction = .03). The overall HR for major adverse cardiovascular events (CVD, myocardial infarction or ischaemic stroke) was 0.93 (95% CI 0.84, 1.03) with dapagliflozin versus placebo, with no interaction by baseline GLA (Pinteraction > .05). The renal-specific outcome was reduced with dapagliflozin versus placebo in the overall cohort (HR [95%CI] 0.53[0.43-0.66]), with no interaction by baseline GLA (Pinteraction > .05). All of these outcomes were similar in those with versus those without baseline metformin use. CONCLUSIONS: The effects of dapagliflozin on cardiorenal outcomes were generally consistent regardless of baseline GLA, with consistent benefits regardless of baseline metformin use. The potential clinical benefit of combining sodium-glucose co-transporter-2 inhibitors with GLP-1 RAs, given some evidence of cardiovascular risk reduction with both classes, should be explored further.

[Continuous glucose monitoring. Utility and indications]. / Monitoreo continuo de glucosa. Utilidad e indicaciones.

An adequate glycemic control prevents and/or delays the development and/or progression of chronic complications in patients with diabetes mellitus (DM). To achieve this control, it is necessary to adjust insulin doses, in type 1 or insulinized type 2 DM persons, based on traditional capillary glucose self-monitoring, which has limitations to generate an adequate data record, is invasive and has low adherence. In contrast, new continuous glucose monitoring (CGM) systems provide more complete and dynamic information, and better compliance. In these systems, a subcutaneous sensor continuously sends glucose values which are captured and stocked by a receptor module. Real-time models (CGMRT) allow continuous and real-time readings of interstitial glucose, whereas CGM-Flash/EI systems require lector approach to sensor module performing intermittent scanning. CGM shows if glycemic levels are increasing or decreasing and how fast it is happening (tendency). CGM decreases glycosylated hemoglobin between 0.53% and 1.0%, as well as time in hypoglycemia by 38%, increasing the time in range of glucose levels, in patients with high adherence. The objectives of this review are to describe the glycemic homeostasis, to evaluate the accuracy of the CGM to interpret the data adequately and finally, based on the information provided by these novel monitoring systems, to suggest a practical way to be added to the traditional intensive insulin therapy.

[Efficacy and safety of IdegLira for the intensification of type 2 diabetes treatment]. / Eficacia y seguridad de IdegLira para la intensificación del tratamiento en la diabetes tipo 2.

Diabetes mellitus is a true pandemic; type 2 diabetes in particular, with its progressive nature, constitutes a serious health problem. Despite advances and innovations in treatment, it continues to generate high morbidity and mortality. Many patients do not achieve their metabolic control objectives, due to clinical inertia, fear of hypoglycaemia, weight gain, the complexity of the treatment and the lack of adherence to it. Recently, the clinical results of the combined use of basal insulin and agonist receptor of the glucagon-like peptide type 1 (AR-GLP1) have been successfully evaluated. Therefore, the combined use of a basal insulin (insulin degludec) with an AR-GLP1 (liraglutide), in a single device (IdegLira), is proposed as an effective and safe therapeutic alternative for the treatment intensification in people with type 2 diabetes. IdegLira has shown greater reductions in HbA1c compared to its individual components, with a low risk of hypoglycaemia and weight loss, both in insulin naïve patients and in those previously insulinized. In this review we describe the pharmacology, the rational of the combination and the most relevant clinical evidence on IdegLira safety and efficacy.

[Insulin therapy in special conditions]. / Insulinoterapia en situaciones especiales.

Hyperglycemia during hospitalization is a common condition associated with poor prognosis. To date, insulin is the best strategy to treat hyperglycemia in these patients. An adequate glycemic control is associated with better clinical results. Nevertheless, glycemic goals are still controversial due to the increase of hypoglycemia and other adverse events. Diabetes mellitus is still the main cause of chronic renal failure in our country and its treatment deserves a special analysis considering that insulin pharmacokinetics is altered. Recommendations in this setting are based in expert panel opinions, focusing mainly in intermediate or long acting insulins combined with regular insulin and/or rapid acting analogues. During pregnancy, NPH and regular insulin are safe and effective. It is worth mentioning that the development of new long and rapid acting molecules yielded lower glycemic variability, better post-prandial control and less hypoglycemia. The aim of this study is to provide a review of the proper use of insulin in these special conditions.

[Insulinization in type 2 diabetes mellitus. Intensification options]. / Insulinización en la diabetes mellitus tipo 2. Alternativas de intensificación.

