RESUMEN
Healthcare networks play a central role in the French healthcare system. A reflection on their future and the evolutions to be envisaged is currently in progress. Moreover, the French Directorate General for Healthcare Provision should soon publish a methodological guide concerning these networks. Three players in healthcare networks review the current status of the networks and consider their development.
Asunto(s)
Redes Comunitarias/organización & administración , Redes Comunitarias/tendencias , Atención a la Salud , Francia , Accesibilidad a los Servicios de Salud , HumanosAsunto(s)
Redes Comunitarias/organización & administración , Atención a la Salud/organización & administración , Redes Comunitarias/tendencias , Atención a la Salud/economía , Atención a la Salud/métodos , Diabetes Mellitus/terapia , Costos de la Atención en Salud , Necesidades y Demandas de Servicios de Salud/economía , Necesidades y Demandas de Servicios de Salud/organización & administración , Humanos , Mejoramiento de la Calidad , Calidad de la Atención de Salud/economíaRESUMEN
OBJECTIVE: We investigated the relationship between carbohydrate intake and postprandial blood glucose (BG) levels to determine the most influential meal for type 2 diabetic subjects treated with basal insulin and needing prandial insulin. RESEARCH DESIGN AND METHODS: Three-day BG profiles for 37 type 2 diabetic subjects, with A1C levels of 7.7%, treated with sulfonylurea and metformin, and well titrated on insulin glargine, were analyzed using a continuous glucose monitoring system. Food intake from 680 meals was recorded and quantified during continuous glucose monitoring. RESULTS: The median BG excursion (DeltaBG) was higher at breakfast than at lunch or dinner (111 [81; 160] vs. 69.5 [41.5; 106] and 82.5 mg/dl [53; 119] mg/dl, P < 0.0001). There was a weak overall correlation between DeltaBG and carbohydrate intake. Correlation improved when mealtime was taken into account. Simple relationships were established: DeltaBG (mg/dl) = 65 x carbohydrate/body weight + 73 for breakfast (R(2) = 0.20, P < 0.0001); the slope was reduced by half at lunch and by one-third at dinner. Twelve relevant variables likely to affect DeltaBG were integrated into a polynomial equation. This model accounted for 49% of DeltaBG variability. Two groups of patients were identified: responders, in whom DeltaBG was well correlated with carbohydrate intake (R(2) >or= 0.30, n = 8), and nonresponders (R(2) < 0.30, n = 29). Responders exhibited a greater insulinopenic profile than nonresponders. CONCLUSIONS: The carbohydrate intake in responders clearly drives DeltaBG, whereas, in nonresponders, other factors predominate. This sort of characterization should be used to guide therapeutic choices toward more targeted care with improved type 2 diabetes management.
Asunto(s)
Glucemia/metabolismo , Diabetes Mellitus Tipo 2/sangre , Anciano , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Carbohidratos de la Dieta/efectos adversos , Femenino , Cromatografía de Gases y Espectrometría de Masas , Humanos , Hipoglucemiantes/uso terapéutico , Insulina/análogos & derivados , Insulina/uso terapéutico , Insulina Glargina , Insulina de Acción Prolongada , Masculino , Metformina/uso terapéutico , Persona de Mediana Edad , Periodo Posprandial , Compuestos de Sulfonilurea/uso terapéuticoRESUMEN
Numerous prospective studies support the concept of postprandial glycaemia (PPG) as a risk factor for cardiovascular diseases (CVDs) in individuals with impaired glucose tolerance (IGT). A meta-analysis has demonstrated an exponential relationship between 2-hour postchallenge glucose levels and the incidence of CVD. This relationship is stronger than those observed with fasting glycaemia or glycosylated haemoglobin (HbA(1c)), and persists after adjustment for other vascular risk factors. Although there are fewer data available for the diabetic population, those that are available also support PPG as a risk factor for CVD. Treating PPG with acarbose is associated with a reduction in cardiovascular events in both patients with IGT and diabetes mellitus. Acarbose also reduces the progression of intima-media thickness (IMT), which is a surrogate endpoint for atherosclerosis. It has been suggested that the beneficial effect could be related to an improvement in postprandial hyperglycaemia and associated atherogenic factors - oxidative stress, endothelial dysfunction and pro-coagulation factors - and to an improvement in other cardiovascular risk factors such as systolic blood pressure (by decreasing water and salt absorption), postprandial hypertriglyceridaemia and insulin resistance. Treating PPG with glinides improves IMT as well as interleukin-6 and C-reactive protein levels, while treating PPG with rapid-acting insulin analogues is also associated with improvements in endothelial dysfunction. The Kumamoto study suggests that reduced PPG is strongly associated with reductions in retinopathy and nephropathy. Finally, decreasing PPG in patients with IGT reduces the progression of diabetes. In conclusion, physicians should increase efforts to control PPG in order to further improve HbA(1c), and should also ensure close control of postprandial hyperglycaemic peaks so as to optimise patients' chances of avoiding cardiovascular complications. As for the prevention of CVD, further prospective intervention trials, powered to answer this question, are still required.