Type 2 diabetes: Prevalence of hypoglycemia in public versus private health care system

Social vulnerability has proved to be an independent risk factor for hypoglycemia in patients with diabetes. In some countries, patients who are in a vulnerable situation are assisted in the public health system which provides free medical care. This study compares the prevalence of hypoglycemia among patients with type 2 diabetes (T2D), in public versus private sector and its relationship with social vulnerability. This multicentric descriptive study included 600 patients with T2D from public and private care institutions of Argentina. Socioeconomic level (SEL) was evaluated through the Marketing Argentinean Association survey. Number of severe, documented symptomatic and asymptomatic hypoglycemias were registered. Among the patients included, 66% were assisted in the public sector. The 41% of patients (n = 246) registered at least 1 episode of any hypoglycemia event being more prevalent in the public sector compared to the private sector (50% vs. 22%). In the adjusted analysis it was observed a greater risk of hypoglycemia in public sector (OR 4, 95% CI 2.65-6.04) and in patients that did not have diabetological education (OR 2.28 95% CI 1.35-3.84). Similarly, unemployment (OR 5.04 95% CI 2.69-9.46), and marginal SEL (OR 60.79 95% CI 14.89-248.13) increased the risk of hypoglycemia. Several factors related to social vulnerability as unemployment, marginal SEL and poor sanitary education showed a significant increase in the hypoglycemia risk. Professionals working with people with diabetes must take into account these factors for a safe treatment of the disease.

La vulnerabilidad social ha demostrado ser un factor de riesgo independiente de hipoglucemia en pacientes con diabetes. Los pacientes que se encuentran en situación de vulnerabilidad social reciben asistencia en el sistema de salud pública que brinda atención médica gratuita. Este estudio compara la prevalencia de hipoglucemia en pacientes con diabetes tipo 2 en el sector público frente al privado y su relación con la vulnerabilidad social. Se realizó un estudio multicéntrico descriptivo que incluyó 600 pacientes con diabetes tipo 2 de instituciones de atención pública y privada de Córdoba. El nivel socioeconómico se evaluó a través de la encuesta de la Asociación Argentina de Marketing que evalúa la dimensión social, educativa y económica para estratificar el nivel socioeconómico. Se registró el número de hipoglucemias graves, documentadas sintomáticas y asintomáticas. El 66% de los pacientes pertenecían al sector público. El 41% de los pacientes (n = 246) registró al menos 1 episodio de cualquier evento de hipoglucemia. En el análisis ajustado, se observó un mayor riesgo de hipoglucemia en el sector público (OR 4, 95% CI 2.65-6.04), en pacientes que no tenían educación diabetológica previa (OR 2.28, 95% CI 1.35-3.84), en desempleados (OR 5.04, 95% CI 2.69-9.46) y en aquellos con nivel socioeconómico marginal (OR 60.79 95% CI 14.89-248.13). Factores relacionados con la vulnerabilidad social como el desempleo, el nivel socioeconómico marginal y educación sanitaria deficiente mostraron un aumento en el riesgo de hipoglucemia. Los profesionales que trabajan con personas con diabetes deben tener en cuenta estos factores para un tratamiento seguro de la enfermedad.

Performance during a strenuous swimming session is associated with high blood lactate: pyruvate ratio and hypoglycemia in fasted rats

The aim of this study was to investigate the effect of lactatemia elevation and glycemia reduction on strenuous swimming performance in fasted rats. Three rats were placed in a swimming tank at the same time. The first rat was removed immediately (control group) and the remaining ones were submitted to a strenuous swimming session. After the second rat was exhausted (Exh group), the third one was immediately removed from the water (Exe group). According to the period of time required for exhaustion, the rats were divided into four groups: low performance (3-7 min), low-intermediary performance (8-12 min), high-intermediary performance (13-17 min), and high performance (18-22 min). All rats were removed from the swimming tanks and immediately killed by decapitation for blood collection or anesthetized for liver perfusion experiments. Blood glucose, lactate, and pyruvate concentrations, blood lactate/pyruvate ratio, and liver lactate uptake and its conversion to glucose were evaluated. Exhaustion in low and low-intermediary performance were better associated with higher lactate/pyruvate ratio. On the other hand, exhaustion in high-intermediary and high performance was better associated with hypoglycemia. Lactate uptake and glucose production from lactate in livers from the Exe and Exh groups were maintained. We concluded that there is a time sequence in the participation of lactate/pyruvate ratio and hypoglycemia in performance during an acute strenuous swimming section in fasted rats. The liver had an important participation in preventing hyperlactatemia and hypoglycemia during swimming through lactate uptake and its conversion to glucose.

