Asunto(s)

Diabetes Mellitus Tipo 1 , Retinopatía Diabética , Humanos , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 1/diagnóstico , Hemoglobina Glucada , Estudios de Seguimiento , Retinopatía Diabética/diagnóstico , Retinopatía Diabética/epidemiología , Retinopatía Diabética/etiología , Factores de Riesgo

RESUMEN

Aim: The primary aim of this study was to assess insulin requirements and carbohydrate to insulin ratio (CHO/IR) in normal weight, overweight, and obese pregnant women with type 1 diabetes across early, middle, and late pregnancy. Methods: In this multicenter, retrospective, observational study we evaluated 86 of 101 pregnant Caucasian women with type 1 diabetes under pump treatment. The women were trained to calculate CHO/IR daily by dividing CHO grams of every single meal by insulin units injected. Since the purpose of the study was to identify the CHO/IR able to reach the glycemic target, we only selected the CHO/IR obtained when glycemic values were at target. Statistics: SPSS 20. Results: We studied 45 normal weight, 31 overweight, and 10 obese women. Insulin requirements increased throughout pregnancy (p < 0.0001 and <0.001 respectively) in the normal and overweight women, while it remained unchanged in the obese women. Insulin requirements were different between groups when expressed as an absolute value, but not when adjusted for body weight. Breakfast CHO/IR decreased progressively throughout pregnancy in the normal weight women, from 13.3 (9.8-6.7) at the first stage of pregnancy to 6.2 (3.8-8.6) (p = 0.01) at the end stage, and in the overweight women from 8.5 (7.1-12.6) to 5.2 (4.0-8.1) (p = 0.001), while in the obese women it remained stable, moving from 6.0 (5.0-7.9) to 5.1 (4.1-7.4) (p = 0.7). Likewise, lunch and dinner CHO/IR decreased in the normal weight and overweight women (p < 0.03) and not in the obese women. The obese women gained less weight than the others, especially in early pregnancy when they even lost a median of 1.25 (-1 -1.1) kg (p = 0.005). In early pregnancy, we found a correlation between pregestational BMI and insulin requirements (IU/day) or CHO/IR at each meal (p < 0.001 and p = 0.001, respectively). In late pregnancy, a relationship between pre-gestational BMI and CHO/IR change was found (P = 0.004), as well as between weight gain and CHO/IR change (p=0.02). The significance was lost when both variables were included in the multiple regression analysis. There was no difference in pregnancy outcomes except for a higher pre-term delivery rate in the obese women. Conclusion: Pre-gestational BMI and weight gain may play a role in determining CHO/IR during pregnancy in women with type 1 diabetes under pump treatment.

Asunto(s)

Diabetes Mellitus Tipo 1/terapia , Carbohidratos de la Dieta/administración & dosificación , Insulina/administración & dosificación , Embarazo en Diabéticas , Adulto , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/epidemiología , Cálculo de Dosificación de Drogas , Femenino , Edad Gestacional , Humanos , Peso Corporal Ideal/fisiología , Sistemas de Infusión de Insulina , Italia/epidemiología , Comidas , Necesidades Nutricionales , Obesidad/sangre , Obesidad/complicaciones , Obesidad/epidemiología , Obesidad/terapia , Sobrepeso/sangre , Sobrepeso/complicaciones , Sobrepeso/epidemiología , Sobrepeso/terapia , Embarazo , Complicaciones del Embarazo/sangre , Complicaciones del Embarazo/epidemiología , Complicaciones del Embarazo/terapia , Resultado del Embarazo/epidemiología , Embarazo en Diabéticas/sangre , Embarazo en Diabéticas/tratamiento farmacológico , Embarazo en Diabéticas/epidemiología , Estudios Retrospectivos , Adulto Joven

RESUMEN

Diabetes and cancer frequently coexist in the same subject, often with relevant clinical effects on the management and prognosis of the comorbid patient. The existing guidelines, however, do not appropriately address many clinical issues in this setting. Although collaboration between diabetologists and oncologists should play an important role in achieving appropriate levels of care, close coordination or agreement between these specialists is seldom offered. There is an urgent need for greater interdisciplinary integration between all specialists involved in this setting, for a shared approach ensuring that organisational silos are overcome. To this end, the Italian Associations of Medical Diabetologists (AMD) and the Italian Association of Medical Oncology (AIOM) recently established a dedicated Working Group on 'Diabetes and Cancer'. The working group outlined a diagnostic and therapeutic clinical pathway dedicated to hospitalised patients with diabetes and cancer. In this article, we describe the Italian proposal including some suggested measures to assess, monitor and improve blood glucose control in the hospital setting, to integrate different specialists from both areas, as well as to ensure discharge planning and continuity of care from the hospital to the territory.

