Executive summary on the treatment of type 2 diabetes mellitus in elderly or frail individuals. 2022 update of the 2018 consensus document "Treatment of type 2 diabetes mellitus in the elderly".

The population with type 2 DM (DM2) is highly heterogeneous, representing an important challenge for healthcare professionals. The therapeutic choice should be individualized, considering the functional status, frailty, the occurrence of comorbidities, and the preferences of patients and their caregivers. New evidence on the cardiovascular and renal protection of specific therapeutic groups and on the usefulness of new technologies for DM2 management, among other aspects, warrant an update of the consensus document on the DM2 in the elderly that was published in 2018.

Position statement of the SEMI, SED, redGDPS, SEC, SEEDO, SEEN, SEMERGEN y SEMFYC.

Obesity and excess weight are the main preventable causes of type 2 diabetes (DM2). When diagnosing type 2 diabetes, clinicians should establish the degree of obesity according to the body mass index (BMI) and, for patients with excess weight, measure the waist circumference. The proper treatment of DM2 requires a simultaneous approach to excess weight/obesity and the other cardiovascular risk factors, such as hypertension, dyslipidaemia and smoking. Nondrug interventions (e.g., diet and exercise) have proven benefits in preventing and treating patients with DM2 and excess weight/obesity and should follow an individual and multidisciplinary approach, with structured programs equipped with specific resources. Weight gain associated with antidiabetic treatment can hinder glycaemic control, compromise treatment adherence, worsen the vascular risk profile and limit the cardiovascular benefits of treatment. Therefore, it is significant to avoid weight gain, a measure that can be cost-effective. Antidiabetic drugs with benefits in body weight have also demonstrated their benefit in patients with BMIs <30. In general, the treatment of patients with DM2 and obesity will depend both on the degree of obesity and the associated comorbidity. Clinical trials on DM2 intervention should consider combined objectives that include not only glycaemic control but also other variables such as the risk of hypoglycaemia and the effect of treatment on body weight.

Quality of life and fear for hypoglycaemia in patients with type 2 diabetes mellitus. / Calidad de vida y grado de preocupación por las hipoglucemias en pacientes con diabetes mellitus tipo 2.

OBJECTIVES: Hypoglycaemia can negatively impact many aspects of type 2 diabetes mellitus (T2DM) management. The aim was to determine the impact of hypoglycaemia and the fear for hypoglycemic episodes on HRQoL in T2DM patients in Spain, as well as healthcare professionals' attitudes and knowledge of these issues. PATIENTS AND METHODS: An observational, cross-sectional study, with consecutive recruitment of T2DM patients in 661 healthcare centers, between September 2010 and May 2011. Sociodemographic and clinical variables were recorded. HRQoL (ADDQoL questionnaire) and fear for hypoglycaemia (HFS-II) were evaluated. Two groups were compared: with and without reported hypoglycaemia in the previous 6 months. Physicians responded 4 questions (visual analogue scales). RESULTS: 4.054 patients participated, of which 3,812 were selected [mean age (SD)=64 (11) years; male=54%; 10 (7) years for diagnostic of T2DM]. Patients with hypoglycaemia (45%) expressed higher fear for hypoglycemia [31.32 (15.71) vs. 18.85 (16.03); p<0.0001] and the overall impact of T2DM on their HRQoL was more negative [-2.48 (1.61) vs. -1.64 (1.36); p<0.001]. Respondent physicians occasionally used HRQoL questionnaires, knew about hypoglycaemia risk, explored fear for hypoglycaemia and modified treatments accordingly. CONCLUSIONS: T2DM patients with hypoglycaemia show an increase of fear for them, negatively affecting T2DM patients HRQoL. However physicians know the risk of hypoglycaemia, they explore the fear for hypoglycemic episodes occasionally.

Glycaemic control and implementation of the ADA/EASD-2006 consensus algorithm in type 2 diabetes mellitus patients in primary care in Spain.

