Consenso multidisciplinar sobre el manejo individualizado de la diabetes en atención primaria. Estudio ICANDAP / Delphi consensus on the individualised management of diabetes in primary care. ICANDAP study

Introducción. Se trata de explorar el grado de aceptación y consenso en el abordaje individualizado y determinadas recomendaciones sobre el manejo clínico-terapéutico de la diabetes mellitus de tipo 2 (DM2) entre los médicos de Atención Primaria (AP) españoles y explorar las diferentes barreras que pueden interferir en su implementación en la práctica clínica habitual. Material y métodos. Estudio nacional en el ámbito de la AP, de carácter exploratorio, de acuerdo con la metodología Delphi modificada, con 2 rondas de consenso. Evaluación por parte de un panel homogéneo formado por 152 médicos de AP a través de un cuestionario dividido en 6 áreas temáticas y constituido por 27 ítems. Resultados. De manera global, se consiguió el consenso en 19 (70,4%) de los 27 ítems: 12 de acuerdo (44,4%) y 7 de desacuerdo (25,9%). No se alcanzó consenso en 8 de los ítems (29,6%). Conclusiones. Aunque hay aspectos que reflejan un aceptable consenso sobre el manejo de la diabetes de tipo 2 con base en el perfil individualizado del paciente, como el establecimiento de los objetivos de control o la selección de los fármacos antidiabéticos, persiste una amplia diversidad de opiniones entre los médicos de AP en nuestro medio (AU)

Introduction. To determine the level of acceptance of the message of individualised management of type 2 diabetes mellitus among Spanish Primary Care (PC) physicians, and to evaluate the factors that may interfere with its implementation in clinical practice. Material and methods. National study in the field of PC, exploratory, and following a two-round modified Delphi method. Evaluation by a homogeneous panel of 152 physicians using a 27-items questionnaire divided into 6 thematic areas. Results. Overall, consensus was achieved in 19 (70.4%) of the 27 items, 12 in agreement (44.4%), and 7 in disagreement (25.9%). There was no consensus in 8 (29.6%) of the items. Conclusions. Although there are certain aspects indicating the good acceptance of the message of diabetes management based on the individual patient profile, such as in the establishment of targets or the selection of antidiabetic drugs, the message has not been assimilated by all Spanish PC physicians. Further studies, involving a large number of physicians, are required to corroborate these results, and identify more factors that may be interfering with the implementation in clinical practice (AU)

Abordaje de la diabetes en el hipertenso / Management of diabetes in patients with hypertension

La diabetes mellitus es un grupo de enfermedades metabólicas cuyo nexo en común es la hiperglucemia secundaria a un déficit de la secreción de insulina, al defecto de su actividad metabólica o a ambos, lo que ocasiona complicaciones crónicas micro- y/o macrovasculares. Su prevalencia es del 13,6% y los costes directos, de 2.500 millones de euros anuales. El adecuado abordaje de la diabetes en el paciente hipertenso incluye alcanzar un control integral de todos los factores de riesgo cardiovascular presentes. Se deben individualizar los objetivos en función de distintos factores como la edad, el tiempo de evolución de la diabetes, la presencia o ausencia de complicaciones y la frecuencia de hipoglucemias, la capacidad de cada paciente en función de su estado cognitivo, el apoyo sociofamiliar y la esperanza de vida

The diabetes mellitus is a group of metabolic diseases whose common link is hyperglycemia secondary to a deficit of insulin secretion, the defect of metabolic activity or both, causing micro and / or macrovascular chronic complications. Its prevalence is 13.6% and the direct costs of 2,500 million euros annually. Proper management of diabetes in hypertensive patients includes reaching a comprehensive control of all cardiovascular risk factors present. Objectives should be individualized depending on various factors such as age, duration of diabetes, presence or absence of complications and frequency of hypoglycemia, the capacity of each patient based on their cognitive status, support socio-family and Life expectancy

[Management of diabetes in patients with hypertension]. / Abordaje de la diabetes en el hipertenso.

The diabetes mellitus is a group of metabolic diseases whose common link is hyperglycemia secondary to a deficit of insulin secretion, the defect of metabolic activity or both, causing micro and / or macrovascular chronic complications. Its prevalence is 13.6% and the direct costs of 2,500 million euros annually. Proper management of diabetes in hypertensive patients includes reaching a comprehensive control of all cardiovascular risk factors present. Objectives should be individualized depending on various factors such as age, duration of diabetes, presence or absence of complications and frequency of hypoglycemia, the capacity of each patient based on their cognitive status, support socio-family and Life expectancy. © 2017 SEHLELHA. Published by Elsevier España, S.L.U. All rights reserved.

