[Pilot study of two different strategies to reinforce self care behaviors and treatment compliance among type 2 diabetes patients from low income strata]. / Estudio piloto de dos diferentes estrategias para reforzar conductas de autocuidado y adherencia al tratamiento en pacientes de bajos recursos económicos con diabetes tipo 2.

UNLABELLED: Long term diabetes self-management behaviors, and strict glycemic control are difficult to achieve in clinical practice. OBJECTIVE: Asesss two different reinforcement strategies for diabetes selfcare management, psychological distress and glycemic control in a one year follow up study. METHODS: 70 consecutive type 2 diabetic patients, were recruited and randomly assigned to three study groups. Subjects in the control group (CG) continued with their normal treatment schedule. The second group received a reinforcement course at 6 months (RCG) and in the third group, patients were contacted monthly by phone (PHCG) to promote self-management attitudes and address problems as they arose. A battery of questions and laboratory work-up were obtained at baseline and at one year follow-up. RESULTS: At one year follow-up, the three groups significantly increased their diabetes-related knowledge. Both experimental groups displayed improved treatment compliance and had better adherence to the recommended meal plan (p=0.06 and 0.003). In addition, the PHCG significantly increased (p<0.0001) their adherence to pharmacological treatment. No significant differences were observed in glycemic control, prevalence of depression or diabetes related distress. CONCLUSIONS: Follow-up patient reinforcement strategies improve strategic diabetes self-care management behaviors. Further studies are needed to demonstrate the positive impact of these benefits on diabetes related outcomes.

Nonadherence to insulin therapy in low-income, type 2 diabetic patients.

OBJECTIVE: To evaluate the psychosocial barriers to insulin use in low-income, type 2 diabetic patients; the clinical characteristics of these patients; and the possible causes of nonadherence to insulin regimens months after prescription. METHODS: We studied a prospective cohort of low-income patients with type 2 diabetes mellitus, aged 45 to 75 years, attending a tertiary health care center in Mexico City, Mexico. Patients were eligible if their diabetes was not controlled with oral agents, and they were excluded if they had type 1 diabetes mellitus, a secondary cause of diabetes, had been admitted to the hospital within the month before study commencement, had been previously treated with insulin, had severe diabetic complications, or had a chronic or disabling medical illness. All patients were prescribed 6 to 10 units of neutral protamine Hagedorn insulin before bedtime and received a referral to visit with a diabetes nurse educator. The main outcome was adherence or nonadherence to insulin therapy, and it was correlated with several variables including attitudes toward insulin, diabetes self-management, diabetes-related knowledge, depression, and diabetes-related distress. Brief medical history, complete battery of questionnaires, and laboratory workup were obtained at baseline and 1 to 3 months after insulin prescription. RESULTS: Twenty-nine consecutive patients were included. Mean age (+/- standard deviation) was 59 +/- 8 years, 18 (62%) were women, mean diabetes duration was 14 +/- 9 years, and mean hemoglobin A1c level was 10.8 +/- 1.4%. Negative attitudes toward insulin were very common, particularly in patients with less education and poorer diabetes-related knowledge (odds ratio, 6.2; 95% confidence interval, 1.04-47.3; P = .02). Even when they received precise recommendations, 12 patients (41%) did not adhere to insulin treatment. Patients who did not adhere to therapy were most commonly women and were depressed (P = .05). Improved adherence was significantly associated with the additional support of a diabetes nurse educator (odds ratio, 6.6; 95% confidence interval, 1.0-55.7; P = .02). CONCLUSIONS: Improving patient perception and acceptance of insulin with the help of diabetes educators can facilitate earlier and more aggressive intervention and thus optimize glycemic control.

