Manejo de perfiles de pacientes con diabetes mellitus tipo2 en la práctica clínica de la atención primaria en España: Programa CONTROVERTI2 / Management of patient profiles with type2 diabetes mellitus in Primary Care in Spain: CONTROVERTI2 Program

Objetivo: Identificar controversias existentes en el manejo habitual de los pacientes con diabetes mellitus tipo2 (DM2) y contrastarlas con la última evidencia científica y guías clínicas, con el fin de optimizar y homogeneizar el tratamiento de los pacientes con DM2 en la atención primaria (AP) en España. Material y métodos: 240 médicos de familia respondieron a un cuestionario online sobre el manejo de 6 perfiles de pacientes con DM2 de complejidad creciente. Resultados: Los factores clínicos más influyentes en la elección del tratamiento antihiperglucémico son una HbA1c >10% y la presencia de enfermedad cardiovascular (ECV), aunque en el paciente evolucionado cobran más relevancia la tasa de filtrado glomerular estimada y el riesgo de hipoglucemia. En el paciente recién diagnosticado con HbA1c>9% se sigue iniciando el tratamiento con monoterapia (24%). En el paciente no controlado con metformina suelen añadirse inhibidores de la dipeptidil peptidasa4 (iDPP4, 54%) seguido de inhibidores del cotransportador sodio-glucosa tipo2 (iSGLT2, 39%). Los agonistas del receptor del péptido similar al glucagón tipo1 (arGLP1) se asocian principalmente al paciente con DM2 obeso. En el paciente no controlado con metformina+sulfonilurea (SU) se prefiere sustituir la SU a añadir un tercer agente antihiperglucémico al tratamiento (77% vs. 23%). Conclusiones: Todavía persiste en AP un enfoque del tratamiento de la DM2 centrado en la reducción de la HbA1c y en la seguridad de los tratamientos. Por ello, los iDPP4 son fármacos ampliamente utilizados. Los iSGLT2 se reservan habitualmente para pacientes con DM2 y ECV y los arGLP1 para pacientes con DM2 obesos, siendo su uso muy limitado (AU)

Aim: To identify existing controversies in the routine management of patients with T2D and to contrast them with the latest scientific evidence and clinical guidelines, in order to help optimize and homogenize the treatment of patients with T2D in Primary Care (PC) in Spain. Material and methods: 240 family doctors responded to an online questionnaire about the management of 6 patient profiles with T2D of increasing complexity. Results: The main drivers for the antihyperglycemic treatment choice are an HbA1c>10% and the presence of cardiovascular disease (CVD), although in evolved patients, the estimated glomerular filtration rate and the risk of hypoglycemia become more relevant. In newly diagnosed patients with an HbA1c>9%, treatment is still initiated with monotherapy (24%). In patients not controlled with metformin, dipeptidyl peptidase 4 inhibitors (DPP4-I, 54%) or sodium-glucose cotransporter 2 inhibitors (SGLT2-I, 39%) are usually added. On the other hand, type1 glucagon-like peptide receptor agonists (GLP1-RA) are mainly associated with obese patients with T2D. In patients not controlled with metformin+sulfonylurea (SU), SU replacement is preferred to adding a third antihyperglycemic agent to background therapy (77% vs. 23%). Conclusions: T2D treatment in PC is still focused on HbA1c reduction and treatment safety. Thus, DPP4-I are widely used. SGLT2-I are usually preferred for patients with T2D and CVD and GLP1-RA for patients with T2D and obesity, although their use in PC is low (AU)

Atomic force microscopy for quantitative understanding of peptide-induced lipid bilayer remodeling.

A number of peptides are known to bind lipid bilayer membranes and cause these natural barriers to leak in an uncontrolled manner. Though membrane permeabilizing peptides play critical roles in cellular activity and may have promising future applications in the therapeutic arena, significant questions remain about their mechanisms of action. The atomic force microscope (AFM) is a single molecule imaging tool capable of addressing lipid bilayers in near-native fluid conditions. The apparatus complements traditional assays by providing local topographic maps of bilayer remodeling induced by membrane permeabilizing peptides. The information garnered from the AFM includes direct visualization and statistical analyses of distinct bilayer remodeling modes such as highly localized pore-like voids in the bilayer and dispersed thinned membrane regions. Colocalization of distinct remodeling modes can be studied. Here we examine recent work in the field and outline methods used to achieve precise AFM image data. Experimental challenges and common pitfalls are discussed as well as techniques for unbiased analysis including the Hessian blob detection algorithm, bootstrapping, and the Bayesian information criterion. When coupled with robust statistical analyses, high precision AFM data is poised to advance understanding of an important family of peptides that cause poration of membrane bilayers.

Volumetric assessment of the sella turcica: a re-evaluation.

