Angiotensin-converting enzyme gene single polymorphism as a genetic biomarker of diabetic peripheral neuropathy: longitudinal prospective study.

BACKGROUND: Identifying patients at risk of developing diabetic peripheral neuropathy (DPN) is of paramount importance in those with type 2 diabetes mellitus (T2DM) to provide and anticipate secondary prevention measures as well as intensify action on risk factors, particularly so in primary care. Noteworthy, the incidence of DPN remains unknown in our environment. AIMS: (i) To analyze a single angiotensin-converting enzyme (ACE) gene polymorphism (D/I) as a genetic marker of risk of developing DPN, and (ii) to determine the incidence of DPN in our environment. RESEARCH DESIGN AND METHODS: Longitudinal study with annual follow-up for 3years involving a group of T2DM (N=283) randomly selected. ACE gene polymorphism distribution (I=insertion; D=deletion) was determined. DPN was diagnosed using clinical and neurophysiology evaluation. RESULTS: Baseline DPN prevalence was 28.97% (95% CI, 23.65-34.20). ACE polymorphism heterozygous genotype D/I presence was 60.77% (95% CI, 55.05-66.5) and was independently associated with a decreased risk of DPN (RR, 0.51; 95% CI, 0.30-0.86). DPN correlated with age (P<0.001) but not with gender (P=0.466) or time of evolution of T2DM (P=0.555). Regarding end point, DPN prevalence was 36.4% (95% CI, 30.76-42.04), and accumulated incidence was 10.4% 3years thereafter. In the final Poisson regression analysis, the presence of heterozygous genotype remained independently associated with a decreased risk of DPN (RR, 0.71; (95% CI, 0.53-0.96). DPN presence remained correlated with age (P=0.002), but not with gender (P=0.490) or time of evolution (P=0.630). CONCLUSIONS: In our series, heterozygous ACE polymorphism (D/I) stands as a protective factor for DPN development. Accumulated incidence of DPN was relevant. Further prospective studies are warranted.

Body composition after endogenous (Cushing's syndrome) and exogenous (rheumatoid arthritis) exposure to glucocorticoids.

Exposure to chronic glucocorticoid (GC) excess determines changes in body composition. The aim of the study was to compare body composition in women exposed to endogenous hypercortisolism (Cushing's syndrome, CS), exogenous glucocorticoid treatment (rheumatoid arthritis, RA) and controls. Fifty-one CS women, 26 RA women treated with low-dose prednisone (5 mg/day or 10 mg/2 days), and 78 female controls were included. Fourteen CS patients were hypercortisolemic, 37 in remission (10 required hydrocortisone substitution after surgery). Body composition parameters were measured by dual-energy X-ray absorptiometry scanning (DEXA). RA patients had a greater waist-hip ratio (WHR) (p<0.01), less lean body mass (LBM) (p<0.01), and lumbar bone mineral density (BMD) (p<0.01) than controls. CS patients, globally and those with cured disease, had more total fat (both percentage and kg) and trunk fat percentage, and less whole body-BMD than RA patients (p<0.05, p<0.01, p<0.05, respectively). Active CS patients had less whole body-BMD and more LBM than RA patients (p<0.05, p=0.01, respectively). Cured CS patients not taking hydrocortisone had more total fat [both percentage (p<0.05) and kg (p<0.05)], trunk fat percentage (p<0.05), lumbar BMD (p<0.01) than RA patients. Cured CS patients requiring hydrocortisone only differed from RA patients by smaller WHR (p<0.01). All the differences in BMD disappeared when the data were reanalyzed including only the estrogen-deficient groups. Hypercortisoliof CS determines an irreversible increase in body fat, greater than in RA. Endogenous and exogenous exposure to GC negatively affects body composition by increasing the WHR. There appears to be no additional effect on BMD in estrogen-deficient women.

Clinical screening and diagnosis of diabetic polyneuropathy: the North Catalonia Diabetes Study.

