Relationship between time-weighted average glucose and mortality in critically ill patients: a retrospective analysis of the MIMIC-IV database.

Blood glucose management in intensive care units (ICU) remains a controversial topic. We assessed the association between time-weighted average glucose (TWAG) levels and ICU mortality in critically ill patients in a real-world study. This retrospective study included critically ill patients from the Medical Information Mart for Intensive Care IV database. Glycemic distance is the difference between TWAG in the ICU and preadmission usual glycemia assessed with glycated hemoglobin at ICU admission. The TWAG and glycemic distance were divided into 4 groups and 3 groups, and their associations with ICU mortality risk were evaluated using multivariate logistic regression. Restricted cubic splines were used to explore the non-linear relationship. A total of 4737 adult patients were included. After adjusting for covariates, compared with TWAG ≤ 110 mg/dL, the odds ratios (ORs) of the TWAG > 110 mg/dL groups were 1.62 (95% CI 0.97-2.84, p = 0.075), 3.41 (95% CI 1.97-6.15, p < 0.05), and 6.62 (95% CI 3.6-12.6, p < 0.05). Compared with glycemic distance at - 15.1-20.1 mg/dL, the ORs of lower or higher groups were 0.78 (95% CI 0.50-1.21, p = 0.3) and 2.84 (95% CI 2.12-3.82, p < 0.05). The effect of hyperglycemia on ICU mortality was more pronounced in non-diabetic and non-septic patients. TWAG showed a U-shaped relationship with ICU mortality risk, and the mortality risk was minimal at 111 mg/dL. Maintaining glycemic distance ≤ 20.1 mg/dL may be beneficial. In different subgroups, the impact of hyperglycemia varied.

Inadequate diabetes knowledge is associated with poor glycemia control in patients with type 2 diabetes / El conocimiento inadecuado de la diabetes se asocia con un control glucémico deficiente en pacientes con diabetes de tipo 2

Objective: To identify the association between glycemia control with level of diabetes knowledge, diabetes education, and lifestyle variables in patients with type 2 diabetes. Design: Cross-sectional analytical study. Site: Clinics of the Mexican Institute of Social Security (IMSS), Mexico. Participants: Patients with type 2 diabetes. Main measurements: Glycated hemoglobin (HbA1c), glucose, and lipid profile levels were measured from fasting venous blood samples. Assessment of disease knowledge was performed using the Diabetes Knowledge Questionnaire (DKQ-24). Systolic and diastolic blood pressure was measured. Weight and abdominal circumference were measured, as well as body composition using bioimpedance. Sociodemographic, clinical, and lifestyle variables were obtained. Results: A total of 297 patients were included, sixty-seven percent (67%) were women with a median of six years since the diagnosis of diabetes. Only 7% of patients had adequate diabetes knowledge, and 56% had regular knowledge. Patients with adequate diabetes knowledge had a lower body mass index (p=0.016), lower percentage of fat (p=0.008), and lower fat mass (p=0.018); followed a diet (p=0.004) and had received diabetes education (p=0.002), and to obtain information about their illness (p=0.001). Patients with low levels of diabetes knowledge had a higher risk of HbA1c≥7% (OR: 4.68; 95% CI: 1.48,14.86; p=0.009), as well as those who did not receive diabetes education (OR: 2.17; 95% CI: 1.21–3.90; p=0.009) and those who did not follow a diet (OR: 2.37; 95% CI: 1.01,5.55; p=0.046). Conclusion: Inadequate knowledge of diabetes, lack of diabetes education, and dietary adherence are associated with poor glycemia control in patients with diabetes.(AU)