Estudio piloto de dos diferentes estrategias para reforzar conductas de autocuidado y adherencia al tratamiento en pacientes de bajos recursos económicos con diabetes tipo 2 / Pilot study of two different strategies to reinforce self care behaviors and treatment compliance among type 2 diabetes patients from low income strata

Antecedentes: Es difícil establecer conductas apropiadas de autocuidado y cumplir los objetivos terapéuticos en pacientes con diabetes tipo 2. El objetivo de esta investigación fue evaluar el impacto de dos estrategias de reforzamiento en el autocuidado de la diabetes, variables psicosociales y control glucémico a un año de seguimiento. Métodos: Se incluyeron 70 pacientes con diabetes tipo 2 asignados en forma aleatoria a tres grupos de estudio: grupo control (GC) que continuó con el programa habitual de tratamiento; un segundo grupo (GCR), que recibió un curso educativo después de seis meses; un tercer grupo (GRT), asignado a recibir llamadas telefónicas mensuales para promover conductas de autocuidado e intentar detectar y solucionar problemas. Se practicaron diversos cuestionarios y análisis de laboratorio al inicio y un año después. Resultados: Al año de seguimiento, los tres grupos mejoraron en forma significativa sus conocimientos en diabetes. Ambos grupos experimentales mejoraron su adherencia al plan de alimentación (p=0.06 y 0.003). El GRT también mejoró su adherencia al tratamiento farmacológico (p<0.0001). No se observaron cambios significativos en el control glucémico, prevalencia de depresión o disfunción emocional asociada a la diabetes. Conclusiones: Las estrategias de reforzamiento mejoran el autocuidado de la diabetes. Se requieren estudios a largo plazo para demostrar el impacto de estos beneficios en la calidad de vida y el logro de los objetivos terapéuticos.

Long term diabetes self-management behaviors, and strict glycemic control are difficult to achieve in clinical practice. OBJECTIVE: Asesss two different reinforcement strategies for diabetes selfcare management, psychological distress and glycemic control in a one year follow up study. METHODS: 70 consecutive type 2 diabetic patients, were recruited and randomly assigned to three study groups. Subjects in the control group (CG) continued with their normal treatment schedule. The second group received a reinforcement course at 6 months (RCG) and in the third group, patients were contacted monthly by phone (PHCG) to promote self-management attitudes and address problems as they arose. A battery of questions and laboratory work-up were obtained at baseline and at one year follow-up. RESULTS: At one year follow-up, the three groups significantly increased their diabetes-related knowledge. Both experimental groups displayed improved treatment compliance and had better adherence to the recommended meal plan (p=0.06 and 0.003). In addition, the PHCG significantly increased (p<0.0001) their adherence to pharmacological treatment. No significant differences were observed in glycemic control, prevalence of depression or diabetes related distress. CONCLUSIONS: Follow-up patient reinforcement strategies improve strategic diabetes self-care management behaviors. Further studies are needed to demonstrate the positive impact of these benefits on diabetes related outcomes.

Diagnostic challenge of glucagonoma: case report and literature review.

OBJECTIVE: To report the diagnostic difficulties encountered in a case of glucagonoma. METHODS: We provide a literature review and present the clinical findings, pertinent laboratory data, and results of related studies in a patient with a glucagonoma. RESULTS: A 54-year-old-man, with no relevant history of endocrine disorders, presented to the hospital with a 5-year history of recurrent stomatitis and glossitis, a more recent weight loss of 11.5 kg, and recurrent pruritic maculae on the scalp in conjunction with raised erythematous maculae in the scrotal region and perineum that gradually migrated to the distal extremities, becoming bullous and painful. The patient was hospitalized, and because of the dermatologic findings suggestive of necrolytic migratory erythema, the presence of a glucagonoma was suspected. His blood glucose levels were in the normal range. Glucagon levels were found to be elevated, and imaging studies confirmed the presence of an enlarged mass in the pancreatic tail, without evidence of extension to surrounding structures. Liver metastatic lesions were also excluded. After surgical removal of the tumor, the skin and oral mucosal lesions disappeared spontaneously. The histologic appearance and immunohistochemical staining results confirmed the diagnosis of a glucagonoma. Subsequently, all related symptoms resolved, and the glucagon levels normalized. CONCLUSION: The diagnosis of glucagonoma is often delayed. Clinicians should be aware of the unusual initial manifestations of this tumor and the potential for less than a full spectrum of the characteristic features of the glucagonoma syndrome.

