[Self monitoring of capillary blood glucose. Evaluation of long-term results (3 to 7 years)]. / Autocontrol de la glucemia capilar. Evaluación del resultado a largo plazo (3 a 7 años).

We analyzed data provided by 60 diabetic patients (DP) included in a Program (P) of Self Blood Glucose Monitoring (SBGM) which showed an initial adherence of at least 6 months. Total follow-up was 67,293 DP-days (110,504 capillary glycemias). Only 50% of DP's remained for > 3 years. Rates of drop-out (DO) peaked early (3th semester (S) and late (10th. S) mean +/- SE of daily SBGM reported in the preprogram period and during the 1st S on P-SBGM by the future DO was significantly higher (4.25 +/- 0.22) than those reported by their P-SBGM-mates who stayed in the program (3.11 +/- 0.29; p < 0.01). DO showed a higher % of capillary glycemias < 60 mg/dl (hypoglycemia) (5.34 +/- 1.49 vs 2.85 +/- 1.14; p < 0.01). During the 3rd S early DO showed significantly higher Glycosilated Hemoglobin (HbA1) levels (10.4 +/- 0.49%) than late DO (8.19 +/- 0.45%; p < 0.01). HbA1's recorded by the late DO's just before leaving P-SBGM were significantly higher (10.14 +/- 0.61%) than those seen at 2nd/5th S (8.2 +/- 0.2; p < 0.01). However, HbA1's of 1-DO at time of abandoning P-SBGM were comparable to those shown by those DP's who remained (10.14 +/- 0.61 vs 9.46 +/- 0.27%). DP's performed daily SBGM's in 70% of possible days during 4 years and in only 50% afterwards. Daily SBGM's was 3.3 +/- 1 during the first 3 years and 2.1 +/- 0.8 thereafter. Compared to preprogram period, all DP's improved HbA1's (12.5 +/- 0.31 vs 9.46 +/- 0.27; p < 0.001) and mean blood glucose (166 +/- 5.2 vs 146 +/- 3.6; p < 0.01). DP's who reached a faster and more satisfactory degree of glycemic control in earlier stages of P-SBGM showed the highest rates of drop-out. Early identification of such patients, as well as setting of feasable and individualy adjusted goals of glycemic control may improve current compliance of DP's on long term tight control.

[Intensified insulin therapy in the management of gestational diabetes]. / Insulinoterapia intensificada en el manejo de la diabetes pregestacional.

A total of 35 pregnancies in 28 Pregestational Diabetic Patients (PDP) were followed with the goal of achieving and maintaining near normoglycemia (as many pre-postprandial glycemias as possible between 60-140 mg/dl); 13 patients (16 pregnancies) were assigned to Subcutaneous Continuous Preprogrammed Insulin Infusion (SCII) because of high risk pregnancies (HRP) (at least one of the following: former history of spontaneous abortions, stillbirths, premature deliveries and/or sterility). The remaining 12 PDP's (15 pregnancies with no past history of the above nature) were treated with Multiple Conventional Insulin Injections (MCII). Both groups were comparable regarding the following clinical parameters: age, time of onset and class of diabetes. All patients were instructed in performing 3 to 7 daily Self Capillary Blood Glucose controls (SCBG). Mean follow-up observation period was (mean +/- SEM) 28.5 +/- 2.5 weeks for SCII and 3.2 MCII and 28.8 +/- 3.2 weeks for MCII. All the 3 PDP drop out's (4 pregnancies) belonged to the CMII group. No drop out's were recorded in the SCII group. Both insulin therapy approaches were similarly effective in improving metabolic control in that comparable levels of mean blood glucose (MBG) and HbA1 were attained by SCII and MCII (Fig. 1). Compliance, as evidenced by average of daily SCBG was also similar in both groups (Fig. 2). Such satisfactory metabolic control was achieved mostly because of an increase in the percentage (65%) of "fair" glycemias (60-139 mg/dl) and not because of an increase in hypoglycemias (< 60 mg/dl) which could have canceled out an undesirable degree of hyperglycemias thus rendering "false satisfactory" MBG's and HbA1 (Fig. 1). With the above degree of metabolic control obtained there occurred no severe hypoglycemic episodes requiring medical intervention. All newborns to the PDP's who remained under treatment showed an adequate APGAR (X +/- SEM, 9.5 +/- 0.2) regardless of the modality (SCII or MCII) of insulin delivery used (Tables 1, 2). The single malformed baby found in this series was born to a patient on SCII who happened to start on the intensified insulin treatment rather late in her pregnancy (21st week) and, in addition, the patient self medicated with high doses of chlorpromazine because of recurrent vomiting episodes. Incidence of neonatal hypoglycemia (HY) or macrosomy (MS) was comparable in both groups (Tables 1, 2). It is to be pointed out, however, that PDP's who bore the babies with no HY or MS had presented a larger number of low glycemic values than mothers who bore the babies with HY and/or MS.(ABSTRACT TRUNCATED AT 400 WORDS)

Evaluation of the hypothalamic-pituitary-gonadal axis in eugonadal men with type 2 diabetes mellitus.