BACKGROUND: To evaluate the prevalence of diabetic polyneuropathy (DPN) and develop a simple and accurate method for the evaluation of DPN risk in primary care settings. MATERIALS AND METHODS: Cross-sectional descriptive study in a random sample (N = 307) of type 2 diabetes mellitus participants. DPN was diagnosed by both clinical neurological examination and simplified DPN Selection Method in each patient. Correlation between the two methods was obtained. RESULTS: Prevalence of DPN was 23.13% (confidence interval,18.38-27.87) according to clinical neurological examination. Noteworthy, clinical neurological evaluation scores were related to nerve conduction studies (r = 0.882; P < 0.0005). DPN presence was positively related to age, metabolic control (HbA1c levels), known duration of diabetes, diabetic retinopathy, cardiovascular disease, peripheral ischemia and systolic and diastolic blood pressure, but was negatively related to current high-density lipoprotein cholesterol (HDL-C) levels (P < 0.0001). The sensitivity and specificity of our DPN Selection Method (using four clinical parameters: age, retinopathy, HbA1c and HDL-C plasma levels) for diagnosis of DPN was 74.20% and 74.90%, respectively. CONCLUSIONS: The expected prevalence of DPN was observed. The sensitivity of the DPN Selection Method correlated well with formal clinical neurological exam in detection of the condition. We therefore conclude the DPN Selection Method is a useful tool in primary care settings in the evaluation and diagnosis of DPN.

Persistent correlation of ghrelin plasma levels with body mass index both in stable weight conditions and during gastric-bypass-induced weight loss.

BACKGROUND: Studies done on serial changes in plasma ghrelin levels after gastric bypass (GBP) have yielded contrasting results since decreased, unchanged, or increased levels have been reported in the literature. This study investigates whether or not GBP has an inhibitory effect on fasting ghrelin levels independently of weight loss. METHODS: Fasting ghrelin levels were measured in 115 stable body weight females, classified as normal body weight (NW; body mass index (BMI)<25 kg/m2), overweight (OW; BMI 25-30 kg/m2), and obese subjects, divided in three subgroups with increasing BMI (BMI 30-40 kg/m2; BMI 40-50 kg/m2; BMI>50 kg/m2). RESULTS: Each obese subgroup showed significantly lower ghrelin levels as compared to both NW (p<0.0001) and OW subjects (p<0.05 or 0.005); however, no significant differences were observed within the three obese subgroups. Forty-nine obese patients underwent a GBP. Plasma ghrelin, measured at 3, 6, and 12 months after GBP, significantly increased from the sixth month on (p<0.0001). When patients were classified, at each postoperative time point, according to their actual BMI, ghrelin was significantly (p=0.0002) related to postoperative BMI and not significantly different from ghrelin measured in stable body weight conditions. CONCLUSIONS: Fasting ghrelin displays an inversely significant correlation with BMI in both stable body weight conditions and after GBP. No evidence was found that GBP had an effect on fasting ghrelin levels, independent of weight loss.

The effects of liposuction removal of subcutaneous abdominal fat on lipid metabolism are independent of insulin sensitivity in normal-overweight individuals.

