Glycemic control and maternal and fetal outcomes in pregnant women with type 1 diabetes according to the type of basal insulin.

OBJECTIVE: To examine the potential role of the type of basal insulin on glycemic control and maternal and foetal outcomes in pregnant women with type 1 diabetes (T1DM). STUDY DESIGN: Retrospective cohort study of pregnancies attended at 18 Spanish tertiary hospitals. INCLUSION CRITERIA: T1DM, singleton pregnancies, delivery between 2002-2010, and use of the same basal and prandial insulin from before pregnancy until delivery. RESULTS: A total of 1534 pregnancies were included. The basal insulin most commonly used was Neutral Protamine Hagedorn (NPH) (51.7%), followed by glargine (23.2%) and continuous subcutaneous insulin infusion (CSII) (21.1%). CSII users had longer diabetes duration. Multiple logistic regression analysis showed that CSII was independently associated with lower doses of insulin, higher glycated haemoglobin (HbA1c) in all trimesters, and higher rates of miscarriage, preterm birth and neonatal hypoglycemia. Glargine was related to a higher risk of preterm birth and a small-for-gestational age infant (SGA). The odds ratios (OR) of the associations between insulin type and clinical outcomes (from 0.642 to 4.894) have a relevant magnitude. CONCLUSIONS: In this observational study of pregnant women with T1DM, the type of basal insulin was independently associated with metabolic variables and foetal outcomes.

Gestational diabetes mellitus in Europe: prevalence, current screening practice and barriers to screening. A review.

BACKGROUND: Gestational diabetes mellitus is a potentially serious condition that affects many pregnancies and its prevalence is increasing. Evidence suggests early detection and treatment improves outcomes, but this is hampered by continued disagreement and inconsistency regarding many aspects of its diagnosis. METHODS: The Vitamin D and Lifestyle Intervention for Gestational Diabetes Mellitus Prevention (DALI) research programme aims to promote pan-European standards in the detection and diagnosis of gestational diabetes and to develop effective preventive interventions. To provide an overview of the context within which the programme will be conducted and its findings interpreted, systematic searching and narrative synthesis have been used to identify and review the best available European evidence relating to the prevalence of gestational diabetes, current screening practices and barriers to screening. RESULTS: Prevalence is most often reported as 2-6% of pregnancies. Prevalence may be lower towards the Northern Atlantic seaboard of Europe and higher in the Southern Mediterranean seaboard. Screening practice and policy is inconsistent across Europe, hampered by lack of consensus on testing methods, diagnostic glycaemic thresholds and the value of routine screening. Poor clinician awareness of gestational diabetes, its diagnosis and local clinical guidelines further undermine detection of gestational diabetes. CONCLUSIONS: Europe-wide agreement on screening approaches and diagnostic standards for gestational diabetes could lead to better detection and treatment, improved outcomes for women and children and a strengthened evidence base. There is an urgent need for well-designed research that can inform decisions on best practice in gestational diabetes mellitus screening and diagnosis.

Severe Hypocalcemia due to Vitamin D Deficiency after Extended Roux-en-Y Gastric Bypass.

Vitamin D deficiency is a well-known comorbidity of obesity that can be exacerbated after bariatric surgery and can predispose the patient for hypocalcemia. Vitamin D and calcium doses to prevent and treat vitamin D deficiency after weight loss surgery are not well defined. We describe a patient who developed severe hypocalcemia due to vitamin D deficiency 5 years after an extended Roux-en-Y gastric bypass for a type II obesity. No precipitating factors were present and malabsorption induced by the bypass was considered to be the main causative factor. High doses of vitamin D and calcium were needed to reach and maintain normal calcium and vitamin D concentrations. This case emphasises the importance of routine screening for vitamin D deficiency in obese individuals and reflects that while consensus does not exist regarding optimal dosage, vitamin D replacement should be tittered based on calcidiol levels.

Coexistence of two different pseudohypoparathyroidism subtypes (Ia and Ib) in the same kindred with independent Gs{alpha} coding mutations and GNAS imprinting defects.

