Detección de diabetes tipo LADA en pacientes diabéticos con exceso ponderal. ¿Es adecuado el tratamiento con metformina? / Detection of LADA-type diabetes in overweight diabetic patients. Is treatment with metformin suitable?

Objetivos. Detectar pacientes con diabetes tipo LADA (latent autoinmune diabetes of adult) tipo 1 en diabéticos adultos con sobrepeso y describir las variaciones metabólicas tras administrar metformina. Diseño. Estudio observacional, multicéntrico, basado en una serie de casos. Emplazamiento. Atención primaria, provincia de Barcelona. Participantes. Diabéticos con sobrepeso u obesidad, con diagnóstico de diabetes < 2 años, entre 35 y 65 años de edad, sin complicaciones microvasculares o macrovasculares ni tratamiento farmacológico inicial antidiabético. Intervención. Administración de metformina, 1.700 mg/día. Mediciones. La variable de control metabólico fue la hemoglobina glucosilada (HbA1c); otras variables fueron el índice de masa corporal (IMC), la glucemia en ayunas, la insulinemia, el péptido C y la valoración de la insulinorresistencia (HOMA-IR). Para el diagnóstico de diabetes tipo LADA se determinaron los anticuerpos ICA, anti-GAD y anti-IA2. Resultados. En la muestra de diabéticos estudiada (n = 103) se detectaron 3 casos de LADA tipo 1 (prevalencia del 2,9%; intervalo de confianza del 95%, 0,6-8,3%). Estos pacientes presentaron valores basales más elevados de HbA1c, insulina y sobre todo de HOMA-IR. El tratamiento con metformina mejoró la HbA1c en ambos grupos de pacientes (con o sin LADA de tipo 1). El descenso de la insulinemia al cabo de un año en los pacientes con LADA de tipo 1 fue más marcado que en el resto de diabéticos. Conclusiones. Dada su frecuencia, hay que reflexionar sobre si deberían buscarse con más frecuencia anticuerpos frente a células β pancreáticas en atención primaria. Los pacientes con LADA de tipo 1 presentaron buen control de la HbA1c en tratamiento con metformina y un drástico descenso de la insulina. Faltan estudios que evalúen si la metformina mejora el control glucémico, aunque tal vez no proteja la reserva insulínica, y confrontarla con otros fármacos

Objectives. To detect type-1 LADA (latent auto-immune diabetes in adults) in adults with overweight. To describe the metabolic variations in these patients after metformin treatment. Design. Observational, multi-centre study based on a series of cases. Setting. Health centres in Barcelona province, Spain. Participants. Diabetic patients with overweight or obesity, diagnosed with diabetes for <2 years, aged between 35 and 65, and without clinical micro-macrovascular complications and without initial glycaemia-lowering drug treatment. Intervention. Metformin administration (1700 mg/day). Measurements. The metabolic control variable was HbA1c. Other variables measured were: body mass index (BMI), glucose in fast, insulinaemia, C-peptide, and insulin resistance (HOMA-IR). We determined ICA, GADAb and IA2Ab antibodies to diagnose LADA-type diabetes. Results. In our sample of diabetics (N=103), we detected 3 type-1 LADA cases. These patients had higher levels of HbA1c, insulin and, especially, HOMA-IR. Metformin treatment for one year improved HbA1c in both groups (with and without type-1 LADA). However, the decrease in insulin one year afterwards was greater in type-1 LADA patients. Conclusions. The percentage of type-1 LADA in our sample made us wonder whether we should search for pancreatic antibodies more often in primary care. More studies on the prevalence of type-1 LADA in our country are needed, especially in diabetic patients with overweight. Type-1 LADA patients improved their metabolic control after metformin treatment and showed a drastic decrease in insulin levels. Further studies are needed to evaluate whether metformin improves metabolic control, even though it may not protect insulin reserves, and to contrast metformin with other drugs

[Cardiovascular risk and the new diagnostic categories for diabetes mellitus proposed by the American Diabetes Association]. / Riesgo cardiovascular asociado a las nuevas categorías diagnósticas de la diabetes mellitus propuestas por la Asociación Americana de Diabetes.