BACKGROUND: Abdominal fat (both visceral and subcutaneous) accumulation is associated with an increased risk of developing insulin resistance. The latter stands as the basis upon which diabetes, hypertension, and atherogenic dyslipidemia tend to build up. Hence, abdominal liposuction (AL) could theoretically hold metabolic benefits. We undertook the present study to assess the effects of AL on carbohydrate and lipid metabolism. METHODS: This is a prospective study including 20 healthy volunteers (M2/F18) aged 39.6 +/- 7.7 years old (24-52), body mass index (BMI) = 25.3 +/- 4.7 kg/m(2) (19.8-36) who underwent AL. Before and 4 months after AL, we measured glucose and insulin concentrations, HOMA index [glucose (mM) x IRI (microUI/l)/22.5], free fatty acids (FFA), glycerol, total cholesterol and triglycerides, high-density lipoprotein (HDL)-cholesterol (HDL-c), low-density lipoprotein (LDL)-cholesterol (LDL-c), very low-density lipoprotein (VLDL)-cholesterol (VLDL-c) and apolipoproteins (apo) B, AI and AII, adiponectin (Adp), and ultra-sensitive C-reactive protein (CRP). RESULTS: Lipo-aspirate averaged 5.494 +/- 5.297 cc (600-19.000). Weight, BMI, and waist circumference decreased significantly 4 months after surgery by 4.6, 4.6 and 5.9%, respectively. There were significant decrements in FFA (-35%, p < 0.0001), glycerol (-63%, p < 0.0005), VLDL-c (-15.2%; p < 0.001), and triglycerides (-21.3%, p < 0.002), an increase in HDL-c (+10%, p < 0.03), Apo AI (+10.1%, p < 0.02), and Apo AII (+11.8%, p < 0.001). Total cholesterol, LDL-c, ApoB, and the LDL-c/ApoB ratio raised by +15% (p < 0.0005), +27.3% (p < 0.000), +15.1% (p < 0.008) and +2.76% (p < 0.008), respectively. Glucose, insulin, the HOMA index, Adp, and CRP were not significantly altered after AL. CONCLUSION: AL in healthy normal weight or slightly overweight subjects improves the major lipoprotein components of obesity-associated dyslipidemia. This improvement occurs independent of insulin sensitivity.

Gender-based dimorphic pattern for interleukin-1 receptor antagonist in type 2 diabetes mellitus.

UNLABELLED: Adipose tissue secretes a variety of cytokines, some of which are increased in the serum of obese patients. The anti-inflammatory interleukin-1 receptor antagonist (IL-1Ra) is the most highly elevated known cytokine in human obesity, and its serum levels are strongly associated with the degree of insulin resistance in non-diabetic patients. AIM: The present study examined serum levels of IL-1Ra in type 2 diabetic patients (T2DM) and their relationships with three other adipokines (leptin, interleukin-6 [IL-6], adiponectin). Their correlation with anthropometric and biochemical variables was examined, as well as their intraindividual fluctuations. METHODS: Fifty T2DM patients, aged 58+/-13 years, were consecutively recruited among those electively hospitalized for a one-week intensive training course with our Diabetes Education Service. Anthropometric measurements and blood samples were taken after an overnight fast on admission (baseline) and after four days. RESULTS: Mean serum levels of IL-1Ra and leptin, but not of IL-6 and adiponectin, were significantly higher in women than in men (P<0.0006), and this difference persisted after correction for body mass index (BMI) (P<0.0004). In addition, IL-1Ra and leptin were strongly correlated with the BMI (P<0.0004). By contrast, no significant correlations were observed between IL-1Ra and glucose-control parameters. Finally, all four adipokines exhibited wide interindividual variability, but with limited intraindividual fluctuations over the short time period. CONCLUSION: IL-1Ra, leptin and adiponectin serum levels exhibit marked interindividual variation with high intraindividual consistency. A gender-based dimorphic pattern for IL-1Ra, independent of the degree of adiposity and glucose control, was also found.

[Parathyroid carcinoma associated to secondary hyperparathyroidism in hemodialyzed patients. Two cases reports]. / Carcinoma de paratiroides asociado a hiperparatiroidismo secundario en pacientes en hemodiálisis.

Parathyroid carcinoma (PC) is an infrequent disease with a subtle initial presentation and a variable course, necessitating a high index of suspicion to make the correct diagnosis. In chronic failure patients on haemodialysis it becomes even more difficult to suspect this entity since the high prevalence of secondary hyperparathyroidism(SHP). Two patients with PC out of a series of 160 patients with moderate-to-severe SHP submitted for parathyroidectomy are reported. Their clinical features are compared with those of the twenty-two cases previously reported in the literature with a discussion of this pathology. Patients with PC showed higher blood levels of iPTH, total calcium, phosphate and total alkaline phosphatase than the SHP population. The final diagnosis of PC was made after histological study revealing capsular or blood vessel invasion.