Diabetes mellitus is associated with vascular complications and high rates of morbidity and mortality. Timely insulin therapy, intensified when necessary, represent appropriate measures to prevent or delay the onset of complications. However, the incidence of hypoglycemia and difficulties in treatment adherence represent barriers to achieve therapeutic success. Premixes analogs and, specially, combinations of insulin analogues are associated with pharmacokinetic and pharmacodynamic advantages, that translate into clinical benefits such as improved metabolic control, decreased hypoglycemic events and, for their simplicity, potentially greater adherence.

[Therapeutic compliance and flexibility in the use of basal insulins]. / Adherencia terapéutica y flexibilidad en el uso de insulinas basales.

Since 1921, the benefits achieved by insulin therapy research have been constant. However, the fear of a hypoglycemia incidence and rigid time schedules of insulin therapy still interfere with treatment adherence, which is essential to achieve optimal glycemic control and minimize complications in diabetic patients. The possibility of using an ultra long- acting insulin analogue (degludec), which has an extensive and predictable pharmacokinetic profile over 24 hours, is analyzed in this context. Clinical trials have shown that this ultra long-acting insulin analogue administered in a flexible dosage treatment, reached a good glycaemic control with no increase on hypoglycemia risk. Although to follow a predefined plan in clinical practice is recommended, the possibility of flexibility in day to day dosage timing of this specific insulin analogue on requirement, could improve adherence in patients with a non-predictable and active social life and workday.

[Insulin and diabetes control in Argentina]. / Insulina y control de la diabetes en la Argentina.

As in the rest of the world, there is a significant gap between scientific knowledge regarding diabetes mellitus and the daily practice outcome, in Argentina. Inadequate diabetes control combined with associated cardiovascular risk factors are responsible for an elevated morbid-mortality incidence and the consequent raise in the socioeconomic burden. Some of the factors leading to this situation are the late diagnosis of the disease, the clinical "inertia" (reluctance to prescribe insulin) and the poor education given to the health care team as well as the persons with diabetes. The implementation of a national diabetologic education program targeting health care providers, the persons with diabetes and their families, could contribute to optimize the appropriate insulin prescription, and consequently improve their life quality, while reducing the disease socioeconomic burden. In order to optimize the education program's strategy outcome, insulinization cabinets should be incorporated, the participation of all health systems (public health, social security and private health insurance companies), the media, health sciences, schools and the pharmaceutical industry are needed.

[Diabetes, alexithymia and depression]. / Diabetes, alexitimia y depresión.

Diabetes Mellitus and Depression are two increasing pathologies. Several articles indicate that Depression in Diabetes is twice as important as in the general population. Yet, Depression in diabetic patients is underdiagnosed. On the other hand, Alexithymia might be a factor associated to Depression. We therefore carried out a research in order to evaluate the relationship between Depression and Alexithymia in diabetic patients at the Italian Hospital of Buenos Aires. We performed psychiatric interviews, which led to diagnoses based on DSM-IV, and applied the following scales: HAM-D, TAS-26, DBI and M.I.N.I. We evaluated 59 patients who had been diagnosed Type II Diabetes. Crossing variables, we observed a negative correlation between the results of Beck's Depression Inventory and those of Hamilton's Depression Scale. On the contrary, these last results showed a positive correlation with results obtained through TAS-26, which reveals a significant relationship between Depression and the presence of Alexithymia. According to the link between Depression, Diabetes Mellitus II and Alexithymia and considering that Alexithymia has consequences on the illness evolution and the treatment of both pathologies, it seems important to determine when and how to include its evaluation.

[Evaluation of sexual issues by professionals who assist type 2 diabetic men]. / Evaluación de temas sexuales por profesionales que asisten a hombres con diabetes tipo 2.

INTRODUCTION: Our objective was to assess whether physicians who care for people with type 2 diabetes address andrological symptoms such as erectile sexual dysfunction, decreased libido, and symptoms and/or signs of hypogonadism. METHODS: An anonymous survey was carried out with 171 doctors, 113 were females (66.1%), the mean age was 46 ± 10 years (females: 45 ± 10 and males: 49 ± 10, p = 0.006). RESULTS: There were no differences in responses according to gender. Regarding the presence of erectile sexual dysfunction and/or decreased libido, 44.4% (n = 76) and 55.6% (n = 95) did not ask about them, respectively. In patients with symptoms of hypogonadism, 50.9% (n = 87) did not request a testosterone measurement. Regarding the improvement of the metabolic profile of type 2 diabetes mellitus and sexual symptoms after replacement with testosterone, 65.8% of the respondents answered that both conditions could improve after treatment. In the presence of symptoms compatible with hypogonadism, 74.7% of those surveyed stated that the measurement of testosterone should be performed. A total of 108 (63.2%) showed interest in being trained on topics related to type 2 diabetes and disorders of the sexual sphere. CONCLUSION: A large percentage of physicians who take care of men with type 2 diabetes do not inquire about andrological disorders. It is necessary to raise awareness and train doctors to detect, treat and/or refer these frequent health problems, not only to improve the quality of life of patients but also to effectively respond and prevent a major health problem.