Asunto(s)

Complicaciones de la Diabetes/complicaciones , Oncología Médica/métodos , Neoplasias/complicaciones , Prestación Integrada de Atención de Salud , Humanos , Italia , Pronóstico

RESUMEN

OBJECTIVE: To determine clinical diabetes-related risk factors for fragility fractures in type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS: History of bone fragility fractures occurring after T1D diagnosis was assessed by questionnaire in this cross-sectional study in 600 T1D subjects. Glycated hemoglobin A1c (HbA1c) over the previous 5 years was used as an index of long-term glycemic control; complications were adjudicated by physician assessment. Multinomial logistic regression models were used to assess the associations between diabetes-related risk factors and fracture history. RESULTS: One-hundred-eleven patients (18.5%) reported at least one fracture; of these 73.8% had only one and 26.2% had more than one fracture. Average age was 41.9 ±â€¯12.8 years, with even gender distribution; disease duration was 19.9 ±â€¯12.0 years; and BMI was 24.4 ±â€¯3.7 kg/m2. The 5-year average HbA1c was 7.6 ±â€¯1.0% (60 mmol/mol). In adjusted models, reduced risk for 1 fracture was found in those with higher creatinine clearance rate (CCr) (RRR 0.22 [95% CI: 0.06-0.83] for 1 unit increase in lnCCr, p = 0.03) and increased risk in those with neuropathy (RRR 2.57 [1.21-5.46], p = 0.01). Increased risk for ≥2 fractures was found in subjects in the highest tertile of HbA1c (≥7.9%) compared with the lowest tertile (≤7.17%) (RRR 3.50 [1.04-11.7], p = 0.04) and of disease duration (≥26 years versus <14 years) (RRR 7.59 [1.60-35.98], p = 0.01). CONCLUSIONS: Poor glycemic control and long exposure to the disease are independent diabetes-related risk factors for multiple bone fractures in T1D.

Asunto(s)

Glucemia/fisiología , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/fisiopatología , Fracturas Óseas/sangre , Hiperglucemia/sangre , Hiperglucemia/fisiopatología , Adolescente , Adulto , Anciano , Diabetes Mellitus Tipo 1/complicaciones , Femenino , Fracturas Óseas/epidemiología , Humanos , Hiperglucemia/complicaciones , Masculino , Persona de Mediana Edad , Factores de Riesgo , Adulto Joven

RESUMEN

We evaluated gender-differences in quality of type 1 diabetes (T1DM) care. Starting from electronic medical records of 300 centers, 5 process indicators, 3 favorable and 6 unfavorable intermediate outcomes, 6 treatment intensity/appropriateness measures and an overall quality score were measured. The likelihood of women vs. men (reference class) to be monitored, to reach outcomes, or to be treated has been investigated through multilevel logistic regression analyses; results are expressed as Odd Ratios (ORs) and 95% confidence intervals (95%CIs). The inter-center variability in the achievement of the unfavorable outcomes was also investigated. Overall, 28,802 subjects were analyzed (45.5% women). Women and men had similar age (44.5±16.0 vs. 45.0±17.0 years) and diabetes duration (18.3±13.0 vs. 18.8±13.0 years). No between-gender differences were found in process indicators. As for intermediate outcomes, women showed 33% higher likelihood of having HbA1c ≥8.0% (OR = 1.33; 95%CI: 1.25-1.43), 29% lower risk of blood pressure ≥140/90 mmHg (OR = 0.71; 95%CI: 0.65-0.77) and 27% lower risk of micro/macroalbuminuria (OR = 0.73; 95%CI: 0.65-0.81) than men, while BMI, LDL-c and GFR did not significantly differ; treatment intensity/appropriateness was not systematically different between genders; overall quality score was similar in men and women. Consistently across centers a larger proportion of women than men had HbA1c ≥8.0%, while a smaller proportion had BP ≥140/90 mmHg. No gender-disparities were found in process measures and improvements are required in both genders. The systematic worse metabolic control in women and worse blood pressure in men suggest that pathophysiologic differences rather than the care provided might explain these differences.

