[Evaluation of a follow-up program for diabetes after hospital discharge]. / Evaluación de un protocolo de seguimiento para diabetes tras el alta hospitalaria.

BACKGROUND: Given the higher rate of hospital admissions among diabetic patients, discharge should be used to optimize outpatient treatment. We evaluate a follow-up program for diabetic patients after hospital discharge to determine the evolution of glycemic control. METHOD: Retrospective collection of data on 375 diabetic patients enrolled in the follow-up program for optimization treatment: telephonic follow-up where treatment was adjusted if needed; and three months after discharge an in-person consultation was scheduled. Factors potentially associated with a 1% improvement in HbA1c were studied by multivariate logistic regression. RESULTS: Seventy-three percent of enrolled patients completed the follow-up program; each patient received an average of 4.6 phone calls. Globally, basal mean HbA1c was significantly lower three months later regarding the initial value (8.6 vs. 7.2%); the most relevant lowering was found in the group of hyper-glycemia by poor metabolic control (from 9.9 to 7.7%), combined hyperglycemia (from 9.3 to 7.3%) and debut (from 8.3 to 6.4%). Twenty percent of patients reported capillary hypoglycemia, with two severe events. A shorter duration of diabetes, absence of corticotherapy and absence of hypoglycemia during the follow-up period were independent predictors for a 1% reduction in three-months HbA1c. CONCLUSION: In patients whose treatment is changed on hospital discharge, a program allowing frequent treatment adjustment would improve HbA1c levels. These results could help to organize health resources more rationally.

Comparison of treatment with continuous subcutaneous insulin infusion versus multiple daily insulin injections with bolus calculator in patients with type 1 diabetes.

OBJECTIVES: A study of the glycemic control, quality of life, and fear and perception of hypoglycemia by comparing continuous subcutaneous insulin infusion (CSII) group with multiple daily inyections (MDI) with bolus calculator group. MATERIAL AND METHODS: This is a retrospective cohort study with following up during the first 12 months that CSII group (n=30) begins the use of "bolus wizard" and the MDI-calculator (n=30) group begins the use of the bolus calculator (Accu-Chek(®) Aviva Expert). PRIMARY OUTCOME: HbA1c (3, 6 and 12 months). Questionnaires used: EsDQOL (quality of life), FH-15 (fear of hypoglycemia), and Clarke (perception of hypoglycemia). STATISTICAL ANALYSIS: T Student and nonparametric tests. RESULTS: The average reduction in HbA1c during the study was significantly higher in CSII group (-0.56±0.84%) compared with the MDI group (0.097±0.94%), P=.028. The average basal insulin dose was significantly higher in the MDI group (at baseline, 6 and 12 months). No significant differences were found between the 2 treatment groups after analyzing the EsDQOL, FH-15 and Clarke questionnaires. In the CSII group, perceived quality of life assessed by the EsDQOL questionnaire was found to be better at the end of the study than at the beginning of using the insulin pump. CONCLUSIONS: The average reduction in HbA1c was significantly higher in the CSII group. In the CSII group, perceived quality of life was better at the end of the study than at the beginning.

Análisis de los resultados de la terapia subcutánea continua de insulina como alternativa al tratamiento intensivo en pacientes con diabetes mellitus tipo 1 / Analysis of the results of continuous subcutaneous insulin therapy as an alternative to intensive treatment in type 1 diabetic patients

Objetivo: Verifi car la efectividad del tratamiento y determinar las característicasclínicas de los pacientes que han podido infl uir en elcontrol metabólico posterior. Materiales y métodos: Se estudió a37 pacientes (21 varones y 16 mujeres), con una media de edad de36,2 ± 9,4 años. El tiempo de evolución de la diabetes previa a lainfusión subcutánea continua de insulina (ISCI) fue de 16,2 ± 7,4 años.Las complicaciones angiopáticas fueron la retinopatía (50%), la nefropatía(19%) y la neuropatía (11,4%). Los motivos de indicaciónde ISCI fueron los siguientes: mal control (33,3%), petición propia(27,8%), hipoglucemias (22,2%), variabilidad glucémica (13,9%)y otros (2,7%). Resultados: Se observó un descenso de la hemoglobinaglucosilada (HbA1c) a los 12 meses de –0,71 ± 0,58%(p <0,001), que se mantuvo a los 36 meses en valores de –0,9 ±0,54% (p <0,001). Los requerimientos de insulina basal disminuyerony posteriormente se mantuvieron estables (inicio: 0,29 ± 0,08U/kg/día; 36 meses: 0,32 ± 0,14 U/kg/día). Se apreció una gananciade peso en los pacientes de 2,7 ± 4,8 kg a los 3 años con ISCI.Los participantes con una mayor HbA1c basal y un tiempo más largode evolución de la diabetes presentaron un descenso superior de laHbA1c con ISCI. Conclusiones: Se constató una mejora mantenidadel control glucémico y un descenso de las necesidades de insulinabasal. El mayor descenso de la HbA1c se obtuvo en los pacientes conuna mayor evolución de la diabetes y un peor control, que eran factorespronóstico de una mejor respuesta a esta terapia(AU)

