[Treatment of type 2 diabetes in the elderly]. / Tratamiento de la diabetes tipo 2 en el paciente anciano.

Treatment of type 2 diabetes in the elderly represents a major challenge both in terms of clinical management and public health. Aging is causing a marked increase in the pandemic of diabetes in elderly people. However, scientific evidence to support the most appropriate treatment for diabetes in the elderly is scarce. Given the heterogeneity of the elderly population, which includes subjects with very different functional and cognitive capacities, co-morbidities, and life expectancy, it is critical to make a comprehensive assessment from a biopsychosocial perspective, to address the vascular risk factors integrally, and to establish individually tailored targets for glycemic control. In frail elderly or individuals with a short life expectancy, it may be reasonable to maintain HbA1c between 7.6%-8.5%. The therapeutic strategy for elderly patients with type 2 diabetes should be individualized and agreed with the patient and their caregivers, according to the objective. Improving quality of life, assuring patient safety and avoiding the adverse effects of antidiabetic treatment should be prioritized. Given the increased susceptibility of the elderly to severe hypoglycemia and its consequences, antidiabetic therapies that minimize the risk of hypoglycemic events should be selected.

Rentabilidad de un hospital de día: análisis de actividad, coste y eficacia / Profitability of a day hospital: analysis of activity, cost and effectiveness

Objetivo El hospital de día supone una alternativa asistencial a la hospitalización convencional. Durante el año 2009 se realizó un análisis del funcionamiento y la rentabilidad del hospital de día del Hospital Clínico de Valladolid, España. Expresamos la rentabilidad como la prestación de una idéntica cobertura sanitaria a un menor coste generado respecto a la hospitalización convencional y cumpliendo unos indicadores de calidad. Métodos Estudio de tipo retrospectivo, transversal, observacional y descriptivo, sobre la información obtenida de cada paciente atendido en el hospital de día, entre el 1 de enero y el 31 de diciembre de 2009. Se determinaron cuatro indicadores de calidad: la determinación de la cancelación de sesiones, la tasa de reacciones transfusionales, el índice de ambulatorización y el índice de satisfacción. El ahorro estimado de cada proceso atendido resulta de la diferencia del coste medio por proceso en hospitalización menos el coste medio del proceso en hospital de día. Resultados La patología más prevalente fueron las enfermedades sistémicas y del tejido conectivo, que representan el 25,4%; de ellas, el 17,1% corresponde a artritis reumatoide. La satisfacción global de los pacientes es del 93%, la cancelación de sesiones y la tasa de reacciones transfusionales fue del 0%, y el índice de ambulatorización de un 26%. Los costes del hospital de día representan el 8,6% de los costes generados en la hospitalización convencional, con un ahorro de 78.390,69 euros. Conclusión El hospital de día es rentable, debido al ahorro generado respecto a la hospitalización convencional, a la vez que consigue unos adecuados índices de calidad(AU)

Objective Day hospitals are an alternative to conventional hospital care. We analyzed the functioning and profitability of the day hospital of Hospital Clínico de Valladolid, Spain, in 2009. Profitability is expressed as the provision of identical health coverage at a lower cost than that generated by conventional hospital care and with adequate quality indicators. Methods We performed a retrospective, observational and descriptive study of the information obtained on each patient attended in the day hospital from January 1 to December 31, 2009. We studied four quality indicators: cancellation of meetings, the rate of transfusion reactions, the out-patient rate and the satisfaction index. The estimated savings for each process was calculated as the difference in the average cost of hospitalization minus the average cost of the process in the day hospital. Results The most frequent diseases were systemic and connective tissue diseases, accounting for 25.4% of the processes treated; of these, 17.1% corresponded to rheumatoid arthritis. Patient satisfaction was 93%. Meetings cancellations and the rate of transfusion reactions were 0%. The out-patient rate was 26%. Day hospital costs were 8.6% of conventional hospital costs, with savings of 78,390.69 euros. Conclusion The day hospital is cost effective due to savings compared with conventional hospitalization and has a satisfactory quality index (AU)

[Profitability of a day hospital: analysis of activity, cost and effectiveness]. / Rentabilidad de un hospital de día: análisis de actividad, coste y eficacia.