BACKGROUND: Pseudohypoparathyroidism (PHP) defines a rare group of disorders whose common feature is resistance to the parathyroid hormone. Patients with PHP-Ia display additional hormone resistance, Albright hereditary osteodystrophy (AHO) and reduced Gsalpha activity in easily accessible cells. This form of PHP is associated with heterozygous inactivating mutations in Gsalpha-coding exons of GNAS, an imprinted gene locus on chromosome 20q13.3. Patients with PHP-Ib typically have isolated parathyroid hormone resistance, lack AHO features and demonstrate normal erythrocyte Gsalpha activity. Instead of coding Gsalpha mutations, patients with PHP-Ib display imprinting defects of GNAS, caused, at least in some cases, by genetic mutations within or nearby this gene. PATIENTS: Two unrelated PHP families, each of which includes at least one patient with a Gsalpha coding mutation and another with GNAS loss of imprinting, are reported here. RESULTS: One of the patients with GNAS imprinting defects has paternal uniparental isodisomy of chromosome 20q, explaining the observed imprinting abnormalities. The identified Gsalpha coding mutations include a tetranucleotide deletion in exon 7, which is frequently found in PHP-Ia, and a novel single nucleotide change at the acceptor splice junction of intron 11. CONCLUSIONS: These molecular data reveal an interesting mixture, in the same family, of both genetic and epigenetic mutations of the same gene.

Cambios en el perfil del paciente diabético hospitalizado en una sala de cirugía vascular y de los procedimientos quirúrgicos utilizados en 1985 y 2007 / Changes of the in-hospital diabetic patient profile in the employed in a vascular surgery department and surgical procedures between 1985 and 2007

Objetivos: 1. Conocer las características de los pacientes con piediabético hospitalizados en cirugía vascular durante los años 1985y 2007, los procedimientos quirúrgicos utilizados, la estancia mediay la mortalidad, y 2. Conocer el grado de control de la diabetes y losfactores de riesgo asociados en los mismos pacientes en 2007.Material y métodos: Se analizaron datos de la diabetes (tipo,tiempo de evolución, tratamiento y complicaciones), factores deriesgo, procedimientos quirúrgicos, estancia media y mortalidad enlos años 1985 y 2007. En 2007 se valoraron además: hemoglobinaglucosilada (HbA1c), perfil lipídico y presión arterial (PA). Resultados:Se evaluaron 162 pacientes (91 en 1985, 71 en 2007). Laprevalencia de complicaciones microangiopáticas, el número de fumadoresy los pacientes en tratamiento con insulina fueron superioresen 1985. La edad y prevalencia de hipertensión y dislipemiafueron mayores en 2007. La distribución por sexos y duración de ladiabetes fueron similares. En 1985 se practicaron más amputaciones,y en 2007 más cirugía conservadora, asociada o no a amputaciónmenor, y menos amputaciones, sobre todo mayores. En 2007no se practicaron simpatectomías lumbares, frecuentes en 1985. Lamortalidad y la estancia media fueron inferiores en 2007, pero sóloun 36% de pacientes tenía una HbA1c <7%, un 24% presentaba PAinferior al objetivo y un 29% cumplía objetivos lipídicos. Conclusiones:Los sujetos ingresados en 2007 presentan menos complicacionesde la diabetes que los de 1985 con el mismo tiempo deevolución. Ya no se realizan simpatectomías lumbares, se han reducidolas amputaciones, sobre todo mayores, y se realiza más cirugíarevascularizadora. En 2007 el grado de control de la diabetes, la PAy los lípidos es subóptimo(AU)

Objectives: To know: 1) The features of patients hospitalised fordiabetic foot in the department of vascular surgery, the years 1985and 2007, surgical procedures used, average stay and mortality.2) Metabolic control and associated cardiovascular risk factors of thesame patients in 2007. Material and methods: Data related todiabetes (type, time evolution, treatment, complications), other riskfactors, surgical procedures, average stay and mortality in the years1985 and 2007, were registered. In 2007 other parameters werealso registered: HbA1c, lipid profile and blood pressure. Results: Atotal of 162 diabetic patients were evaluated (91 in 1985 and 71 in2007). The prevalence of microangiopathic complications, currentsmokers and number of patients treated with insulin were higher in1985. Age, prevalence of hypertension and dyslipidemia were higherin 2007. Sex distribution and diabetes duration were similar. In1985 more amputations were carried out. In 2007 more conservativesurgery associated or not with minor amputation was executed,with less number of amputations (especially major). In 2007, lumbarsympathectomy was not performed, whereas it was frequent in1985. Mortality and average stay were reduced in 2007, but only 36% of subjects presented HbA1c <7%, only 24% presented bloodpressure below goals and only 29% had lipid profile below goals.Conclusions: Patients hospitalised in 1987 had more complicationsof diabetes than those hospitalised in 2007, with the sametime of evolution. Nowadays, lumbar sympathectomy has been abandoned,amputations have been reduced (especially major amputations)and more revascularization surgery is performed. In 2007,control of diabetes, lipids and blood pressure are suboptimal(AU)

Influence of exogenous insulin on C-peptide levels in subjects with type 2 diabetes.