Introducción: Los trastornos andrológicos son frecuentes en varones con diabetes tipo 2. El objetivo fue evaluar si los médicos que atienden a personas con diabetes tipo 2 abordan problemas andrológicos como disfunción sexual eréctil, disminución de libido y síntomas de hipogonadismo. Métodos: Se llevó a cabo una encuesta anónima a 171 médicos, de ellos 113 fueron mujeres (66.1%) con una edad media de 46 ± 10 años (mujeres: 45 ± 10 y varones: 49 ± 10, p = 0.006). Resultados: No hubo diferencias en las respuestas según el género. El 44.4% (n = 76) y el 55.6% (n = 95) no preguntan sobre la presencia de disfunción sexual eréctil y/o disminución de libido, respectivamente. El 50.9% (n = 87) no solicitó medición de testosterona en pacientes con síntomas de hipogonadismo. El 65.8% de los participantes respondió que el reemplazo con testosterona puede mejorar el perfil metabólico de la diabetes mellitus tipo 2 y los síntomas sexuales. El 74.7% de los encuestados afirmó que la medición de testosterona debería realizarse ante la presencia de síntomas compatibles con hipogonadismo. El 63.2% (n = 108) mostró interés en formación sobre temas relacionados a diabetes tipo 2 y trastornos de la esfera sexual. Conclusión: Un gran porcentaje de médicos que asisten a varones con diabetes tipo 2 no indaga sobre trastornos andrológicos. Es necesario concientizar y entrenar a los médicos, para detectar, tratar y/o derivar estos problemas de salud tan frecuentes, no solo para mejorar la calidad de vida de los pacientes sino para responder y prevenir efectivamente a un problema mayor de salud.

[Renal effects of GLP-1 agonists in type 2 diabetes]. / Efectos renales de los agonistas GLP-1 en la diabetes tipo 2.

The prevalence of type 2 diabetes mellitus (DM2) is increasing, generating a great impact both at individual and public health level. Nearly half of the patients with DM2 develop impaired renal function, so nephron-protection is highly important. The robust body of evidence that shifted the therapeutic focus from glycemic to cardio-renal metabolic therapy in DM2 led to the inclusion of new therapies with cardiovascular and renal benefits in international guidelines. Type 1 glucagon (GLP-1) receptor agonists have showed favorable effects on renal function and their potential protective actions are multifactorial, beyond glycemic control. These benefits have been demonstrated in efficacy and safety clinical studies, as well as in cardiovascular outcomes and real-life studies. This comprehensive review describes the direct and indirect effects of these molecules, as well as evidence obtained from pivotal clinical (LEADER, SUSTAIN 6 and REWIND) and real-life studies demonstrating their beneficial effects on renal function, and also introduces expectations of future results from ongoing studies with renal endpoints.

La prevalencia de diabetes mellitus tipo 2 (DM2) está en aumento, generando un gran impacto tanto a nivel individual como en salud pública. Cerca de la mitad de los pacientes con DM2 sufren un deterioro de la función renal, por esto la nefroprotección resulta de fundamental importancia. El conjunto de evidencia que cambió del enfoque terapéutico glucocéntrico al cardiorrenometabólico en la DM2 motivó la inclusión en las recomendaciones internacionales de nuevas terapias con beneficios cardiovasculares y renales. Los agonistas del receptor del péptido similar al glucagón tipo 1 (GLP-1) tienen efectos favorables sobre la función renal y sus posibles acciones protectoras son multifactoriales, más allá del control glucémico. Estos beneficios han sido demostrados en los estudios clínicos de eficacia y seguridad, así como también en los estudios de resultados cardiovasculares y de vida real. En esta revisión narrativa se describen los efectos directos e indirectos de estas moléculas, así como su evidencia en los principales estudios clínicos (LEADER, SUSTAIN 6 y REWIND) y de vida real que demuestran sus efectos beneficiosos sobre la función renal e introduce la expectativa de los resultados futuros de los estudios en curso con objetivos renales.

Glycemic Control and Prevention of Diabetic Complications in Low- and Middle-Income Countries: An Expert Opinion.