Carcinoma de paratiroides asociado a hiperparatiroidismo secundario en pacientes en hemodiálisis / Parathyroid carcinoma associated to secondary hyperparathyroidism in patients on dialysis: two cases reports

El carcinoma de paratiroides (CP) es una enfermedad rara caracterizada por la rápida aparición de sus síntomas y su variable evolución, precisando un índice alto de sospecha para su correcto diagnóstico, siendo más difícil de sospechar en los enfermos con enfermedad renal crónica en hemodiálisis, dada la elevada prevalencia de hiperparatiroidismo secundario (HPS) en pacientes en diálisis. Analizamos dos casos de pacientes con CP extraídos de una serie de 160 con HPS moderado-severo sometidos a paratiroidectomía y comparamos sus hallazgos clínicos con los 22 casos publicados previamente con una discusión de su patología. Comparados con la población de HPS, observamos que los pacientes con CP mostraban niveles séricos más elevados de PTHi, calcio, fósforo y fosfatasas alcalinas. El diagnóstico final de CP ha sido siempre histopatológico, mostrando invasión capsular o de los vasos sanguíneos

Parathyroid carcinoma (PC) is an infrequent disease with a subtle initial presentation and a variable course, necessitating a high index of suspicion to make the correct diagnosis. In chronic failure patients on haemodialysis it becomes even more difficult to suspect this entity since the high prevalence of secondary hyperparathyroidism (SHP). Two patients with PC out of a series of 160 patients with moderate-to-severe SHP submitted for parathyroidectomy are reported. Their clinical features are compared with those of the twenty-two cases previously reported in the literature with a discussion of this pathology. Patients with PC showed higher blood levels of iPTH, total calcium, phosphate and total alkaline phosphatase than the SHP population. The final diagnosis of PC was made after histological study revealing capsular or blood vessel invasion

Link between obesity and type 2 diabetes.

The relationship between obesity and diabetes is of such interdependence that the term 'diabesity' has been coined. The passage from obesity to diabetes is made by a progressive defect in insulin secretion coupled with a progressive rise in insulin resistance. Both insulin resistance and defective insulin secretion appear very prematurely in obese patients, and both worsen similarly towards diabetes. Thus, the classic 'hyperbolic relationship' between insulin resistance and insulin secretion and the 'glucose allostasis concept' remain prevailing concepts in this particular field of knowledge. An increase in overall fatness, preferentially of visceral as well as ectopic fat depots, is specifically associated with insulin resistance. The accumulation of intramyocellular lipids may be due to reduced lipid oxidation capacity. The ability to lose weight is related to the capacity to oxidize fat. Thus, a relative defect in fat oxidation capacity is responsible for energy economy and hampered weight loss.

Renal transplantation in a C-ANCA(+) patient with Behcet disease and rapidly progressive glomerulonephritis.

Behcet's disease (BD) is a chronic, relapsing, inflammatory disorder, and the underlying histophatological lesion is vasculitis of unknown cause. Some case reports of BD with positive C-ANCA titers have been reported, but only 2 case reports have documented the association of ANCA-associated glomerulonephritis (GN) and BD, and no renal transplantation cases have been described. We report such a case. A 27-year-old male was referred for consultation due to acute renal failure. Seven years before, BD was diagnosed. At the time of consultation he suffered from uveitis and generalized arthralgias. The serum creatinine was 14 mg/dl and urinalysis showed 4+ protein and microscopic hematuria. Results of serological tests were normal. The ANCA PR 3 titer was 1:100 of cytoplasmic pattern. A renal biopsy showed a rapidly progressive type III glomerulonephritis. In spite of immunosuppressive therapy with cyclophosphamide and high steroid doses, renal function did not recover and hemodialysis therapy was initiated. One year later, the patient underwent a renal transplantation. Follow-up was absolutely normal, and 5 years after transplantation, renal function persisted to be normal, without urinary abnormalities and signs of reactivation of original disease, except for occasional arthralgias. C-ANCA titer was decreased and remained stable (<1:30). He is now receiving maintenance immunosupression with cyclosporin and prednisone. This report shows the long-term successful renal transplantation in a patient with ANCA-associated glomerulonephritis and BD. The success of renal transplant in BD with renal involvement is encouraging and should be pursued.