OBJECTIVE: Day hospitals are an alternative to conventional hospital care. We analyzed the functioning and profitability of the day hospital of Hospital Clínico de Valladolid, Spain, in 2009. Profitability is expressed as the provision of identical health coverage at a lower cost than that generated by conventional hospital care and with adequate quality indicators. METHODS: We performed a retrospective, observational and descriptive study of the information obtained on each patient attended in the day hospital from January 1 to December 31, 2009. We studied four quality indicators: cancellation of meetings, the rate of transfusion reactions, the out-patient rate and the satisfaction index. The estimated savings for each process was calculated as the difference in the average cost of hospitalization minus the average cost of the process in the day hospital. RESULTS: The most frequent diseases were systemic and connective tissue diseases, accounting for 25.4% of the processes treated; of these, 17.1% corresponded to rheumatoid arthritis. Patient satisfaction was 93%. Meetings cancellations and the rate of transfusion reactions were 0%. The out-patient rate was 26%. Day hospital costs were 8.6% of conventional hospital costs, with savings of 78,390.69 euros. CONCLUSION: The day hospital is cost effective due to savings compared with conventional hospitalization and has a satisfactory quality index.

Insulin resistance is associated with a poor response to intravenous thrombolysis in acute ischemic stroke.

OBJECTIVE: Insulin resistance (IR) may not only increase stroke risk, but could also contribute to aggravate stroke prognosis. Mainly through a derangement in endogenous fibrinolysis, IR could affect the response to intravenous thrombolysis, currently the only therapy proved to be efficacious for acute ischemic stroke. We hypothesized that high IR is associated with more persistent arterial occlusions and poorer long-term outcome after stroke thrombolysis. RESEARCH DESIGN AND METHODS: We performed a prospective, observational, longitudinal study in consecutive acute ischemic stroke patients presenting with middle cerebral artery (MCA) occlusion who received intravenous thrombolysis. Patients with acute hyperglycemia (≥155 mg/dL) receiving insulin were excluded. IR was determined during admission by the homeostatic model assessment index (HOMA-IR). Poor long-term outcome, as defined by a day 90 modified Rankin scale score ≥ 3, was considered the primary outcome variable. Transcranial Duplex-assessed resistance to MCA recanalization and symptomatic hemorrhagic transformation were considered secondary end points. RESULTS: A total of 109 thrombolysed MCA ischemic stroke patients were included (43.1% women, mean age 71 years). The HOMA-IR was higher in the group of patients with poor outcome (P = 0.02). The probability of good outcome decreased gradually with increasing HOMA-IR tertiles (80.6%, 1st tertile; 71.4%, 2nd tertile; and 55.3%, upper tertile). A HOMA-IR in the upper tertile was independently associated with poor outcome when compared with the lower tertile (odds ratio [OR] 8.54 [95% CI 1.67-43.55]; P = 0.01) and was associated with more persistent MCA occlusions (OR 8.2 [1.23-54.44]; P = 0.029). CONCLUSIONS: High IR may be associated with more persistent arterial occlusions and worse long-term outcome after acute ischemic stroke thrombolysis.

Thigh and buttock exertional pain for the diagnosis of peripheral arterial disease.

OBJECTIVES: To evaluate the prevalence of both non-calf intermittent claudication (IC) and classic IC in patients with no known atherosclerotic disease, and their accuracy to detect peripheral arterial disease (PAD). DESIGN: Cross sectional, observational study conducted at 96 internal medicine services. MATERIALS AND METHODS: 1487 outpatients with no known atherosclerotic disease, and either diabetes or a SCORE risk estimation of at least 3% were enrolled. IC was assessed using the Edinburgh Claudication Questionnaire and PAD was confirmed by an ankle-brachial index (ABI) <0.9. RESULTS: Overall, 7.2% met criteria of classic and 5.8% of non-calf IC. PAD was diagnosed in 393 cases (26.4%). In these PAD patients, 17.8% exhibited classic and 13.2% non-calf IC. Both calf and non-calf IC had similar overall accuracy for detecting PAD. Considering both categories as a whole, the sensitivity of IC to predict a low ABI was 31% and the specificity 93%. CONCLUSIONS: Non-calf IC is comparable to classic IC for the diagnosis of PAD in patients with no known arterial disease. The systematic implementation of Edinburgh Claudication Questionnaire could be a valuable call-to-action to improve clinical evaluation of PAD, bearing in mind that PAD detected by either non-calf or classic IC must be confirmed by ABI testing.