Asunto(s)

Diabetes Mellitus Tipo 1/terapia , Disparidades en Atención de Salud/estadística & datos numéricos , Calidad de la Atención de Salud/estadística & datos numéricos , Adulto , Índice de Masa Corporal , Estudios Transversales , Femenino , Tasa de Filtración Glomerular , Hemoglobina Glucada/análisis , Humanos , Masculino , Persona de Mediana Edad , Indicadores de Calidad de la Atención de Salud , Factores Sexuales , Resultado del Tratamiento

RESUMEN

AIM: The aim of this study was to assess carbohydrate (CHO)-to-insulin ratio (CHO/IR) values in pregnant women with type 1 diabetes and to describe differences in CHO/IR across each week of pregnancy. MATERIALS AND METHODS: This was a multicenter, retrospective, observational study (2006-2012) of 101 white pregnant women with a mean age of 32 (range, 18-43) years who had type 1 diabetes and were under continuous subcutaneous insulin infusion (CSII) therapy. These patients had the following characteristics: type 1 diabetes duration was 1 year (range, 1-31 years), the pregestational glycosylated hemoglobin level was 6.9% (range, 6.8-12.1%), the median weight gain during pregnancy was 14 kg (-3; 25 kg), with delivery at 37 weeks (range, 30-40 weeks), and the child had a birth weight of 3.530 kg (range, 1.480-5.250 kg). The CHO/IR was measured by dividing the CHO (in g) of each meal by insulin unit injected to acquire and maintain the following glycemic targets: fasting <90 mg/dL and 1-h postprandial <130 mg/dL. Simultaneously, CHO/IR indices were calculated through 500/total daily doses of insulin and 300/total daily doses of insulin. Education and management before and during pregnancy were in agreement with Italian Association of Dietitians, Association of Medical Diabetologists, and Italian Society of Diabetology recommendations. Data were analyzed using SPSS software (version 20.0; SPSS, Inc., Chicago, IL). RESULTS: The CHO/IR decreased on average from 9.6 (5-18) to 5.4 (2.3-8) at breakfast, from 10 (3.5-16) to 8.4 (3.0-17.8) at lunch, and from 12.5 (8-20) to 6.1 (4.2-12) at dinner. The CHO/IR calculated using the "500 rule" decreased from 14.3 (10-20.3) to 8.6 (4.1-15.9). Using the "300 rule," the ratios decreased from 8.5 (6-12.1) to 5.2 (2.4-9.5). The bivariate correlation between the values calculated more appropriate values using the "300 rule" for breakfast and the "500 rule" for lunch and dinner across all weeks of pregnancy. CONCLUSIONS: CHO/IR reduction in pregnancy is likely due to an increase in insulin resistance.

Asunto(s)

Carbohidratos/sangre , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Insulina/sangre , Insulina/uso terapéutico , Embarazo en Diabéticas/sangre , Embarazo en Diabéticas/tratamiento farmacológico , Adolescente , Adulto , Algoritmos , Glucemia/análisis , Femenino , Edad Gestacional , Humanos , Hipoglucemiantes/administración & dosificación , Insulina/administración & dosificación , Sistemas de Infusión de Insulina , Comidas , Embarazo , Estudios Retrospectivos , Adulto Joven

RESUMEN

This document has been developed by a group of Italian diabetologists with extensive experience in continuous subcutaneous insulin infusion (CSII) therapy to provide indications for the clinical management of CSII in diabetic patients (both type 1 and type 2) based on delivery mode operating in Italy. Although the potential benefits of pump therapy in achieving glycemic goals is now accepted, such results cannot be obtained without specific knowledge and skills being conveyed to patients during ad hoc educational training. To ensure that these new technologies reach their full effectiveness, as demonstrated theoretically and clinically, a careful assessment of the overall therapeutic and educational process is required, in both qualitative and quantitative terms. Therefore, to ensure the cost-effectiveness of insulin pump therapy and to justify reimbursement of therapy costs by the National Health System in Italy, in this article we present a model for diabetes and healthcare centers to follow that provides for different levels of expertise in the field of CSII therapy. This model will guarantee the provision of excellent care during insulin pump therapies, thus representing the basis for a successful outcome and expansion of this form of insulin treatment in patients with diabetes while also keeping costs under control.