New interdisciplinary cognitive-behavioural-nutritional approach to obesity treatment: a 5-year follow-up study.

OBJECTIVE: The aim of this prospective case-control study was to assess the long-term effectiveness of interdisciplinary cognitive-behavioural-nutritional therapy, combined with daily physical exercise and relaxation sessions, on weight and psychosocial issues during a 6-week in-hospital stay. SETTING: Five years (60 +/- 1 months) later, the patients were readmitted for a one-day medical evaluation including a physical examination and laboratory work-up, and the completion of a detailed questionnaire focusing on dietary and psychosocial factors that may affect weight loss/regain. SUBJECTS: The follow-up population consisted of 55 morbidly obese subjects aged 49.5 +/- 2 years (45 females and 10 males; BMI: 40 +/- 0.7 kg/m2). During their initial 6-week in-hospital stay, they lost an average of 7.6 +/- 0.4 kg. RESULTS: Five years later, 25.5% of the patients had lost a further 11.9 +/- 1.8 kg, 20% maintained their initial weight loss (0.6 +/- 0.4 kg), and 54.5% regained weight (10.4 +/- 1 kg). The weight changes significant correlated with the degree of psychosocial difficulties (p < 0.001), eating behaviour problems (p < 0.001), dietary fat intake (p < 0.005) and total energy intake (p < 0.05). Fasting plasma insulin and blood glucose concentrations were significantly higher in the patients who regained weight after five years, and significantly lower in those who had lost more weight. CONCLUSION: As a whole, these results show the efficacy of an interdisciplinary approach to the long-term treatment of morbidly obese patients. It is likely that an outpatient psychological follow-up would have improved this therapeutic success.

A new table for prevention of hypoglycaemia during physical activity in type 1 diabetic patients.

OBJECTIVE: The ability to adjust both insulin and nutrition to allow safe participation in physical activity and high performance has recently been recognized as an important management strategy in these patients. In particular, the important role played by the patient in self-monitoring blood glucose during physical activity and then using these data to improve performance and decrease hypoglycaemias is now fully accepted. The primary objective of this study is to compare different therapeutic options in exercising Type 1 diabetic patients (n=67) with or without CHO compensation and/or with or without insulin dosage reduction in order to prevent hypoglycaemias during and after exercise. METHODS: Sixty-seven type 1 diabetic patients were aggregated into four treatment categories according to four strategies to prevent hypoglycaemia episodes, with or without carbohydrate compensation and/or with or without insulin dosage reduction. The protocol included 7 different disciplines and 9 subgroups according to 3 different durations (<20 min., 20-60 min., > 60 min.) and 3 intensity degrees (<60% of Maximal Heart Rate, 60-75% and > 75%). RESULTS: Our study shows that by replacing adequately the carbohydrates during the practice of physical exercise it is possible to prevent almost all hypoglycaemia episodes, independently of the insulin dosage adjustments. Furthermore, the amount of extra-carbohydrates correlates well with the number of hypoglycaemia while the decrease in insulin dosage does not. CONCLUSION: Adequate carbohydrate replacement during and after exercise seems to be the most important measure to prevent hypoglycaemia. However, the insulin dosage adjustment does not play such an important role. A decrease from 20 to 30% seems reasonable only for a long duration exercise (> 60 min.). Finally, a new user-friendly table for prevention of hypoglycaemia is proposed for physical activity of different intensity and duration.

Reflex sympathetic dystrophy syndrome in renal transplanted patients under immunosuppression with tacrolimus.