Aim: To verify the efficacy of CSII treatment and determine patient’sclinical features that could have influenced the posterior metaboliccontrol. Methods: 37 patients; 21 males and 16 females, meanage of 36.2 ± 9.4 years. Mean duration of diabetes prior to CSII of16.2 ± 7.4 years and previous year mean A1c of 8.1 ± 0.9%. Diabeticcomplications: 50% retinopathy, 19% nephropathy, and 11.4%neuropathy. Indications for CSII: poor metabolic control (33.3%), patientrequest (27.8%), frequent hypoglycaemia (22.2%), glycaemicvariability (13.9%) and other (2.8%). Results: Starting A1c was loweredsignificantly in the first year of CSII –0.71 ± 0.58% (p <0.001)and stable –0.9 ± 0.54% (p <0.001) after 36 months. Basal insulinrequirements decreased and subsequently remained stable(start: 0.29 ± 0.08 U/kg/d; after 36 months: 0.32 ± 0.14 U/kg/d;p <0.001). The greatest reduction in A1c was found in patients withhigher baseline A1c and longer duration of diabetes. Conclusions:CSII resulted in a steady improvement in glycaemic control and reductionin insulin requirements. it could be considered a predictorfactor of treatment effect(AU)

Persistent increase of PRL after oral contraceptive treatment. Alterations in dopaminergic regulation as possible etiology.

BACKGROUND: The mechanism involved in estrogen induced hyperprolactinemia is not completely known, although one of the possible theories suggest inhibition of dopaminergic tone. Our objective was to study the mechanism implied in the increment of PRL levels as a consequence of oral contraceptive treatment and possible modifications in TSH levels. MATERIAL AND METHODS: We performed a trial on 21 healthy women, nulliparas. We administered 35 microg of Etinil-Estradiol (EE) and 2 mg of Ciproterone Acetate (CA) for a period of 12 months. Stimulation tests with Metoclopramide and TRH were carried out before treatment, after 3, 6 and 12 months of treatment and finally 6 months after cessation of treatment. RESULTS: Basal levels of PRL (mean=12.62 ng/ml) increased significantly (p<0.05) during the year of treatment (mean12=17.04 ng/ml) and maintained higher levels 6 months after cessation (meanl8=17.53 ng/ml). Maximum values obtained in response to metoclopramide (mean1=154.78) were significantly higher after 12 months (mean12=173.29), persisting 6 months after cessation of treatment (mean18=245.28). We also observed significant differences in the maximum response of TSH to metoclopramide during the same period of study (mean6=2.45), (mean12=2.76) and (mean18=2.07) respectively (p<0.05). We did not find changes in PRL and TSH responses to TRH stimulation after a year of treatment with EE and CA. CONCLUSION: Treatment with EE (35 microg) and CA (2 mg) induces an increase in PRL levels that persist 6 months after cessation of treatment. Our results rule out the possibility that this increase in PRL is due to a decrease in dopaminergic tone or an increase in TRH sensitivity.

[Recurrence of Graves-Basedow disease: the influence of treatment schedule]. / Recidivas en la enfermedad de Graves-Basedow: influencia de la pauta de tratamiento.

BACKGROUND: The aim of the present study was to evaluate the possible influence of 2 different methods of treatment (antithyroid drugs and antithyroid drugs plus levothyroxine) on the number of recurrences in Graves' disease, as well as to study the possible prognostic factors for the evolution of the disease. METHODS: Seventy-six patients allocated in to 2 treatment groups were studied. Group A included those patients treated with decreasing doses of carbimazole and group B included patients treated with high doses of carbimazole plus levothyroxine. The follow-up of these patients was carried out over a minimum of 36 months after discontinuation of treatment. RESULTS: No significant differences were observed in either the clinical characteristics or hormonal or antibody values in both groups on initiation and at the end of treatment. The percentage of recurrence in group A patients during the first 12 months of follow-up was significantly greater (65% vs 23%, p < 0.001) than in group B. The percentage of recurrence equalled (62.8% vs 60.7%, p = NS) on prolongation of follow-up of up to 36 months. Recurrence was not correlated with either the clinical or biochemical parameters evaluated, although it did correlate with goiter size with recurrence observed in 100% of the patients with goiter greater than or equal to II. CONCLUSION: The association of levothyroxine to treatment with carbimazole in Graves' disease delays the appearance of recurrence but does not significantly decrease it in comparison with the treatment with carbimazole in decreasing doses. Only the size of goiter on initiation of treatment may be a prognostic factor for disease evolution.