Asunto(s)

Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemiantes/administración & dosificación , Infusiones Subcutáneas , Insulina/administración & dosificación , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Manejo de la Enfermedad , Adhesión a Directriz , Humanos , Sistemas de Infusión de Insulina , Italia/epidemiología , Pautas de la Práctica en Medicina

RESUMEN

Background. Dyslipidemia contribute to the excess of coronary heart disease (CHD) risk observed in women with type 2 diabetes (T2DM). Low density lipoprotein-cholesterol (LDL-C) is the major target for CHD prevention, and T2DM women seem to reach LDL-C targets less frequently than men. Aim. To explore age- and gender-related differences in LDL-C management in a large sample of outpatients with T2DM. Results. Overall, 415.294 patients (45.3% women) from 236 diabetes centers in Italy were included. Women were older and more obese, with longer diabetes duration, higher total-cholesterol, LDL-C, and HDL-C serum levels compared to men (P < 0.0001). Lipid profile was monitored in ~75% of subjects, women being monitored less frequently than men, irrespective of age. More women did not reach the LDL-C target as compared to men, particularly in the subgroup treated with lipid-lowering medications. The between-genders gap in reaching LDL-C targets increased with age and diabetes duration, favouring men in all groups. Conclusions. LDL-C management is worst in women with T2DM, who are monitored and reach targets less frequently than T2DM men. Similarly to men, they do not receive medications despite high LDL-C. These gender discrepancies increase with age and diabetes duration, exposing older women to higher CHD risk.

RESUMEN

OBJECTIVE: To investigate the quality of type 2 diabetes care according to sex. RESEARCH DESIGN AND METHODS: Clinical data collected during the year 2009 were extracted from electronic medical records; quality-of-care indicators were evaluated. Multilevel logistic regression analysis was applied to estimate the likelihood of women versus men to be monitored for selected parameters, to reach clinical outcomes, and to be treated with specific classes of drugs. The intercenter variability in the proportion of men and women achieving the targets was also investigated. RESULTS: Overall, 415,294 patients from 236 diabetes outpatient centers were evaluated, of whom 188,125 (45.3%) were women and 227,169 (54.7%) were men. Women were 14% more likely than men to have HbA1c>9.0% in spite of insulin treatment (odds ratio 1.14 [95% CI 1.10-1.17]), 42% more likely to have LDL cholesterol (LDL-C)≥130 mg/dL (1.42 [1.38-1.46]) in spite of lipid-lowering treatment, and 50% more likely to have BMI≥30 kg/m2 (1.50 [1.50-1.54]). Women were less likely to be monitored for foot and eye complications. In 99% of centers, the percentage of men reaching the LDL-C target was higher than in women, the proportion of patients reaching the HbA1c target was in favor of men in 80% of the centers, and no differences emerged for blood pressure. CONCLUSIONS: Women show a poorer quality of diabetes care than men. The attainment of the LDL-C target seems to be mainly related to pathophysiological factors, whereas patient and physician attitudes can play an important role in other process measures and outcomes.

Asunto(s)

Diabetes Mellitus Tipo 2/sangre , Anciano , Presión Sanguínea/fisiología , HDL-Colesterol/sangre , LDL-Colesterol/sangre , Estudios Transversales , Manejo de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores Sexuales , Triglicéridos/sangre

RESUMEN

Early intensive therapy in type 2 diabetes can prevent complications. Nevertheless, metabolic control is often sub-optimal in newly diagnosed patients. This web-based survey aimed to evaluate opinions of physicians about treatment, priorities, and barriers in the care of patients first referred to diabetes clinics. Data on physician attitudes toward therapeutic preferences for two clinical case models (same clinical profile, except HbA1c levels of 8.6 and 7.3% at the first access, respectively) were collected. Participants were asked to rank from 1 (most important) to 6 (least important) a list of priorities and barriers associated with the care of new patients. Overall, 593 physicians participated. In both case models, metformin and education were primary options, although their combination with other classes of drugs varied substantially. Main priorities were "to teach the patient how to cope with the disease" and "to achieve HbA1c target"; main barriers were "lack of time" and "long waiting list". At multivariate analyses, physicians from the South of Italy had a twofold higher likelihood to attribute a rank 1­2 to organizational barriers than those operating in the North (South vs. North: OR: 2.4; 95% CI 1.4­4.1; Center vs. North: OR: 2.4; 95% CI 0.9­3.2). In the absence of a widely accepted evidence-based therapeutic algorithm driving the therapeutic choices according to the patient characteristics, prescriptions vary according to physician preferences. Education is perceived as a key-strategy, but organizational barriers and geographic disparities are an obstacle. These findings can drive new strategies to reduce clinical inertia, attitudes variability, and geographic disparities.