BACKGROUND: The sella turcica volume is widely measured by the Di Chiro-Nelson method. The purpose is to compare the fidelity of a proposed volumetry method vs. the Di Chiro-Nelson method, using computed tomography (CT) images. MATERIALS AND METHODS: Morphometric examination of 173 CT scans were included, of which 52.6% were female. The mean age was 53.2 ± 17.6 years. Considering the Di Chiro-Nelson method, two measurements were added for each axis in the CT evaluation: length (central, left, and right), width (central, anterior, and posterior), and height (central, left, and right). RESULTS: The mean measurements were length: central 10.11 ± 1.44, left 7.45 ± 1.67, right 7.53 ± 1.59; width: central 12.27 ± 2.11, anterior 10.99 ± 1.92, posterior 10.10 ± 1.74; height: central 7.68 ± 1.38, left 7.16 ± 1.35, right 7.40 ± 1.41. A statistically significant difference between sexes was found only in the anterior width (p = 0.01). Using the proposed method, the volume was 342.2 ± 88.5 and 378. 6 ± 113.9 mm³, respectively for females and males (p = 0.02) vs. 476.1 ± 132.4 and 523.8 ± 186.0 mm3 (p = 0.05) using the Di Chiro-Nelson's method. CONCLUSIONS: Women had significantly smaller sella turcica volume than men. This proposed method considers the sella turcica as a not strictly symmetrical structure and indicates reduced variation between the maximum and minimum values, compared to the Di Chiro-Nelson's. Our findings may be useful for reassessment the volume of the sella turcica as the measurements indicate a higher precision.

[Management of patient profiles with type2 diabetes mellitus in Primary Care in Spain: CONTROVERTI2 Program]. / Manejo de perfiles de pacientes con diabetes mellitus tipo2 en la práctica clínica de la atención primaria en España: Programa CONTROVERTI2.

AIM: To identify existing controversies in the routine management of patients with T2D and to contrast them with the latest scientific evidence and clinical guidelines, in order to help optimize and homogenize the treatment of patients with T2D in Primary Care (PC) in Spain. MATERIAL AND METHODS: 240 family doctors responded to an online questionnaire about the management of 6 patient profiles with T2D of increasing complexity. RESULTS: The main drivers for the antihyperglycemic treatment choice are an HbA1c>10% and the presence of cardiovascular disease (CVD), although in evolved patients, the estimated glomerular filtration rate and the risk of hypoglycemia become more relevant. In newly diagnosed patients with an HbA1c>9%, treatment is still initiated with monotherapy (24%). In patients not controlled with metformin, dipeptidyl peptidase 4 inhibitors (DPP4-I, 54%) or sodium-glucose cotransporter 2 inhibitors (SGLT2-I, 39%) are usually added. On the other hand, type1 glucagon-like peptide receptor agonists (GLP1-RA) are mainly associated with obese patients with T2D. In patients not controlled with metformin+sulfonylurea (SU), SU replacement is preferred to adding a third antihyperglycemic agent to background therapy (77% vs. 23%). CONCLUSIONS: T2D treatment in PC is still focused on HbA1c reduction and treatment safety. Thus, DPP4-I are widely used. SGLT2-I are usually preferred for patients with T2D and CVD and GLP1-RA for patients with T2D and obesity, although their use in PC is low.

Effect of hepatitis B virus on steatosis in hepatitis C virus co-infected subjects: A multi-centre study and systematic review.

It remains unclear whether hepatitis B virus (HBV) infection may modify the severity of viral steatosis in patients coinfected with chronic hepatitis C virus (HCV). We examined the influence of coinfection with HBV on prevalence of steatosis in chronic hepatitis C in a multi-centre cohort of HBV-HCV subjects, and by performing a systematic review and meta-analysis of the literature. We centrally and blindly assessed steatosis prevalence and severity in a cohort of HBV-HCV coinfected subjects compared to HCV and HBV monoinfected controls and we performed a systematic review of studies addressing the prevalence of steatosis in HBV-HCV subjects compared to HCV controls. In the clinical cohort, we included 85 HBV-HCV, 69 HBV and 112 HCV subjects from 16 international centres. There was no significant difference in steatosis prevalence between the HBV-HCV and the HCV groups (33% vs 45%, P = .11). In subgroup analysis, lean HBV-HCV subjects with detectable HBV DNA had less steatosis than lean HCV subjects matched for HCV viremia (15% vs 45%, P = .02). Our literature search identified 5 additional studies included in a systematic review. Overall, prevalence of steatosis > 5% was similar in HBV-HCV infection compared to HCV (pooled odds ratio [OR] 0.91, 95% CI 0.53-1.6) although there was significant heterogeneity (I2 69%, P = .007). In conclusion, although the prevalence of steatosis is similar in HBV-HCV compared to HCV subjects, our analysis suggests that there may be an inhibitory effect of HCV-induced steatogenesis by HBV in certain subgroups of patients.