Objetivo: Identificar la asociación entre el control de la glicemia con el nivel de conocimiento, la educación y las variables de estilo de vida en pacientes con diabetes tipo 2. Diseño: Estudio transversal analítico. Sitio: Clínicas del Instituto Mexicano del Seguro Social, México. Participantes: Pacientes con diabetes tipo 2. Medidas principales: Se midió el nivel de hemoglobina glicosilada (HbA1c), glucosa y perfil de lípidos en ayuno. La evaluación del conocimiento de la enfermedad se realizó con el Cuestionario de Conocimiento de la Diabetes (DKQ-24). Se midió presión arterial, peso y circunferencia abdominal, así como la composición corporal con bioimpedancia. Las variables clínicas y de estilo de vida fueron registradas. Resultados: Se incluyó a 297 participantes y 67% fueron mujeres, con una mediana de diagnóstico de diabetes de seis años. Solo 7% tuvo un conocimiento adecuado de la diabetes y 56% un conocimiento regular. Los pacientes con conocimiento adecuado de la diabetes tuvieron un índice de masa corporal más bajo (p = 0,016), seguían una dieta (p = 0,004), recibieron educación en diabetes (p = 0,002), y obtuvieron información de su enfermedad (p = 0,001). Los pacientes con bajo nivel de conocimiento tuvieron mayor riesgo de HbA1c ≥ 7% (OR: 4,68; IC 95%: 1,48-14,86; p = 0,009), así como aquellos sin educación en diabetes (OR: 2,17; IC 95%: 1,21-3,90; p = 0,009) y quienes no seguían una dieta (OR: 2,37; IC 95%: 1,01-5,55; p = 0,046). Conclusión. El conocimiento inadecuado de diabetes, la falta de educación en diabetes y adherencia a la dieta se asocian a un control glucémico deficiente en pacientes con diabetes.(AU)

Inadequate diabetes knowledge is associated with poor glycemia control in patients with type 2 diabetes.

OBJECTIVE: To identify the association between glycemia control with level of diabetes knowledge, diabetes education, and lifestyle variables in patients with type 2 diabetes. DESIGN: Cross-sectional analytical study. SITE: Clinics of the Mexican Institute of Social Security (IMSS), Mexico. PARTICIPANTS: Patients with type 2 diabetes. MAIN MEASUREMENTS: Glycated hemoglobin (HbA1c), glucose, and lipid profile levels were measured from fasting venous blood samples. Assessment of disease knowledge was performed using the Diabetes Knowledge Questionnaire (DKQ-24). Systolic and diastolic blood pressure was measured. Weight and abdominal circumference were measured, as well as body composition using bioimpedance. Sociodemographic, clinical, and lifestyle variables were obtained. RESULTS: A total of 297 patients were included, sixty-seven percent (67%) were women with a median of six years since the diagnosis of diabetes. Only 7% of patients had adequate diabetes knowledge, and 56% had regular knowledge. Patients with adequate diabetes knowledge had a lower body mass index (p=0.016), lower percentage of fat (p=0.008), and lower fat mass (p=0.018); followed a diet (p=0.004) and had received diabetes education (p=0.002), and to obtain information about their illness (p=0.001). Patients with low levels of diabetes knowledge had a higher risk of HbA1c≥7% (OR: 4.68; 95% CI: 1.48,14.86; p=0.009), as well as those who did not receive diabetes education (OR: 2.17; 95% CI: 1.21-3.90; p=0.009) and those who did not follow a diet (OR: 2.37; 95% CI: 1.01,5.55; p=0.046). CONCLUSION: Inadequate knowledge of diabetes, lack of diabetes education, and dietary adherence are associated with poor glycemia control in patients with diabetes.

Time-restricted eating improves glycemic control and dampens energy-consuming pathways in human adipose tissue.

