Systematic review of the biological variation data for diabetes related analytes.

BACKGROUND: Objective interpretation of laboratory test results used to diagnose and monitor diabetes mellitus in part requires the application of biological variation data (BVD). The quality of published BVD has been questioned. The aim of this study was to quality assess publications reporting BVD for diabetes-related analytes using the Biological Variation Data Critical Appraisal Checklist (BIVAC); to assess whether published BVD are fit for purpose and whether the study design and population attributes influence BVD estimates and to undertake a meta-analysis of the BVD from BIVAC-assessed publications. METHODS: Publications reporting data for glucose, HbA1c, adiponectin, C-peptide, fructosamine, insulin like growth factor 1 (IGF-1), insulin like growth factor binding protein 3 (IGFBP-3), insulin, lactate and pyruvate were identified using a systematic literature search. These publications were assessed using the BIVAC, receiving grades A, B, C or D, where A is of highest quality. A meta-analysis of the BVD from the assessed studies utilised weightings based upon BIVAC grades and the width of the data confidence intervals to generate global BVD estimates. RESULTS: BIVAC assessment of 47 publications delivered 1 A, 3 B, 39C and 4 D gradings. Publications relating to adiponectin, C-peptide, IGF-1, IGFBP-3, lactate and pyruvate were all assessed as grade C. Meta-analysis enabled global BV estimates for all analytes except pyruvate, lactate and fructosamine. CONCLUSIONS: This study delivers updated and evidence-based BV estimates for diabetes-related analytes. There remains a need for delivery of new high-quality BV studies for several clinically important analytes.

[Nutrient intake and eating habits in hemodialysis patients: comparison with a model based on mediterranean diet]. / Principales déficits del consumo alimentario de los pacientes en hemodiálisis: aproximación a un modelo de alimentación saludable basado en la dieta mediterránea.

OBJECTIVES: Inadequate nutrient intake seems to be one of the most important cause of malnutrition in hemodialysis patients. The purpose of this study was to analyse their nutrient intake and eating habits, comparing food groups' intake with standard Mediterranean diet values (Healthy Diet Guide 2004, Nutrition Community Spanish Society). MATERIAL AND METHODS: There were 28 stable hemodialysis (HD) patients, 15 males and 13 females, mean age 62,9 +/- 16 years. Dietary evaluation was based on 7-day dietary recalls conducted by a single observer. We compare nutrients intake with recommended hemodialysis intake and we contrast food groups consumption with the theoretical ideal based on Mediterranean diet. RESULTS: The protein intake was 1,33 +/- 0,2 g/kg/day and the energy intake 29,5 +/- 2,1 kcal/kg/day. Carbohydrates accounted 43,1% of energy intake, proteins 19% and lipids 37,9% (55,5% monounsaturated fatty acids, 16,4% polyunsaturated fatty acids and 28,1% saturated fatty acids). Complex carbohydrates (potatoes, cereals, vegetables, fruits) and olive oil consumption was lower than that recommended to the Spanish healthy population and to the chronic hemodialysis patients. The animal protein intake (meat, fish, eggs) was correct, although excessive in red and processed meats. Results: Potatoes and cereals recommended frequency (RF) 4-6 portions/day, HD patients frequency (HDF) 4,1 portions/day; vegetables RF > 2 portions/day, HDF 1,2; fruits RF > 3 portions/day, HDF 1,3; olive oil RF 3-6 portions/day, HDF 1,5; Fish RF 3-4 portions/week, HDF 4,2; White meat RF 3-4 portions/week, HDF 1,5; Poultry RF 3-4 portions/week, HDF 2,3; Eggs RF 3-4 portions/week, HDF 3,6; Pulses RF 3-4 portions/week, HDF 1,7; Nuts RF 3-7 portions/week, HDF 0; Red meat RF occasionally, HDF 4,8 portions/week; Processed meats RF occasionally, HDF 4,6 portions/week; Sweets, snacks, soft drinks RF occasionally, HDF 1,7 portions/week; Butter, margarine, processed bakery products, biscuits RF occasionally , HDF 0,5 portions/week. CONCLUSIONS: Nutritional abnormalities are frequently found even in apparently stable patients on chronic hemodialysis. Caloric rather than protein undernutrition is the major abnormality. Inadequate caloric intake (< 35 kcal/kg/day) can lead to a negative nitrogen balance. Their eating habits are healthy and natural, but there is a deficit in slowly absorbed carbohydrates and olive oil intake (with caloric intake reduction), and an excessive consumption of red and processed meats (with saturated fats increase). The individual correction of these dietary patterns could reduce the saturated fats and increase the energy intake, obtaining a balanced diet integrated into our geographic region and culture.