BACKGROUND: In 2006, the American Diabetes Association and the European Association for the Study of Diabetes established a consensus algorithm (ADA/EASD-2006) for the adjustment of drug therapy for type 2 diabetes mellitus (T2DM). AIMS: To study glycaemic control in T2DM patients and the implementation of the ADA/EASD-2006 recommendations in primary care centres in Spain. METHODS: Prospective observational study in 1194 patients with T2DM conducted in 250 primary care centres in Spain. Patients were assessed at study inclusion (V0) and at 3 (V1) and 6 months (V2) post baseline. Information was collected at the level of DM control, HbA(1c) < 7% (HbC) and implementation of the ADA/EASD-2006 guidelines. RESULTS: Type 2 diabetes mellitus patients (53% women; mean age 64.9 years) had a mean (SD) HbA(1c) 7.8 (1.4)% and HbC 25.2% at baseline, 95% of them were receiving oral antihyperglycaemic agents (AAs) only. At V1, HbA(1c) was 7.3 (1.1)% and HbC was 38.1%; 65.0% of patients were receiving oral AAs, 5.6% insulin and 27.9% oral AAs plus insulin. At V2, HbA(1c) was 7.1 (0.9)% and HbC was 48.0%; 57.1% of patients were receiving oral AAs, 5.0% insulin and 36.9% oral AAs plus insulin. The ADA/EASD-2006 algorithm was adhered to in 33% patients up to study month 3, vs. 17.2% throughout the entire 6-month period. CONCLUSION: In patients with T2DM seen in primary care, the HbA1c target was met in 48.0% after adjusting their AAs. However, this is not reflected in greater implementation of the ADA/EASD-2006 guidelines, which are adhered to in only 17%.

Barriers associated with poor control in Spanish diabetic patients. A consensus study.

BACKGROUND: Delphi technique allows developing a multidisciplinary consensus to establish solutions. AIM: To identify barriers and solutions to improve control in patients with Type-2 Diabetes Mellitus (DM2). METHODS: An observational study using the 2-round Delphi technique (June-August 2011). A panel of 108 experts in DM2 from medical and nursing fields (primary care providers and specialists) from different regions completed via email a questionnaire with 41 Likert statements and 9 scores for each one. Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the two groups (Kappa index and McNemar chi-square). RESULTS: Response rate: 65%. Degree of agreement: 63.4% (95% CI 48.7-78.1%) in medicine, and 78.1% (95% CI 65.4-90.8) in nursing (p > 0.05). Overall level of agreement: Kappa = 0.43, (χ(2) = 2.5 p > 0.05). Regarding non-compliance with therapy, it improves with: the information to the partner/family/caregiver, patient education degree in diabetes, patient motivation and ability to share and agree on decisions with the patient. Clinical inertia improves with: motivation degree of healthcare professionals and the calculation of cardiovascular risk; and gets worse with: the shortage of time in consultation, absence of data in medical record, border high limits measurements accepted as normal readings, lack of a treatment goals, lack of teamwork (Physician/Nurse), scarcity of resources and lack of alarm systems in the electronic medical record on goals to achieve. CONCLUSION: The participants achieved an agreement in interventions in non-therapeutic compliance and clinical inertia to improve DM2 control.

[Cerebral sinovenous thrombosis in a girl with acute lymphoblastic leukaemia carrying the prothrombin G20210A variant]. / Trombosis de senos venosos cerebrales en una niña con leucemia linfoblástica, portadora de la variante de la protrombina G20210A.

Although cerebral venous thrombosis is rare, it is more commonly associated with children suffering from acute lymphoblastic leukaemia. We report the case of a 7-year-old girl who developed massive cerebral sinovenous thrombosis on day 22 of induction therapy for high-risk acute lymphoblastic leukaemia. Clinical symptoms were gradual onset of headache, decreasing consciousness, and ensuing left hemiplegia. A subsequent prothrombotic study revealed a heterozygous prothrombin G20210A variant in the child and mother. We analysed the prothrombotic factors found in the case before and after thrombosis. We confirm the importance of early exploration of patients for clinical predisposing risk factors of thrombosis and primary prothrombotic states in children with acute lymphoblastic leukaemia. This might help identify patients at particular risk from thrombosis and so administer thromboprophylaxis.