OBJECTIVE: To study the cardiovascular risk (CVR) associated with the diagnostic criteria for diabetes proposed by the American Diabetes Association. DESIGN: Cross-sectional, descriptive study. SETTING: Urban health district. PATIENTS: 1840 patients > 14 years old, selected by simple randomised sampling from the clinical records (CR) archive, were studied. METHOD: Through review of the CR, the patients were classified as having: normal glycaemia, disturbed basal glycaemia (DBG) and type-2 diabetes mellitus (DM2). CVR was studied through the simplified Framingham method and the CVR factors of obesity, tobacco dependency, hypertension, hypercholesterolaemia and hypertriglyceridaemia. The likelihood of having high or very high CVR and the CVR factors described in the patients with DBG or DM2 were compared with the same in those with normal glycaemia, through logistical regression with the odds ratio adjusted for age and sex. RESULTS: 1351 patients were classified: 995 with normal glycaemia, 146 with DBG and 210 with DM2. Patients with DBG or DM2 had greater likelihood of high or very high CVR, with some OR at 2.26 (95% CI, 1.39-3.69) and 2.74 (95% CI, 1.81-4.15), respectively. They also had differences (p < 0.05) for obesity (OR, 1.76 and 1.58), hypertension (OR, 1.75 and 2.15) and hypertriglyceridaemia (OR, 1.73 and 2.70), respectively. There were no differences (p > 0.05) for tobacco dependency and hypercholesterolaemia. No differences were found (p > 0.05) between DBG and DM2 for CVR and the CVR factors studied. CONCLUSIONS: Patients with DBG and DM2 are at high CVR.

Riesgo cardiovascular asociado a las nuevas categorías diagnósticas de la diabetes mellitus propuestas por la asociación americana de diabetes / Cardiovascular risk and the new diagnostic categories for diabetes mellitus proposed by the american diabetes association

Objetivo. Estudiar el riesgo cardiovascular (RCV) asociado a las categorías diagnósticas de la diabetes propuestas por la Asociación Americana de Diabetes. Diseño. Estudio descriptivo, transversal. Emplazamiento. Área básica de salud (ABS) urbana. Pacientes. Se estudiaron 1.840 pacientes 15 años, seleccionados por muestreo aleatorio simple del archivo de historias clínicas (HC). Método. Mediante revisión de la HC se clasificó a los pacientes en normoglucemia, glucemia basal alterada (GBA) y diabetes mellitus tipo 2 (DM2). Se estudió el RCV mediante el método de Framingham simplificado y los factores de RCV obesidad, tabaquismo, hipertensión arterial, hipercolesterolemia y hipertrigliceridemia. La probabilidad de tener un RCV elevado o muy elevado y los factores de RCV descritos en los pacientes con GBA y DM2 respecto a los normoglucémicos se estudiaron mediante regresión logística, ajustando la odds ratio (OR) por edad y sexo. Resultados. Se clasificó a 1.351 pacientes: 995 normoglucémicos, 146 pacientes GBA y 210 pacientes DM2. Los pacientes con GBA y DM2 tuvieron una probabilidad superior de presentar un RCV elevado o muy elevado, con unas OR de 2,26 (IC del 95 por ciento, 1,39-3,69) y 2,74 (IC del 95 por ciento, 1,81-4,15), respectivamente. También presentaron diferencias (p 0,05) respecto al tabaquismo y la hipercolesterolemia. No se detectaron diferencias (p > 0,05) entre GBA y DM2 respecto al RVC y los factores de RCV estudiados. Conclusiones. Los pacientes con GBA y DM2 tienen un elevado RCV (AU)

[Attitude of primary care physicians to early detection of prostatic cancer through prostate-specific antigen]. / Actitud del médico de atención primaria en la detección precoz del cáncer de próstata mediante el antígeno prostático específico.

OBJECTIVES: To study the attitude of primary care doctors when a high (> or = 4 ng/ml) prostate-specific antigen (PSA) is found and to examine the variables linked to a prostate biopsy and the diagnosis of prostate cancer (PC). DESIGN: Descriptive, observational study. SETTING: Urban health district. PATIENTS: Ninety-four men not previously diagnosed with PC who in 1998 had a PSA figure > or = 4 ng/ml. The list was obtained from the pertinent laboratory. MEASUREMENTS: The following variables were gathered from review of clinical records: family background of PC, age, PSA figure, reason for request for PSA (if not given, it was considered a screening), referral to the urologist, rectal touch, transrectal echography, prostate biopsy and final diagnosis. RESULTS: Average age was 70 (SD, 9.31). The reason for requesting PSA was: urine symptoms in 25 (26.6%), other signs or symptoms in 25 (26.6%), request of patient in 2 cases (2.1%) and screening in 42 (44.7%). Rectal touch took place in 16 cases. Twenty-nine people were referred for examination to the urologist. 36 patients had an echography and biopsy. Variables linked to the prostate biopsy in the logistic model were: higher value of the PSA (OR 1.1; 95% CI, 1.03-1.18), being older (OR 0.92; CI, 0.87-0.98) and rectal touch performed (OR 3.58; CI, 1.02-12.51). Ten cases of PC were diagnosed. CONCLUSIONS: The most common reason for a PSA request was screening. Prostate biopsy was not requested for 58 men. A primary care guide to action concerning PC diagnosis in cases of PSA > or = 4 ng/ml would be useful.

