Outcomes of a multidisciplinary Diabetic Foot Day Unit.

OBJECTIVE: To analyse the main characteristics of patients and the health outcomes obtained and to evaluate the impact of peripheral artery disease (PAD) in patients treated in our multidisciplinary Diabetic Foot Unit. RESEARCH DESIGN AND METHODS: Observational prospective study. 273 patients from two different populations (with and without PAD - classified according to the presence of distal pulses) treated over a 14-month period in the multidisciplinary Diabetic Foot Unit were included. The data on patient characteristics and outcomes were analysed for the purpose of comparison. For the inference study, a comparison of medians with the non-parametric test for independent samples for the quantitative variables and a χ2 test for the comparison of proportions in qualitative variables were performed. RESULTS: Patients with PAD ulcers were older (60 (54-67) vs. 64 (75-81), p=0.000) and had a higher macrovascular burden (8.1% vs. 29% for ischaemic heart disease history, p=0.000; 6.7% vs. 18.1% for cerebrovascular disease history, p=0.004). Their Texas Score was higher (p=0.000) and their major amputation rate was higher (1.4% vs. 12.3%, p=0.001). They had less background of previous ulcers (52.6% vs. 26.8%, p=0.000), their episode duration was shorter (4 (0-10) vs. 0 (0-3) weeks, p=0.000), and their proportional need for antibiotic therapy was lower (64.4% vs. 51.4%, p=0.03). CONCLUSIONS: The differences found between ulcers with and without vascular involvement support the need for a different approach and for the inclusion of vascular surgeons on the team. The multidisciplinary care model for diabetic foot patients could be effective and improve health outcomes.

Description of a Cohort of Type 1 Diabetes Patients: Analysis of Comorbidities, Prevalence of Complications and Risk of Hypoglycemia.

BACKGROUND: Despite major medical advances, Type 1 Diabetes (T1D) patients still have greater morbimortality than the general population. Our aim was to describe our cohort of T1D patients and identify potential risk factors susceptible to prevention strategies. METHODS: Cross-sectional, observational study, including T1D patients treated at our center, from 1 March 2017 to 31 March 2020. INCLUSION CRITERIA: T1D, age > 14 years and signed informed consent. EXCLUSION CRITERIA: diabetes other than T1D, age < 14 years and/or refusal to participate. RESULTS: Study population n = 2181 (49.8% females, median age at enrollment 41 years, median HbA1c 7.7%; 38.24% had at least one comorbidity). Roughly 7.45% had severe hypoglycemia (SH) within the prior year. Macro/microvascular complications were present in 42.09% (5.83% and 41.14%, respectively). The most frequent microvascular complication was diabetic retinopathy (38.02%), and coronary disease (3.21%) was the most frequent macrovascular complication. The risk of complications was higher in males than in females, mainly macrovascular. Patients with SH had a higher risk of complications (OR 1.42; 1.43 in males versus 1.42 in females). CONCLUSIONS: Our T1D population is similar to other T1D populations. We should minimize the risk of SH, and male patients should perhaps be treated more aggressively regarding cardiovascular risk factors.

Ketoacidosis Due to Empagliflozin, a Paradigm Shift: Case Report and Review of Literature.

INTRODUCTION: Sodium-glucose cotransporter 2(SGLT2)-inhibitors are new antihyperglycemic agents that have shown a reduction in cardiovascular events in type 2 diabetes mellitus. Recent warnings have been developed about an increased risk of euglycemic and moderate hyperglycemic diabetic ketoacidosis with the use of SGLT2 inhibitors, but its real incidence is not available yet. CASE REPORT: We present a case of DKA with moderate hyperglycemia in a patient treated with metformin and empagliflozin. CONCLUSION: DKA in patients treated with SGLT2 inhibitors can be presented as euglycemic and moderated hyperglycemia. This special presentation poses a physician's challenge.

Enfermedad de Hirata: a propósito de un caso / Hirata's disease: report of a case

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Polineuropatía y diabetes mellitus de larga evolución / Polineuropathy and longstanding diabetes mellitus

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[Erectile dysfunction as a marker of silent cardiovascular disease in type-2 diabetic patients in Spain. The DIVA (DIabetes and VAscular disease) study]. / Disfunción eréctil como marcador de vasculopatía en la diabetes mellitus tipo 2 en España. Estudio DIVA.