Sublingual tacrolimus administration provides similar drug exposure to per-oral route employing lower doses in liver transplantation: a pilot study.

BACKGROUND: Per-oral tacrolimus administration is not always practicable. Sublingual administration is a potential alternative, but its feasibility and effectiveness compared with oral route has not been established. AIM: To compare tacrolimus drug exposure after sublingual and oral administration in liver transplant recipients. METHODS: Experimental, open-label, non-randomised, cross-over study. Tacrolimus exposure was evaluated in 32 liver transplant recipients receiving oral administration. 12 h tacrolimus area-under-the-curve (AUC0-12 h ) was calculated using tacrolimus blood concentrations at 0-0.5-1-2-4-6-8-12 hrs post-dose. Recipients were switched to sublingual administration, and dose was adjusted to reach similar trough levels, new AUC0-12 h was calculated. Correlation between AUC0-12 h and trough levels was determined for both oral and sublingual phases. RESULTS: Similar trough levels were accomplished with oral and sublingual administration (6.68 ± 2 ng/mL vs. 6.62 ± 1.9 ng/mL (P = 0.8)). Although concentration 2 h post dose was higher in oral phase (15.36 ± 7.14 vs. 13.18 ± 5.64, P = 0.015), AUC0-12 h was similar in both phases (116.6 ± 34.6 vs. 111.5 ± 36.93 ng/mL* h, P = 0.19). Daily dose of tacrolimus required in sublingual phase was 37% lower than that used in oral phase (P < 0.0001), suggesting significantly increased bioavailability of tacrolimus when employing sublingual route. Good correlation between AUC0-12 h and trough levels was observed in sublingual phase (r2 = 0.74). Twenty-two recipients were maintained on sublingual administration after the end of study (mean follow-up: 18.7 ± 5.8 months). No difference in liver function tests or rejection rates was found during follow-up period. CONCLUSIONS: Sublingual administration of tacrolimus is feasible and provides similar drug exposure compared with oral administration. In our study, at long-term follow-up, sublingual administration was not associated with liver transplant rejection.

Satisfacción de las personas con diabetes mellitus tipo 2 tras iniciar tratamiento con insulina / Satisfaction of patients with type 2 diabetes mellitus after starting treatment with insulin

Objetivos. El 'miedo al pinchazo' de muchos pacientes con diabetes tipo 2 (DM2) puede retrasar el inicio del tratamiento con insulina. Nuestro objetivo es valorar si superar dicha barrera e iniciar el tratamiento con insulina mejora el control clínico y produce mayor satisfacción del paciente con su tratamiento. Material y métodos. Estudio observacional, multicéntrico, de pacientes con DM2 —realizado en atención primaria— con un mal control glucémico (A1c≥8%), en tratamiento con antidiabéticos orales y a los que se aplicó una intervención motivacional para vencer el miedo al pinchazo y se inició el tratamiento con insulina. Se valoró el grado de satisfacción con el tratamiento mediante el Diabetes Treatment Satisfaction Questionnaire (DTSQ). Resultados. Quinientos setenta y tres pacientes, 64±10 años. Puntuación global media del cuestionario DTSQs de 18,3±6,3. El cambio de tratamiento produjo una mejoría de la satisfacción del paciente con respecto al tratamiento anterior (puntuación media DTSQc 8,8±5,9). La A1c descendió desde 8,7% (desviación típica 0,8) hasta 7,5% (desviación típica 0,7) (p<0,001). La frecuencia de hiperglucemia percibida fue significativamente menor después de superar el miedo al pinchazo (35,6% frente a 11,5%; p<0,001), sin encontrar diferencias estadísticamente significativas en la frecuencia de hipoglucemias (32% frente a 35%; p=0,059). Conclusión. En pacientes con DM2 mal controlados con antidiabéticos orales, vencer el miedo al pinchazo e iniciar el tratamiento con insulina se asoció a una mejoría global de la satisfacción con el tratamiento, y disminuyó la percepción de episodios de hiperglucemia. El control glucémico y el perfil metabólico de los pacientes también mejoraron de forma estadísticamente significativa (AU)