OBJECTIVE: We sought to examine the effects of 8 wk of time-restricted eating (TRE) on glucose metabolism and the adipose tissue transcriptome during a metabolic ward stay in men with obesity. METHODS: In a single-arm, pre-post trial, 15 men (ages 63 ± 4 y, body mass index = 30.5 ± 2.4 kg/m2, waist circumference = 113 ± 4 cm) with obesity but no history of diabetes were enrolled and underwent 2 wk of baseline monitoring before they were instructed to eat their regular diets within a contiguous 10-h time frame each day for 8 wk. Metabolic testing was performed at baseline and week 8 during a 35-h metabolic ward stay, during which all food intake was strictly timed and controlled. Identical meal-tolerance tests were performed at breakfast and dinner. Blood glucose, glucoregulatory hormones, and subjective appetite score were measured. Subcutaneous adipose tissue biopsies were performed and the transcriptome was assessed. RESULTS: The primary outcome, plasma glucose area under the curve, was altered by TRE, being unchanged at breakfast but increased at dinner. However, TRE reduced fasting glucose, glycated hemoglobin, body weight, and body fat, and increased glucose-dependent insulinotropic peptide area under the curve at dinner. In subcutaneous adipose tissue, 117 genes were up-regulated and 202 genes down-regulated by TRE. Pathway analysis revealed down-regulation of genes involved in proteasome function and mitochondrial regulation. CONCLUSIONS: TRE had a net effect of reducing glycemia and dampening energy-consuming pathways in adipose tissue.

Analysis of the Adherence and Safety of Second Oral Glucose-Lowering Therapy in Routine Practice From the Mediterranean Area: A Retrospective Cohort Study.

The aims of our study was compare adherence measured by the medical possession ratio (MPR), time until discontinuation and describe adverse events after adding a DPP-4i, SGLT-2i, or sulfonylureas (SU) to metformin in a primary care population with insufficient glycemic control. We used routinely-collected health data from the SIDIAP database. The included subjects were matched by propensity score. The follow-up period was up to 24 months or premature discontinuation. The primary outcomes were the percentage of subjects with good adherence, treatment discontinuation and adverse events among treatment groups. The proportion of patients with good adherence (MPR> 0.8) after the addition of DPP-4i, SGLT-2i or SU was 53.6%, 68.7%, and 43.0%, respectively. SGLT-2i users were 1.7 times more likely to achieve good adherence compared with DPP-4i users (odds ratio [OR]:1.72, 98% confidence interval [CI]:1.51, 1.96), and 2.8 times more likely compared with SU users (OR: 0.35, 98% CI: 0.07, 0.29). The discontinuation hazard ratios were 1.43 (98%CI: 1.26; 1.62) and 1.60 (98%CI: 1.42; 1.81) times higher among SGLT-2i and SU users than DPP-4i users during the follow-up period. No differences were observed for adverse events among the treatment groups. In conclusion, in our real-world setting, the combination of SGLT-2i with metformin was associated with better adherence. The mean time until discontinuation was longer in the SGLT-2i group in comparison with the DPP-4i or SU groups.

Quantitative levels of serum N-glycans in type 1 diabetes and their association with kidney disease.

We investigated associations of quantitative levels of N-glycans with hemoglobin A1c (HbA1c), renal function and renal function decline in type 1 diabetes. We measured 46 total N-glycan peaks (GPs) on 1565 serum samples from the Scottish Diabetes Research Network Type 1 Bioresource Study (SDRNT1BIO) and a pool of healthy donors. Quantitation of absolute abundance of each GP used 2AB-labeled mannose-3 as a standard. We studied cross-sectional associations of GPs and derived measures with HbA1c, albumin/creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR), and prospective associations with incident albuminuria and final eGFR. All GPs were 1.4 to 3.2 times more abundant in SDRTN1BIO than in the healthy samples. Absolute levels of all GPs were slightly higher with higher HbA1c, with strongest associations for triantennary trigalactosylated disialylated, triantennary trigalactosylated trisialylated structures with core or outer arm fucose, and tetraantennary tetragalactosylated trisialylated glycans. Most GPs showed increased abundance with worsening ACR. Lower eGFR was associated with higher absolute GP levels, most significantly with biantennary digalactosylated disialylated glycans with and without bisect, triantennary trigalactosylated trisialylated glycans with and without outer arm fucose, and core fucosylated biantennary monogalactosylated monosialylated glycans. Although several GPs were inversely associated prospectively with final eGFR, cross-validated multivariable models did not improve prediction beyond clinical covariates. Elevated HbA1c is associated with an altered N-glycan profile in type 1 diabetes. Although we could not establish GPs to be prognostic of future renal function decline independently of HbA1c, further studies to evaluate their impact in the pathogenesis of diabetic kidney disease are warranted.