Reflex sympathetic dystrophy syndrome (RSDS), which probably has a multifactorial etiology, may appear after kidney transplantation. Its clinical manifestations include severe periarticular pain with inflammatory signs, especially in knees and ankles, causing functional disability. Symptoms develop during the first 3 months after transplantation and usually disappear 3 to 6 months later without sequelae. In renal transplant recipients it has previously been related to immunosuppressive treatment with cyclosporine. Therefore we had suggested that introducing tacrolimus could be a therapeutic option. We now present four cases of RSDS in kidney transplant recipients treated with tacrolimus. All but one patient were receiving tacrolimus monotherapy, excluding other drugs that might have been involved to cause the syndrome. It is also interesting that one of our cases develop RSDS long after transplantation when immunosuppressive treatment was changed. Symptoms correlated with an increase in alkaline phosphatase and with bone scintigraphy findings. All patients recovered without sequels 3 to 6 months afterward. In conclusion, RSDS is a relevant osteoarticular complication in patients receiving either anticalcineurinic drug (CyA or tacrolimus), even under monotherapy or with a low steroid dose.

Interest of pronostic score for optimal clinical management of obese patients.

OBJECTIVE: The aim of this retrospective study was to identify key factors favoring weight regain. METHODS: Therefore, prognostic factors for weight loss and regain have been retrieved and identified among 186 obese patients (40 +/- 2 y and 34 +/- 0.3 kg/m(2)) through the use of a simple questionnaire which considered psychological issues such as depression, anxiety and the patient's individual capacity to follow a diet. All patients have been prescribed a low-calorie diet (1200 kcal/day) being either balanced, food-combining or low-CHO. Follow-up averaged 6.4 +/- 0.3 months of which weight loss accounted for 4.4 +/- 0.1 months. RESULTS: Weight loss was similar in all 3 groups and averaged 6.0 +/- 0.2 kg. The final weight loss and weight regain results have been identical for the 3 groups. A high/bad prognostic score rating is associated with weight regain (P<0.02). Weight regain is significantly influenced by the initial weight loss speed (P<0.0001). CONCLUSIONS: The proposed prognostic score is likely to be helpful for clinicians better to profile the therapeutic approach to individualized obesity management and follow-up. Diet composition does not influence either weight loss or weight regain.

Double-phase parathyroid 99mTc-Sestamibi scintigraphy in chronic haemodialysis patients: correlation with biochemical markers of parathyroid function.

99mTc-Sestamibi identifies the presence of hyperfunctioning autonomous parathyroid glands in patients with secondary hyperparathyroidism (SHP). The objectives of this study were: (i) to evaluate the interdependence between biochemical markers of SHP and 99mTc-Sestamibi uptake; and (ii) to determine whether 99mTc-Sestamibi uptake could be efficiently predicted by any combination of the former variables. Double-phase parathyroid 99mTc-Sestamibi uptake and total serum calcium, phosphorus, intact parathormone, 25-OH vitamin D and 1,25(OH) vitamin D determinations were performed simultaneously in 74 patients (36 female, 38 male) with SHP. Planar images of the neck and upper thorax were obtained in anterior view, 15 min (early phase) and 120 min (delayed phase) after the injection of 740 MBq of 99mTc-Sestamibi. In each patient, a final parathyroid/thyroid (P/T) activity index was obtained by adding the results of the P/T index of all parathyroid lesions. There was a significant correlation between intact parathormone levels and delayed 99mTc-Sestamibi uptake ( r=0.656; P<0.01). Of all the variables, intact parathormone was the only significant predictor of delayed 99Tc-Sestamibi uptake ( r=0.487; P<0.001). Calcium, phosphorus, vitamin D metabolites, age, gender, time spent on haemodialysis and cause of chronic renal failure displayed no significant correlation with 99mTc-Sestamibi uptake. It can be concluded that 99mTc-Sestamibi uptake is a potential predictor of parathyroid function in SHP patients. Hence, 99mTc-Sestamibi scintigraphy could be useful to assess parathyroid function and in the clinical follow-up of these patients.

Acarbose improves indirectly both insulin resistance and secretion in obese type 2 diabetic patients.