Actitud del médico de atención primaria en la detección precoz del cáncer de próstata mediante el antígeno prostático específico / Attitude of primary care doctors to early detection of prostate cancer through the prostate-specific antigen

Objetivo. Estudiar la actitud del médico de atención primaria cuando obtiene un antígeno prostático específico (PSA) elevado (>= 4 ng/ml) y las variables asociadas a la práctica de biopsia de próstata y al diagnóstico de carcinoma de próstata (CP). Diseño.Estudio observacional descriptivo. Emplazamiento. ABS urbana. Pacientes. Noventa y cuatro varones no diagnosticados previamente de CP que durante el año 1998 tuvieron un valor de PSA >= 4 ng/ml. El listado se obtuvo del laboratorio de referencia. Mediciones. Por revisión de las historias clínicas se recogieron las variables: antecedentes familiares de CP, edad, valor del PSA, motivo de petición del PSA (si no constaba se consideraba cribado), derivación al urólogo, práctica de tacto rectal, ecografía transrectal, biopsia de próstata y diagnóstico final. Resultados. La edad mediaera de 70 años (DE, 9,31). El motivo de petición del PSA fue: sintomatología urinaria en 25 (26,6 por ciento), otros signos o síntomas en 25 (26,6 por ciento), petición del paciente en 2 (2,1 por ciento) y cribado en 42 (44,7 por ciento). Se realizó tacto rectal en 16 casos. Veintinueve sujetos se derivaron al urólogo para estudio. Constaba ecografía y biopsia en 36 pacientes. Las variables asociadas a la realización de biopsia de próstata en el modelo logístico fueron: valor superior del PSA (OR, 1,1; IC del 95 por ciento, 1,03-1,18), mayor edad (OR, 0,92; IC del 95 por ciento, 0,87-0,98) y practicado tacto rectal (OR, 3,58; IC del 95 por ciento, 1,02-12,51). Se diagnosticaron 10 CP. Conclusiones. El motivo más frecuente de petición del PSA fue por cribado. No se solicitó biopsia de próstata en 58 varones. Sería conveniente una guía de actuación para la atención primaria en relación al diagnóstico de CP para valores de PSA >= 4 ng/ml (AU)

[Impact of the new diagnostic criteria proposed by the American Diabetes Association (ADA-97) on the diagnostic prevalence of type 2 diabetes mellitus]. / Impacto de los nuevos criterios diagnósticos propuestos por la Asociación Americana de Diabetes (ADA-97) sobre la prevalencia diagnóstica de diabetes mellitus tipo 2.

OBJECTIVE: To compare the diagnostic prevalence of type-2 Diabetes Mellitus (DM2) according to the criteria of the American Diabetes Association (ADA-97) and the WHO. DESIGN: Crossover descriptive study. SETTING: Urban Health Centre, with a total of 34,234 clinical histories (CH). PATIENTS: 782 patients, selected through simple random sampling from medical records, aged 45 or over, with a minimum of 5 attendances recorded in their CH and at least 3 attendances in the previous 2 years, were studied. MEASUREMENTS AND MAIN RESULTS: Through review of the CH, the variables age, sex and presence of obesity (BMI3 30) were collected. DM2 patients were classified according to WHO criteria, in the three ADA-97 categories: DM2, basal glucaemia altered (BGA) and normal glucaemia (NG) and other situations with altered glucaemia. Mean age was 62.6 (SD 10.8), with 56.4% women. 95 patients (12.1%) had no glucaemia recorded. 15.6% of the patients with WHO criteria (10.7% through oral overload) were diagnosed with DM2, proportion that went up to 18.3% (CI 95% of difference: -1 to 6.4%) on application of the ADA-97 criteria. 12.8% had BGA, 54.1% NG and 2.7% other situations. Additional DM2 cases diagnosed with ADA-97 criteria had a greater proportion of obese people (p = 0.03), with no differences for age and sex found. CONCLUSIONS: We found a 2.7% increase in the prevalence of DM2 diagnosis in the 45 or over population on applying the ADA-97 criteria. These criteria simplify the diagnosis and will enable an appreciable number of patients not diagnosed under WHO criteria (since oral overload is little used) to be diagnosed. This will foment early action to retard micro and macrovascular complications caused by the disease.

[Effectiveness of the physician's advice to quit smoking: evaluation of the impact a year after the fact]. / Efectividad del consejo médico para dejar de fumar: evaluación del impacto al año de la intervención.

The results of a physician-based intervention on smoking done by general practitioners in Barcelona (Spain) are described one month and one year after its inception. Among the 208 smokers in the intervention group there were more attempts to quit, and they were more successful than in the 216 smokers in the control group. The proportions of quitters after a year was 5.3% and 2.3% in each group (p less than 0.05). Among the variables related to success in quitting are self-reliance, the willingness to reduce or quit smoking, the intensity of the habit and the family environment.