Domain organization within repeated DNA sequences: application to the study of a family of transposable elements.

MOTIVATION: The analysis of repeated elements in genomes is a fascinating domain of research that is lacking relevant tools for transposable elements (TEs), the most complex ones. The dynamics of TEs, which provides the main mechanism of mutation in some genomes, is an essential component of genome evolution. In this study we introduce a new concept of domain, a segmentation unit useful for describing the architecture of different copies of TEs. Our method extracts occurrences of a terminus-defined family of TEs, aligns the sequences, finds the domains in the alignment and searches the distribution of each domain in sequences. After a classification step relative to the presence or the absence of domains, the method results in a graphical view of sequences segmented into domains. RESULTS: Analysis of the new non-autonomous TE AtREP21 in the model plant Arabidopsis thaliana reveals copies of very different sizes and various combinations of domains which show the potential of our method. AVAILABILITY: DomainOrganizer web page is available at www.irisa.fr/symbiose/DomainOrganizer/.

Adherence to treatment: the key for avoiding long-term complications of diabetes.

Behavioral changes and adherence to pharmacological treatment are essential for improving the prognosis in chronic illness. Lack of adherence to treatment is a common problem in every practice and many patients drop out of care prematurely. The present article is a review of our knowledge regarding adherence to treatment in type 2 diabetic patients and the strategies we can implement to improve it. Diabetes regimens contain many aspects that make compliance difficult; it is a chronic disorder, lifestyle changes are required, and treatment may be complex, intrusive and inconvenient. Prevention, instead of symptom reduction or cure, is usually the main goal. Successful interventions to improve adherence are labor intensive but ultimately cost effective. Educating patients, keeping regimens as simple as possible, negotiating priorities, monitoring adherence and attendance at appointments and reinforcing the patient's efforts to adhere at each visit provide practical and effective help. Clinicians must understand that failure to achieve the therapeutic goals might be related to inadequate self-management. Instead of changing prescriptions, increasing drug dosage, or switching or adding medications, clinicians should consider counseling patients on how to improve adherence.

Psychosocial factors associated with poor diabetes self-care management in a specialized center in Mexico City.

To examine the relationship between demographic, clinical and psychosocial variables and diabetes self-care management in Mexican type 2 diabetic patients. Cross-sectional study of 176 consecutive patients with type 2 diabetes aged 30-75 years, attending a tertiary health-care center in Mexico City. A brief medical history and previously validated questionnaires were completed. The study group consisted of 64 males/112 females, aged 55 +/- 11 years, mean diabetes duration of 12 +/- 8 years and HbA1c of 9.0 +/- 2.0%, 78.4% reported following the correct dose of diabetes pills or insulin, 58% ate the recommended food portions, and 44.3% did exercise three or more times per week. A good adherence to these three recommendations was observed in only 26.1% of the patients. These patients considered as a group were characterized by a greater knowledge about the disease (P < 0.00001), regular home blood glucose monitoring (P < 0.01), an inner perception of better diabetes control (P = 0.007), good health (P = 0.004) and better communication with their physician (P < 0.02). A poor adherence to two or the three main diabetes care recommendations was associated with a depressive state (OR 2.38, 95% CI 1.1-4.9, P < 0.01) and a history of excessive alcohol intake (OR 4.03, 95% CI 1.1-21.0, P = 0.03). Poor adherence to standard diabetes care recommendations is frequently observed in patients with type 2 diabetes attending a specialized health care center in Mexico City. Depression must be identified and treated effectively.