Objectives. The objective of this study is to evaluate if overcoming the barrier of starting treatment with insulin can lead to better clinical control and a higher level of patient satisfaction with their treatment. Material and methods. This is an observational, multicentre study of patients diagnosed with DM2 who attended primary care centres with poor glycaemic control (A1c≥8%) under treatment with oral antidiabetic drugs (OADs), and who were given motivational treatment to overcome their fear of injections, and started treatment with insulin. The level of satisfaction with the treatment was evaluated using the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The questionnaire was used before initiating the treatment with insulin and in the follow-up visit (3-4 months from the beginning of treatment with basal insulin). Results. A total of 573 patients with a mean age of 64±10 years were recruited. The overall mean score from the DTSQs satisfaction questionnaire was 18.3±6.3, and the change of treatment led to an improvement in patient satisfaction compared to the previous treatment (DTSQc mean score 8.8±5.9). A1c dropped from an initial value of 8.7% (SD 0.8) to 7.5% (SD 0.7) (P<.001). The frequency of hyperglycaemic episodes perceived by the patients was significantly lower after they overcame their fear of injections (35.6% compared to 11.5%; P<.001), but no statistically significant differences were found in the frequency of hypoglycaemic episodes (32% compared to 35%; P=.059). Conclusion. In patients with DM2 poorly controlled with OADs, overcoming a fear of injections and starting treatment with insulin was associated with an overall improvement in satisfaction with the new treatment, and decreased the perception of hyperglycaemic episodes. Glycaemic control and the metabolic profile of the patients also improved to a statistically significant degree with the change of treatment (AU)

[Satisfaction of patients with type 2 diabetes mellitus after starting treatment with insulin]. / Satisfacción de las personas con diabetes mellitus tipo 2 tras iniciar tratamiento con insulina.

OBJECTIVES: The objective of this study is to evaluate if overcoming the barrier of starting treatment with insulin can lead to better clinical control and a higher level of patient satisfaction with their treatment. MATERIAL AND METHODS: This is an observational, multicentre study of patients diagnosed with DM2 who attended primary care centres with poor glycaemic control (A1c≥8%) under treatment with oral antidiabetic drugs (OADs), and who were given motivational treatment to overcome their fear of injections, and started treatment with insulin. The level of satisfaction with the treatment was evaluated using the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The questionnaire was used before initiating the treatment with insulin and in the follow-up visit (3-4 months from the beginning of treatment with basal insulin). RESULTS: A total of 573 patients with a mean age of 64±10 years were recruited. The overall mean score from the DTSQs satisfaction questionnaire was 18.3±6.3, and the change of treatment led to an improvement in patient satisfaction compared to the previous treatment (DTSQc mean score 8.8±5.9). A1c dropped from an initial value of 8.7% (SD 0.8) to 7.5% (SD 0.7) (P<.001). The frequency of hyperglycaemic episodes perceived by the patients was significantly lower after they overcame their fear of injections (35.6% compared to 11.5%; P<.001), but no statistically significant differences were found in the frequency of hypoglycaemic episodes (32% compared to 35%; P=.059). CONCLUSION: In patients with DM2 poorly controlled with OADs, overcoming a fear of injections and starting treatment with insulin was associated with an overall improvement in satisfaction with the new treatment, and decreased the perception of hyperglycaemic episodes. Glycaemic control and the metabolic profile of the patients also improved to a statistically significant degree with the change of treatment.

[Role of classical oral glucose-lowering medications in current treatment]. / Papel de los hipoglucemiantes orales clásicos en el tratamiento actual.

Classical oral glucose were discovered in the mid twentieth century. Despite the time elapsed since then and the lack of large studies to support the use of some of these drugs, they continue to be employed, are indicated in all clinical practice guidelines and consensus documents and, overall, remain among the most widely prescribed drugs in the national health system. The main arguments for their continued use are their widespread and prolonged prescription, their effectiveness, and cost. Their main disadvantages have always been and continue to be their adverse gastrointestinal effects, weight gain, the risk of hypoglycemia and other adverse effects, which have encouraged the development of new glucose-lowering drugs with an improved pharmacological profile that would cover the various mechanisms of hyperglycemia. Currently, deep knowledge of glucose-lowering drugs is required in the patient-centered management of diabetes. Furthermore, this knowledge should be adapted to each individual patient to acquire the experience necessary to achieve effective metabolic control, delay the development of chronic complications, and improve the quality of life and life expectancy of patients with diabetes.

Papel de los hipoglucemiantes orales clásicos en el tratamiento actual / Role of classical oral glucose-lowering medications in current treatment

A pesar del tiempo trascurrido desde su descubrimiento, a mediados del siglo pasado, de estar inmersos de pleno en la segunda década del siglo XXI, de que algunos no tengan grandes estudios propios que avalen suficientemente su evidencia, los hipoglucemiantes orales clásicos siguen manteniendo su vigencia, aparecen indicados en todas las guías y consensos y, globalmente, continúan en los primeros puestos de prescripción en el Sistema Nacional de Salud. Los principales argumentos para mantener el uso actual son el amplio y prolongado uso, la eficacia y el coste, mientras que sus principales inconvenientes siempre han sido y son los efectos gastrointestinales, la ganancia ponderal, el riesgo de hipoglucemia u otros efectos secundarios, motivos que han promovido el desarrollo de nuevos hipoglucemiantes que mejorasen el perfil farmacológico y cubriesen los diferentes mecanismos de la hiperglucemia. Actualmente, en el manejo centrado del paciente con diabetes resulta necesario tener un conocimiento profundo de los hipoglucemiantes y aplicarlo a las peculiaridades de cada individuo para adquirir la experiencia necesaria que logre un control metabólico efectivo, retrasar las complicaciones crónicas y el objetivo final de mejora en la calidad y expectativa de vida del paciente con diabetes (AU)