Dipyrone in association with atropine inhibits the effect on gastric emptying induced by hypoglycemia in rats

Atropine (AT) and dipyrone (Dp) induce a delay of gastric emptying (GE) of liquids in rats by inhibiting muscarinic receptors and activating β2-adrenergic receptors, respectively. The objective of the present study was to determine the effects of pretreatment with AT and Dp, given alone or in combination, on the effect of hypoglycemia in the liquid GE in rats. Male Wistar adult rats (280-310 g) were pretreated intravenously with AT, Dp, AT plus Dp or their vehicle and then treated 30 min later with iv insulin or its vehicle (n=8-10 animals/group). Thirty min after treatment, GE was evaluated by determining, in awake rats, the percent gastric retention (%GR) of a saline meal labeled with phenol red administered by gavage. The results indicated that insulin induced hypoglycemia in a dose-dependent manner resulting in a significant reduction in %GR of liquid only at the highest dose tested (1 U/kg). Pretreatment with AT significantly increased %GR in the rats treated with 1 U/kg insulin. Surprisingly, after pretreatment with AT, the group treated with the lowest dose of insulin (0.25 U/kg) displayed significantly lower %GR compared to its control (vehicle-treated group), which was not seen in the non-pretreated animals. Pretreatment with Dp alone at the dose of 40 mg/kg induced an increase in %GR in both vehicle and 0.25 U/kg-treated rats. A higher dose of Dp alone (80 mg/kg) significantly reduced the effect of a marked hypoglycemia induced by 1 U/kg of insulin on GE while in combination with AT the effect was completely abolished. The results with AT suggest that moderate hypoglycemia may render the inhibitory mechanisms of GE ineffective while Dp alone and in combination with AT significantly overcame the effect of hypoglycemia on GE.

Nível de atividade física e exercício físico em pacientes com diabetes mellitus / Physical activity level and exercise in patients with diabetes mellitus

OBJETIVO: Comparar nível de atividade física (NAF) e cuidados relacionados ao exercício físico (EF) em pacientes com diabetes mellitus (DM). MÉTODOS: Pacientes com DM ambulatoriais (adultos e usuários de insulina) foram avaliados conforme NAF (questionário internacional; atividades moderadas, intensas e caminhadas realizadas em uma semana típica), questionados sobre prática formal de EF, autocuidado e episódios de hipoglicemia relacionados ao EF e motivos para não praticá-lo. RESULTADOS: Foram avaliados 225 pacientes: 107 (47,6%) com diabetes mellitus tipo 2 (DM2) e 118 (52,4%) com diabetes mellitus tipo 1 (DM1), sendo maior o número de pacientes com DM2 classificados como pouco ativos [33 (30,7%) vs. 12 (10,3%)] e menor a proporção dos muito ativos [9 (8,7%) vs. 29 (25%)], quando comparados com pacientes com DM1. Não praticantes de EF (n = 140) o faziam por motivos diferentes: pacientes com DM2 por "desconforto", "restrição médica" e "não gostarem"; pacientes com DM1 por "falta de tempo", "preguiça" e "hipoglicemia". Apenas 85 pacientes praticavam EF regularmente, independente do NAF, e 38,8% realizavam autocuidados como alimentação, alongamento, monitoramento da glicemia capilar. Pacientes com DM2 [5 (14,3%)] relataram menos episódios de hipoglicemia relacionada ao EF do que aqueles com DM1 [17 (34%)]. CONCLUSÃO: Pacientes com DM2 possuem NAF e comportamento relacionado à prática de EF diferentes de pacientes com DM1.

OBJECTIVE: To compare physical activity level (PAL) and care related to exercise in patients with diabetes mellitus (DM). METHODS: DM outpatients (adult, insulin-user patients) were assessed for PAL (international questionnaire; moderate- and high-level activities, as well as walking, over a typical week) and questioned about formal exercise practice, self-care, and hypoglycemic episodes related to exercise or reasons for not exercising. RESULTS: Two hundred twenty five patients were assessed: 107 (47.6%) had type 2 diabetes mellitus (DM2) and 118 (52.4%) had type 1 diabetes mellitus (DM1), with a larger percentage of patients with DM2 being classified as poorly active [33 (30.7%) versus 12 (10.3%)] and a lower percentage being classified as highly active [9 (8.7%) versus 29 (25%)], compared with patients having DM1. Patients who do not exercise (n = 140) gave different reasons for not doing so: patients with DM2 claimed that they "felt uncomfortable", "presented medical restrictions", and "did not like it"; DM1 patients claimed that they "had no time to exercise", "were lazy", and "had hypoglycemic episodes". Only 85 patients exercised regularly, regardless of the PAL, and 38.8% performed self-care, such as eating, stretching, and capillary glucose monitoring. Patients with DM2 [5 (14.3%)] reported a lower number of hypoglycemic episodes related to exercise than those with DM1 [17 (34%)]. CONCLUSION: Patients with DM2 have different PAL and behavior related to exercise than those seen in DM1 patients.