BACKGROUND: Acarbose is an oral antidiabetic mainly acting on postprandial blood glucose, inhibiting alphaglucosidase. Through this mechanism, it could improve the peripheral insulin sensitivity and/or increase the insulin secretion. The aim of the present study is to assess the therapeutic efficacy of Acarbose in obese type 2 diabetic patients on both insulin resistance and insulin secretion. METHODS: 17 obese non insulin-dependent diabetic patients, well controlled with diet alone were randomized into 2 groups: acarbose (2 x 50 mg) or placebo during 16 weeks. A glucagon test allowed to evaluate insulin secretion before and after treatment as well as a triple test (glucose-insulin-somatostatin) with indirect calorimetry allowed to evaluate insulin sensitivity. RESULTS: A significant improvement in post-prandial plasma glucose was detected only in the Acarbose group (8.0 +/- 0.5 mmol/l before vs 6.5 0.5 mmol/l after, p<0.05). Basal C-peptide secretion was similar between groups and remained unchanged after treatment. However, stimulated insulin secretion was significantly increased by 30%, p<0.05, in the Acarbose group while no change was detected in the placebo group. Interestingly, the group receiving Acarbose disclosed a 15% reduction in insulin resistance (15.0 +/- 1.8 mmol/l before vs 12.8 +/- 1.4 mmol/l after). CONCLUSIONS: Our results show that a treatment with Acarbose is efficient even in diabetic patients presenting a good glucose control without any other associated treatment. By decreasing post-prandial blood glucose, acarbose improves both insulin sensitivity and secretion.

Causas de satisfacción y de insatisfacción de los pacientes en hospitales y atención primaria / Causes of patients' satisfaction and dissastisfaction

Introducción: En el sector sanitario se utilizan diferentes aproximaciones metodológicas (tanto cuantitativas como cualitativas) para identificar los aspectos de la atención sanitaria más importantes para los pacientes. Estos estudios han sido utilizados para diseñar instrumentos de evaluación de la satisfacción del paciente, identificando las dimensiones que debían ser evaluadas para conocer mejor sus opiniones. Objetivo: Identificar los aspectos que los pacientes señalan como causa de satisfacción e insatisfacción en diferentes servicios médicos. Método: Diseño cualitativo combinando las técnicas de grupo focal y grupo nominal. En total creamos 20 grupos de trabajo, colaborando 10 hospitales y 4 centros de salud. Sujetos: Participó un total de 171 pacientes que habían sido atendidos en diferentes servicios sanitarios: medicina y cirugía, obstetricia, pediatría, consultas externas y urgencias y centros de atención primaria. Resultados: Los pacientes, independientemente del grupo en el que participaban, consideraron como causas de satisfacción: el trato humano y personalizado, la empatía, la capacidad de respuesta, la calidad de la información recibida y el confort de las instalaciones. Por otro lado, consideraron como causas de insatisfacción: la falta de coordinación del personal sanitario cuando sucedía, las listas de espera y los retrasos en la atención, en obtener los resultados de las diferentes pruebas o en comunicar el diagnóstico. Conclusiones: Empatía, trato y confort son los motivos más frecuentes de "buenas experiencias", mientras que la accesibilidad y ciertos aspectos organizativos son los motivos más citados como causas de insatisfacción (AU)

Evaluation of a psycho-educational nutritional program in diabetic patients.

In this study, we have retrospectively (2 years) assessed the efficacy of the nutritional education (NE) program provided to 83 diabetic patients during an in-hospital training week. Two years after NE, type 1 diabetic patients have decreased significantly their total caloric intake, protein (P<0.05) and fat consumption. Type 2a diabetic patients disclosed a significant increase in CHO consumption while type 2b diabetic patients decreased their fat consumption, SFA consumption and total caloric intake. The percentage of patients following the European Association Study for Diabetes (EASD) nutritional recommendations regarding fat intake has increased significantly in all three diabetic groups and in type 2a diabetic patients regarding CHO consumption. In conclusion, a psycho-educational nutritional education program of 1 week allows a significant improvement of the alimentary behavior 2 years thereafter with 45% of the diabetic patients following the current EASD dietary recommendations.