Efectividad de ezetimiba en la práctica clínica habitual. Efecto en el perfil lipídico y otros parámetros analíticos / Effectiveness of ezetimibe in routine clinical practice. Effect on lipid profile and other laboratory parameters

Introducción y objetivos: La dislipemia se relaciona frecuentemente con el síndrome metabólico, proceso de elevado riesgo cardiovascular. En ocasiones, el tratamiento con estatinas no es suficiente para alcanzar las concentraciones plasmáticas de lípidos recomendadas. El objetivo del estudio fue evaluar el efecto de ezetimiba administrado con estatinas en el perfil lipídico de pacientes dislipémicos que no alcanzaron los objetivos deseables sólo con estatinas, así como valorar la acción sobre parámetros de riesgo cardiovascular y su tolerancia. Métodos: Estudio descriptivo, prospectivo, realizado en 50 pacientes hipercolesterolémicos consecutivos mal controlados sólo con estatinas, en los que se valora la mejoría del perfil lipídico y las concentraciones de insulina, ferritina y homocisteína plasmáticos tras tratamiento combinado con ezetimiba al cabo de 3 meses. Resultados: Se observó una disminución de las lipoproteínas de baja densidad (p < 0,001), con una reducción media del colesterol total (p < 0,001) y de los triglicéridos (p = 0,002), así como la de las concentraciones plasmáticas de ferritina (p = 0,016), insulina (p = 0,010) y homocisteína (p < 0,001), con una reducción porcentual en las concentraciones del 5, el 5 y el 14%, respectivamente. No se objetivaron modificaciones en los parámetros de función hepática ni muscular. Conclusiones: La coadministración de ezetimiba y estatina mejoró, de forma marcada y significativa, el perfil lipídico en pacientes con hipercolesterolemia mal controlada con estatinas, sin efectos deletéreos en los parámetros hepáticos o musculares y es probable que pueda acompañarse de efectos beneficiosos adicionales en las concentraciones plasmáticas de homocisteína, insulina y ferritina Objective: To assess the safety and efficacy of biphasic insulin aspart 30/70 in patients with type 2 diabetes mellitus (DM2). Material and methods: We performed an observational, multicenter, prospective study in 3,054 DM2 patients from primary care and specialized settings, treated with biphasic insulin aspart 30/70 (started within 15 days prior to inclusion). In all patients, the following information was available before starting insulin treatment: HbA1c levels, fasting plasma glucose (FPG), 4-point glucose profile (before and 90 minutes after breakfast and dinner) and number of hypoglycemic episodes/week. A total of 2,887 patients completed the study (26 ± 1 week). The variables evaluated were rate of adverse events (AE), number of hypoglycemic episodes/week, HbA1c, FPG and 4-point glucose profile. Results: At least one AE occurred in 10.7% of the patients (2.3% related to the study drug and 1.4% severe). There was a significant decrease (end of study vs baseline; p < 0.0001 for all the comparisons) in HbA1c (7.3% and 8.9%, respectively), the mean number of minor (0.3/0.5) and major (0.02/0.07) hypoglycemic episodes/week, FPG (145/207 mg/dl) and postprandial glycemia (162/225 mg/dl). The improvement in metabolic control was achieved both in patients previously treated with oral antidiabetic drugs and in those treated with insulin. The number of hypoglycemic episodes decreased in patients previously treated with insulin. Conclusions: Treatment with biphasic insulin aspart 30/70 in patients with DM2 improves glycemic control, irrespective of previous treatment, with a low rate of AE and fewer hypoglycemic episodes in patients previously treated with insulin (AU)

