RESUMEN

Background and objective: Advantages of continuous subcutaneous insulin infusion (CSII) over multiple daily injections with glargine (MDI/G) are still uncertain. We compared CSII vs. MDI/G therapy in unselected patients with type 1 diabetes using continuous glucose monitoring (CGSM). The primary end-points were glycaemic control and quality of life (QOL). Methods: A total of 45 patients with long-term diabetes and mean HbA1c values of 8.6 ± 1.8% (70.5 ± 15.4 mmol/mol), previously treated with MDI/NPH, were switched to MDI/G for 6 months and then, unfulfilling therapy CSII indication, were randomly assigned to CSII or MDI/G for another six months. We evaluated QOL (EsDqol) and glycaemic control by measuring HbA1c levels, rate of hypoglycaemia, ketoacidosis and CGSM data. Results: After the first phase (MDI/NPH to MDI/G) there was a significant improvement in total EsDQOL (99.72 ± 18.38 vs. 92.07 ± 17.65; p < 0.028), a 0.5% decrease in HbA1c values (8.4 ± 1.2 vs. 7.9 ± 0.7% [68 ± 9.7 vs. 63 ± 5.5 mmol/mol]; p < 0.032), an improvement in glycaemic variability (standard deviation 66.9 ± 14 vs. 59.4 ± 16 mg/dl; p < 0.05), a decrease in insulin requirements (0.87 ± 0.29 vs. 0.80 ± 0.25 U/kg; p < 0.049), a decrease in number of severe hypoglycaemia episodes (0.44 ± 0.9 vs. 0.05 ± 0.2; p < 0.014), and an increase in periods of normoglycaemia measured with CGSM (15.8 ± 10.9% vs. 23 ± 18.4%; p < 0.003). Six months after randomization, significant improvements were seen in the HbA1c (7.9 ± 0.7 vs. 7 ± 0.6% [63 ± 5.5 vs. 53 ± 4.5 mmol/mol]; p < 0.001) and EsQOL (91.66 ± 22 vs. 84.53 ± 1.63; p < 0.045) only in the CSII group. The HbA1c value was significantly lower when compared with the MDI/G group (CSII 7 ± 0.6% [53 ± 4.5 mmol/mol] vs. MDI/G 7.6 ± 0.9% 59.6 ± 7.7 mmol/mol];p < 0.03). Conclusions: Intensive insulin therapy with CSII vs. MDI/G was associated with better levels of HbA1c in patients with long-term type 1 diabetes (AU)

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Introducción y objetivo: Las ventajas de la infusión subcutánea continua de insulina (ISCI) sobre múltiples inyecciones diarias de insulina con glargina (MDI/G) son todavía inciertas. Comparamos ISCI frente a MDI/G en pacientes con diabetes tipo 1 sin indicación de terapia ISCI utilizando la monitorización continua de glucosa (CGSM). Los objetivos primarios fueron el control glucémico y la calidad de vida (QOL). Métodos: Un total de 45 pacientes con diabetes 1 de largo tiempo de evolución y valores medios de HbA1c de 8,6 ± 1,8% (70,5 ± 15,4 mmol/mol), previamente tratados con MDI/NPH, fueron cambiados a MDI/G durante 6 meses y luego sin cumplir criterios clínicos para terapia ISCI asignados aleatoriamente a ISCI o MDI/G durante seis meses. Se evaluó la calidad de vida (EsDqol) y el control de la glucemia mediante la medición de los niveles de HbA1c, la tasa de hipoglucemias, cetoacidosis y datos de CGSM. Resultados: Después de la primera fase (MDI/NPH a MDI/G) hubo una mejora significativa en EsDQOL total (99,72 ± 18,38 vs. 92,07 ± 17,65; p < 0.028), una disminución de 0,5% en los valores de HbA1c (8,4 ± 1,2 vs. 7,9 ± 0,7% [68 ± 9,7 vs. 63 ± 5,5 mmol/mol]; p < 0,032), una mejora en la variabilidad de la glucemia (desviación estándar 66,9 ± 14 vs. 59,4 ± 16 mg/dl; p <0,05), una disminución en las necesidades de insulina (0,87 ± 0,29 vs. 0,80 ± 0,25 U/kg; p <0,049), una disminución en el número de episodios de hipoglucemia grave (0,44 ± 0,9 vs. 0,05 ± 0,2; p <0,014), y un aumento en los periodos de normoglucemia medidos con CGSM (15,8 ± 10,9% vs. 23 ± 18,4%; p <0,003). Seis meses después de la aleatorización, se observaron mejoras significativas en la HbA1c (7,9 ± 0,7 vs. 7 ± 0,6%; [63 ± 5,5 vs. 53 ± 4.5 mmol/mol]; p <0,001) y la calidad de vida (91,66 ± 22 vs. 84,53 ± 1,63; p <0,045) sólo en el grupo ISCI. El valour de HbA1c fue significativamente menor en ISCI en comparación con el grupo MDI/G (CSII 7 ± 0,6% [53 ± 4,5 mmol/mol] vs. MDI/G 7,6 ± 0,9% [59,6 ± 7,7 mmol/mol]; p < 0,03). Conclusiones: La terapia insulínica intensiva con ISCI vs. MDI/G se asoció con mejores niveles de HbA1c en pacientes con diabetes tipo 1 de larga evolución (AU)

