Assessment of Alimentación Normal con Ajuste de Insulina (ANAIS), a Spanish version of the DAFNE programme, in people with Type 1 diabetes: a randomized controlled parallel trial.

AIM: To evaluate the effects of Alimentación Normal con Ajuste de Insulina (ANAIS), a group-based, therapeutic education programme for Type 1 diabetes based on a flexible insulin regimen adjusted to the individual's food intake. METHODS: Participants with Type 1 diabetes and HbA1c levels of 53-86 mmol/mol (7-10%) were recruited from outpatient clinics at a tertiary care centre. They were randomized (using opaque, sealed envelopes, with a 2:1 treatment allocation ratio) to attend the training course immediately (immediate ANAIS; intervention group) or a year later (delayed ANAIS; control group). The main outcome was HbA1c level at 1 year. Secondary outcomes included lipid levels, weight, hypoglycaemic events, insulin dose, treatment satisfaction, self-perceived dietary freedom, quality of life and participant-defined goals. RESULTS: A total of 48 participants were assigned to the intervention group and 32 to the control group. Twelve months after completing the training, adjusted HbA1c was not significantly different in the intervention group [64 ± 1.3 vs 68 ± 1.6 mmol/mol (8.0 ±0.1% vs 8.4 ±0.1%); P=0.081]. Treatment satisfaction was significantly higher in the intervention group, but no differences were found in hypoglycaemic events, weight, insulin dose or changes in dietary freedom. At 1 year after the intervention, 72% of the participants (vs 33% in the control group; P=0.046) reported exceeding their expectations regarding achievement of their main personal goal. CONCLUSION: Promoting dietary freedom and empowering people with Type 1 diabetes through structured education programmes, such as ANAIS, improves treatment satisfaction and self-defined goals. No significant improvement in HbA1c level was achieved.

MUSCLE INFARCTION AND SEVERE DETERIORATION OF RENAL FUNCTION IN A PATIENT WITH TYPE 1 DIABETES MELLITUS AND CHRONIC KIDNEY DISEASE.

CONTEXT: Spontaneous muscle infarction is a rare complication of diabetes mellitus, mainly affecting women and patients with long-lasting type 1 diabetes. OBJECTIVE: This report is aimed to describe the case of a patient with type 1 diabetes and diabetic nephropathy in whom a severe deterioration of renal function was triggered by a muscle infarction. SUBJECT AND METHODS: Subject of the study was a 33-years-old woman with an 18 years history of type 1 diabetes mellitus, proliferative diabetic retinopathy, nephropathy at stage 3 chronic kidney disease, somatic sensory-motor polyneuropathy and autonomic neuropathy. RESULTS: The patient presented with severe pain and dysfunction of the left thigh without prior trauma plus progressive deterioration of the renal function. Nuclear magnetic resonance of the thigh showed inflammatory changes in the external vastus with hyperintensity on T2 sequence and edema of the subcutaneous cellular tissue. After other possible etiologies were ruled out, a clinical diagnosis of spontaneous muscle infarction was established. The patient needed hospital admission for two months, during which the renal function worsened until she required hemodialysis. No other possible triggers of kidney injury were identified. CONCLUSIONS: Up to our knowledge, this is the first described case where muscle infarction is suspected to have caused exacerbation of an existing chronic kidney failure. Monitoring the renal function should be considered in patients with diabetic nephropathy presenting with this rare complication of diabetes.

Differences in traditional and emerging cardiovascular risk factors of subjects discordantly classified by metabolic syndrome definitions of the International Diabetes Federation and the National Cholesterol Education Program.

BACKGROUND AND AIM: Several working definitions of metabolic syndrome have been proposed for clinical use. However, individuals can be discordantly classified as having or not having metabolic syndrome depending on the choice of one or another definition. This study compared the cardiovascular risk profile of subjects concordantly and discordantly diagnosed by the criteria of the National Cholesterol Education Program (NCEP) and the criteria of the International Diabetes Federation (IDF). METHODS AND RESULTS: Nine hundred and twenty-nine non-diabetic adult subjects belonging to a cross-sectional population-based study in Gran Canaria island (Spain) were assessed. Participants completed a questionnaire and underwent physical examination, fasting blood analyses, and a standardized oral glucose tolerance test. Two hundred and four subjects (22%) had metabolic syndrome according to both definitions, 31 (3.3%) only by the IDF criteria, and 5 (0.5%) only by the NCEP criteria. Participants fulfilling both proposals showed more adverse age and sex-adjusted measures of BMI, waist, HDL cholesterol, triglycerides, post-load glucose, HOMA-IR and plasminogen inhibitor activator-1 (PAI-1) than individuals exclusively satisfying the IDF criteria. Moreover, in contrast to subjects meeting both criteria, those that fulfilled only the IDF criteria had levels of BMI, waist, total and HDL cholesterol, post-load glucose, glycated HbA1c, C-reactive protein, PAI-1 and fibrinogen not significantly different from those observed in subjects without metabolic syndrome. CONCLUSION: The IDF definition identifies a surplus of individuals whose cardiovascular risk profile, particularly regarding to some non-traditional cardiovascular risk factors, is less adverse than that observed in subjects also diagnosed by the NCEP definition.