Introduction and objectives: Dyslipidemia is frequently related to metabolic syndrome, which carries high cardiovascular risk. Statin therapy sometimes fails to achieve the recommended plasma lipid targets. The aim of this study was to evaluate the joint effect of ezetimibe and statin on lipid profile in dyslipidemic patients not achieving target values with statins alone and to determine the action of this combination on cardiovascular risk parameters, as well as its tolerability. Methods: We performed a descriptive prospective study in 50 consecutive hypercholesterolemic patients treated with statin alone and with poor metabolic control. Lipid profile and plasma concentrations of insulin, ferritin and homocysteine were evaluated after 3 months of combined treatment with ezetimibe. Results: We found a significant reduction in low density lipoproteins (p < 0.001), a mean reduction in total cholesterol (p < 0.001) and triglycerides (p = 0.002), as well as decreases in plasma concentrations of ferritin (p = 0,016), insulin (p = 0,010) and homocysteine (p < 0.001) of 5%, 5% and 14%, respectively. There were no changes in either hepatic or muscular function. Conclusions: Combined treatment with ezetimibe and statin significantly improved lipid profile in poorly-controlled hypercholesterolemic patients treated with statin alone. There were no collateral effects on either hepatic or muscular parameters and there may be additional benefits on plasma levels of homocysteine, insulin and ferritin Objective: To assess the safety and efficacy of biphasic insulin aspart 30/70 in patients with type 2 diabetes mellitus (DM2). Material and methods: We performed an observational, multicenter, prospective study in 3,054 DM2 patients from primary care and specialized settings, treated with biphasic insulin aspart 30/70 (started within 15 days prior to inclusion). In all patients, the following information was available before starting insulin treatment: HbA1c levels, fasting plasma glucose (FPG), 4-point glucose profile (before and 90 minutes after breakfast and dinner) and number of hypoglycemic episodes/week. A total of 2,887 patients completed the study (26 ± 1 week). The variables evaluated were rate of adverse events (AE), number of hypoglycemic episodes/week, HbA1c, FPG and 4-point glucose profile. Results: At least one AE occurred in 10.7% of the patients (2.3% related to the study drug and 1.4% severe). There was a significant decrease (end of study vs baseline; p < 0.0001 for all the comparisons) in HbA1c (7.3% and 8.9%, respectively), the mean number of minor (0.3/0.5) and major (0.02/0.07) hypoglycemic episodes/week, FPG (145/207 mg/dl) and postprandial glycemia (162/225 mg/dl). The improvement in metabolic control was achieved both in patients previously treated with oral antidiabetic drugs and in those treated with insulin. The number of hypoglycemic episodes decreased in patients previously treated with insulin. Conclusions: Treatment with biphasic insulin aspart 30/70 in patients with DM2 improves glycemic control, irrespective of previous treatment, with a low rate of AE and fewer hypoglycemic episodes in patients previously treated with insulin (AU)

Effectiveness of ezetimibe in routine clinical practice. Effect on lipid profile and other laboratory parameters.

INTRODUCTION AND OBJECTIVES: Dyslipidemia is frequently related to metabolic syndrome, which carries high cardiovascular risk. Statin therapy sometimes fails to achieve the recommended plasma lipid targets. The aim of this study was to evaluate the joint effect of ezetimibe and statin on lipid profile in dyslipidemic patients not achieving target values with statins alone and to determine the action of this combination on cardiovascular risk parameters, as well as its tolerability. METHODS: We performed a descriptive prospective study in 50 consecutive hypercholesterolemic patients treated with statin alone and with poor metabolic control. Lipid profile and plasma concentrations of insulin, ferritin and homocysteine were evaluated after 3 months of combined treatment with ezetimibe. RESULTS: We found a significant reductionin low density lipoproteins (p<0.001), a mean reduction in total cholesterol (p<0.001) and triglycerides (p=0.002), as well as decreases in plasma concentrations of ferritin (p=0,016), insulin (p=0,010) and homocysteine (p<0.001) of 5%, 5% and 14%, respectively. There were no changes in either hepatic or muscular function. CONCLUSIONS: Combined treatment with ezetimibe and statin significantly improved lipid profile in poorly-controlled hypercholesterolemic patients treated with statin alone. There were no collateral effects on either hepatic or muscular parameters and there may be additional benefits on plasma levels of homocysteine, insulin and ferritin.

Insulina inhalada y sus efectos sobre el pulmón / Inhaled insulin and its effects on the lungs

No disponible

No disponible

Importancia de la monitorización continua de glucosa en el control de la diabetes mellitus tipo 1 / Importance of continuous glucose monitoring in the control of type 1 diabetes mellitus

Introducción: Optimizar el control metabólico en el paciente con diabetes mellitus tipo 1 (DM1) mediante la medida frecuente de la glucemia capilar es difícil en ocasiones. Han salido al mercado sistemas de monitorización continua de glucosa parcialmente invasivos. El Continuous Glucose Monitoring System (CGMS®) de MiniMed aporta información sobre los valores de glucosa intersticial durante un tiempo aproximado de 72 h. Objetivos: Analizar las variaciones de la concentración de glucosa y el número, el tipo, la intensidad y la duración de las hipoglucemias en pacientes adultos con DM1. Pacientes y método: Estudio prospectivo sobre un total de 24 pacientes con DM1, de ambos sexos y 35 años de edad media, monitorizados con CGMS® durante 3 días. Se registraron los valores de glucosa basal, preprandial y posprandial de cada comida, así como el número, la intensidad y la duración de las hipoglucemias, tanto diurnas como nocturnas, y su relación con las complicaciones vasculares. Resultados: La media de la glucosa preprandial osciló entre 201,50 ± 81,11 mg% y 175,88 ± 83,19 mg% y la de las posprandiales, entre 201,50 ± 81,11 mg% y 182,02 ± 88,97 mg%. En total se detectaron 57 hipoglucemias, de las que el 72,2% fueron asintomáticas y el 22,8%, sintomáticas. El 57,9% fueron diurnas, frente a un 42,1% de nocturnas, con una proporción de asintomáticas mayor en las nocturnas que en las diurnas. La duración media fue de 161,6 min. Sólo el 37,65% del día se encontraban en rango de glucosa normal. Los pacientes con retinopatía diabética presentaban un significativamente menor número de hipoglucemias. No se ha producido ningún caso de rechazo, reacción alérgica o efectos secundarios al monitor. Conclusiones: La monitorización continua de glucosa intersticial es un buen sistema para conocer el perfil glucémico del paciente diabético y pone de manifiesto que con la terapia insulínica habitual no se alcanzan los objetivos de control. Es útil para el estudio de las hipoglucemias y para la detección de las nocturnas asintomáticas