Potential anti-diabetic properties of Merlot grape pomace extract: An in vitro, in silico and in vivo study of α-amylase and α-glucosidase inhibition.

A practical approach to control glycemia in diabetes is to use plant natural products that delay hydrolysis of complex sugars and promote the diminution of the release of glucosyl units into the blood plasma. Polyphenolics have been described as being effective in inhibiting amylases and α-glucosidases. Grape pomace is an important sub product of the wine industry, still rich in many compounds such as polyphenolics. In this context, the purpose of this study was to search for possible effects of a grape pomace extract on salivary and pancreatic α-amylases and α-glucosidase, as well as on intestinal glucose absorption. The Merlot grape pomace extract (MGPE) was prepared using a hydroalcoholic mixture (40% ethanol + 60% water). In vitro inhibition was quantified using potato starch (for amylases) and maltose (for α-glucosidase) as substrates. In vivo inhibition was evaluated by running starch and maltose tolerance tests in rats with or without administration of MGPE. Ranking of the extract compounds for its affinity to the α-amylases was accomplished by computer simulations using three different programs. Both α-amylases, pancreatic and salivary, were inhibited by the MGPE. No inhibition on α-glucosidase, however, was detected. The IC50 values were 90 ± 10 µg/mL and 143 ± 15 µg/mL for salivary and pancreatic amylases, respectively. Kinetically this inhibition showed a complex pattern, with multiple binding of the extract constituents to the enzymes. Furthermore, the in silico docking simulations indicated that several phenolic substances, e.g., peonidin-3-O-acetylglucoside, quercetin-3-O-glucuronide and isorhamnetin-3-O-glucoside, besides catechin, were the most likely polyphenols responsible for the α-amylase inhibition caused by MGPE. The hyperglycemic burst, an usual phenomenon that follows starch administration, was substantially inhibited by the MGPE. Our results suggest that the MGPE can be adequate for maintaining normal blood levels after food ingestion.

The Effects of Soy Protein and Cocoa With or Without Isoflavones on Glycemic Control in Type 2 Diabetes. A Double-Blind, Randomized, Placebo-Controlled Study.

Objective: Soy and cocoa have been suggested to be beneficial for diabetes. The aim of this study was to identify the effects of soy protein, isoflavones, and cocoa on glycemic control parameters. Research design and methods: The study was a parallel, double-blind, placebo-controlled study where patients with diet or metformin controlled type 2 diabetes were randomized to, casein soy protein with or without isoflavones (SPI, SP), and with or without cocoa (SPIC, SPC) arms for an 8 week period. Glycemic control and cardiovascular risk factors were assessed prior to and after the completion of the dietary intervention. Sixty participants completed the study. Results: Soy protein improved HbA1c compared to casein (p < 0.05). The addition of isoflavones improved indices of insulin resistance and LDL [delta QUICKIE (SPI: -0.12 ± 0.04 vs. SP: 0.03 ± 0.06, p = 0.03); delta LDL (-0.27 ± 0.41 vs. 0.22 ± 0.43, p = 0.02); percentage change in HOMA (31.02 ± 54.75 vs. -14.42 ± 27.07, p = 0.02); percentage change in QUICKIE (-3.89 ± 7.07 vs. 6.11 ± 10.54, p = 0.01)]. However, the addition of cocoa provided no benefit with or without isoflavones. Summary: Soy protein had intrinsic activity on glycemic control compared to casein. Isoflavones improved both insulin resistance and LDL, but cocoa did not have added benefit on these indices. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01754662.