Asunto(s)

Humanos , Masculino , Femenino , Adulto Joven , Adulto , Persona de Mediana Edad , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/prevención & control , Diabetes Mellitus Tipo 1/terapia , Insulina/análogos & derivados , Insulina/administración & dosificación , Insulina/uso terapéutico , Hemoglobina Glucada/administración & dosificación , Hemoglobina Glucada/análisis , Hemoglobina Glucada , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/complicaciones , Insulina/análisis , Insulina/sangre , Calidad de Vida , Cetosis/diagnóstico , Cetoacidosis Diabética

RESUMEN

BACKGROUND AND OBJECTIVE: Advantages of continuous subcutaneous insulin infusion (CSII) over multiple daily injections with glargine (MDI/G) are still uncertain. We compared CSII vs. MDI/G therapy in unselected patients with type 1 diabetes using continuous glucose monitoring (CGSM). The primary end-points were glycaemic control and quality of life (QOL). METHODS: A total of 45 patients with long-term diabetes and mean HbA1c values of 8.6±1.8% (70.5±15.4mmol/mol), previously treated with MDI/NPH, were switched to MDI/G for 6 months and then, unfulfilling therapy CSII indication, were randomly assigned to CSII or MDI/G for another six months. We evaluated QOL (EsDqol) and glycaemic control by measuring HbA1c levels, rate of hypoglycaemia, ketoacidosis and CGSM data. RESULTS: After the first phase (MDI/NPH to MDI/G) there was a significant improvement in total EsDQOL (99.72±18.38 vs. 92.07±17.65; p<0.028), a 0.5% decrease in HbA1c values (8.4±1.2 vs. 7.9±0.7% [68±9.7 vs. 63±5.5mmol/mol]; p<0.032), an improvement in glycaemic variability (standard deviation 66.9±14 vs. 59.4±16mg/dl; p<0.05), a decrease in insulin requirements (0.87±0.29 vs. 0.80±0.25U/kg; p<0.049), a decrease in number of severe hypoglycaemia episodes (0.44±0.9 vs. 0.05±0.2; p<0.014), and an increase in periods of normoglycaemia measured with CGSM (15.8±10.9% vs. 23±18.4%; p<0.003). Six months after randomization, significant improvements were seen in the HbA1c (7.9±0.7 vs. 7±0.6% [63±5.5 vs. 53±4.5mmol/mol]; p<0.001) and EsQOL (91.66±22 vs. 84.53±1.63; p<0.045) only in the CSII group. The HbA1c value was significantly lower when compared with the MDI/G group (CSII 7±0.6% [53±4.5mmol/mol] vs. MDI/G 7.6±0.9% [59.6±7.7mmol/mol]; p<0.03). CONCLUSIONS: Intensive insulin therapy with CSII vs. MDI/G was associated with better levels of HbA1c in patients with long-term type 1 diabetes.

Asunto(s)

Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hipoglucemiantes/administración & dosificación , Insulina Glargina/administración & dosificación , Insulina Lispro/administración & dosificación , Adolescente , Adulto , Anciano , Glucemia/análisis , Automonitorización de la Glucosa Sanguínea , Complicaciones de la Diabetes/epidemiología , Complicaciones de la Diabetes/prevención & control , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/psicología , Esquema de Medicación , Femenino , Hemoglobina Glucada/análisis , Humanos , Hipoglucemia/inducido químicamente , Hipoglucemia/prevención & control , Hipoglucemiantes/efectos adversos , Hipoglucemiantes/uso terapéutico , Infusiones Subcutáneas , Inyecciones Subcutáneas , Insulina Glargina/efectos adversos , Insulina Glargina/uso terapéutico , Insulina Lispro/efectos adversos , Insulina Lispro/uso terapéutico , Masculino , Comidas , Persona de Mediana Edad , Calidad de Vida , Resultado del Tratamiento , Adulto Joven

RESUMEN

INTRODUCTION: Metastatic tumors account for 1.4-2.5% of thyroid malignancies. About 25-30% of patients with clear cell renal carcinoma (CCRC) have distant metastasis at the time of diagnosis, being the thyroid gland a rare localization [5%]. PRESENTATION OF THE CASE: A 62-year woman who underwent a cervical ultrasonography and a PAAF biopsy reporting atypical follicular proliferation with a few intranuclear vacuoles "suggestive" of thyroid papillary cancer in the context of a multinodular goiter was reported. A total thyroidectomy was performed and the histology of a clear cell renal carcinoma (CCRC) was described in four nodules of the thyroid gland. A CT scan was performed and a renal giant right tumor was found. The patient underwent an eventful radical right nephrectomy and the diagnosis of CCRC was confirmed. DISCUSSION: Thyroid metastasis (TM) from CCRC are usually apparent in a metachronic context during the follow-up of a treated primary (even many years after) but may sometimes be present at the same time than the primary renal tumor. Our case is exceptional because the TM was the first evidence of the CCRC, which was subsequently diagnosed and treated. CONCLUSION: The possibility of finding of an incidental metastatic tumor in the thyroid gland from a previous unknown and non-diganosed primary (as CCRC in our case was) is rare and account only for less than 1% of malignancies. Nonetheless, the thyroid gland is a frequent site of metastasis and the presence of "de novo" thyroid nodules in oncologic patients must be always considered and studied.