Glycaemic control among patients with type 2 diabetes mellitus in seven European countries: findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) study.

OBJECTIVE: This study was undertaken to assess glycaemic control as well as changes in glycaemic control over time in patients with type 2 diabetes mellitus (T2DM) who added a sulphonylurea (SU) or thiazolidinedione (TZD) to their metformin monotherapy in typical treatment settings within seven European countries. METHODS: An observational, cross-sectional multicentre study with retrospective medical chart review was conducted in Finland, France, Germany, Norway, Poland, Spain and UK. T2DM patients who added a SU or a TZD to metformin monotherapy between January 2001 and January 2006 (i.e. index date) and who had > or = 1 haemoglobin A1C (HbA1C) measurement within 12 months before the visit date, which occurred from June 2006 to February 2007, were included in the study. Demographic and clinical data were collected from medical records. The main study outcome measure was the proportion of patients with adequate glycaemic control (defined according to the International Diabetes Federation as HbA1C < 6.5%) using the most recent HbA1C measurement before the visit date. In addition, patients were grouped based upon the interval from the index date to the most recent HbA1C measurement to evaluate goal attainment and treatment changes over time. FINDINGS: In this European cohort of 2023 T2DM patients on metformin and either an SU or a TZD (mean age = 60.4 years), 25.5% of patients had adequate glycaemic control. The average HbA1C level was 7.2% after a mean of 2.6 years of treatment with combination oral antihyperglycaemic agent (AHA) therapy. Among the patients (n = 227) with most recent HbA1C measurement within 1 year after first adding an SU or a TZD, 27% had adequate glycaemic control (HbA1C < 6.5%), with a mean (s.d.) HbA1C of 7.1% (1.0); 1.3% of these patients were using some type of insulin therapy. Among the patients (n = 176) with most recent HbA1C measurement occurring > or = 5 years after adding an SU or a TZD, 20% had adequate glycaemic control, with a mean (s.d.) HbA1C of 7.4% (1.17), and 29.6% of these patients were using insulin. Overall, patients with (vs. without) adequate glycaemic control had significantly (p < 0.05) lower HbA1C levels (7.6 vs. 8.2%) at the time of adding an SU or a TZD to ongoing metformin monotherapy, were less likely to report a history of macrovascular complications (20 vs. 26%) and were more often engaged in physical activity three to five times a week (29 vs. 23%). CONCLUSIONS: Approximately one quarter of European out-patients with T2DM had adequate glycaemic control after a mean of 2.6 years following initiation of combination AHA therapy. Overall glycaemic control modestly declined over time, even though more patients were being treated with insulin. These findings highlight the progressive nature of the disease and need for more effective disease management/therapeutic alternatives.

Hypoglycaemic symptoms, treatment satisfaction, adherence and their associations with glycaemic goal in patients with type 2 diabetes mellitus: findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) Study.