Progressively resistive exercise improves autonomic nervous functioning in patients with type 2 diabetes melli-tus / 中华物理医学与康复杂志

Objective To explore the effect and possible mechanism of 12 weeks of progressively resistive exercises on the autonomic nervous function of patients with type 2 diabetes mellitus ( T2DM) fasting and after an oral glucose tolerance test ( OGTT) . Methods Fifty T2DM patients were randomly divided into an exercise group ( E, n=30) and a control group ( C, n=20) . Group E performed progressively resistive exercises for 12 weeks, while group C maintained their normal lifestyle. Blood glucose, insulin, glycosylated hemoglobin, an insulin resist-ance index ( IRI) , heart rate variability, blood pressure variability and baroreflex sensitivity were measured after fasting and after an OGTT before and after the intervention. Results After the intervention, in the fasting state and after an OGTT, all of group E's glycemic control variables except insulin levels were significantly lower than be-fore the intervention ( P≤0.05) . No significant changes were observed in the autonomic nervous function parame-ters. However, after the intervention total power (LnTP), a comprehensive indicator of autonomic nervous system activity, normalized low frequency power (LFn), LnLF/high frequency power (LnLR/HF) and the low-frequency component of systolic blood pressure (LFSBP) increased significantly after OGTT in group E (P≤0.05), while there were no significant changes in the control group. Moreover, after the intervention there were no significant differences between the two groups in the indicators of autonomic nervous system functioning after fasting, but the LnTP, LFn, LnLF/HF and LFSBP2 of group E were significantly higher than those of group C after an OGTT (P≤0.05). In addition, the △LnLF/HF of group E was negatively correlated with △IRI (r=-0.469, P≤0.05). Conclusions Twelve weeks of progressively resistive exercises has no effect on autonomic nervous functioning after fasting for patients with T2DM, but it improves sympathetic neural responses after an OGTT. This may be related to its ameliorating insulin resistance.

Influence of a Pay-for-Performance Program on Glycemic Control in Patients Living with Diabetes by Family Physicians in a Canadian Province.

OBJECTIVES: We evaluated the influence of the introduction of a pay-for-performance program implemented in 2010 for family physicians on the glycemic control of patients with diabetes. METHODS: Administrative data for all 583 eligible family physicians and 83,580 adult patients with diabetes in New Brunswick over 10 years were used. We compared the probability of receiving at least 2 tests for glycated hemoglobin (A1C) levels and achieving glycemic control before (2005-2009) and after (2010-2014) the implementation of the program and between patients divided based on whether a physician claimed the incentive or did not. RESULTS: Patients living with diabetes showed greater odds of receiving at least 2 A1C tests per year if the detection of their diabetes occurred after (vs. before) the implementation of the program (OR, 99% CI=1.23, 1.18 to 1.28), if a physician claimed the incentive (vs. not claiming it) for their care (1.92, 1.87 to 1.96) in the given year, and if they were followed by a physician who ever (vs. never) claimed the incentive (1.24, 1.15 to 1.34). In a cohort-based analysis, patients for whom an incentive was claimed (vs. not claimed) had greater odds of receiving at least 2 A1C tests per year before implementation of the incentive, and these odds increased by 56% (1.49 to 1.62) following its implementation. However, there was no difference in A1C values among the various comparison groups. CONCLUSIONS: Introduction of the incentive was associated with greater odds of having a minimum of 2 A1C tests per year, which may suggest that it led physicians to provide better follow-up care for patients with diabetes. However, the incentive program has not been associated with differences in glycemic control.

Recent advances in managing and understanding diabetic nephropathy.

Diabetic nephropathy is the commonest cause of end-stage renal disease in most developed economies. Current standard of care for diabetic nephropathy embraces stringent blood pressure control via blockade of the renin-angiotensin-aldosterone system and glycemia control. Recent understanding of the pathophysiology of diabetic nephropathy has led to the development of novel therapeutic options. This review article focuses on available data from landmark studies on the main therapeutic approaches and highlights some novel management strategies.