INTRODUCTION: Trends on glycemic control and diabetes complications are known for high-income countries, but comprehensive data from low- and middle-income countries (LMIC) are lacking. METHODS: This is an expert opinion based on two retrospective studies. Here we examine the recent subset analysis of relevant data from the IDMPS Wave 7 (International Diabetes Management-Practices Study, 2015-2016) and the GOAL study conducted in multiple LMICs. RESULTS: Wave 7 sub-analysis was performed in 6113 people with type 2 diabetes from 24 LMIC. Poorly controlled diabetes (hemogloblin A1c [HbA1c] ≥ 7%) was found in 58.6, 73.0 and 78.3% of participants with diabetes duration of < 5, 5-12 and > 12 years, respectively (in association with a high prevalence of macro- and microvascular complications). Moreover, 37.7% of participants with diabetes duration of 5-12 years were treated only with oral antihyperglycemic drugs. The GOAL study investigated the efficacy of insulin in 2704 poorly controlled participants (mean HbA1c 9.7%; diabetes duration 10.1 ± 6.7 years; 10 LMIC). A significant 2% reduction in mean HbA1c levels was observed after 12 months of treatment. Only 7.2% of participants experienced a symptomatic episode of hypoglycemia (nocturnal or severe hypoglycemia events were infrequent). CONCLUSION: The rate of well-controlled participants (HbA1c < 7.0%) in the Wave 7 sub-analysis was lower than that observed in the USA (NHANES survey) or in European countries (GUIDANCE study), and the incidence of microvascular complications was higher. The GOAL study showed that insulin treatment improves glycemic control and reduces this gap. The Expert Panel recommends intensifying diabetes treatment as soon as possible, as well as patients' education and other preventive measures, initiatives which require modest costs compared to hospitalization and treatment of diabetes complications.

Efectos renales de los agonistas GLP-1 en la diabetes tipo 2 / Renal effects of GLP-1 agonists in type 2 diabetes

Resumen La prevalencia de diabetes mellitus tipo 2 (DM2) está en aumento, generando un gran impacto tanto a nivel individual como en salud pública. Cerca de la mitad de los pacientes con DM2 sufren un deterioro de la función renal, por esto la nefroprotección resulta de fundamental importancia. El conjunto de evidencia que cambió del enfoque terapéutico glucocéntrico al cardiorrenometabólico en la DM2 motivó la inclu sión en las recomendaciones internacionales de nuevas terapias con beneficios cardiovasculares y renales. Los agonistas del receptor del péptido similar al glucagón tipo 1 (GLP-1) tienen efectos favorables sobre la función renal y sus posibles acciones protectoras son multifactoriales, más allá del control glucémico. Estos beneficios han sido demostrados en los estudios clínicos de eficacia y seguridad, así como también en los estudios de re sultados cardiovasculares y de vida real. En esta revisión narrativa se describen los efectos directos e indirectos de estas moléculas, así como su evidencia en los principales estudios clínicos (LEADER, SUSTAIN 6 y REWIND) y de vida real que demuestran sus efectos beneficiosos sobre la función renal e introduce la expectativa de los resultados futuros de los estudios en curso con objetivos renales.

Abstract The prevalence of type 2 diabetes mellitus (DM2) is increasing, generating a great impact both at individual and public health level. Nearly half of the patients with DM2 develop impaired renal function, so nephron-protection is highly important. The robust body of evidence that shifted the therapeutic focus from glycemic to cardio-renal metabolic therapy in DM2 led to the inclusion of new therapies with cardiovascular and renal benefits in international guidelines. Type 1 glucagon (GLP-1) receptor agonists have showed favorable effects on renal function and their potential protective actions are multifactorial, beyond glycemic control. These benefits have been demonstrated in efficacy and safety clini cal studies, as well as in cardiovascular outcomes and real-life studies. This comprehensive review describes the direct and indirect effects of these molecules, as well as evidence obtained from pivotal clinical (LEADER, SUSTAIN 6 and REWIND) and real-life studies demonstrating their beneficial effects on renal function, and also introduces expectations of future results from ongoing studies with renal endpoints.