Men with type 2 diabetes mellitus (DM2) have lower testosterone levels and a higher prevalence of hypogonadism. It still remains unclear the mechanism by which there is a relationship between hypogonadism and DM2. The objective was to evaluate the hypothalamic-pituitary-gonadal axis at different levels in eugonadal patients with DM2. Fourteen patients with DM2 (DM2 group) and 15 subjects without DM2 (normal glucose tolerance test) as control group (CG) were included. We assessed: (i) fasting glucose, insulin, Homeostasis Model Assessment (HOMA); (ii) luteinizing hormone (LH) pulsatility through blood collections every 10 min for 4 h; (iii) gonadotropin-releasing hormone (GnRH) test: basal LH and 30, 60 and 90 min after 100 µg of i.v. GnRH; (iv) human chorionic gonadotropin (hCG) test: basal total testosterone (TT), bioavailable testosterone (BT), free testosterone (FT), estradiol (E2), bioavailable E2 (BE2) and sex hormone-binding globulin (SHBG) and 72 h post 5000 IU of i.m. hCG. There were no differences in age, body mass index and waist circumference between groups. Glucose was higher in the DM2 group vs. CG: 131.1 ± 25.5 vs. 99.1 ± 13.6 mg/dL, p = 0.0005. There were no difference in basal insulin, HOMA, TT, BT, FT, E2, BE2, SHBG and LH levels between groups. The DM2 group had lower LH pulse frequency vs. CG: 0.8 ± 0.8 vs. 1.5 ± 0.5 pulses, p = 0.009. Differences in LH pulse amplitude were not found. A negative correlation was found between the number of LH pulses and glucose, r: -0.39, p = 0.03. There were no differences in the response of LH to GnRH between groups nor in the response of sexual steroids and SHBG to hCG. Patients with DM2 showed lower hypothalamic pulse frequency without changes in the pituitary response to GnRH nor testicular response to hCG. Glucose levels negatively correlated with the number of LH pulses which suggests a negative effect of hyperglycaemia in the hypothalamic secretion of GnRH.

An algorithm for the treatment of type 2 diabetes in Latin America.

Diabetes is a principal and growing health concern in Latin America, accounting for significant mortality and morbidities. Large, randomized, prospective trials of various interventional therapies in patients with both type 1 and type 2 diabetes have demonstrated that reductions in hyperglycaemia and management of diabetes-related risk factors can significantly reduce the micro- and macrovascular complications of diabetes. Therefore, patients with type 2 diabetes will benefit from more aggressive treatment regimens to help decrease the occurrence and rate of progression of diabetic complications. Given the many complexities of diabetes management, it is often difficult for general practice physicians to stay abreast of emerging treatment strategies and therapies. Owing to the high prevalence of type 2 diabetes in Latin America, the majority of patients with diabetes are treated by generalists rather than specialists. This article was intended to assist physicians and other healthcare professionals in developing and using effective treatment strategies to stem the growing epidemic of diabetes and its complications in Latin America.

Growth hormone-insulin-like growth factor-I axis in adult insulin-dependent diabetic patients: evidence for central hypersensitivity to growth hormone-releasing hormone and peripheral resistance to growth hormone.

The aim of this study was to assess the GH-IGFI axis, GH receptor availability, as reflected by the levels of GH-BP, and the amount of GH-dependent IGFBP-3 in adult IDDM patients with different degrees of metabolic control. Thus, 10 adult well-controlled IDDMs (HbA1 7.8 +/- 0.4%), 10 adult non-ketotic poorly controlled IDDMs (HbA1 13.3 +/- 7%) and 14 sex- and age-matched healthy controls were subjected to two intravenous GH-RH stimulation tests with 0.1 and 1.0 microg/kg body weight respectively, and a plasma IGF-1 generation test induced by the administration of hGH. Poorly controlled IDDM patients exhibited an exaggerated GH response to 1.0 microg/kg of GH-RH when compared to healthy control subjects. Low fasting plasma IGF-1 levels and a blunted IGF-1 response to exogenously administered hGH were also found in poorly controlled IDDMs when compared to the healthy control group. GH-BP levels were significantly lower in IDDMs than in normal controls, and correlated positively with the IGF-1 generation capacity after hGH. Serum IGFBP-3 levels measured by RIA were similar in IDDM and control groups. Good glycemic control for 5.7 +/- 0.9 months did not correct the above mentioned abnormalities of the GH-IGF-1 axis. Our findings suggest that IDDM is associated with a diminished availability of GH receptors and synthesis of IGF-1. GH might then increase as a compensatory mechanism, further down-regulating liver GH receptors, and thus perpetuating the initial abnormality.