A secreção residual do peptídeo C faz diferença no tratamento do diabetes melito tipo 1?: [revisão] / C-peptide residual secretion makes difference on type 1 diabetes management?: [review]

O diabetes melito tipo 1 (DM1) é uma doença crônica causada por destruição progressiva das células-beta das ilhotas pancreáticas, o que leva à insulinopenia e à hiperglicemia. Uma proporção significativa de pacientes acometidos pode apresentar manutenção de alguma função secretora por longos períodos, identificada clinicamente por meio da detecção de peptídeo C sérico. Há evidências de que isso possa trazer alguns benefícios, como redução do risco de complicações crônicas, maior facilidade em atingir o controle metabólico adequado e menor frequência de hipoglicemias graves. É possível que o próprio peptídeo C, atuando diretamente em tecidos-alvo, contribua para esses efeitos.

Type 1 diabetes is a chronic disease characterized by progressive destruction of the pancreatic beta cells, what leads to insulin deficiency and hyperglycemia. However, a significant secretory function may persist for long periods in a few patients, what is clinically evident through the detection of serum C peptide. This phenomenon might reduce the risk of chronic complications, severe hypoglycemias and allow easier metabolic control. It is possible that these advantages are caused, at least partially, by C peptide itself, acting directly in its target tissues.

Hipoglicemia reacional: do diagnóstico ao tratamento / Hypoglycemia reactive: from diagnosis to treatment

A hipoglicemia reacional (HR) caracteriza-se por níveis de glicose menores que 60mgdl (3,3mmol/ml) e sintomas simpaticomiméticos observados poucas horas após a ingestão de alimentos. Sua fisiopatologia ainda não está completamente elucidade, porém muitos de seus mecanismos já são conhecidos. Com a revisão da literatura pôde-se comparar a eficiência dos diversos métodos diagnósticos e estabelecer tratamentos mais adequados. A HR deve ser diagnosticada pela observação dos sintomas juntamente à hipoglicemia química, evitando erros diagnósticos. O melhor teste diagnóstico é a dieta hiperglicídica e o tratamento se faz com dieta adequada. Quando esta não é suficiente, a droga de escolha é a acorbose.

Reactive hypoglycemia is due to a biochemical blood glucose less then 3.3mmol/l (60mg/dl) and sympathetic symptoms occurring a few hours after food intake. Although it's pathophysiology is not completely elucidated, many of it's mechanisms are already known. After a literature review, is was possible to compare different diagnose tests in order to propose the most accurate treatment. In order to avoid misdiagnosis, the disease should be diagnosed through the observation of symptoms and chemical hypoglycemia. The best diagnose test is hyperglucidic test, and the main treatment should be diet. If diet itself is not enough, the drug of choise is acarbose.

Modulation by insulin rather than blood glucose of the pain threshold in acute physiological and flavone induced antinociception in mice.

The present study investigated the cause effect relationship between glycemic and algesic states. The hypo- and hyperglycemic conditions were induced physiologically through exercise (3 min swim at room temperature 28 degrees - 30 degrees C) and external dextrose (2 g/kg, ip) administration respectively in mice. Besides, flavone (50 mg/kg, sc) a known antinociceptive drug was chosen to study such a cause effect relationship. The anti-nociception was assessed by acetic acid assay, blood glucose measured using glucometer (Ames) and serum insulin by radioimmunoassay. The findings revealed that irrespective of the glycemic state whether hypo-, hyper, or euglycemic induced by swim stress, dextrose or flavone per se respectively, significant antinociceptive response was recorded. Pretreatment with flavone (50 mg/kg, sc) always exhibited a tendency to reverse the hyperglycemia, if any, but enhanced the antinociceptive response either after swim stress or after dextrose. These data support the contention that changes in the glycemic state in acute condition is not responsible for antinociceptive response and thereby suggesting dissociation between these two parameters. Extended studies estimating serum insulin level after the above mentioned maneuvers showed a significant rise whenever antinociceptive response was recorded irrespective of the glycemic state. It is suggested that serum insulin level, a hormonal parameter rather than the blood glucose level, which is a metabolic parameter, appears more reliable. It appears that the changes in serum insulin level produced by various treatments may have a relationship with the antinociceptive response. However, this study has the limitation that the results can apply only for acute conditions and extrapolation to clinical conditions is debatable.