Serum enzymes activities at rest and after a marathon race.

With the purpose of determining the long and short term changes in serum enzyme activities after a marathon race, a survey involving nine healthy male runners was carried out. A basal blood sample was extracted from each 24 hours prior to the race and three further extractions were made immediately after the race, as well as at 1 and a final 24 h after the end of the race. In the enzymes of preferably hepatic origin--alkaline phosphatase (AP), ganna-glutamyltransferase (GGT) and alanine aminotransferase (ALT)--scanty modifications were found and these could be related to the changes observed in the plasma volume. Enzymes such as aspartate aminotransferase (AST) and lactate dehydrogenase (LDH), which are widely distributed in the tissues, were found to have undergone more marked variations and these could not be related to the changes in the volume of the plasma, while in enzymes of muscular origin such as aldolase (ALD), creatine kinase (CK) and its cardiac isoenzyme (CK-MB), notable increases were observed due to the muscular injury suffered. The greatest example of this was the increase found in total CK 24 h after the end of the marathon (414.6%). The high serum percentages found in CK-MB in these endurance-trained runners in relation to total CK activity should be carefully assessed in order to avoid false diagnosis of acute myocardial infarction.

[Evaluation of food intake in hemodialysis using a food consumption and appetite questionnaire]. / Valoración de la ingesta en hemodiálisis mediante un cuestionario de consumo alimentario y apetito.

Protein calorie malnutrition is a common complication in chronic hemodialysis patients (CHP). Although many factors could promote malnutrition, inadequate nutrient intake seems to be one of the most important. An Appetite and Diet Assessment Questionnaire (ADAQ) was developed, and we have performed a cross-sectional study in 44 CHP to investigate its capacity to predict an inadequate intake. Dietary evaluation was based on a diet diary-assisted recalls (DDAR). On the other hand, the validity of PCR and the differences in the DDAR and ADAQ between the days of dialysis and the days without dialysis were studied. The predictive value of inadequate intake of the ADAQ and the PCR were analysed with the ROC curve. The protein intake was 1.3 +/- 0.3 g/kg/day and the energy intake 29.2 +/- 0.6 kcal/kg/day. The average PCR was 1.14 +/- 0.3. The ROC curve to predict inadequate intake from the ADAQ shows an area under the curve of 0.84 for the protein intake and 0.73 for the energy intake. A cut-off ponit of 18 gives a sensitivity of 100% and a specificity of 44% for the detection of poor protein intake (< 1.2 g/kg/day) and of 74% and 56% for the detection of poor energy intake (< 30 kcal/kg/day). The ROC curve to predict inadequate protein intake from the PCR obtains an area under the curve of 0.81. The cut-off 1.06 gives the best sensitivity (100%) and specificity (64%) for the detection of insufficient protein intake. We did not find any significant difference in the DDAR or in the ADAQ between the days of dialysis and the days without dialysis. Despite the subjective interpretation, the relationship between ADAQ and protein-energy intakes analysed by DDAR was highly significant. The questionnaire is simple and can therefore be used as a screening rest to detect and correct alterations in the diet which could otherwise lead to malnutrition. The determination of PCR gives a good sensitivity and specificity for the detection of poor protein intake, although the results are modified in anabolic or catabolic states which can clinically go undetected. We do not register differences in diet between the days of dialysis and the days without dialysis.