Classical oral glucose were discovered in the mid twentieth century. Despite the time elapsed since then and the lack of large studies to support the use of some of these drugs, they continue to be employed, are indicated in all clinical practice guidelines and consensus documents and, overall, remain among the most widely prescribed drugs in the national health system. The main arguments for their continued use are their widespread and prolonged prescription, their effectiveness, and cost. Their main disadvantages have always beenand continue to betheir adverse gastrointestinal effects, weight gain, the risk of hypoglycemia and other adverse effects, which have encouraged the development of new glucose-lowering drugs with an improved pharmacological profile that would cover the various mechanisms of hyperglycemia. Currently, deep knowledge of glucose-lowering drugs is required in the patient-centered management of diabetes. Furthermore, this knowledge should be adapted to each individual patient to acquire the experience necessary to achieve effective metabolic control, delay the development of chronic complications, and improve the quality of life and life expectancy of patients with diabetes (AU)

Glycaemic control in patients with type 2 diabetes switching from premixed insulin to long-acting basal insulin analogue plus oral antidiabetic drugs: an observational study.

AIM: To evaluate whether administration of long-acting basal insulin analogue plus oral antidiabetic drugs (OADs) improves glycaemic control in type 2 diabetic patients with glycosylated haemoglobin (HbA1c) > 7% (53 mmol/mol) under premixed insulin therapy. METHODS: This is a multicentre, observational, retrospective study performed in type 2 diabetic patients switching from premixed insulin to long-acting basal insulin analogue plus OADs. Data on patients' medical history and assessments were retrieved from patients' medical charts prior to switching the treatment and 6 months thereafter. RESULTS: A total of 131 evaluable patients were enrolled (mean age, 68.2 ± 9.4 years; female, 65.6%; mean diabetes duration, 12.7 ± 6.9 years; mean time on insulin therapy, 53.2 ± 41.9 months). Patients were receiving premixed insulin (once-daily, 4.7%; twice-daily, 85.0%; thrice-daily, 10.2%), 82.4% of whom in combination with OADs (metformin, 79.4%). After the treatment was switched, only 14.5% required intensification of treatment with additional preprandial insulin. HbA1c decreased -1.4% [mean ± SD, 8.4 ± 1.0% (68.7 ± 11.4 mmol/mol) vs. 7.0 ± 1.0% (53.6 ± 10.9 mmol/mol), p < 0.001] and the proportion of patients achieving HbA1c < 7% (53 mmol/mol) increased to 52.7% (p < 0.001). The percentage of patients with hypoglycaemia decreased (19.2% vs. 10.8%, p < 0.05; symptomatic, 17.6% vs. 4.6%, p < 0.01) and body weight diminished by -1.9 kg (mean ± SD, 78.5 ± 14.7 kg vs. 76.6 ± 13.9 kg, p < 0.05). Basal insulin plus OADs was considered more convenient and flexibly adapted to patients' life in 98.4% and 99.2% of patients, respectively. Additionally, 96.9% of patients reported being more satisfied and 96.9% would recommend it. CONCLUSIONS: Switching the treatment from premixed insulin to long-acting basal insulin analogue plus OADs is a feasible and convenient approach to improve glycaemic control of type 2 diabetic patients poorly controlled with premixed insulin under routine clinical practice conditions.

Prevención de la tendinopatía rotuliana con ejercicios excéntricos en deportistas / Patellar tendinopathy prevention in athletes with eccentric exercise

Objetivo: Conocer el efecto de dos programas de entrenamiento excéntrico sobre la morfología del tendón rotuliano. Material y método: Estudio experimental con pre y pos-test y grupo control. La muestra estuvo compuesta por 85 sujetos deportistas; 25 jugadores de baloncesto (BC) y 60 estudiantes de educación física (CAFD) que practican ejercicio físico regulado, mínimo 3 veces por semana. El entrenamiento excéntrico llevado a cabo en ambos grupos tuvo una duración de 12 semanas entre una valoración ecográfica inicial y la final. En el grupo formado por los estudiantes de CAFD se incrementó la carga de forma progresiva que no varió en el grupo de BC. Resultados: Se encontraron diferencias significativas entre la interacción del momento de la medida y el grupo. Las mediciones ecográficas aumentaron de forma significativa (p<0.001) en el grupo CAFD. El grupo experimental BC no mostró cambios, y en el grupo control obtuvo menores longitudes en el post test (p<0.05). La anchura aumentó en el grupo experimental CAFD (p<0.001) y en el grupo experimental BC (p=0.042). Conclusión: El entrenamiento excéntrico provoca una hipertrofia sobre el tendón en pacientes sin tendinopatía rotuliana. Estas mejoras deben basarse sobre una correcta progresión de la carga de trabajo y prestando atención de forma individualizada a cada sujeto (AU)