Evaluación de temas sexuales por profesionales que asisten a hombres con diabetes tipo 2 / Evaluation of sexual issues by professionals who assist type 2 diabetic men

Resumen Introducción: Los trastornos andrológicos son frecuentes en varones con diabetes tipo 2. El objetivo fue evaluar si los médicos que atienden a personas con diabetes tipo 2 abordan problemas andro lógicos como disfunción sexual eréctil, disminución de libido y síntomas de hipogonadismo. Métodos: Se llevó a cabo una encuesta anónima a 171 médicos, de ellos 113 fueron mujeres (66.1%) con una edad media de 46 ± 10 años (mujeres: 45 ± 10 y varones: 49 ± 10, p = 0.006). Resultados: No hubo diferencias en las res puestas según el género. El 44.4% (n = 76) y el 55.6% (n = 95) no preguntan sobre la presencia de disfunción sexual eréctil y/o disminución de libido, respectivamente. El 50.9% (n = 87) no solicitó medición de testosterona en pacientes con síntomas de hipogonadismo. El 65.8% de los participantes respondió que el reemplazo con testosterona puede mejorar el perfil metabólico de la diabetes mellitus tipo 2 y los síntomas sexuales. El 74.7% de los encuestados afirmó que la medición de testosterona debería realizarse ante la presencia de síntomas compatibles con hipogonadismo. El 63.2% (n = 108) mostró interés en formación sobre temas relacionados a diabetes tipo 2 y trastornos de la esfera sexual. Conclusión: Un gran porcentaje de médicos que asisten a varones con diabetes tipo 2 no indaga sobre trastornos andrológicos. Es necesario concientizar y entrenar a los médicos, para detectar, tratar y/o derivar estos problemas de salud tan frecuentes, no solo para mejorar la calidad de vida de los pacientes sino para responder y prevenir efectivamente a un problema mayor de salud.

Abstract Introduction: Our objective was to assess whether physicians who care for people with type 2 dia betes address andrological symptoms such as erectile sexual dysfunction, decreased libido, and symptoms and/ or signs of hypogonadism. Methods: An anonymous survey was carried out with 171 doctors, 113 were females (66.1%), the mean age was 46 ± 10 years (females: 45 ± 10 and males: 49 ± 10, p = 0.006). Results: There were no differences in responses according to gender. Regarding the presence of erectile sexual dysfunction and/or decreased libido, 44.4% (n = 76) and 55.6% (n = 95) did not ask about them, respectively. In patients with symptoms of hypogonadism, 50.9% (n = 87) did not request a testosterone measurement. Regarding the improvement of the metabolic profile of type 2 diabetes mellitus and sexual symptoms after replacement with testosterone, 65.8% of the respondents answered that both conditions could improve after treatment. In the presence of symptoms compatible with hypogonadism, 74.7% of those surveyed stated that the measurement of testosterone should be performed. A total of 108 (63.2%) showed interest in being trained on topics related to type 2 diabetes and disorders of the sexual sphere. Conclusion: A large percentage of physicians who take care of men with type 2 diabetes do not inquire about andrological disorders. It is necessary to raise awareness and train doctors to detect, treat and/or refer these frequent health problems, not only to improve the quality of life of patients but also to effectively respond and prevent a major health problem.

Guía de recomendaciones para pacientes con diabetes mellitus y patología cardiovascular / Recommendations guide for patients with diabetes mellitus and cardiovascular disease

Frente a los significativos y rápidos cambios en los conocimientos relacionados con la fisiopatología de la diabetes mellitus (DM) y los mecanismos involucrados en el desarrollo de las enfermedades cardiovasculares (ECV) por un lado y, por otro, frente al desarrollo de diferentes fármacos con inesperados efectos a nivel cardiovascular, nos propusimos desarrollar un consenso actualizado entre la Sociedad Argentina de Cardiología y la Sociedad Argentina de Diabetes, dos sociedades con reconocida trayectoria en la confección de guías y consensos que, en última instancia, tienen el objetivo de brindar un material actualizado y práctico para el manejo de los pacientes que presentan DM y ECV. Si bien nuestra tarea conjunta había comenzado hace tiempo atrás, este Consenso sale a la luz en medio de una de las peores crisis sanitarias a nivel mundial con el surgimiento del SARS-CoV2 y su manifestación clínica, la COVID-19.