Evidence of linkage between neurocardiogenic dysfunction and reactive hypoglycemia / Evidencia de una posible asociación entre disfunción neurocardiogénica e hipoglicemia reactiva

La hipoglucemia reactiva es un problema común en la práctica clínica cuya patofisiología es motivo de controversia. El objetivo del presente estudio fue investigar la prevalencia de anormalidades del sistema nervioso autónomo en pacientes con hipoglucemia reactiva comparada con controles sanos. Material y métodos. Se incluyeron para el estudio a seis mujeres con hipoglucemia reactiva con edad media de 31 ñ 5 años y 5 mujeres sanas con edad media de 24 ñ 4 años. Se investigó la variabilidad de la frecuencia cardiaca y los cambios en la presión arterial después de una prueba de inclinación con y sin isoproterenol. Se definió como prueba positiva a la presencia de síncope o presíncope asociados a bradicardia, hipotensión o ambas. Resultados. En respuesta a la prueba de inclinación con o sin isoproterenol 5 de 6 pacientes comparado con 1 de 5 controles sanos presentaron una prueba positiva. Las pacientes presentaron un tono hiperadrenérgico con una relación simpático/parasimpático de 2.3 ñ 0.8 en condiciones basales y 10.1 ñ 4.1 durante la infusión de isoproterenol, en comparación a 0.7 ñ 0.3 (p = 0.06) y 0.5 ñ 0.1 (p < 0.01) respectivamente en el grupo control. Conclusiones. Los pacientes con hipoglucemia reactiva pueden estar en un extremo de variabilidad biológica normal. Pueden cursar con un tono hiperadrenérgico y después de un estímulo provocativo la descarga simpática o la liberación sináptica de norepinefrina pueden ser insuficientes para mantener un tono vascular adecuado. Otra posibilidad es que la respuesta vascular a norepinefrina esté alterada. No se observó una respuesta vasovagal paradójica o excesiva.

Hipoglicemia na infância - ainda um desafio / Childhood hypoglycemia - still a challenge

Objetivo: A hipoglicemia na infância tem o potencial de graves conseqüências deletéreas ao sistema nervoso central (SNC), de modo que a demora na soluçäo do programa pode deixar seqüelas irrevesíveis. O objetivo desta revisäo é fornecer elementos para um adequado atendimento diante de uma situaçäo de hipoglicemia. Métodos: Procedemos a um levantamento bibliográfico no Medline, abrangendo um período de 10 anos, e selecionamos os artigos que melhor resumissem os dados fisiopatológicos e de conduta terapêutica frente a uma hipoglicemia. Resultados: Há ainda hoje grande divergência quanto à melhor conduta diante de quadros de hiperinsulinismo, que usualmente apresentam-se já no neonato e acometem a criança em sua fase mais vulnerável em termos de integridade do seu SNC...

Hipoglucemia del diabético / Hypoglycemia in diabetic patients

La hipoglucemia es una situación clínica frecuente; la más común de las emergencias metabólicas y de especial interés en Atención Primaria dada su potencial gravedad y la necesidad de establecer un diagnóstico rápido y efectivo. La Diabetes Mellitus representa la primera causa etiológica de hipoglucemia, principalmente en pacientes insulino-dependientes. Los síntomas de hipoglucemia no dependen del valor absoluto de la glucemia a pesar de que en la mayoría de los pacientes los mismos se inician cuando la glucemia se encuentra alrededor de 60-50 mg/dl o menos. Probablemente importe más la velocidad de descenso de la glucemia y la sensibilidad individual de los sistemas nerviosos central y autónomo. Se revisan y actualizan los aspectos patogénicos, clínicos y terapéuticos de la hipoglucemia en el diabético. En lo que respecta al tratamiento se diferencian las conductas a seguir en el paciente conciente o inconciente con el fin de obtener un correcto restablecimiento clínico del cuadro sin incurrir en variaciones bruscas del metabolismo hidrocarbonado. Se destacan las implicancias legales del tema y la importancia de la educación diabetológica a nivel del propio paciente, su núcleo familiar-laboral y en la comunidad para su prevención y correcto tratamiento

Insulinoma: primer caso resuelto en el Hospital de Talca / Insulinoma: first case solved at Talca Hospital