The effectiveness of Internet intervention on 926 patients with diabetes mellitus for up to 30 months.

OBJECTIVE: To assess the long-term effect of an Internet blood glucose monitoring system (IBGMS) on patients with type 1 diabetes mellitus and patients with type 2 diabetes. METHODS: In all, 1200 patients were offered to be taught to communicate with their endocrinologists using standardized glucose level reports by e-mail, and received feedback within 24 hours. The first 926 patients enrolled were reviewed consecutively from March 2011 to October 2013. Seventy-seven of these patients were excluded owing to lack of glycated hemoglobin (A1C) data. The remaining 849 patients consisted of 295 patients with type 1 diabetes and 554 patients with type 2 diabetes. Nonreporters are patients with no record of reporting (n=167), whereas the reporters had reported at least once (n=682). The A1C values were obtained at registration; follow-up values at 3-month intervals were recommended. RESULTS: Reporter A1C decreased from 8.13%±1.34% to 7.74%±1.11% (p<0.0001). Reporters with type 1 diabetes dropped from 8.04%±1.23% to 7.72%±1.03% (n=238; p<0.0001). Reporters with type 2 diabetes dropped from 8.18%±1.40% to 7.75%±1.14% (n=444; p<0.0001) and were subdivided based on treatment: those on oral hypoglycemic agents declined from 7.96%±1.38% to 7.49%%±1.03% (p<0.0001), and those on insulin with or without oral hypoglycemic agents declined from 8.40%%±1.39% to 8.02%±1.20% (p<0.0001). The nonreporters did not show a significant change in A1C. CONCLUSIONS: Initial and prolonged improvement was found in A1C levels for all reporters. The data support that numerous patients can be followed up effectively using the Internet for as long as 30 months.

An interprofessional qualitative study of barriers and potential solutions for the safe use of insulin in the hospital setting.

OBJECTIVE: Insulin is regularly used in hospitalized patients for glycemic control but is associated with significant risks. The goals of this study were to describe the strengths and weaknesses of a university health centre in the safe use of insulin, to collect improvement proposals from health professionals involved in the management of insulin therapy and to assess inpatient glycemic control. METHODS: This is a qualitative study. Physicians, nurses and pharmacists practising at the Centre Hospitalier Universitaire de Sherbrooke (CHUS) for at least 2 years were invited to join focus groups on safe insulin treatment. Themes up for discussion were roles of professionals in insulin therapy, problems encountered, solutions put forward and strengths of the hospital. The Quality Hyperglycemia Score (QHS) was assessed using an existing cohort of inpatients who were prescribed insulin. RESULTS: A total of 5 focus groups were held in February and March of 2012, involving 31 healthcare professional participants. Several groups pointed out the same problems, namely, lack of access to useful information for optimal management of insulin therapy and lack of communication among personnel on different work shifts. Results of the QHS suggest room for improvement in blood glucose control at our institution. CONCLUSION: These focus groups allowed better identification of the management problems related to the use of insulin in our health institution and possible interventions to solve them. The QHS will be reassessed to measure quality of inpatient glycemic control over time.

Control glucémico en el proceso perioperatorio de los pacientes con diabetes mellitus / Glycemia control in the perioperative process of patients presenting with diabetes mellitus