BACKGROUND AND OBJECTIVES: Erectile dysfunction (ED) is a sign of vascular disease in type 2 diabetic patients. The present subanalysis of the DIVA Registry, whose main objective was to estimate the prevalence of clinical vascular disorder and silent vascular disorder, as well as risk factors in type 2 diabetic patients treated in Spain, aims to analyze the relationship between those data and the prevalence of ED in these patients. PATIENTS AND METHODS: A total of 2444 type 2 diabetic patients (56% male; mean age 65.2 years) attended by 387 cardiologists and endocrinologists at ambulatory care were included. RESULTS: Coronary heart disease was present in 37% of the patients, cerebrovascular disease in 12%, and peripheral arterial disease in 13%. Forty percent of male patients had ED (according to the IIEF criteria), although in this group, as compared to those patients without ED, the prevalence of cardiovascular disease and signs of subclinical vascular disorder (microalbuminuria and abnormal ankle/brachial index (ABI)) was higher. The only independent predictor of ED was left ventricular hypertrophy (OR 5.2; 95% CI: 1.1-24.1; P=.03), with the ABI <0,9 being of borderline significance (OR 5.9; 95% CI: 0.9-39.9; P=.06). Poor glycemic and lipemic control (P<.05 in both cases) as well as cerebrovascular and peripheral arterial disease (P<.01 in both cases) and renal dysfunction (P<.001) were all more frequent among patients with severe ED. CONCLUSIONS: Forty percent of diabetic patients suffer from ED. The results of this study suggest that ED may be considered as an atherosclerosis marker and could be included in algorithms for risk stratification and subclinical vascular disorder detection.

Disfunción eréctil como marcador de vasculopatía en la diabetes mellitus tipo 2 en España. Estudio DIVA / Erectile dysfunction as a marker of silent cardiovascular disease in type-2 diabetic patients in Spain. The DIVA (Diabetes and Vascular disease) study

Fundamento y objetivo: la disfunción eréctil (DE) es un signo de enfermedad vascular en los sujetos con diabetes mellitus tipo 2 (DM2). El objetivo principal del estudio DIVA (por las letras iniciales de diabetes y vasculopatía) fue estimar la prevalencia de vasculopatía clínica y asintomática, así como la prevalencia de factores de riesgo en los sujetos diabéticos atendidos por especialistas en España; en él se analizó la relación de los datos citados con la prevalencia de DE. Pacientes y método: registro transversal compuesto por 2.444 sujetos consecutivos (56% varones con una edad media de 65,2 años) diagnosticados de DM2, atendidos en consulta por 387 cardiólogos y endocrinólogos. Resultados: el 37% de los sujetos presentaba cardiopatía isquémica, el 12% presentaba enfermedad cerebrovascular (ECRV) y el 13% presentaba arteriopatía periférica. El 40% de los varones tenía DE (según criterios del Índice internacional de la función eréctil), aunque en comparación con los grupos que no presentaban DE, en este grupo la enfermedad cardiovascular era significativamente más prevalente, así como los signos de vasculopatía subclínica (albuminuria e índice tobillo-brazo [ITB] anormal). El único factor predictor de DE independiente de otras variables de confusión fue la hipertrofia ventricular izquierda (riesgo relativo [RR] de 5,2; intervalo de confianza [IC] del 95%: 1,1¿24,1; p=0,03); el ITB fue menor que 0,9 de significación limítrofe (RR de 5,9; IC de 95%: 0,9¿39,9; p=0,06). El mal control glucémico y lipídico (p<0,05 en ambos casos) así como la presencia de ECRV, de enfermedad arterial periférica (p<0,01 en ambos casos) y de disfunción renal (p<0,001) eran más prevalentes en sujetos con DE grave. Conclusiones: el 40% de los varones diabéticos presenta DE. Los resultados de este estudio demuestran que la DE puede considerarse como marcador de aterosclerosis e incluirse en los algoritmos de estratificación de riesgo y detección de vasculopatía asintomática (AU)