AIMS: This study was undertaken to evaluate (i) factors associated with patient-reported hypoglycaemia; (ii) association of patient-reported hypoglycaemic symptoms with treatment satisfaction and barriers to adherence and (iii) association between treatment satisfaction, adherence and glycaemic control among patients with type 2 diabetes who added a sulphonylurea or a thiazolidinedione to ongoing metformin. METHODS: This observational, cross-sectional, multicentre study was conducted in seven countries (Finland, France, Germany, Norway, Poland, Spain and UK) from June 2006 to February 2007. Patients with type 2 diabetes who added a sulphonylurea or a thiazolidinedione to ongoing metformin therapy on a date (index date) from January 2001 through January 2006 and who had at least one haemoglobin A1C (HbA1C) measurement in the 12-month period before the visit date were eligible. Questionnaires were used to ascertain patients' reports of hypoglycaemic symptoms, treatment satisfaction, and treatment adherence. The Treatment Satisfaction Questionnaire for Medication was used to measure patients' treatment satisfaction. An adherence and barriers questionnaire was used to measure patients' adherence to treatment. Glycaemic control was based on documented HbA1C measurements within the prior 12 months. RESULTS: The mean +/- s.d. age was 62.9 +/- 10.6 years, and the mean +/- s.d. duration of diabetes was 7.8 +/- 5.1 years. HbA1C in this population of patients who had failed metformin monotherapy and were treated with oral antihyperglycaemic agents was below the International Diabetes Federation goal of 6.5% in only 477 (27.9%) patients. Approximately 38% of patients reported hypoglycaemic symptoms during the past year. Hypoglycaemia was significantly more likely in patients with a history of macrovascular complications of diabetes (OR = 1.346; 95% CI = 1.050-1.725) and with no regular physical activity (OR = 1.295; 95% CI = 1.037-1.618). Patients reporting hypoglycaemia had significantly lower treatment satisfaction scores (71.6 +/- 17.6 vs. 76.3 +/- 16.8; p < 0.0001 for global satisfaction). Compared with their counterparts reporting no hypoglycaemic symptoms, patients with such symptoms were also significantly more likely to report barriers to adherence, including being unsure about instructions (37.0 vs. 30.5%; p = 0.0057). Patients at HbA1C goal had significantly higher treatment satisfaction and adherence compared with those who were not. CONCLUSIONS: Patients' reports of hypoglycaemic symptoms are common in European outpatients with type 2 diabetes and are associated with significantly lower treatment satisfaction and with barriers to adherence. In addition, being at HbA1C goal is associated with treatment satisfaction and adherence.

[Lupus anticoagulant in children. Report of 4 cases]. / Anticoagulante lúpico en pediatría. Presentación de 4 casos.

OBJECTIVE: We present four cases of lupus anticoagulant (AL) in children. In addition, as a result of the lack of literature published on the subject in our country. We also evaluate the epidemiological, clinical and prognostic characteristics of AL in children. PATIENTS AND METHODS: The diagnostic criteria established by the "Subcommittee for the Standardization of Lupus Anticoagulant" were followed. RESULTS: Over a ten-year period (1988-1998), 46 cases of children with TTPA prolongation were documented. Nine children showed circulating anticoagulant, 4 of which were lupus type anticoagulants. The age of the patients ranged from 4 to 13 and there was a prevalence of males (3/4). Half of the children had a family history of bleeding dyscrasia and it was these who showed hemorrhage or thrombotic symptoms. The case that started with ecchymosis and hemorrhaging showed prothrombin prolongation due to factor II deficit. In 3 of the 4 children, AL was linked to acute respiratory infections and was transitory. The other coincided with two thrombotic episodes of the lower extremities in a healthy child. Positive anticardiolipin antibodies were detected in two patients, both showing repeated AL episodes, one with thrombosis and the other always asymptomatic. CONCLUSIONS: Diagnosis of AL in children is difficult and has probably been underestimated. Although it is usually transitory, it can appear in repeated episodes. Its early detection is important as it can be linked to both prothrombin deficit, as well as significant symptoms of hemorrhaging.

Predictive factors of Mycobacterium tuberculosis infection and pulmonary tuberculosis in prisoners.

BACKGROUND: Tuberculosis currently represents a serious problem in prison populations. METHODS: With the aim of studying the predictive factors for, and the prevalence of, Mycobacterium tuberculosis infection and pulmonary tuberculosis in a Spanish prison, all those admitted during 1991 and 1992 were included (N = 1314). The tuberculin skin test, HIV serology, chest X-ray and bacteriological examination of sputum were carried out. Statistical analysis was done by univariant tests, stratified analysis and logistic regression. RESULTS: The prevalence of M. tuberculosis infection was 55.5% (95% confidence interval [CI] 52.5-58.5). An association was found with sex, imprisonment more than once, HIV infection and age. The co-infection rate (tuberculosis plus HIV) was 9.2%. Logistic regression showed a greater risk with age (4.4% per year), time spent in prison and for males. The prevalence of pulmonary tuberculosis was 1.26% and an association was found with M. tuberculosis infection, HIV infection (odds ratio [OR] = 13.7), intravenous drug users (OR = 17.2) and imprisonment more than once (OR = 7.3). Logistic regression showed an association with HIV co-infection (OR = 20.2). CONCLUSIONS: The prevalence of M. tuberculosis infection and pulmonary tuberculosis is high when compared with similar studies. The influence of age, time spent in prison and co-infection with HIV is relevant to recommendations for specific tuberculosis prevention programmes in correctional facilities.