[Characteristics of acute renal failure in elderly patients admitted to a small town hospital]. / Epidemiología, aspectos clínicos y manejo del fracaso renal agudo en una población envejecida dependiente de un hospital comarcal.

We studied the features of acute renal failure (ARF) in elderly patients treated in a hospital, without an intensive care unit, to identify etiological factors and establish adequate preventive measures and treatment. During twelve consecutive months we studied prospectively 99 patients with ARF diagnosed by conventional criteria, an incidence of 1,238 cases per million per year. ARF affected 1.78% of patients admitted to hospital. We analyzed age, sex, serum creatinine, diuresis, etiology, type of ARF, preexisting chronic diseases, treatment, complications and outcome. Preexisting chronic diseases were common, the most frequent being hypertension (54%) and diabetes (39%). Previous treatments for cardiovascular diseases were frequent (angiotensin-renin system blockade 35.4%, diuretics 50.5%). 79% of ARF arose in hospital, 21% outside hospital. ARF was pre-renal in 60%, renal in 31% and post-renal in 9%. 34.7% were caused by volume depletion, 23.4% by low cardiac output and 23.4% by infection. 44.4% of ARF patients had oliguria or anuria latrogenic factors contributed to the ethiology of ARF in 35.3% of patients. Hospital stay was doubled by ARF the presence of ARF and the mortality was 36.4%. The rate was higher in ARF arising in hospital than in ARF acquired before admission. Factors that had a significant influence on the mortality rate were comorbid conditions, oliguroanuria, ARF of renal origin and serum albumin. We conclude that ARF has a high incidence, morbidity and mortality in this elderly population. Volume depletion, associated cardiovascular pathology and pharmacological treatment are important etiological factors in those with ARF outside hospital. Adequate treatment of ARF and avoidance of nephrotoxic medications are necessary in hospital.

[Comparison of clinical arterial pressure, home-arterial pressure measurement, and ambulatory arterial pressure monitoring in patients with type II diabetes mellitus and diabetic nephropathy]. / Comparación de presión arterial clínica, automedida domiciliaria de presión arterial y monitorización ambulatoria de presión arterial en el paciente con diabetes mellitus tipo 2 y nefropatía diabética.

BACKGROUND: Hypertension is common in type 2 diabetes with diabetic nephropathy, and increases the risk of cardiovascular complications and renal chronic insufficiency. The aim of our evaluation in these patients was: a) to study the correlation between office blood pressure (BP), self-monitored (SMBP) and 24-hour ambulatory blood pressure monitoring (ABPM). b) To study the correlation between these methods and cardiovascular and renal complications. METHODS: We studied 60 patients (mean age 66.7 +/- 9 years, mean duration of diabetes 11.3 +/- 7 years) with arterial hypertension, type 2 diabetes and diabetic nephropathy. Macroangiopathy and echocardiography were recorded. We measured, SMBP and ABPM without modifying the antihypertensive treatment. The white coat phenomenon (WCP) was determined and patients were classified as dippers or non dippers according to their blood pressure diurnal rhythm. RESULTS: Mean glycated haemoglobin was 7.8% and mean serum creatinine 1.2 +/- 0.5 mg/dl, 30% of patients had proteinuria and 70% microalbuminuria The mean number of antihypertensive drugs was 2.2 +/- 1. The mean BP was: Office BP: 158.2 +/- 24/85.3 +/- 9 mmHg, pulse pressure (PP) 72.9 +/- 21 mmHg; SMBP: 145.4 +/- 18/77.5 +/- 7 mmHg, PP 67.9 +/- 18 mmHg and BP in the early morning 150.2 +/- 20/79.9 +/- 9 mmHg; ABPM: diurnal mean 138.9 +/- 15/74.1 +/- 6 mmHg, PP 64.8 +/- 15 mmHg and BP in the early morning 146.5 +/- 16/78.5 +/- 7 mmHg. The three techniques showed a good correlation and WCP was detected in 46.7% of patients with SMBP and in 56.7% with ABPM. We found no correlation between BP and macroangiopathy, but an increase of systolic BP in SMBP and ABPM in proteinuric patients were found and correlation between mass left ventricular index (MLVI) and PP in office and systolic BP and PP in SMBP and ABPM was significant. 70% of patients were non dippers, with a higher MLVI. CONCLUSIONS: Decreases in BP in type 2 diabetes with diabetic nephropathy are difficult of maintain despite combinations of different antihypertensive drugs. These patients present an important WCP and worse prognosis data, such as elevation of systolic BP, increased PP, poor night BP fall and a BP rise in the early morning. Also, we can't reduced the BP during 24 hours in an important number of patients. These characteristics can be detected by combining the office BP measurement, SMBP and ABPM. The alternative possibility would be lifestyle modification, appropriate drug combinations and to start treatment at lower levels than those currently used as thresholds (the guidelines for antihypertensive treatment have been drastically shifted in this direction over the past years).