[Delphi consensus on the individualised management of diabetes in primary care. ICANDAP study]. / Consenso multidisciplinar sobre el manejo individualizado de la diabetes en atención primaria. Estudio ICANDAP.

INTRODUCTION: To determine the level of acceptance of the message of individualised management of type 2 diabetes mellitus among Spanish Primary Care (PC) physicians, and to evaluate the factors that may interfere with its implementation in clinical practice. MATERIAL AND METHODS: National study in the field of PC, exploratory, and following a two-round modified Delphi method. Evaluation by a homogeneous panel of 152 physicians using a 27-items questionnaire divided into 6 thematic areas. RESULTS: Overall, consensus was achieved in 19 (70.4%) of the 27 items, 12 in agreement (44.4%), and 7 in disagreement (25.9%). There was no consensus in 8 (29.6%) of the items. CONCLUSIONS: Although there are certain aspects indicating the good acceptance of the message of diabetes management based on the individual patient profile, such as in the establishment of targets or the selection of antidiabetic drugs, the message has not been assimilated by all Spanish PC physicians. Further studies, involving a large number of physicians, are required to corroborate these results, and identify more factors that may be interfering with the implementation in clinical practice.

Inhibidores del cotransportador sodio-glucosa tipo 2(SGLT2): de la glucosuria renal familiar al tratamiento de la diabetes mellitus tipo 2 / Sodium-glucose cotransporter type 2 inhibitors (SGLT2): from familial renal glycosuria to the treatment of type 2 diabetes mellitus

Durante siglos, el riñón se ha considerado principalmente un órgano de eliminación y un regulador de la sal y del equilibrio iónico. A pesar de que una vez se pensó que era la causa estructural de la diabetes, y que en los últimos años ha sido ignorado como regulador de la homeostasis de la glucosa, actualmente es reconocido como un actor importante en el ámbito de la regulación del metabolismo glucídico. Durante el ayuno, el 55% de la glucosa proviene de la gluconeogénesis. Sólo 2 órganos tienen esta capacidad: el hígado y el riñón. Este último es responsable del 20% de la producción total deglucosa y del 40% de la producida por la gluconeogénesis. Hoy en día tenemos una mejor comprensión de la fisiología del transporte de glucosa renal a través de transportadores específicos, como el cotransportador sodio-glucosa tipo 2(SGLT2 por sus siglas en inglés: Sodium Glucose Cotransporter). Un compuesto natural, floricina, se aisló a principios de1800 y durante décadas desempeñó un papel importante enla diabetes y la investigación de la fisiología renal. Finalmente, en el nexo de estos descubrimientos antes mencionados, se reconoció el efecto de compuestos floricina-like en los transportadores de glucosa renal, lo que ha ofrecido un nuevo mecanismo para el tratamiento de la hiperglucemia. Esto ha llevado al desarrollo de varias modalidades terapéuticas potencialmente eficaces para el tratamiento de la diabetes (AU)

For centuries, the kidney has been considered primarily an organ of elimination and a regulator of salt and ion balance. Although once thought that the kidney was the structural cause of diabetes, which in recent years has been ignored as a regulator of glucose homeostasis, is now recognized as a major player in the field of metabolic regulation carbohydrate. During fasting, 55% of the glucose comes from gluconeogenesis. Only 2 organs have this capability: the liver and kidney. The latter is responsible for 20% of total glucose production and 40%of that produced by gluconeogenesis. Today we have a better understanding of the physiology of renal glucose transport via specific transporters, such as type 2 sodiumglucose cotransporter (SGLT2). A natural compound, phlorizin, was isolated in early 1800 and for decades played an important role in diabetes and renal physiology research. Finally, at the nexus of these findings mentioned above, recognized the effect of phlorizin-like compounds in the renal glucose transporter, which has offered a new mechanism to treat hyperglycemia. This has led to the development of several potentially effective treatment modalities for the treatment of diabetes (AU)

[Sodium-glucose cotransporter type 2 inhibitors (SGLT2): from familial renal glucosuria to the treatment of type 2 diabetes mellitus]. / Inhibidores del cotransportador sodio-glucosa tipo 2 (SGLT2): de la glucosuria renal familiar al tratamiento de la diabetes mellitus tipo 2.

