[Epidemiology of diabetes and its non-coronary complications]

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017)

INTRODUCTION

Diabetes mellitus (DM) is one of the most prevalent chronicdiseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease (VD) reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models.

OBJECTIVE

To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM).

PATIENTS AND METHODS

A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model.

RESULTS

During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level < 8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction (AMI) and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (P = .001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14 ± 1.73%; 95% CI: 0.73-1.55; P = .0001) and cholesterol (11.28 ± 40 mg/dL; 95% CI: 2.07-20.48; P = .012).

CONCLUSIONS

This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

Prevalence, Patterns and Predictors of Chronic Complications of Diabetes Mellitus at a Large Referral Hospital in Ethiopia: A Prospective Observational Study

PURPOSE

Diabetes mellitus complications are responsible for increased disability, morbidity, and mortality. This study aimed to assess prevalence, patterns, and predictors of chronic complications of diabetes among people with diabetes.

PATIENTS AND METHODS

The study was conducted using a prospective observational study design which was done on people with diabetes attending the ambulatory clinic of Mettu Karl Referral Hospital. The data were collected using a consecutive type of sampling technique from April 15 to August 9, 2019. The data were entered into Epidata manager version 4.4.2. Logistic regression analysis was done to identify predictors of chronic complications of diabetes.

RESULTS

A total of 330 participants were included in this study. The mean age of participants was 49.9±14.2, and 156 (47.3%) were 41 to 60 years old. About 127 (38.5%) had one or more chronic complications. The predictors of chronic diabetes complications were resident in urban areas [AOR: 1.94; 95% CI: (1.17, 3.20); p = 0.010], duration of diabetes 10 years [AOR: 2.05, 95% CI: (1.21, 3.47); p = 0.007], hypertension [AOR: 4.19; 95% CI: (2.54, 6.91); p < 0.001] and poor glycemic control [AOR: 2.82; 95% CI: (1.53, 5.21); p = 0.001].

CONCLUSION

Almost two-fifth of the study participants had chronic complications of diabetes. Residents in urban areas, longer duration of diabetes, hypertension and poor glycemic control were predictors of chronic diabetes complications. It is important to achieve good glycemic control and manage comorbid diseases like hypertension to minimize the risk of chronic diabetes complications.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017)

INTRODUCTION

Diabetes mellitus (DM) is one of the most prevalent chronic diseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models.

OBJECTIVE

To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM).

PATIENTS AND METHODS

A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model.

RESULTS

During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level<8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (p=0.001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14±1.73%; 95% CI: 0.73-1.55; p=0.0001) and cholesterol (11.28±40mg/dL; 95% CI: 2.07-20.48; p=0.012).

CONCLUSIONS

This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

Trace elements in saliva and plasma of patients with type 2 diabetes: Association to metabolic control and complications

AIM

An analysis is made of the saliva and plasma levels of trace elements in patients with type 2 diabetes mellitus and their association to metabolic control and the presence of chronic complications.

METHODS

A cross-sectional observational clinical study was carried out in 74 patients with type 2 diabetes mellitus. Mass spectrometry (ICP-MS) was used to determine the following trace elements in plasma and unstimulated basal saliva: ¹³Al, ¹⁶S, ⁴Be, ⁵B, ²⁰Ca, ²⁷Co, ²⁹Cu, ²⁴Cr, ³⁸Sr, ¹⁵P, ³Li, ¹²Mg, ²⁵Mn, ²⁸Ni, ⁸²Pb, ³⁷Rb, ²²Ti, ²³V and ³⁰Zn.

RESULTS

The levels of cobalt (p = 0.048) in saliva and of strontium (p = 0.001) in plasma were related to the presence of chronic complications. Significant differences with respect to metabolic control were observed for beryllium (p = 0.038), boron (p = 0.023) and phosphorus in saliva (p = 0.046), and for rubidium (p = 0.005), titanium (p = 0.016) and zinc in plasma (p = 0.013). A significant correlation (p < 0.001) was found between boron in plasma and boron in unstimulated basal saliva.

CONCLUSIONS

The determination of trace elements in plasma and saliva constitutes a complementary tool for the assessment of metabolic control and for predicting chronic complications associated to type 2 diabetes mellitus. Further studies involving the biomonitoring of trace elements in saliva and plasma are needed.