Asunto(s)

Actitud del Personal de Salud , Diabetes Mellitus Tipo 2/terapia , Médicos , Adulto , Edad de Inicio , Recolección de Datos , Complicaciones de la Diabetes/epidemiología , Complicaciones de la Diabetes/prevención & control , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiología , Endocrinología/organización & administración , Femenino , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Médicos/psicología , Médicos/estadística & datos numéricos , Práctica Profesional/estadística & datos numéricos , Calidad de la Atención de Salud/estadística & datos numéricos , Sociedades Médicas , Encuestas y Cuestionarios , Factores de Tiempo

RESUMEN

Continuous subcutaneous insulin infusion (CSII) represents an increasingly popular method of treating diabetes. Patients with diabetes are often hospitalized, and current data indicate that inpatient hyperglycemia results in poorer outcomes. When patients on insulin pump therapy require hospitalization, practitioners caring for them face the issue of how to manage the inpatient care of these patients. We believe that patients using insulin pumps can safely have their therapy transitioned when hospitalized. Moreover, CSII during hospitalization should be regarded not only as a fundamental tool in patients already on insulin pump therapy, but also as an effective method to obtain euglycemia, in critically ill patients. However, a standard policy on CSII use during hospitalization is still lacking, and literature data are inconclusive about the benefits of insulin pump on glycemic homeostasis, in hospitalized patients. We suggest that a CSII unit should be activated inside the hospital, in order to increase compliance with required procedures and to properly address the unmet needs of CSII in inpatient setting.

Asunto(s)

Hipoglucemiantes/administración & dosificación , Insulina/administración & dosificación , Humanos , Pacientes Internos , Sistemas de Infusión de Insulina

RESUMEN

OBJECTIVE: We investigated whether supplementation of the active form of vitamin D (calcitriol) in recent-onset type 1 diabetes can protect beta-cell function evaluated by C-peptide and improve glycemic control assessed by A1C and insulin requirement. RESEARCH DESIGN AND METHODS: Thirty-four subjects (aged 11-35 years, median 18 years) with recent-onset type 1 diabetes and high basal C-peptide >0.25 nmol/l were randomized in a double-blind trial to 0.25 microg/day calcitriol or placebo and followed-up for 2 years. RESULTS: At 6, 12, and 24 months follow-up, A1C and insulin requirement in the calcitriol group did not differ from the placebo group. C-peptide dropped significantly (P < 0.001) but similarly in both groups, with no significant differences at each time point. CONCLUSIONS: At the doses used, calcitriol is ineffective in protecting beta-cell function in subjects (including children) with recent-onset type 1 diabetes and high C-peptide at diagnosis.

Asunto(s)

Calcitriol/uso terapéutico , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/metabolismo , Células Secretoras de Insulina/efectos de los fármacos , Células Secretoras de Insulina/metabolismo , Adolescente , Adulto , Péptido C/metabolismo , Calcitriol/farmacología , Niño , Femenino , Hemoglobina Glucada/metabolismo , Humanos , Hipoglucemiantes/farmacología , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Masculino , Adulto Joven