Síndrome hipoglucémico asociado a tumor solitario pulmonar. Reporte de caso / Severe hypoglycemia associated with solitary pulmonary tumor. Case report

El síndrome paraneoplásico de Doege-Potter (SDP) se asocia a la presencia de tumores intratorácicos y diafragmáticos que generan un cuadro de hipoglucemia por excesivo consumo de glucosa por parte del tumor, y aumento de producción de IGF-2 (insulin growth factor 2) con mayor captación de glucosa periférica. Comunicamos el caso de una paciente femenina de 57 años, sin antecedentes de diabetes ni ingestión de fármacos hipoglucemiantes, que ingresó por un cuadro de hipoglucemia severa con glucemia de 38 mg/dL. Otros resultados: péptido C 1,05 ng/mL, insulinemia 10,5 uUI/mL, IGF-1 de 174 ng/mL, cortisol y prolactina normales. No disponíamos del dosaje de IGF-2. Ecografía abdominal sin patología evidente. Se inició alimentación rica en carbohidratos complejos. Continuó con hipoglucemias. A raíz de cervicalgia, se solicitó radiografía cervical y de tórax, evidenciándose opacidad en vértice izquierdo. La tomografía de tórax informó proceso pulmonar atípico. Por punción se diagnosticó carcinoma pulmonar pobremente diferenciado. Se inició quimioterapia, con reducción del tumor, y de la frecuencia y magnitud de las hipoglucemias. Concluimos que frente a cuadros de hipoglucemia en ausencia de factores causales debería sospecharse la presencia de un SD

Doege-Potter (SDP) is a paraneoplastic syndrome mostly associated with big intrathoracic or diaphragmatic tumors, causing hypoglycemia in non-diabetic patient due to an increased glucose consumption by the tumor cells and excessive production of IGF-2 (insulin growth factor 2). Case report: 57-year-old female patient without diabetes mellitus and not receiving hypoglycemic drugs who was assisted by severe hypoglycemia (38 mg/dL) with the following laboratory tests: C peptide 1.05 ng/mL, 10.5 uIU/mL insulinemia, 174 ng/mL IGF-1, normal cortisol and prolactin. IGF-2 was not available. Non-pathological abdominal ultrasound. In spite of a feeding rich in complex carbohydrate continued with hypoglycaemia. She started with neck pain and a cervical and chest X-ray was requested, which shows opacity in the left vertex. Chest tomography reported atypical lung process. The biopsy reported poorly differentiated carcinoma of the lung. After treatment with chemotherapy a reduction in tumor size and less episodes of hypoglycemia were observed. Conclusion: in the event of recurrent hypoglycaemia and in the absence of known etiologies we should consider the presence of SDP

Monitoreo continuo de glucosa: indicaciones, interpretación de datos y toma de decisiones terapéuticas. Recomendaciones de expertos / Continuous glucose monitoring: indications, data interpretation and making therapeutic decisions. Expert recommendations

Las herramientas para evaluar el grado de control glucémico se modificaron últimamente. La emoglobina glicosilada (HbA1c), parámetro de referencia (gold standard), refleja el control glucémico de los últimos tres meses de manera retrospectiva, sin expresar la variabilidad glucémica. El automonitoreo glucémico capilar (AGC) brinda información inmediata y prospectiva, pero dispone de pocos datos glucémicos para generar promedios y desviaciones estándares representativas. No detecta tendencias y tiene limitaciones para obtener datos nocturnos o durante la actividad física. Es invasivo y muchas veces rechazado. Contrariamente, el monitoreo continuo de glucosa (MCG) mide la glucosa instantáneamente, y muestra sus tendencias y su variabilidad en forma continua, incorporando nuevas métricas de control. Mediante el perfil ambulatorio de glucosa (PAG) se analizan los patrones del control glucémico durante el sueño, los ayunos prolongados, la actividad física y las intercurrencias, expresándolos como curvas con sus desviaciones estándar durante períodos de horas (8 a 24 horas) o días (7, 14, 30 y 90 días). El PAG contiene las siguientes métricas: porcentaje de tiempo en rango TIR (del inglés, time in range), porcentaje de tiempo por encima del rango TAR (del inglés, time above range), porcentaje de tiempo por debajo del rango o hipoglucemia TBR (del inglés, time below range) y coeficiente de variabilidad (%CV). La información continua permite tomar decisiones inmediatas, ya sea con la ingesta de carbohidratos o con la aplicación de insulina. El MCG con terapéuticas insulínicas inyectables (TII) o bomba portable de insulina (BPI) es una herramienta muy útil y complementaria para el tratamiento de la diabetes mellitus tipo 1 (DM1) y la DM2 en la insulinoterapia. Su utilización se asoció con descensos significativos en la HbA1c, disminución de la variabilidad glucémica, reducción de las hipoglucemias totales y nocturnas, y mejoría de la calidad de vida en estos pacientes. Nuestro propósito como grupo de expertos es generar una guía práctica para regular la implementación del MCG.