El paciente diabético requiere con frecuencia algún tipo de cirugía o la realización de un proceder diagnóstico invasivo, que puede, incluso, ser realizado de urgencia. En la actualidad el riesgo quirúrgico del diabético ha disminuido gracias a los avances en las técnicas anestésicas y al control metabólico perioperatorio, aunque las complicaciones aún son más frecuentes, y generan una hospitalización prolongada y una tasa mayor de invalidez. En la evaluación preoperatoria se deben precisar las características de la diabetes, el tipo de proceder quirúrgico, el riesgo anestésico quirúrgico, y realizar los ajustes necesarios al tratamiento habitual. La infusión continua de insulina endovenosa con aporte de glucosa es el método más racional y fisiológico en la mayoría de las intervenciones quirúrgicas, lo que implica monitoreo glucémico frecuente con ajustes inmediatos. Algunas situaciones especiales, como las cirugías complejas o las de urgencia, requieren esquemas terapéuticos específicos, por lo que cada equipo debe tener su protocolo de trabajo, según las particularidades de las intervenciones quirúrgicas que realicen. El control metabólico perioperatorio es esencial para evitar las alteraciones metabólicas e hidroelectrolíticas agudas y favorecer la evolución satisfactoria en el posoperatorio. Por su importancia, se realiza una revisión con un enfoque actual, que ayude a mejorar la calidad de la atención al paciente diabético que requiere de una intervención quirúrgica.(AU)

The diabetic patients require frequently some type of surgery or the implementation of an invasive diagnostic procedure which may even be carried out as an emergence. Nowadays the surgical risk of the diabetic patient has decrease thanks to the advances in the anesthetic techniques and to the perioperative metabolic control, although the complications are more frequent and to generate a lengthy hospitalization and a great disability rate. In the preoperative assessment it is necessary to specify exactly the diabetes's features, the type of surgical procedure, surgical anesthetic risk and to perform the fitting necessary in the habitual treatment. The continuous infusion of intravenous insulin with glucose is the more rational and physiologic method in most of surgical interventions, involving the frequent glycemia monitoring with immediate fittings. Some special situations including complicated surgeries or those of emergence, require specific therapeutical schemes, thus each staff must to have its work protocol, according the peculiarities of the surgical interventions performed. The perioperative metabolic control is essential to avoid the metabolic and acute hydroelectrolytic alterations and to favor the satisfactory course during the postoperative period. Due its significance, authors carried out a review with the current approach helping to improve the quality of care of diabetic patient requiring a surgical intervention.(AU)

Control glucémico en el proceso perioperatorio de los pacientes con diabetes mellitus / Glycemia control in the perioperative process of patients presenting with diabetes mellitus

El paciente diabético requiere con frecuencia algún tipo de cirugía o la realización de un proceder diagnóstico invasivo, que puede, incluso, ser realizado de urgencia. En la actualidad el riesgo quirúrgico del diabético ha disminuido gracias a los avances en las técnicas anestésicas y al control metabólico perioperatorio, aunque las complicaciones aún son más frecuentes, y generan una hospitalización prolongada y una tasa mayor de invalidez. En la evaluación preoperatoria se deben precisar las características de la diabetes, el tipo de proceder quirúrgico, el riesgo anestésico quirúrgico, y realizar los ajustes necesarios al tratamiento habitual. La infusión continua de insulina endovenosa con aporte de glucosa es el método más racional y fisiológico en la mayoría de las intervenciones quirúrgicas, lo que implica monitoreo glucémico frecuente con ajustes inmediatos. Algunas situaciones especiales, como las cirugías complejas o las de urgencia, requieren esquemas terapéuticos específicos, por lo que cada equipo debe tener su protocolo de trabajo, según las particularidades de las intervenciones quirúrgicas que realicen. El control metabólico perioperatorio es esencial para evitar las alteraciones metabólicas e hidroelectrolíticas agudas y favorecer la evolución satisfactoria en el posoperatorio. Por su importancia, se realiza una revisión con un enfoque actual, que ayude a mejorar la calidad de la atención al paciente diabético que requiere de una intervención quirúrgica(AU)