RESUMEN

OBJECTIVE: We previously demonstrated the presence of two different populations among individuals with adult-onset autoimmune diabetes: those having either a high titer or a low titer of antibodies to GAD (GADAs). Protein tyrosine phosphatase nonreceptor type 22 (PTPN22) has been identified as a new susceptibility gene for type 1 diabetes and other autoimmune diseases. The aim of the present study was to evaluate whether the phenotypic heterogeneity of adult-onset autoimmune diabetes based on the GADA titer is associated with the PTPN22 C1858T polymorphism. RESEARCH DESIGN AND METHODS: Analysis for the C1858T polymorphism using the TaqMan assay was performed in 250 subjects with adult-onset autoimmune diabetes, divided into two subgroups with low (32 arbitrary units) GADA titers and 450 subjects with classic type 2 diabetes (from the Non Insulin Requiring Autoimmune Diabetes [NIRAD] Study cohort of 5,330 subjects with adult-onset diabetes) and in 558 subjects with juvenile-onset type 1 diabetes and 545 normoglycemic subjects. RESULTS: Genotype, allele, and phenotype distributions of the PTPN22 C1858T variant revealed similar frequencies in autoimmune diabetes with high GADA titer and juvenile-onset type 1 diabetes. An increase in TT and CT genotypes was observed in individuals with a high GADA titer compared with a low GADA titer, those with type 2 diabetes, and control subjects (P < 0.002 for all comparisons). The PTPN22 1858T allele and phenotype frequencies were increased in high GADA titer compared with a low GADA titer, type 2 diabetic, and control subjects (P < 0.001 for all comparisons, odds ratio 2.6). CONCLUSIONS: In adult-onset autoimmune diabetes, the PTPN22 1858T variant is associated only with a high GADA titer, providing evidence of a genetic background to clinical heterogeneity identified by GADA titer.

Asunto(s)

Autoanticuerpos/inmunología , Diabetes Mellitus Tipo 1/genética , Diabetes Mellitus Tipo 1/inmunología , Glutamato Descarboxilasa/inmunología , Proteína Tirosina Fosfatasa no Receptora Tipo 22/genética , Adulto , Alelos , Distribución de Chi-Cuadrado , Femenino , Frecuencia de los Genes , Predisposición Genética a la Enfermedad , Genotipo , Antígenos HLA/genética , Humanos , Masculino , Persona de Mediana Edad , Fenotipo , Polimorfismo de Nucleótido Simple

RESUMEN

BACKGROUND: In Italy many diabetics still lack adequate care in general practice. We assessed the effectiveness of different strategies for the implementation of an evidence-based guideline for the management of non-complicated type 2 diabetes among General Practitioners (GPs) of Lazio region. METHODS: Three-arm cluster-randomised controlled trial with GPs as units of randomisation (clusters). 252 GPs were randomised either to an active strategy (training module with administration of the guideline), or to a passive dissemination (administration of the guideline only), or to usual care (control). Data on prescriptions of tests and drugs were collected by existing information systems, whereas patients' data came from GPs' databases. Process outcomes were measured at the cluster level one year after the intervention. Primary outcomes concerned the measurement of glycosilated haemoglobin and the commissioning of micro- and macrovascular complications assessment tests. In order to assess the physicians' drug prescribing behaviour secondary outcomes were also calculated. RESULTS: GPs identified 6395 uncomplicated type 2 patients with a high prevalence of cardiovascular risk factors. Data on GPs baseline performance show low proportions of glycosilated haemoglobin assessments. Results of the C-RCT analysis indicate that the active implementation strategy was ineffective relating to all primary outcomes (respectively, OR 1.06 [95% IC: 0.76-1.46]; OR 1.07 [95% IC: 0.80-1.43]; OR 1.4 [95% IC:0.91-2.16]. Similarly, passive dissemination of the guideline showed no effect. CONCLUSION: In our region compliance of GPs with guidelines was not enhanced by a structured learning programme. Implementation through organizational measures appears to be essential to induce behavioural changes. TRIAL REGISTRATION: ISRCTN80116232.

Asunto(s)

Diabetes Mellitus Tipo 2/tratamiento farmacológico , Medicina Familiar y Comunitaria/normas , Adhesión a Directriz , Hipoglucemiantes/administración & dosificación , Análisis por Conglomerados , Diabetes Mellitus Tipo 2/diagnóstico , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Utilización de Medicamentos/normas , Medicina Basada en la Evidencia , Medicina Familiar y Comunitaria/tendencias , Femenino , Humanos , Italia , Masculino , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/tendencias