Introduction: Optimizing metabolic control in type 1 diabetic patients by continuous capillary glycemia measurements is often difficult. Partially invasive continuous glucose monitoring systems have come onto the market. The MiniMed Continuous Glucose Monitoring System (CGMS®) provides information on interstitial glucose values for approximately 72 h. Objective: To analyze the number, type, intensity, and duration of hypoglycemias in type 1 diabetic adults. Patients and method: We performed a prospective study in 24 type 1 diabetic men and women with a mean age of 35 years, monitored with the CGMS® for 3 days. Pre- and postprandial basal glucose values were registered at each meal. The number, intensity and duration of diurnal and nocturnal hypoglycemias and their association with vascular complications were also recorded. Results: The mean preprandial glucose levels ranged between 201.5 ± 81.11 mg% and 175.88 ± 83.19 mg%. Postprandial values were between 201.50 ± 81.11 mg% and 182.02 ± 88.97 mg%. Fifty-seven hypoglycemias were detected, of which 72.2% were asymptomatic and 22.8% were symptomatic. A total of 57.9% of hypoglycemias were diurnal and 42.1% were nocturnal; most nocturnal hypoglycemias were asymptomatic. The mean duration of hypoglycemias was 161.6 minutes. Glucose levels were within the normal range only 37.65% of the time. Hypoglycemia was less frequent in patients with diabetic retinopathy than in those without. There were no cases of rejection, allergic reaction, or secondary effects. Conclusions: The MiniMed® continuous glucose monitoring system is highly reliable in measuring interstitial sugar levels in diabetic patients and reveals that routine insulin therapy does not achieve adequate glycemic control. This method is useful for studying hypoglycemia and for detecting nocturnal asymptomatic hypoglycemia

Síndrome metabólico y diabetes mellitus / Metabolic syndrome and diabetes mellitus

La diabetes mellitus (DM) es una enfermedad metabólica crónica que está adquiriendo en los últimos años proporciones de auténtica epidemia. Se asocia frecuentemente con obesidad, alteraciones del metabolismo lipídico y proteínico, así como con hipertensión arterial y otros factores de riesgo cardiovascular, lo que constituye el síndrome metabólico. La DM tipo 2 (DM2) es un factor de riesgo importante para la enfermedad coronaria y la aterosclerosis precoz. Su etiopatogenia es multifactorial y está muy relacionada con la resistencia insulínica (RI), que es el proceso fisiopatológico común al conjunto de factores de riesgo cardiovascular. Respecto a la prevención y el tratamiento de la DM2, es fundamental la modificación del estilo de vida, con especial hincapié en la alimentación equilibrada y la introducción del ejercicio físico aeróbico en la vida cotidiana. Cuando las pautas higiénico-dietéticas no son suficientes, se debe recurrir a fármacos que actúen sobre la diana de la resistencia insulínica, como la metformina y las tiazolidinas (AU)

Diabetes mellitus is a chronic metabolic disease that has acquired the nature of an epidemic in recent years. It is frequently associated with obesity, abnormalities of the lipid and protein metabolism, high blood pressure, and other cardiovascular risk factors, which are often clustered together in the metabolic syndrome. Type 2 diabetes mellitus is an important risk factor for coronary disease and premature atherosclerosis. It has a multifactorial pathogenesis and it is closely linked to insulin resistance, which is also involved in the pathophysiology of cardiovascular risk factors associated with metabolic syndrome. One fundamental intervention for the prevention and treatment of type 2 diabetes mellitus is lifestyle modification, in particular the adoption of a balanced diet and the inclusion of aerobic physical activity in daily life. When these measures are insufficient, the use of drugs that target insulin resistance, such as metformin and thiazolidinediones, is necessary (AU)