Background and objectives: Erectile dysfunction(ED) is a sign of vascular disease in type 2 diabetic patients. The presents ubanalys is of the DIVA Registry, whos emain objective wast o estimate the prevalence of clinical vascular disorder and silent vascular disorder, as well as risk factors in type2diabetic patients treated in Spain, aims to analyze the relationship between those data and the prevalence of ED in these patients. Patients and Methods: A total of 2444 type 2 diabetic patients (56%male; meanage 65.2 years) attended by 387 cardiologists and endocrinologists at ambulatory care were included. Results: Coronary heart disease was present in 37%of the patients, cerebrovascular disease in12%,and peripheral arterial disease in 13%. Forty percent of male patients had ED (according to the IIEF criteria),although in this group, as compared to those patients without ED, the prevalence of cardiovascular disease and signs of subclinical vascular disorder (microalbuminuria and abnormalankle/brachialindex (ABI)) was higher. The only independent predictor of ED was left ventricular hypertrophy (OR5.2;95%CI: 1.1–24.1; P ¼ .03), with the ABI o0,9 being of border line significance (OR5.9;95%CI:0.9–39.9;P ¼ .06).Poor glycemic and lipemic control (Po.05 in both cases)as well as cerebrovascular and peripheral arterial disease (Po.01inbothcases) and renaldys function (Po.001)were all more frequent among patients with severe ED. Conclusions: Forty percent of diabetic patients suffer from ED. The results of this study suggest that EDmay be considered as an at hero sclerosis marker and could be included in algorithms for risk stratification and subclinical vascular disorder detection (AU)

Dificultades en el control glucémico del paciente diabético / Obstacles to achieving glycemic control in diabetics

En la actualidad, el manejo de la diabetes a largo plazo continúa siendo un importante reto para el paciente, su familia y el equipo sanitario. El buen control glucémico es uno de los pilares centrales del tratamiento de la diabetes y sus beneficios son bien conocidos, tanto por los médicos como por los propios pacientes. Pocos años después del descubrimiento de la insulina se puso en evidencia un número importante de dificultades para la consecución de un adecuado control glucémico del paciente diabético. Muchos de estos problemas han venido derivados de las distintas formulaciones de insulina que se usaban inicialmente para obtener insulinas altamente purificadas, posteriormente insulinas humanas y, por último, diversos análogos de insulina de acción rápida y de acción prolongada, que han ido facilitando la consecución de un mejor control metabólico y menos problemas derivados de su tratamiento. El desarrollo de fármacos hipoglucemiantes orales cada vez más específicos, con dianas terapéuticas cada vez más definidas, también ha facilitado el manejo de la diabetes mellitus tipo 2. A las limitaciones que puedan presentar las distintas armas terapéuticas de la diabetes se une la propia historia natural de la enfermedad y la obligatoria implicación del paciente en su manejo, lo cual añade otro amplio grupo de limitaciones. Centrándonos en el paciente con diabetes mellitus tipo 1 o 2 cuando requiere tratamiento insulínico, hemos de reconocer que a pesar del importante avance farmacológico en los preparados insulínicos en la actualidad, todos los profesionales dedicados al manejo de la diabetes tienen experiencia con grupos concretos de pacientes en los que resulta muy difícil conseguir un adecuado control glucémico. Algunos presentan hipoglucemias recurrentes; otros tienen hiperglucemias a pesar de muy altas dosis de insulina, incluso con episodios repetidos de cetoacidosis, y un grupo de ellos combinan cuadros clínicos de hipoglucemia con hiperglucemia. En este espectro de situaciones se encuadra también la entidad conocida como diabetes lábil (AU)

Currently, the long-term management of diabetes continues to pose a major challenge to patients, their families and health teams. Good glycemic control is one of the main pillars of diabetes treatment and its benefits are well known both by physicians and their patients. A few years after the discovery of insulin, a substantial number of obstacles to achieving adequate glycemic control in diabetics became known. Many of these problems were due to the distinct insulin formulations initially used until highly purified formulations became available. Subsequently, human insulin and various rapid-acting and prolonged action insulin analogs have helped to improve metabolic control and reduce treatment-related problems. The development of increasingly specific oral hypoglycemiant agents with well-defined therapeutic targets has also improvement the management of type 2 diabetes mellitus. In addition to the limitations of the various therapeutic options in diabetes, the natural history of the disease and the necessary involvement of the patient in the management of the disease represent further obstacles. All health professionals involved in the management of patients with type 1 or 2 diabetes mellitus requiring insulin therapy have experience of specific groups of patients with difficulties in achieving adequate glycemic control, despite significant improvements in current insulin preparations. Some of these patients show recurrent hypoglycemia, others show hyperglycemia – even with recurrent episodes of ketoacidosis – despite high-dose insulin, and some show a clinical picture of hypoglycemia with hyperglycemia. The entity known as labile diabetes can be included within this spectrum (AU)