RESUMEN

OBJECTIVE: The aim of the present study was to define heterogeneity of adult-onset autoimmune diabetes based on characterization of GAD antibodies (GADAs). RESEARCH DESIGN AND METHODS: Patients enrolled in a nationwide survey, the Non Insulin Requiring Autoimmune Diabetes (NIRAD) Study, have been screened for GADAs and IA-2 antibodies (IA-2As) and further characterized for GADA titer, antibodies to thyroid peroxidase (TPO), and HLA DRB1-DQB1 polymorphisms. RESULTS: Of 4,250 consecutive type 2 diabetic patients, 4.5% had either GADAs and/or IA-2As. Patients with autoimmune diabetes showed a clinical phenotype significantly different from that of type 2 diabetes, including higher fasting glucose and A1C, lower BMI and uric acid, lower prevalence of metabolic syndrome and its components, and higher frequency of TPO antibodies. More interestingly, analysis of GADA titers showed a bimodal distribution that identified two subgroups of patients with high (>32 GADA arbitrary units) and low (< or =32 GADA arbitrary units) GADA titers. Compared with those with low GADA titers, patients with high GADA titers had more prominent traits of insulin deficiency and a profile of more severe autoimmunity resulting in higher A1C, lower BMI, a lower prevalence of metabolic syndrome and its components (P < 0.02 for all), a higher prevalence of IA-2As, TPO antibodies (P < 0.003 for both), and DRB1*03-DQB1*0201 (50 vs. 26.8%, P = 0.001), and a decreasing frequency of DQB1*0602 and DRB1*0403 (from type 2 to low and to high GADA titer autoimmune diabetes; P < 0.001 for trend for both comparisons). CONCLUSIONS: GADA titers identify two subgroups of patients with adult-onset autoimmune diabetes having distinct clinical, autoimmune, and genetic features.

Asunto(s)

Autoanticuerpos/sangre , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/genética , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/genética , Glutamato Descarboxilasa/inmunología , Adulto , Diabetes Mellitus Tipo 1/enzimología , Diabetes Mellitus Tipo 2/enzimología , Glutamato Descarboxilasa/genética , Humanos , Insulina/deficiencia , Italia , Fenotipo

RESUMEN

OBJECTIVE: To evaluate whether a dietary protein restriction is useful for slowing the progression of chronic renal failure (CRF) in diabetic and nondiabetic patients and to analyze the possible risk of malnutrition after such a dietary regimen. DESIGN: Prospective, randomized case-control clinical trial. SETTING: Nephrology outpatients. PATIENTS AND OTHER PARTICIPANTS: A total of 169 patients, 89 affected with CRF and chronic hypertension and 80 affected with overt diabetic nephropathy (24 suffering from type 1 and 56 from type 2 diabetes) and chronic hypertension. INTERVENTION: Diabetic patients and nondiabetic patients were randomly divided into 2 groups: 40 diabetic patients received a low-protein diet (0.8 g/kg/day) and 40 were maintained on a free protein diet; similarly, 44 nondiabetic patients received a low-protein diet (0.6 g/kg/day) and 45 were maintained on a free protein diet. The investigation lasted 1 year. MAIN OUTCOME MEASURE: Renal function and nutritional status. RESULTS: At the end of the study, there were no statistically significant differences in renal function between treated and nontreated diabetic patients, whereas treated nondiabetic patients showed a lower decrease in renal function compared with the nontreated group. In both diabetic and nondiabetic patients, the mean body weight and obesity index decreased significantly in treated patients compared with nontreated ones. Serum albumin and prealbumin were stable in all patients during the whole study time, and there were no other signs of malnutrition. CONCLUSION: An adequate dietary protein restriction is accepted by patients, and it is well tolerated during a 12-month follow-up. Without any sign of malnutrition, it is possible to get near the ideal body weight and to reduce the obesity index and the body mass index, which are both well-established risk factors for developing cardiovascular pathology. In nondiabetic patients only, we observed a significant slowing of the progression of renal damage.