The tools to assess the degree of glycemic control were modified lately. Glycosylated hemoglobin (HbA1c), the gold standard, reflects the glycemic control of the last 3 months retrospectively, without expressing glycemic variability. Selfblood glucose monitoring (SBGM) provides immediate and prospective information, but has little glycemic data to generate representative averages and standard deviations. It does not detect trends and has limitations to obtain nocturnal data or during physical activity. It is invasive and often rejected. On the contrary, continuous glucose monitoring (CGM), allows to measure glucose instantly, shows your trends and variability continuously, incorporating new control metrics. The ambulatory glucose profile (AGP) analyzes the patterns of glycemic control during sleep, prolonged fasting, physical activity and intercurrences, expressing them as curves with their standard deviations during periods of hours (8 to 24 hours) or days (7, 14, 30 and 90 days). The AGP contains the following metrics: percentage time in range (TIR), percentage time above range mg/dl (TAR), percentage time below range or hypoglycemia (TBR) and coefficient of variation (%CV). CGM with IIT or continuous subcutaneous insulin infusion (CSII), is a very useful and complementary tool for the treatment of DM1 and DM2 in insulin therapy. Its use was associated with significant decreases in HbA1c, decreased glycemic variability, reduction of total and nocturnal hypoglycemia and improvement of the quality of life in these patients. Our aim as a group of experts is to generate a practical guide to regulate the implementation of the CGM.

Effect of the embolization of completely unpurified islets on portal vein pressure and hepatic biochemistry in clinical practice.

Here we report on the impact of completely unpurified islet transplantation on the portal vein pressure (PVP) and the hepatic biochemistry in the peritransplant period and on follow-up. Type I diabetic patients underwent simultaneous kidney and islet transplantation. Islets were not purified from the acinar tissue to prevent loss of endocrine mass. Each patient received a mean 521,846 +/- 201,539.4 islet equivalents (7812.1 islet equivalents/kg/recipient). Immunosuppression and peritransplant medication were given according to the Giessen protocol. The islets were injected into the left hepatic lobe through the umbilical vein. PVP was recorded at time 0 and every 5 min throughout cell infusion. Liver function was assessed daily for the first 10 days, and on follow-up. Basal, peak, and final PVP were 12 +/- 3.8, 25.1 +/- 7.9, and 19.5 +/- 6.2 mmHg, respectively (basal vs. final, p < 0.05). Bilirubin, alkaline phosphatase, prothrombin time, and APTT stayed within normal range. Peak aspartate aminotransferase (AST), alanine aminotransferase (ALT), and serum amylase were 109.4 +/- 61.2 IU/L (basal vs. peak, not significant), 79.5 +/- 56.9 IU/L (basal vs. peak, not significant), and 887.5 +/- 153.6 IU/L (basal vs. peak, p = 0.02), respectively. In all cases AST, ALT, and amylase normalized within 6 days posttransplant and remained so on follow-up (longest control, 33 months posttransplant). Although the intrahepatic infusion of unpurified pancreatic islets affects both the portal vein pressure and the hepatic biochemical profile, this effect is transient and does not compromise the safety of the procedure.

Monitoreo continuo de glucosa: Utilidad e indicaciones / Continuous glucose monitoring. Utility and indications

Un adecuado control glucémico evita o retarda la aparición y/o evolución de las complicaciones crónicas en pacientes con diabetes mellitus (DM). Para lograrlo es necesario adecuar las dosis de insulina en personas con DM tipo 1 o tipo 2 en insulinoterapia, por el tradicional automonitoreo de glucosa capilar (AGC) que presenta aún limitaciones para generar un registro adecuado de datos, es invasivo y tiene baja adherencia. En contraposición, los nuevos sistemas de monitoreo continuo de glucosa (MCG) brindan una información más completa, más dinámica y con mejor tolerancia. Están constituidos por un sensor subcutáneo que informa ininterrumpidamente los niveles de glucosa del tejido celular subcutáneo y un módulo receptor que permite su lectura y almacenamiento. Los modelos de tiempo real (MCG-RT) permiten observar continuamente los datos, mientras que los sistemas intermitentes (MCG-Flash/EI) los muestran siempre y cuando se acerque el receptor al módulo sensor, generando una lectura voluntaria e intermitente, aunque almacenan todo en la memoria. El MCG informa además las tendencias glucémicas, indicando si están en ascenso o descenso y a qué velocidad cambian. El uso del MCG vs. AGC reduce la hemoglobina glicosilada (A1c) entre 0.53 y 1.0% con disminución significativa (38%) del tiempo de exposición a hipoglucemias. Presenta además, mayor adherencia. Los objetivos de esta revisión son: describir la homeostasis glucémica, evaluar la precisión del MCG, interpretar los datos adecuadamente y finalmente, sugerir en forma práctica los cambios para incorporar a la insulinoterapia tradicional, basados en la información que aportan estos novedosos sistemas de monitoreo.