Thyrotropin levels and their relationship with cardiovascular risk factors in the island of Gran Canaria, Spain. Implications of lowering the upper reference limit of thyrotropin stimulating hormone.

OBJECTIVE: To characterize the cardiovascular risk profile of subjects with high and normal-high concentrations of serum TSH in a sample of adult Spanish subjects from the island of Gran Canaria. DESIGN: Cross-sectional population-based study. SUBJECTS: After excluding 28 individuals on current treatment with levothyroxine and 9 others with TSH levels below the range of normality (0.3-4.9 mU/l), 704 randomly selected subjects (412 women; age range: 30-82 yr) belonging to the Telde Study were assessed. MEASUREMENTS: Participants underwent physical examination and fasting blood analyses to determinate TSH, serum lipids, homocysteine, fibrinogen, von Willebrand factor, plasminogen activator inhibitor- 1, C-reactive protein, and insulin. RESULTS: Twenty-nine participants had serum TSH concentrations above the normal range of normality. Among all the studied variables, only female sex and diastolic blood pressure were significantly associated with TSH levels > or =5 mU/l in a multivariate logistic regression analysis. If the upper normal limit of TSH was reduced up to 2.4 mU/l, an additional group of 106 subjects would be considered to have elevated TSH levels. A serum TSH > or =2.5 mU/l was positive and independently associated with female sex, body mass index, total cholesterol, and homocysteine, and negatively associated with smoking. CONCLUSIONS: Although the impact of serum TSH levels on cardiovascular risk cannot be established from these findings, TSH values within the upper part of the usually accepted normal range were demonstrated to be associated with well-recognized risk factors for cardiovascular disease.

Dilatación gástrica aguda en un varón con anorexia nerviosa / Acute gastric dilatation in a male with anorexia nervosa

La dilatación gástrica aguda es una rara complicación médica de los trastornos de la conducta alimentaria. Presentamos el caso de un varón de 31 años, diagnosticado de anorexia nerviosa y gravemente malnutrido, que debutó con vómitos incoercibles tras la ingestión de una comida copiosa. La situación se resolvió tras aspiración del contenido gástrico y realimentación del paciente mediante nutrición enteral por sonda nasoyeyunal. Generalmente se acepta que este cuadro puede ser debido al síndrome de la arteria mesentérica superior, tal y como está descrito en otras situaciones de desnutrición extrema. En pacientes con trastornos de la conducta alimentaria, en los que los vómitos autoinducidos son frecuentes, la sospecha clínica de esta posibilidad puede ser crucial para evitar un daño irreversible a la pared gástrica (AU)

Utilidad del cortisol plasmático nocturno en el diagnóstico del síndrome de cushing / Utility of nocturnal plasma cortisol in the diagnosis of cushing's syndrome

La determinación del cortisol plasmático nocturno se ha propuesto como una alternativa en el diagnóstico del síndrome de Cushing, principalmente para diferenciar entre pacientes con síndrome de Cushing y sujetos con estados de seudosíndrome de Cushing. Se analizaron retrospectivamente las medidas de cortisol plasmático a medianoche en 28 pacientes con sospecha clínica de síndrome de Cushing y elevación de la excreción de cortisol libre urinario (20 pacientes con síndrome de Cushing y 8 con seudosíndrome de Cushing). No se realizaron estudios endocrinológicos el día del ingreso. En los 2 días posteriores se tomaron muestras para cortisol sérico a las 8.00 y a las 24.00 h. Los resultados se compararon con otras pruebas diagnósticas realizadas simultáneamente (cortisol libre urinario y test de supresión con 1 mg de dexametasona). El cortisol plasmático a las 24.00 h fue el único parámetro que distinguió a todos los pacientes con síndrome de Cushing de aquellos con seudosíndrome de Cushing. Su valor más bajo entre los pacientes con síndrome de Cushing fue de 11,9 µg/dl, sin que se apreciaran diferencias entre los resultados obtenidos el segundo y el tercer día de ingreso. En el grupo de pacientes con seudosíndrome de Cushing, 3 casos presentaron un cortisol nocturno no suprimido durante el segundo día de hospitalización (6,1-10,2 µg/dl), mientras que todas las determinaciones obtenidas 24 horas más tarde proporcionaron valores menores de 5 µg/dl. Estos datos indican que el estudio del cortisol a medianoche puede requerir de un ingreso de al menos 48 h cuando se evalúa a pacientes con seudosíndrome de Cushing (AU)