Objetive: The aim of this study is to know the effect of different eccentric exercises programs in the morphology of the patellar tendon. Methods: This is an experimental study. Eighty-five athletes were included: 25 college basketball players (GBC) and 60 college students (GCAFD) with regular sport activity (at least 3 times/week). A 12-weeks eccentric exercise program was performed. Morphology of patellar tendon was seen with ultrasound both at the beginning and at the end of the program. The difference between both groups was that in the GCAFD program, strength increased progressively, meanwhile in the GBC group it was the same during the whole 12 weeks. Results: Both tendon diameters increased with the program in the experimental GCAFD (p<0.001) versus control group. The GBC showed no changes between both experimental and control group in APLONG and APTRANS, but these parameters were lower in post-test measurement in the control group (p<0.05). LATMED increased in both experimental groups, GCAFD (p<0.001) and GBC (p=0.042). Conclusion: In athletes without patellar tendinopathy, tendon hypertrophy is seen after a program of eccentric exercises, with increase in both anteroposterior and medial lateral diameter. An individualized program must be designed to achieve these results after the exercises (AU)

Prevención de la diabetes mellitus 2 / Prevention of diabetes mellitus 2

La diabetes mellitus tipo 2 –DM2- es una enfermedad metabólica caracterizada por hiperglucemia. Este defecto es capaz de producir alteraciones vasculares y nerviosas que son el sustrato de sus complicaciones. La DM2 por su doble componente etiológico y su amplio período preclínico permite establecer estrategias que prevengan o demoren su aparición (prevención primaria), o que permitan su detección precoz (prevención secundaria), o que una vez diagnosticada, retrasen o eviten la aparición de las complicaciones (prevención terciaria). Del mismo modo que la aplicación o no de pruebas de cribado de la enfermedad es aún hoy un asunto controvertido, la utilización de tratamientos higiénico dietéticos o farmacológicos en prediabéticos podría recomendarse en algunas situaciones para disminuir la incidencia de esta enfermedad (AU)

Diabetes mellitus type 2, DM2-is a metabolic disorder characterized by hyperglycaemia. This feature causes vascular and nerve disorders that are the basis of long-term complications. The twin-DM2 due to both its aetiology and its broad preclinical period allows strategies to be made that prevent or delay its onset (primary prevention) or to allow early detection (secondary prevention), or once diagnosed, delay or prevent the onset of complications (tertiary prevention). The application or screening tests for the disease is still a controversial issue and hygienic use of dietary or pharmacological treatments in pre-diabetics is recommended to decrease the incidence of this disease (AU)

Elección del agente oral más apropiado, en monoterapia o en combinación, en el paciente anciano con diabetes / Selection of the most appropiate oral agent in monotherapy or in combination in the elderly patient with diabetes

El paciente anciano con diabetes presenta una serie de características que deberemos tener en cuenta al plantear el tratamiento farmacológico, como son la calidad de vida, la presencia de complicaciones crónicas, los grandes síndromes geriátricos y las preferencias del paciente. La escasa evidencia disponible, debida a los pocos estudios realizados en ancianos, explica las limitadas recomendaciones existentes en la mayoría de las guías de práctica clínica actuales. Metformina es el fármaco de elección en monoterapia y su posología debe adaptarse al grado de insufi ciencia renal, situación muy frecuente en los ancianos. Otros grupos farmacológicos también pueden utilizarse teniendo en cuenta sus limitaciones y contraindicaciones. No existe consenso sobre cuál es el tratamiento combinado más indicado en los ancianos cuando fracasa la monoterapia. Cualquier combinación puede utilizarse siempre que se respeten las indicaciones y las contraindicaciones. Ante la necesidad de insulinización se deben valorar los benefi cios y riesgos del uso de insulina, utilizando la pauta más simple y adaptada a las características del anciano y su entorno (AU)