An adequate glycemic control prevents and/or delays the development and/or progression of chronic complications in patients with diabetes mellitus (DM). To achieve this control, it is necessary to adjust insulin doses, in type 1 or insulinized type 2 DM persons, based on traditional capillary glucose self-monitoring, which has limitations to generate an adequate data record, is invasive and has low adherence. In contrast, new continuous glucose monitoring (CGM) systems provide more complete and dynamic information, and better compliance. In these systems, a subcutaneous sensor continuously sends glucose values which are captured and stocked by a receptor module. Real-time models (CGM-RT) allow continuous and real-time readings of interstitial glucose, whereas CGM-Flash/EI systems require lector approach to sensor module performing intermittent scanning. CGM shows if glycemic levels are increasing or decreasing and how fast it is happening (tendency). CGM decreases glycosylated hemoglobin between 0.53% and 1.0%, as well as time in hypoglycemia by 38%, increasing the time in range of glucose levels, in patients with high adherence. The objectives of this review are to describe the glycemic homeostasis, to evaluate the accuracy of the CGM to interpret the data adequately and finally, based on the information provided by these novel monitoring systems, to suggest a practical way to be added to the traditional intensive insulin therapy.

Impacto de la cirugía bariátrica en pacientes con obesidad y diabetes mellitus tipo 1 / Impact of bariatric surgery in patients with obesity and type 1 diabetes mellitus

Introducción: la obesidad es un problema médico serio y en crecimiento en los pacientes con diabetes mellitus tipo 1 (DM1). El tratamiento de reemplazo con insulina es la única terapia disponible y los principales efectos adversos asociados son la hipoglucemia y la ganancia de peso. La cirugía bariátrica (CB) mostró mejoría en el control glucémico en los pacientes con DM2 pero se han reportados pocos casos en DM1. Objetivos: evaluar los cambios en los parámetros metabólicos en pacientes con obesidad y DM1 a quienes se les realizó una CB. Materiales y métodos: en forma retrospectiva se evaluaron las historias clínicas de siete pacientes con DM1 y obesidad que fueron tratados con CB. Se utilizó el test de Wilcoxon para muestras apareadas a fin de evaluar la diferencia entre los datos pre cirugía y al año de la misma. Resultados: se evaluaron siete pacientes con DM1. La media de edad fue de 48 años (IQR 45 a 49). La media de índice de masa corporal basal y al año fue 39,6 Kg/m2 (IQR 35 a 42) y 24,9 Kg/m2 (IQR 24,7 a 29,5) respectivamente. La media de hemoglobina glicosilada basal y al año de seguimiento fue de 9,3% (IQR 8,3 a 10,5) y 7,2% (IQR 6,7 a 8,8). La media del requerimiento de insulina antes y después de la CB fue de 110 UI (IQR 70 a 120) y 24 UI (IQR 16 a 30). Todas las diferencias fueron estadísticamente significativas (p<0,05). Conclusiones: los hallazgos de este estudio alientan a considerar a la CB como una herramienta en los pacientes con DM1 y obesidad con el objetivo de mejorar el control glucémico y el peso corporal

Introduction: obesity is a serious growing medical problem in type 1 diabetes mellitus (DM1). Insulin replacement is the only available therapy for these patients with DM1 and the main problems associated with it are hypoglycemia and weight gain. Bariatric surgery (BS) showed improvement in glycemic control in type 2 but only few cases of DM1 have been reported. Objectives: to evaluate changes in metabolic parameters in obese DM1 patients who underwent BS. Materials and methods: retrospectively, the clinical histories of seven patients with DM1 and obesity who were treated with CB were evaluated. The Wilcoxon test was used for paired samples in order to assess the difference between the pre-surgery data and one year after it. Results: seven patients DM1 were evaluated. The median age was 48 years (IQR 45 to 49). The median body mass index at baseline and at follow-up were 39.6 Kg/m (IQR 35 to 42) and 24.9 Kg/m2 (IQR 24.7 to 29.5) respectively. The median glycated hemoglobin at baseline and at follow-up were 9.3% (IQR 8.3 to 10.5) and 7.2% (IQR 6.7 to 8.8) respectively. The median insulin requirements before and after BS were 110 UI (IQR 70 a 120) and 24 UI (IQR 16 a 30). All differences were statistically significant (p value<0.05). Conclusions: our findings encourage considering BS as a tool in type 1 obese diabetic patients in terms to improve management of glycemic control and body weight