Bomba de infusión o inyecciones intensificadas de insulina: evaluación comparativa en un seguimiento prolongado / Subcutaneous insulin infusion with portable pump versus intensified conventional injections in diabetes: a long term follow up of comparative performance

Se comunica la evolución de 56 pacientes diabéticos insulinodependientes o requirentes enrolados en un Programa de Terapéutica insulínica Intensiva (TII)dirigido a lograr cuasi normoglucemia (60 a 180 mg/dl),durante un período de hasta 24 meses.De ellos,23 recibieron insulina mediante una bomba portable de infusión (BPI) durante XñES: 15.7ñ1.9 meses/pacientes y 33 por medio de inyecciones convencionales intensificadas (ICI) (2a4 por día),durante 19.6ñ1.4 meses/paciente.Fueron instruídos para realizar 3 a 7 autocontroles glucémicos capilares diarios (AGC) pre y/o 90 minutos posprandiales y en cualquier otro momento en que su sintomatología lo justificara.Ambos grupos mejoraron su control glucémico, evidenciado por un descenso significativo de sus glucemias medias capilares (GMC) hacia el 12º mes, para experimentar luego un progresivo deterioro del mismo, como lo muestra el incremento de las GMC, que retornaron a los valores pretratamiento,hacia el final del período de observación. Este deterioro en las GMC fue más precoz e importante en los pacientes en ICI y no sería atribuible a una disminución de la dosis de insulina diaria.Es de destacar que ambos grupos exhibieron controles glucémicos aceptables(GMC 12º mes:XñES: 129ñ3,8 en BPI y 136ñ3,9 en ICI) sólo cuando realizaban un promedio de 3 o más AGC/día. Sin embargo,este deterioro en las GMC (evidenciado por un incremento en el porcentaje de glucemias mayores de 180 mg/dl)no se acompañó de un deterioro de los niveles de HbA1 que,por el contrario,permanecieron dentro de un rango normal alto hasta el fina del período de observación

Bomba portable de insulina versus inyecciones convercionales intensificadas en diabetes / Subcutaneous insulin infusion with a portable pump versus intensified conventional injections in diabetes

Se observó la evolución de 17 pacientes diabéticos que habían permanecido por lo menos 6 meses en un programa de cuasi normoglucemia durante 51 semanas; 8 de ellos recibieron insulina por medio de una infusión subcutánea continua con una bomba portable (BPI) durante -x + ou - ES: 44,75 + ou - 2,1 semanas por paciente y 9 por medio de inyecciones convencionales intensificadas (2 a 4 por día) (ICI), durante 39,5 + ou - 3 semanas por paciente. Se instruyó a los mismos para realizar de 3 a 7 autocontroles glucémicos capilares diarios (AGC) con tirillas reactivas. Los pacientes en ambos grupos experimentaron mejorías similares en sus valores glucémicos hasta la 30ª semana (medias glucémicas: 125 mg/dl). A partir de allí, mientras que los pacientes en BP1 mantuvieron estable dicha mejoría, los pacientes en ICI evidenciaron un progresivo deterioro. Esta diferencia en la evolución tardía no es explicable por una disminución en la dosis de insulina diaria dado que, por el contrario, los pacientes en ICI mostraron un incremento en los requerimientos de la misma, que fue paralelo al deterioro glucémico. Es de destacar que mientras ambos grupos de pacientes exhibieron controles glucémicos comparables estaban realizando un promedio de por lo menos 3 autocontroles diarios. El deterioro glucémico observado en los paciente en ICI se asoció a una caída progresiva en el número diario de autocontroles por debajo de ese valor. Nuestros resultados nos permiten sugerir la necesidad de un mínimo de 3 autocontroles diarios como un factor necesario, aunque no suficiente en sí mismo, para lograr la optimización glucémica a largo plazo mediante cualesquiera de los enfoques insulinoterápicos intensivos (PB1 o IGI) que se adopte