The diabetic patients require frequently some type of surgery or the implementation of an invasive diagnostic procedure which may even be carried out as an emergence. Nowadays the surgical risk of the diabetic patient has decrease thanks to the advances in the anesthetic techniques and to the perioperative metabolic control, although the complications are more frequent and to generate a lengthy hospitalization and a great disability rate. In the preoperative assessment it is necessary to specify exactly the diabetes's features, the type of surgical procedure, surgical anesthetic risk and to perform the fitting necessary in the habitual treatment. The continuous infusion of intravenous insulin with glucose is the more rational and physiologic method in most of surgical interventions, involving the frequent glycemia monitoring with immediate fittings. Some special situations including complicated surgeries or those of emergence, require specific therapeutical schemes, thus each staff must to have its work protocol, according the peculiarities of the surgical interventions performed. The perioperative metabolic control is essential to avoid the metabolic and acute hydroelectrolytic alterations and to favor the satisfactory course during the postoperative period. Due its significance, authors carried out a review with the current approach helping to improve the quality of care of diabetic patient requiring a surgical intervention(AU)

Diabetes mellitus en el paciente con enfermedad renal avanzada / Diabetes mellitus in the chronic renal patient

La diabetes mellitus 2 (DM 2) y la enfermedad renal crónica (ERC) son considerados problemas de salud pública a nivel mundial. Los pronósticos de ambas enfermedades están estrechamente relacionados, por lo que las acciones terapéuticas son complementarias. Un buen control glicémico revierte las alteraciones renales en sus etapas iniciales disminuyendo el deterioro microangiopático y a su vez elintento de obtener un control óptimo de glicemias requiere conocer y tratar las alteraciones provocadas por el ambiente urémico. Es muy importante considerar la existencia de cambios en la interpretación de los análisis de laboratorio, cambios en la farmacocinética y farmacodinamia de los medicamentos hipoglicemiantes e insulinas y finalmente la existencia de dificultades para realizar ejercicios y administrar una alimentación adecuada. Los esquemas de hipoglicemiantes utilizados, tanto medicamentos orales como insulinas, deben ser cuidadosamente personalizados. Se debe evitar la indicación de medicamentos de excreción renal exclusiva por el riesgo de hipoglicemias. Tanto las insulinas análogas como convencionales pueden ser administradas, con precaución en su dosificación y reconociendo la necesidad de un estricto automonitoreo de glicemia digital.

Diabetes Mellitus 2 (DM 2) and the chronic renal disease (CRD) are considered health public problems around the world. The prognoses of both illnesses are narrowly related, so the therapeutic actions are complementary. An appropriate level of glycemia reverses renal alterations in its former stages decreasing the microangiopatic deterioration and, at the same time, the attempt to get an optimal blood sugar control requires to know and treat the alterations caused by the uremic environment. It is very important to consider the existence of changes in the laboratory analyses, the pharmacokinetic and pharmacodynamic changes of the hypoglycemic drugs and insulins and, finally, the existenceof complications to practice physical exercises and to administrate an appropriate nutrition. The hypoglycemic schemes used, whether oral drugs or insulin, must be carefully personalized. It must be avoided excretion renal drug prescriptions, exclusively to avoid hypoglycemic risks. Both analog and conventional insulins can be administrated, being precautious in the dosage and recognizing the needof a strict digital glycemia self-monitoring.

Comorbidity and glycemia control among patients with type 2 diabetes in primary care.

Reports on the relationship between comorbidity and glycemia control in diabetic patients are conflicting and the method of measuring comorbidity varies widely among studies. The aim of the present study was to evaluate the relationship between diabetes control and comorbidity, taking into account all comorbidities and their severity, in a primary care setting. We performed a retrospective descriptive study based on chart review of 96 randomly selected type 2 diabetic patients. Comorbidity was measured with the cumulative illness rating scale (CIRS), an exhaustive comorbidity index. Diabetes was considered as controlled if the mean value of two measurements of glycosylated hemoglobin A (HbA(1c)) was less than 7%. Taking diabetes control as the dependent variable, its relationship with the CIRS score, age, sex, diabetes duration, and diabetes-related complications was explored. Diabetes control was not significantly related with the CIRS score, age, sex or diabetes severity. Diabetes duration was the only variable significantly related to diabetes control. Our study suggests that comorbidity measured with the CIRS in patients with type 2 diabetes is not a factor that prevents the achievement of a good glycemia control.