Correlations between surrogate measures of insulin resistance and cardiovascular risk factors in obese and overweight patients.

There are different equations to estimate insulin sensitivity by using OGTT with a reasonable approximation to whole body sensitivity obtained with the glucose clamp. Further work is needed to address their role in clinical practice as markers of the metabolic syndrome and predictors for cardiovascular disease. In the present study, we determined plasma glucose and insulin values during an OGTT test in 144 overweight and obese individuals. We assessed insulin resistance by the use of different equations and established their relationship with cardiovascular risk factors associated to the insulin resistance syndrome. Distributed the patients by quintiles of body mass index (BMI), the different surrogate measures clearly demonstrated that the more obese individuals were the most insulin resistant, a similar but not significant trend was observed related to the other cardiovascular risk factors. Efforts to use both fasting and post-load glucose and insulin concentrations to create indexes for routine use in clinical practice do not seem to be particularly useful in overweight or obese patients, as most of these patients will be insulin-resistant and insulin resistance is closely linked but not equal to the metabolic syndrome.

Marked abnormalities in heart rate variability are associated with progressive deterioration of renal function in type I diabetic patients with overt nephropathy.

BACKGROUND: Cardiac autonomic neuropathy is a common complication of long-standing, type 1 diabetes and is associated with increased morbidity and mortality. Impaired heart rate variability is a sensitive and reproducible marker of cardiac autonomic neuropathy. We sought to examine the relationship between cardiac autonomic neuropathy as assessed by heart rate variability and overt nephropathy, with emphasis on the progression of renal dysfunction over 1 year. METHOD: Baseline and 12 month clinical and biochemical characteristics, as well as autonomic function tests, were analyzed in 23, type 1 diabetic patients (mean age 37+/-10 years, 65% males), who were prospectively enrolled as a part of a multi-center investigation. In addition, ambulatory, 24-h, 3-channel electrocardiograms were recorded, and heart rate variability indices were assessed in the time and frequency domains over the same period. RESULTS: All heart rate variability indices were markedly decreased in our study population. On univariate analysis, heart rate variability was associated with creatinine clearance, and to a lesser extent, mean 24-h blood pressures and cholesterol. On multivariate analysis, only heart rate variability was a significant and independent predictor of abnormalities in creatinine clearance. Severe reduction in heart rate variability at baseline was also significantly associated with the further deterioration in renal function at 1 year. CONCLUSION: Heart rate variability is significantly reduced in long-standing, type 1 diabetics with proteinuria or overt nephropathy. Marked abnormalities in heart rate variability are significantly associated with and predictive of progressive renal deterioration at 1 year. These findings may have implications for aggressive medical intervention to improve prognosis and survival in this population.

Riñones poliquisticos del adulto: informe de 54 casos / Polycystic Kidneys of the adult: report of 54 cases

Cincuenta y cuatro pacientes con diagnósticos de riñones poliquíticos del adulto confirmado mediante estudios radiológicos, ultrasonográficos y/o histopatológicos y complementados por la presencia de antecedentes y cuadro clínico, sugestivo fueron estudiados en el período comprendido entre 1962-84 en el INNSZ. Todos los pacientes fueron mayores de 20 años, 30 hombres (55%) y 24 mujeres (45%), con edades promedio al inicio de los síntomas de 38 años y de 42 años al establecimiento del diagnóstico. La sintomatología y datos de laboratorio predominantes fueron: hipertensión arterial (72%), hematuria (59%), dolor lumbar (57%), infección de vías urinarias (48%), proteinuria (61%) y anemia (35%). Desarrollaron insuficiencia renal crónica 29 pacientes (42.5%) a los 50 años de edad promedio y requierendo la mayoría tratamiento sustitutivo 2-3 años después de haber presentado niveles de creatinina sérica iguales o mayores de 2 mg/dl. En 19 pacientes (35%) se logró documentar la presencia de enfermedad poliquística asociada en otros órganos particularmente el hígado