Se revisa las causas de hipoglicemia, su diagnóstico diferencial y métodos de estudio, a propósito del primer caso de insulinoma estudiado y operado exitosamente en el Hospital Regional de Talca, destacando la presencia de déficit neurológico focal e hipertensión arterial reactiva que obligaron a destacar un accidente vascular encefálico. Se destaca, además, la utilidad de la arteriografía selectiva de tronco celíaco, al detectar un tumor que no se había logrado localizar con una tomografía computada de alta resolución, lo que permitió una cirugía dirigida, curativa

Hipoglicemia neonatal / Hypoglicemia prenatal

O autor realiza uma revisäo de literatura, na qual disctue a fisiopatologia da hipoglicemia neonatal, divide os principais grupos de risco, segundo alguns autores e, finalemnte, analisa as condutas terapêuticas

Neurodevelopmental outcome of asymptomatic & symptomatic babies with neonatal hypoglycaemia.

A total of 107 babies with hypoglycaemia were studied over a period of 15 months. Symptomatic hypoglycaemia was found in 43 while it was asymptomatic in the others. Asymptomatic hypoglycaemia occurred at a relatively earlier post-natal age (4.5 +/- 2.2 h), as compared to symptomatic hypoglycemia (18.5 +/- 5.4 h, P less than 0.001). The mean blood glucose in hypoglycaemic babies with seizures was found to be significantly lower (P less than 0.001) when compared to those with other features as well as asymptomatic ones. Hypoglycaemia lasted for a significantly longer duration in symptomatic babies as compared to those without symptoms (P less than 0.001). On neurodevelopment follow up the mental developmental index (MDI) and the psychomotor developmental index (PDI) of symptomatic babies with seizures were significantly lower (P less than 0.001) as compared to those with other features of hypoglycaemia as well as asymptomatic babies. The neurodevelopmental status of babies with symptoms other than seizures was also significantly poorer (P less than 0.001), when compared to asymptomatic hypoglycaemic babies. The duration of hypoglycaemia was directly related to the MDI (r = -0.74, y = 102.5 - 0.69x) and PDI (r = -0.81, y = 105.6 - 0.86x). This study indicates that there is a need to identify babies vulnerable to symptomatic hypoglycaemia more precisely.

Diversas etiologías en tres casos de hipoglicemia / Diverse etiologies in three eventes of hypoglycemia

Se presentan tres casos de pacientes hospitalizados en el Hospital Nacional Guillermo Almenara Irigoyen, entre los años 1983*1989. Por la inespecificidad e intermitencia de su sintomatología fueron erróneamente diagnosticados como patologías neurológicas y/o psiquiátricas y tratadas como tales, postergando de meses a años su diagnóstico: HIPOGLICERIA EN ESTADO DE AYUNO. Revisamos los puntos más importantes de la expresión clínica, de los exámenes de laboratorio de ayuda en su diagnóstico, remarcamos el tratamiento quirúrgico como necesario y el examen anatomo*patológico como único en dar la etiología definitiva

Hipoglicemias reactivas e inducidas por drogas / Reactive and drug induced hypoglycemias

Presenta mecanismos generales reguladores de la glucosa sanguinea y sus alteraciones en la genesis de la hipoglicemia; discute la clasificacion y los criterios diagnosticos de este sindrome, los mecanismos fisiopatologicos y las alternativas terapeuticas.

Diabetes mellitus insulino dependiente en la población infantil del Area Oriente de Santiago / Insulin dependent diabetes mellitus in the infantile population of the eastern area in Santiago

Se realiza un estudio retrospectivo, en base a revisión de fichas clínicas, de la forma de presentación y evolución de 33 pacientes (17 mujeres y 16 hombres) portadores de Diabetes Mellitus Insulino Dependiente, de comienzo anterior a los 15 años de edad, que se han controlado en la Unidad de Endocrinología del Hospital L. C. Mackenna en los últimos 10 años: 70% de los pacientes tiene menos de 5 años de enfermedad en el momento de realizar el estudio. 45% de ellos tienen antecedentes familiares de Diabetes. La mayor parte comienza su enfermedad entre los 5 y 9 años de edad. La cetoacidosis diabética es la forma de presentación más frecuente (50% de los casos). El incremento pondoestatural de todos los pacientes estudiados es regular y cercano al Percentil 50 hasta la pubertad; posteriormente se observa menor velocidad de incremento de peso y talla, especialmente en mujeres. La mayor parte de los diabéticos se controlan con 1 U x kg de insulina, administrada en una dosis matinal. La complicación más frecuente es la hipoglicemia (17 pacientes), seguida de cetoacidosis (7 pacientes). Como complicaciones crónicas, sólo hemos observado retinopatía en 3 pacientes y lipoatrofía en dos casos