For centuries, the kidney has been considered primarily an organ of elimination and a regulator of salt and ion balance. Although once thought that the kidney was the structural cause of diabetes, which in recent years has been ignored as a regulator of glucose homeostasis, is now recognized as a major player in the field of metabolic regulation carbohydrate. During fasting, 55% of the glucose comes from gluconeogenesis. Only 2 organs have this capability: the liver and kidney. The latter is responsible for 20% of total glucose production and 40% of that produced by gluconeogenesis. Today we have a better understanding of the physiology of renal glucose transport via specific transporters, such as type 2 sodium-glucose cotransporter  (SGLT2). A natural compound, phlorizin, was isolated in early 1800 and for decades played an important role in diabetes and renal physiology research. Finally, at the nexus of these findings mentioned above, recognized the effect of phlorizin-like compounds in the renal glucose transporter, which has offered a new mechanism to treat hyperglycemia. This has led to the development of several potentially effective treatment modalities for the treatment of diabetes.

Blood pressure, antihypertensive treatment and factors associated with good blood pressure control in hypertensive diabetics: the Tarmidas study.

Numerous population studies confirm the high prevalence of hypertension in type II diabetic (DM2) subjects and that intensive antihypertensive treatment is more beneficial to diabetic than to nondiabetic hypertensive subjects, yet not many of these are specific to Spain. To assess the degree of blood pressure (BP) control and the effects of antihypertensive drugs in the medical management of hypertension in diabetic patients in specialist care centres throughout Spain, we studied the socio-demographic, clinical and relevant laboratory parameters of 796 hypertensive patients with DM2 (mean age 66.09 (95% confidence interval (CI): 64.08-68.10). The percentage of diabetic patients responding positively to BP control measures was lower when compared to the nondiabetic population in both Spain and Europe. The degree of control was poorer for systolic than for diastolic BP, yet 40.6% of the patients were only on monotherapy. The fact that antihypertensive treatment was modified in only 40% of the poorly controlled patients was also highly significant and could be attributed to a nonstringent use of clinical guidelines. Among the other differences between well-controlled and poorly controlled patients, we found that well-controlled patients presented with lower levels of cholesterol and triglycerides, a lower prevalence of excess weight/obesity, and a greater prevalence of cardiovascular and/or cerebrovascular disease despite having a greater percentage of patients on antiplatelet therapy. Better application of therapeutic guidelines and the prevention and treatment of compounding factors could improve the response rate to BP control measures in poorly controlled patients.

Clinically inapparent adrenal mass in a patient with familial adenomatous polyposis.

Familial adenomatous polyposis (FAP) is an autosomal dominant condition characterized by multiple colorectal adenomas that can progress to carcinoma. FAP can be associated with diverse extracolonic manifestation, including desmoid tumors and adrenal masses. We report our experience with a patient diagnosed of FAP, who developed a desmoid tumor and an adrenal mass in the follow-up. To our knowledge, this is the first case in the literature in which a hypersecretion of aldosterone and cortisol in the adrenal mass of a patient diagnosed of FAP has been demonstrated.

Menopausia, hipertensión y riesgo cardiovascular / Menoause, hypertension and cardiovascular risk

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Effects of hyperinsulinemia on vascular blood flows in experimental obesity.

Human obesity, which is very common in Polycystic Ovaries Syndrome and in "X Syndrome", constitutes an insulin-resistance state in which multiple clinical, biochemical and hemodynamic alterations coexist. Insulin resistance in the obese has been recently associated with an endothelial dysfunction. To investigate the possibility that clinical and metabolic derangements related to insulin resistance could induce changes in vascular blood flows, we have studied the levels of mesenteric (MBF), renal (RBF) and femoral (FBF) blood flows in Beagle dogs kept for 2 years on a normal (control group) or high fat diet (obese group). This experimental model exhibits many of the abnormalities with the human syndrome. In addition, we have tested the effects of chronic treatment with captopril (capto group) in monotherapy or in association with pravastatin (prava+capto group) on the hemodynamic changes associated with this diet. After the two year follow-up, Transonic flow probes were placed around the three arteries to measure basal blood flows and their response to a hyperinsulinemic-normoglycemic test in anesthetized animals. During this test the degree of insulin sensitivity was estimated. In association with higher body weight, blood pressure, insulin resistance, and fasting levels of insulin and total cholesterol, the obese group exhibited decreased basal levels of FBF and a greater femoral vasoconstriction during hyperinsulinism (P < 0.05 vs control). Combined therapy with captopril and pravastatin ameliorated the reduction in basal FBF and hyperinsulinism-induced vasoconstriction (P < 0.05), in addition to the beneficial effects on insulin sensitivity, and clinical and metabolic parameters. Synergistic beneficial effects of both drugs on lipid and carbohydrate profiles may account for this positive outcome, by attenuating the atherogenic process associated with this model.