[Effectiveness (accessibility and compliance) of a program of early diagnosis of pulmonary tuberculosis in a penitentiary population]. / Efectividad (accesibilidad y adherencia) de un programa de detección precoz de tuberculosis pulmonar en población reclusa.

The aim of the study was to determine the effectiveness of a pulmonary tuberculosis detection Program in a Spanish prison (280-320 inmates) with a high turn-over rate (500 entries annually). 754 prisoners without antituberculous chemotherapic or chemoprophylaxis were included. 642 (85.1%) had access to the Program; the highest percentage of access was obtained when tuberculin test was performed at the entrance (96.4%) versus 80.5% when it was differed (P < 0.000001). The compliance observed was 82.2%, with no evidence that a greater accessibility was influential al all. The effectiveness was 70%, greater when tuberculin test was performed at the entrance in prison (76.7%) versus 66.8% when it was differed (P < 0.000001). We conclude that since pulmonary tuberculosis rates in prisons are so high and since it is possible to obtain a high effectiveness in detection programs, if were generalize these programs in concurrence with an adequate treatment of tuberculosis cases we shall obtain high efficiency rates.

[Polymorphism of platelet glycoprotein Ib in the Spanish population ]. / Polimorfismo de la glicoproteína Ib plaquetaria en la población española.

PURPOSE: To assess the polymorphism of the platelet membrane glycoprotein in castilians and gypsy people and to confirm the genetic transmission of such glycoprotein by means of family studies. MATERIAL AND METHODS: Two-hundred castilians and 87 gypsy subjects were studied. Glycoprotein Ib was analysed by means of SDS polyacrylamide gel electrophoresis followed by Western-Blotting and labelling with glycoprotein-specific monoclonal antibodies and lectins. The different populations were compared by using the chi-square method (Fisher's test). RESULTS: Only three groups of glycoprotein Ib, namely, B, C and D, were found in both population groups, no differences being observed in the expression of the different phenotypic variants. Lesser polymorphism was present in the gypsy group. The family studies showed that glycoprotein Ib is genetically determined, the two alleles being co-dominantly expressed in each individual. CONCLUSIONS: The polymorphism of glycoprotein Ib is similar to that of caucasians, type A being not found. No differences seem to exist between castilians and gypsy people. The heredity pattern is autosomal co-dominant.

[Blood lead in a population of children with iron deficiency]. / Estudio de la plumbemia en la población infantil con ferropenia.

BACKGROUND: Analysis of blood lead levels in relation to the state of iron metabolism was carried out in children. METHODS: A transversal study of blood lead levels was designed in 89 iron deficient children (serum ferritin < 15 micrograms/l) (group F). Fifty seven of the children did not have anemia (sub-group FS) and 32 had anemia (sub-group AF) with ages ranging between 6 months and 14 years, and 41 children of the same age with normal iron metabolism (group C). A longitudinal study was also carried out by the determination of blood lead levels prior and after iron therapy in 18 of the iron deficient children. RESULTS: A significant difference was seen between the mean of blood lead levels in iron deficient children (group F), 9.41 micrograms/dl and normal children (group C), 6.88 micrograms/dl (p < 0.01). The mean of blood lead levels of the sub-group FS was 7.79 micrograms/dl and the sub-group AF, 12.30 micrograms/dl (p < 0.01). The prevalence of lead poisoning (blood lead levels > 20 micrograms/dl) was 8% in group F (2% in sub-group FS, 19% in sub-group AF) and 0 in group C (p < 0.01). A significant decrease was found in the longitudinal study in the mean of blood lead levels following iron therapy from 14.12 micrograms/dl to 7.51 micrograms/dl (p < 0.05). CONCLUSIONS: The iron deficient state may constitute a predisposing factor of lead poisoning in childhood.

[Submandibular fold. An alternative for the assessment of subcutaneous fat]. / El pliegue submandibular. Una opción para la valoración de la grasa subcutánea.