The elderly patient with diabetes presents a series of features that we need to have in mind when considering drug therapy, such as quality of life, presence of chronic complications, major geriatric syndromes, and patient preferences. The limited evidence available due to the few studies performed in the elderly explains the limited existing recommendations in the most current clinical practice guidelines. Metformin is the drug of choice as monotherapy and its dosage should be adjusted to the degree of renal failure, a situation very common in the elderly. Other pharmacologic groups can also be used taking into account their limitations and contraindications. There is no consensus on what is the most appropriate combination therapy in the elderly when monotherapy fails. Any combination can be used provided that the indications and contraindications are considered. When insulin is necessary, benefits and risks of using insulin should be evaluated, using the simplest regimen adapted to the characteristics of the elderly and its environment (AU)

Recomendaciones de la Sociedad Americana de Diabetes para el manejo de la diabetes mellitus / Recommendations of the American Diabetes Association for the management of diabetes mellitus

El manejo de la diabetes evoluciona con rapidez en los últimos años, ya sea por la incorporación de nuevas propuestas para realizar el diagnóstico, por la modificación de los objetivos intermedios que debemos buscar para reducir el riesgo vascular o por los medios recomendados para alcanzar estos objetivos. Para orientarnos en este terreno movedizo se publican con periodicidad variable varias guías, entre las que destaca por su puntualidad, difusión y predicamento la de la Sociedad Americana de Diabetes. En este artículo resumimos las modificaciones más importantes que se han producido en las recomendaciones este año y recordamos los aspectos más destacables que se mantienen igual que en las versiones previas (AU)

The management of diabetes is rapidly evolving in the last years either by incorporation of new proposals to make the diagnosis, or for modified intermediate objectives that we should seek to reduce vascular risk, or the recommended means to achieve these objetives. For guide us in this area moving at varying intervals published several guides among which stands out for its diffusion and predicament of the American Society of Diabetes. In this article we summarise the most important changes made in the recommendations this year and we remind you of the most significant aspects that remain the same as in previous versions (AU)

Impacto de un programa de educación sanitaria en pacientes con fibromialgia / Impact of a health education program on patients with fibromyalgia

Objetivos. Valorar el impacto de un programa de educación sanitaria sobre la calidad de vida y sobre la frecuentación a consulta de personas con fibromialgia (FM). Material y método. Evaluación clínica prospectiva de una cohorte de voluntarios ante una intervención en salud. Emplazamiento. Centro de Salud Alcalá de Guadaira A, con una cobertura poblacional de 75.000 habitantes. Se constituyó el grupo poblacional sobre la base del número de pacientes diagnosticadas de FM por el reumatólogo o el internista de la zona, según los criterios del American College of Rheumatology de 1990 que consultaron en nuestro centro a causa de su enfermedad en el último año, excluyendo aquellas que padecieran enfermedades reumatológicas graves. Se cumplimentó un protocolo de valoración clínica; para la evaluación de la calidad de vida se utilizó el Fibromyalgia Impact Questionnarie, versión española (SFIQ). Para la percepción de apoyo social (Medical Outscome Study) y para la valoración de síntomas ansiosos depresivos se utilizó la escala de ansiedad y depresión de Golberg. Se registraron datos demográficos, aspectos laborales, tipo de sensación, número de visitas en el último año a consulta por este motivo, patología coadyuvante, y tipo y número de fármacos consumidos. Emplazamiento. osteriormente a la recogida de datos se distribuyó la muestra aleatoriamente en grupos de intervención; se le realizaron, durante 6 meses, cuatro sesiones/mes de educación sanitaria de una hora de duración cada una y en intervalos de una semana. Para ello se dividió a las participantes en 6 grupos de 12. El contenido de las sesiones fue el siguiente: a) información general de la enfermedad; b) medidas fisicorrehabilitadoras/ejercicio físico e higiene postural, y c) técnicas de relajación (se utilizó la técnica de Jacobson). Emplazamiento. Al mes de la intervención se volvió a administrar el SFIQ a todas las participantes del estudio...(AU)

Objectives. To assess the impact of a health education program on the quality of life and frequency of clinic visits on patients with fibromyalgia (FM). Material and method. A prospective clinical study on a volunteer cohort before a health intervention. Setting. Health Centre A Alcala de Guadaira, Seville, Spain, which covers a population of 75,000 inhabitants. The population group was based on the number of patients diagnosed with FM by a rheumatologist or area resident according to the criteria of the American College of Rheumatology of 1990, who attended our clinic due to their disease in the last year, excluding those who suffered severe rheumatic diseases. A clinical assessment protocol was completed. The Fibromyalgia Impact Questionnaire, Spanish version (SFIQ) was used to assess the quality of life, the Medical Outcomes Study for the perception of social support, and for the evaluation of anxiety-depression symptoms, the Goldberg Anxiety-depression Scale (GADS) was used. Demographic data, occupational aspects, type of sensation, number of clinic visits in the past year for this reason, concomitant illnesses, and type and number of drugs taken. Setting. After collecting the data, the sample was randomly distributed into intervention groups. The participants were divided into 6 groups of 12, and they attended four 1-hour sessions of health education per month, at weekly intervals. The sessions contained the following: a) general information on the disease; b) physical-rehabilitation/physical exercise measures and postural hygiene, and c) relaxation techniques (the E. Jacobson technique was used). Setting. After one month of intervention, the SFIQ was completed again by all the study participants. The anxiety-depression symptoms were also measured according to GADS. We recorded the frequency of visits for one year after the intervention...(AU)

Occupancy of nonannular lipid binding sites on KcsA greatly increases the stability of the tetrameric protein.