Therapeutic implications and new perspectives for essential hypertension and renal damage.

The kidney can suffer the consequences of a persistently elevated blood pressure. In fact end-stage renal failure caused by essential hypertension appears to be one of the most prevalent etiologies in patients entering a dialysis program. Blood pressure control is needed in order to prevent the progressive loss of renal function. Target blood pressure control has been established at values as low as 125/75 mm Hg for patients with proteinuria above 1 g/day. Attainment of this target level usually requires the combination of two or more drugs. However, the possibility that differences exist among the different classes of antihypertensive drugs beyond their capacity to simply lower blood pressure remains to be clearly elucidated. The fact that the presence of chronic renal failure is also accompanied by an enhanced cardiovascular risk potentiates the need to explore the renoprotective and cardiovascular protective capacity of the different classes of antihypertensive drugs, in patients with essential hypertension and some degree of renal involvement, characterized by the presence of microalbuminuria, proteinuria and/or an elevated serum creatinine.

Salt sensitivity: concept and pathogenesis.

Almost two decades ago, the existence of a subset of essential hypertensive patients, who were sensitive (according to the increase in blood pressure levels) to the intake of a diet with a high salt content, was described. These patients are characterized by an increase in blood pressure and in body weight when switched from a low to a high sodium intake. The increase in body weight is due to the incapacity of the kidneys to excrete the whole intake of sodium until renal perfusion pressure (mean blood pressure) attains a level that is able to restore pressure-natriuresis relationship to values that enable the kidney to excrete the salt ingested or administered intravenously. Salt sensitivity does not seem to depend on the existence of an intrinsic renal defect to handle sodium, but on the existence of subtle abnormalities in the regulation of the sympathetic nervous system, the renin-angiotensin system or endothelial function. It is also relevant that organ damage secondary to arterial hypertension, has been shown in animal models and in hypertensive humans sensitive to a high salt intake to be significantly higher when compared with that of salt-resistant animals or humans. Interestingly, in humans, salt sensitivity has been shown to correlate with microalbuminuria, an important predictor of cardiovascular morbidity and mortality, which correlates with most of the cardiovascular risk factors commonly associated with arterial hypertension. One of these factors is insulin resistance, that usually accompanies high blood pressure in overweight and obese hypertensives. Insulin resistance and hyperinsulinism are present in a significant percentage of hypertensive patients developing cardiovascular symptoms or death. For these reasons, therapy of arterial hypertension must be directed, not only to facilitate the lowering of BP level, but also, to halt the mechanisms underlying the increase in BP, when salt intake is increased. Furthermore, therapy must preferably improve the diminished insulin sensitivity present in salt-sensitive subjects that contribute independently to increased cardiovascular risk.

[Primary adrenal lymphoma: review and report of a case]. / Linfoma suprarrenal primario: revisión a propósito de un caso.

We present a case of non-Hodgkins lymphoma located in both adrenal glands, with diminished adrenal reserve and fatal evolution with serious metabolic complications, with hypoglycemia, severe lactic acidosis, hyperuricemia, acute renal failure, hepatic affectation and hemogram alterations. Much of these complications can be explained by tumoral lysis syndrome probably prompted by the use of high doses of corticosteroids. Primary adrenal lymphoma is exceptional with only 14 cases described in the literature. In spite of its rarity it should be included in the differential diagnosis of uni or bilateral adrenal masses and an early diagnosis is necessary in order to avoid serious and potentially lethal complications. Percutaneous aspiration biopsy can be a valid method of diagnosis because it can identify specific tumoral antigens. The literature concerning this unusual tumour is reviewed.

[Hypoparathyroidism]. / Hipoparatiroidismo.

Hypoparathyroidism (HP) is caused by abnormalities of parathyroid hormone secretion, disordered parathyroid function and pseudohypoparathyroidism. The term pseudohypoparathyroidism describes a set of syndromes in which the effects of parathyroid hormone are blunted or absent. Patients with HP are hypocalcemic and hyperphosphatemic.