BACKGROUND: Folds are a useful method of measuring subcutaneous fat. This study reports the feasibility of the use of the submandibular fold to evaluate the subcutaneous fat. METHODS: A transversal descriptive study was designed by a poly-staged stratified randomized sample (n = 572). A series of anthropometric measurements (weight, height, different folds and surrounding areas) were performed in addition to the measurement of the submandibular fold. In addition blood pressure was determined as well as oral glucose tolerance test. RESULTS: After correction of the effect of age, the submandibular fold was found to be related with both the Quetelet's index (BMI) (males r = 0.50; females r = 0.61, both p < 0.0001) and the Benn's index (males r = 0.53; females r = 0.60, both p < 0.0001). Their correlations with those of other folds and with the measurements of centralization place the submandibular fold in a median position with respect to central and peripheral fat deposits. Furthermore, the percentage of fat which the increase in BMI carries is practically constant. Likewise, it was associated with the presence of high blood pressure in both sexes (males F = 9.7, p < 0.025; females F = 6.1, p < 0.025), diabetes mellitus (F = 6.1, p < 0.005) and inguinal hernias (F = 10.8, p < 0.0025) in males and in females, as well as to the presence of abdominal striae in females (F = 12.2, p < 0.001). CONCLUSIONS: The submandibular fold may be used by investigators who wish to evaluate subcutaneous fat through one sole fold, which is accessible and easy to measure. This measure is intermediate between the central and peripheral zones. In addition, it may reflect the fat deposit which is produced with both an increase in the body mass index and age.

Self-reported height and weight and prevalence of obesity. Study in a Spanish population.

The objective of this investigation was to evaluate the usefulness of self-reported measures of height and weight under the hypothesis that they under-estimate the prevalence of obesity. A cross-sectional study was carried out on a random sample of the adult population of the province of León, Spain. The study involved 572 participants (262 men and 310 women). All participants were interviewed and questioned about socio-cultural characteristics plus their weight and height. All respondents were later weighted and measured for height using standard methods. A Quetelet or body mass index (BMI) > or = 30 kg/m2 was used as the index for obesity. Many people were unaware of their weight and/or height. Self-reported BMI could not be calculated in 40 men (15%) and 107 women participants (35%). This occurrence was more frequent in women than in men (chi 2 = 3.98; P < 0.05). The prevalence of obesity, based on measured weight and height, was 1.8 times that from self-reported values in men and 2.5 times that from self-reported values in women. If we consider only the measured values for those individuals who supplied self-reported heights and weights, these prevalences fall to 1.7 and 1.6 times those from self-reported values respectively. In addition, the difference between measured and self-reported height increase with age. All these differences are statistically significant. We believe that the use of self-reported values of weight and height in epidemiological studies should be avoided in an elderly population. These measurements could, however, be used on a younger population.

[Obesity in the province of León. Differing criteria, different prevalences]. / La obesidad en la provincia de León. Distintos criterios, diferentes prevalencias.

OBJECTIVE: To assess the prevalence of obesity among the adult population of our province. DESIGN: Cross-sectional. SITE. León Province. PATIENTS OR OTHERS PARTICIPANTS: This was a random sample with 572 individuals over 17. They were picked from the electoral register. The confidence level was 95%, with a 3.5% length of interval. They were selected by means of proportional, multi-stage stratified sampling. The Hansen method was used for a subsequent survey of the cases missed. MAIN MEASUREMENTS AND RESULTS: Socio-demographic data were collected, and weight and size measured, using standard procedures. Those who had a Quetelet index > or = 30 kg/m2 or with a relative weight > or = 120%, in line with different weight tables, were considered to be obese. Under the first criterion there was a 23.25% prevalence of obesity (CI: 19.79-26.71). The second showed long variations, running from 59.92% (CI: 55.64-64.20) to 16.17% (CI: 13.06-19.28). CONCLUSIONS: The prevalence of obesity among adults in our province is above that in other zones of Spain and other countries. The calculation of relative weight is not possible in an important number of cases because age or size are not properly included in the reference table. The criteria for defining someone as obese need to be unified in order to be able to make comparisons between different surveys.