AIM: The aim of this study was to determine whether the influence of insulin therapy on fasting and stimulated C-peptide levels in type 2 diabetic subjects is due to plasma glucose reduction or a direct effect of exogenous insulin. METHODS: Plasma glucose and serum C-peptide levels were determined before and after IV injection of 1mg glucagon on three separate days in 21 type 2 diabetic subjects. Day 1: without pharmacological treatment and fasting plasma glucose > 11.1 mmol/L; day 2: fasting plasma glucose 4.4-7.8 mmol/L, 1h after withdrawing intravenous regular insulin infusion; day 3: fasting plasma glucose 4.4-7.8 mmol/L with bed-time NPH insulin. RESULTS: Fasting and glucagon stimulated C-peptide levels were higher on day 1 than days 2 and 3. Fasting, but not stimulated C-peptide levels, were lower on day 3 than day 2. These differences were not appeared when the percentage of C-peptide increment or the C-peptide/glucose ratio were compared in the three days. CONCLUSIONS: Blood glucose reduction instead of exogenous insulin is responsible for the C-peptide decrease during insulin therapy in type 2 diabetic subjects.

Optimización del tratamiento con ISCI mediante la monitorización continua de glucosa / Optimization of the CSII therapy using the continuous glucose monitoring systems

Los sistemas de infusión continua de insulina (ISCI) representan el tratamiento insulínico más fisiológico de la diabetes mellitus. El inicio del mismo en cuanto al cálculo de la línea basal y de los “bolus” suele hacerse de forma teórica utilizando unos algoritmos preestablecidos, pero posteriormente es necesario realizar ajustes en la pauta en función de los controles de glucemia capilar que realiza el propio paciente. Los sistemas de monitorización continua de glucosa (SMCG) nos ofrecen una información muy detallada del perfil de glucosa del paciente, lo cual es de gran utilidad para ajustar la pauta del tratamiento con ISCI, sobre todo en el período nocturno. En este capítulo se ofrecen recomendaciones para ajustar la línea basal y los “bolus” en pacientes diabéticos tratados con ISCI utilizando SMCG, así como ejemplos prácticos extraídos de pacientes de nuestra consulta

The continuous subcutaneous insulin infusion (CSII) systems are the most physiological treatment of diabetes mellitus. This therapy should be initiated using theoretical algorithms to calculate both basal rate and boluses, but then is necessary to make adaptations using the results of the capillary glucose measurements done for the patient. The continuous glucose monitoring systems (CGMS) offer very detailed information about glucose profile, being very useful to adjust CSII therapy especially during the night. In this chapter, recommendations to adjust basal rate and boluses of diabetic subjects treated with insulin pumps using the CGMS systems are presented, together with practical cases obtained from our clinic

Anestesia epidural para vertebroplastia percutánea / Epidural anestesia for percutaneous vertebroplasty

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Tolerancia y eficacia de calcipotriol ungüento en niños de 2 a 14 años con psoriasis vulgar / Tolerance and efficacy of calpotriol ointment in psoriasis vulgaris in children aged 2 - 14 años

El calcipotriol, un análogo de la vitamina D, es un tratamiento eficaz y seguro para la psoriasis en placas de carácter leve a moderado en pacientes adultos. Objetivos: Evaluar la eficacia y tolerancia del ungüento de calcipotriol en el tratamiento tópico de la psoriasis en niños. Determinar la influencia del mismo sobre el metabolismo cálcico y la presencia de efectos adversos. Materiales y métodos: 14 niños con psoriasis vulgar con menos del 30% de superficie corporal comprometida fueron tratados durante 8 semanas con calcipotriol ungüento 2 veces por día. Se evaluaron clínicamente a través del PASI la extensión y severidad de la enfermedad la eficacia clínica global y la tolerancia de la medicación. Se realizaron estudios de laboratorio (hematología, función renal, hepática, calcio sérico y urinario, fósforo, PTH y 25 hidroxivitamina D, antes de iniciar el tratamiento y las cuatro semanas. Resultados: 14 niños completaron el estudio, 7 mujeres y 7 varones. La edad promedio fue de 9 años. El PASI diminuyó en el 71%. No se detectaron efectos adversos a excepción de un leve ardor en dos pacientes. No hubo alteraciones de los parámetros de laboratorio incluyendo aquellos relacionados con la homeostasis del calcio. La tolerancia de la medicación fue excelente. Conclusiones: El ungüento de calcipotriol es un tratamiento seguro y eficaz para la psoriasis infantil. Constituye una terapéutica aceptable y útil junto a otros tratamientos antipsoriáticos furante la infancia.