[Quality control of general diets served in a county hospital]. / Control de calidad de las dietas generales servidas en un hospital comarcal.

INTRODUCTION: The general diet of a hospital, given to patients who do not require therapeutic modifications, must meet their nutritional demands. MATERIAL AND METHODS: During a 42 consecutive days period, the complete menu of a patient was randomly selected. Using a computer program based on the food composition tables, we verified whether or not the foods the patient received, met the requirements of the theoretical menus of the hospital, designed according to the international recommendations. RESULTS: The provided menus supplied 2,410 kilocalories, of which 900 (37.3%) corresponded to carbohydrates, 1,071 (44.4%) corresponded to lipids, and 439 (18.3%) corresponded to proteins. The level of cholesterol was 422 mg, and the fiber content was 20 g. These values differ significantly from the theoretical values noted previously: 2,200 kilocalories, 55% carbohydrates, 30% lipids, 15% proteins, cholesterol less than 300 mg, and 40 g of fiber (p < 0.001). Within the fats, the monounsaturated fats were the most abundant (45%). With regard to vitamins and minerals, vitamin D was the only deficient vitamin when compared to the international recommendations. CONCLUSION: We have detected that our general menus provide an excess of fats and cholesterol, as well as a deficient supply of carbohydrates, fiber, and vitamin D. We believe it necessary to carry out periodic quality controls to correct the defects that arise on translating the theoretical menus into daily practice.

External quality assurance programs as a tool for verifying standardization of measurement procedures: Pilot collaboration in Europe.

INTRODUCTION: Current external quality assurance schemes have been classified into six categories, according to their ability to verify the degree of standardization of the participating measurement procedures. SKML (Netherlands) is a Category 1 EQA scheme (commutable EQA materials with values assigned by reference methods), whereas SEQC (Spain) is a Category 5 scheme (replicate analyses of non-commutable materials with no values assigned by reference methods). AIM: The results obtained by a group of Spanish laboratories participating in a pilot study organized by SKML are examined, with the aim of pointing out the improvements over our current scheme that a Category 1 program could provide. METHOD: Imprecision and bias are calculated for each analyte and laboratory, and compared with quality specifications derived from biological variation. RESULTS: Of the 26 analytes studied, 9 had results comparable with those from reference methods, and 10 analytes did not have comparable results. The remaining 7 analytes measured did not have available reference method values, and in these cases, comparison with the peer group showed comparable results. The reasons for disagreement in the second group can be summarized as: use of non-standard methods (IFCC without exogenous pyridoxal phosphate for AST and ALT, Jaffé kinetic at low-normal creatinine concentrations and with eGFR); non-commutability of the reference material used to assign values to the routine calibrator (calcium, magnesium and sodium); use of reference materials without established commutability instead of reference methods for AST and GGT, and lack of a systematic effort by manufacturers to harmonize results. CONCLUSIONS: Results obtained in this work demonstrate the important role of external quality assurance programs using commutable materials with values assigned by reference methods to correctly monitor the standardization of laboratory tests with consequent minimization of risk to patients.