KcsA, a homotetrameric potassium channel from prokaryotes, contains noncovalently bound lipids appearing in the X-ray crystallographic structure of the protein. The binding sites for such high-affinity lipids are referred to as "nonannular" sites, correspond to intersubunit protein domains, and bind preferentially anionic phospholipids. Here we used a thermal denaturation assay and detergent-phospholipid mixed micelles containing KcsA to study the effects of different phospholipids on protein stability. We found that anionic phospholipids stabilize greatly the tetrameric protein against irreversible, heat-induced unfolding and dissociation into subunits. This occurs in a phospholipid concentration-dependent manner, and phosphatidic acid species with acyl chain lengths ranging 14 to 18 carbon atoms are more efficient than similar phosphatidylglycerols in protecting the protein. A docking model of the KcsA-phospholipid complex suggests that the increased protein stability originates from the intersubunit nature of the binding sites and, thus, interaction of the phospholipid with such sites holds together adjacent subunits within the tetrameric protein. We also found that simpler amphiphiles, such as alkyl sulfates longer than 10 carbon atoms, also increase the protein stability to the same extent as anionic phospholipids, although at higher concentrations than the latter. Modeling the interaction of these simpler amphiphiles with KcsA and comparing it with that of anionic phospholipids serve to delineate the features of a hydrophobic pocket in the nonannular sites. Such pocket is predicted to comprise residues from the M2 transmembrane segment of a subunit and from the pore helix of the adjacent subunit and seems most relevant to protein stabilization.

[Necrobiotic xanthogranuloma: efficacy of surgery in 2 patients]. / Xantogranuloma necrobiótico: eficacia de la cirugía en dos casos clínicos.

Necrobiotic xanthogranuloma is a rare disease characterized by indurated nodules and yellowish-red plaques in the dermis or subdermal tissues particularly in the periorbital region; the lesions are often ulcerated. This disease is frequently associated with hematological disorders such as monoclonal gammopathy and lymphoproliferative disorders. Its pathogenesis is unknown and the small number of cases makes long-term studies difficult. We present 2 cases of periorbital lesions in which the biopsies established a diagnosis of necrobiotic xanthogranuloma. Both patients were treated with corticosteroids and cyclophosphamide, with no improvement. The lesions were excised and the periorbital regions were reconstructed with skin grafts. After 1 year of follow-up there are no signs of recurrence.

Xantogranuloma necrobiótico: eficacia de la cirugía en dos casos clínicos / Necrobiotic Xanthogranuloma: Efficacy of Surgery in 2 Patients

El xantogranuloma necrobiótico es una enfermedad poco frecuente que se caracteriza por la presencia de nódulos indurados y placas rojo-amarillentas en los tejidos dérmicos o subdérmicos, a menudo ulceradas ,que asientan preferentemente en la región periorbitaria. Suele asociarse con alteraciones hematológicas como gammapatía monoclonal y trastornos linfoproliferativos. Su patogenia es desconocida y el escaso número de casos existentes hace difícil la publicación de estudios a largo plazo. Presentamos dos casos de lesiones periorbitarias cuyas biopsias establecieron el diagnóstico de xantogranuloma necrobiótico. Los pacientes se sometieron a tratamiento con corticoides y ciclofosfamida sin mejoría. Las lesiones fueron tratadas quirúrgicamente mediante escisión y reconstrucción con injertos de piel. Tras un año de seguimiento no hay evidencias de recurrencia de la enfermedad (AU)

Necrobiotic xanthogranuloma is a rare disease characterized by indurated nodules and yellowish-red plaques in the dermis or subdermal tissues particularly in the periorbital region; the lesions are often ulcerated. This disease is frequently associated with hematological disorders such as monoclonal gammopathy and lymphoproliferative disorders. Its pathogenesis is unknown and the small number of cases makes long-term studies difficult. We present 2 cases of periorbital lesions in which the biopsies established a diagnosis of necrobiotic xanthogranuloma. Both patients were treated with corticosteroids and cyclophosphamide, with no improvement. The lesions were excised and the periorbital regions were reconstructed with skin grafts. After 1 year of follow-up there are no signs of recurrence (AU)