Asunto(s)

Complicaciones de la Diabetes/dietoterapia , Dieta con Restricción de Proteínas , Fallo Renal Crónico/dietoterapia , Adulto , Anciano , Presión Sanguínea , Índice de Masa Corporal , Estudios de Casos y Controles , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Nefropatías Diabéticas/complicaciones , Dieta con Restricción de Proteínas/efectos adversos , Ingestión de Energía , Femenino , Humanos , Hipertensión/complicaciones , Riñón/fisiopatología , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/fisiopatología , Masculino , Desnutrición/diagnóstico , Desnutrición/etiología , Persona de Mediana Edad , Obesidad/complicaciones , Prealbúmina/análisis , Estudios Prospectivos , Albúmina Sérica/análisis

RESUMEN

In a pilot study, the metabolic effects of continuous subcutaneous insulin infusion (CSII) versus intensive subcutaneous insulin therapy (ISIT) started at diagnosis in patients with Type 1 diabetes and continued for a 2-year period were evaluated and compared. Twenty-three patients (between 12 and 35 years old, mean +/- SD 18.4 +/- 9 years) were randomized into two treatment groups (CSII vs. ISIT), and both received supplemental nicotinamide (NA), 25 mg/kg of body weight. CSII was started immediately after admission to the hospital. Parameters of metabolic control [insulin dose, hemoglobin A1c (HbA1c), and C-peptide] were evaluated for a 2-year follow-up period. Data are presented for a total of 19 patients who remained in the study for its duration. Two years after diagnosis, mean +/- SD HbA1c was 6.3 +/- 0.5% and 6.2 +/- 0.3% for the CSII and ISIT groups, respectively (p=not significant). Compared with baseline values, an increase of baseline C-peptide of 38% for the CSII group and 27% for the ISIT group was observed; however, the difference between the groups was not significant. The insulin requirement for the entire duration of the study, but not at entry and 3 months, was significantly higher in CSII compared with ISIT patients (0.62 +/- 0.4 IU/kg/day vs. 0.3 +/- 0.4 IU/kg/day, respectively; p<0.01). After trial completion patients on CSII continued with this mode of therapy. Implementation of CSII as well as ISIT at diagnosis of Type 1 diabetes and continuation for 2 years thereafter achieved similar and optimal metabolic control, but more insulin was required with the CSII group. Both types of intensive insulin therapy combined with NA are able to preserve C-peptide secretion or even increase baseline levels for up to 2 years after diagnosis.

Asunto(s)

Diabetes Mellitus Tipo 1/tratamiento farmacológico , Sistemas de Infusión de Insulina , Insulina/uso terapéutico , Análisis de Varianza , Índice de Masa Corporal , Péptido C/sangre , Relación Dosis-Respuesta a Droga , Estudios de Seguimiento , Hemoglobina Glucada/efectos de los fármacos , Hemoglobina Glucada/metabolismo , Humanos , Hipoglucemia/epidemiología , Hipoglucemiantes/administración & dosificación , Hipoglucemiantes/uso terapéutico , Inyecciones Subcutáneas , Insulina/administración & dosificación , Proyectos Piloto , Reproducibilidad de los Resultados , Resultado del Tratamiento

RESUMEN

OBJECTIVE: To evaluate whether restricting protein intake may delay the progression of chronic renal failure caused by overt diabetic nephropathy and also whether this increases the risk of malnutrition. DESIGN: Prospective clinical trial. SETTING: Nephrology outpatients. PATIENTS: Sixty-nine patients (32 affected by type 1 and 37 by type 2 diabetes, all treated with insulin) affected by both overt diabetic nephropathy and hypertension. INTERVENTION: The study was started once hypertension and glycemia had been under control for at least 3 months. Two groups of patients, matched for similar mean glomerular filtration rate value and nutritional status, were studied: a low-protein diet (0.6 g/kg/d) was randomly prescribed to 35 patients, whereas in the other 34 patients a free diet intake was maintained for 12 months. MAIN OUTCOME MEASURE: Renal function and nutritional status. RESULTS: The protein intake was significantly different in the 2 groups of patients, whereas the average decline of glomerular filtration rate during the follow-up was comparable. In the low-protein diet group, serum prealbumin concentration significantly decreased after 9 months, whereas serum albumin decreased at the end of the study. CONCLUSION: Severe dietary protein restriction does not seem to delay the progression of renal disease in patients with overt diabetic nephropathy, whereas it may induce malnutrition.

Asunto(s)

Nefropatías Diabéticas/dietoterapia , Dieta con Restricción de Proteínas , Proteínas en la Dieta/administración & dosificación , Fallo Renal Crónico/dietoterapia , Riñón/fisiopatología , Trastornos Nutricionales/etiología , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estado Nutricional/fisiología , Estudios Prospectivos , Factores de Riesgo