[Comparison of the hemodynamic response in subarachnoid anesthesia with bupivacaine versus bupivacaine with fentanyl in traumatology surgery in elderly patients]. / Comparación de la respuesta hemodinámica en la anestesia subaracnoidea con bupivacaína frente a bupivacaína con fentanilo en cirugía traumatológica en ancianos.

OBJECTIVES: To compare the intraoperative hemodynamic effects and ephedrine requirements in elderly patients undergoing orthopedic surgery under subarachnoid anesthesia with hyperbaric bupivacaine with or without fentanyl. MATERIAL AND METHODS: Sixty patients over 75 years of age and scheduled for semi-urgent surgical repair of a fractured femur were randomized to two groups. Group F received subarachnoid surgery with 5 mg of bupivacaine and 15 micrograms of fentanyl. Group B received 7.5 mg bupivacaine. We recorded blood pressure, heart rate and oxygen saturation every 5 minutes and extension of anesthesia. Hemodynamic changes and ephedrine required by each patient were analyzed, along with side effects. RESULTS: Group F patients were more hemodynamically stable 10 and 20 minutes after infusion of the anesthetic, and more hypotensive episodes occurred in group B. Group B consumed significantly more ephedrine (p < 0.05), administered to 22 patients in group B and 6 in group F. The total dose of ephedrine administered was greater in group B (190 mg) than in group F (40 mg). The extension of anesthetic block was sufficient for surgery in all cases. No side effects from fentanyl administration were observed. CONCLUSION: Adding fentanyl to the local anesthetic used for subarachnoid anesthesia in elderly patients is effective for maintaining greater hemodynamic stability, allowing use of a lower dose of hyperbaric bupivacaine and reducing the need for intravenous ephedrine during surgery.

Anestesia subaracnoidea para una cesárea urgente en la enfermedad de Charcot-Marie-Tooth / Subarachnoid anesthesia for an emergency cesarean delivery in a patient with Charcot-Marie-Tooth disease

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Comparación de la respuesta hemodinámica en la anestesiasubaracnoidea con bupivacaína frente a bupivacaína con fentanilo encirugía traumatológica en ancianos / Hemodynamic response to subarachnoid anesthesia for orthopedic surgery in the elderly: bupivacaine with or without fentanyl

OBJETIVOS: Comparar los efectos hemodinámicos y necesidades de efedrina intraoperatoria en la anestesia subaracnoidea empleando bupivacaína hiperbara con o sin fentanilo en el paciente anciano sometido a cirugía traumatológica. MATERIAL Y MÉTODOS: Estudio prospetivo en 60 pacientes mayores de 75 años, programados para cirugía semiurgente por fractura de fémur, distribuidos aleatoriamente en dos grupos. En el grupo F se realizó anestesia subaracnoidea con 5 mg de bupivacaína y 15 µg de fentanilo; en el grupo B se administraron 7,5 mg de bupivacaína. Se registraron los valores de presión arterial, frecuencia cardíaca y saturación de oxígeno cada cinco minutos, así como el nivel anestésico alcanzado. Se analizaron los cambios hemodinámicos y las necesidades de efedrina en cada paciente, así como los efectos secundarios derivados. RESULTADOS: Los pacientes del grupo F presentaron mayor estabilidad hemodinámica a los 10 y 20 minutos de administrada la anestesia, con un mayor número de episodios hipotensivos en el grupo B. Las necesidades de efedrina fueron significativamente mayores en el grupo B (p < 0,05), en el que 22 pacientes requirieron su administración, frente a 6 pacientes del grupo F. La dosis total de efedrina administrada fue mayor en el grupo B (190 mg), frente a los 40 mg del grupo F. El nivel de bloqueo fue suficiente en todos los casos para realizar la intervención. No existieron efectos secundarios derivados del fentanilo. CONCLUSIÓN: La adición de fentanilo al anestésico local en la anestesia subaracnoidea en el paciente anciano es una técnica eficaz, que permite mantener una mayor estabilidad hemodinámica, con una reducción de la dosis de bupivacaína hiperbara y con unas menores necesidades de administración intraoperatoria de efedrina intravenosa (AU)

Déficit de antitrombina III y anestesia regional / Antithrombin III deficit and regional anesthesia

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