Current Therapeutic Strategies in Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) are the fastest growing chronic complication of diabetes mellitus, with more than 400 million people diagnosed globally, and the condition is responsible for lower extremity amputation in 85% of people affected, leading to high-cost hospital care and increased mortality risk. Neuropathy and peripheral arterial disease trigger deformities or trauma, and aggravating factors such as infection and edema are the etiological factors for the development of DFUs. DFUs require identifying the etiology and assessing the co-morbidities to provide the correct therapeutic approach, essential to reducing lower-extremity amputation risk. This review focuses on the current treatment strategies for DFUs with a special emphasis on tissue engineering techniques and regenerative medicine that collectively target all components of chronic wound pathology.

Structural, Dermal and Ungual Characteristics of the Foot in Patients with Type II Diabetes

Background and Objectives: Diabetes is a chronic and metabolic disease, considered as an important public health problem. The objective of this study was to determine the prevalence of podiatric pathology in type II diabetic patients. Materials and Methods: An observational descriptive study of prevalence in the endocrinology service of Complexo Hospitalario Universitario A Coruña (CHUAC) (A Coruña-Spain) was carried out (n = 153). Type II diabetic patients included, of legal age who signed the informed consent. Sociodemographic variables were studied (age, sex, body mass index (BMI), smoking habit, alcohol consumption, family history), disease variables (time of evolution of diabetes, treatments, low-density lipoprotein (LDL), high-density lipoprotein (HDL), glucose), podiatric variables: measurement of the footprint, metatarsal and digital formula, nail, skin, hindfoot and forefoot alterations. The data collection was done in 2018 and the data analysis was carried out in 2019. Results: The patients with type II diabetes had greater age, obesity and arterial hypertension it compared to the general population. Diabetic patients had a higher prevalence of flat feet than the general population (71.2% vs. 20.7%, p < 0.001), with a predominance of normal foot according to the podoscope. The predominant podological pathology was the presence of claw toes (94.8%), followed by dermal (78.4%) and nail (71.9%) alterations, and the Hallux Valgus (66.0%). The Clarke angle and the Chippaux index showed a Kappa concordance index of 0.26 with the type of footprint measured with the podoscope. The Staheli index showed a Kappa index of 0.27 associated with an observed agreement of 54%. Conclusions: This study shows that foot problems continue to be prevalent in subjects with type II diabetes mellitus and for this reason, podiatry is essential in its treatment.

Trace Elements in Saliva as Markers of Type 2 Diabetes Mellitus

To analyze Mg, Ca, and Zn levels in saliva, comparing patients with type 2 diabetes mellitus and a control group of healthy subjects. This transversal, observational, clinical study included a total sample of 147 patients, 74 with type 2 diabetes mellitus and a control group of 73 healthy subjects. Socio-demographic, anthropometric, diabetological, and metabolic variables were registered. Trace elements in non-stimulated basal saliva were measured using inductively coupled plasma mass spectrometry (ICP-MS): Mg, Ca, and Zn. Concentrations of zinc, calcium, and magnesium were significantly higher in the diabetic group than the control group (p < 0.001). A relation was observed between waist circumference and high cardiovascular risk in men (based on two categories: waist circumference < 102 cm; waist circumference ≥ 102 cm), and magnesium levels in saliva (p = 0.003). Magnesium, zinc, and calcium levels in saliva could be useful markers for differentiating patients with type 2 diabetes mellitus from non-diabetics. The salivary magnesium could be used as a marker of high cardiovascular risk when associated with abdominal obesity represented by a waist circumference ≥ 102 cm in men. The present results do suggest that salivary zinc levels could act as a good marker of type 2 diabetes mellitus, in light of zinc's well-known role as a co-marker of insulin and its relationship to carbohydrate metabolism.

Specific foot health-related quality-of-life impairment in patients with type II versus type I diabetes

The aims of this research were to evaluate and compare the effect in a matched sample of patients with type II and type I diabetes scores using a specific quality-of-life (QoL) tool related to overall and foot health (Foot Health Status Questionnaire [FHSQ]). A sample of 62 patients with an age median of 59.00 ± 19.00 y were divided into type I (n = 31) and type II (n = 31) diabetes groups. Socio-demographics data include: (1) age, (2) gender, (3) body mass index, (4) professional activity, (5) study level, and (6) civil status. The FHSQ was used to evaluate foot (pain, function, footwear, and general health section I domains) and overall (general health, social capacity, physical activity, and vigour section II domains) health related to QoL. Differences between groups were assessed by means of a t test or Mann-Whitney U test for independent samples. There were no statistically significant differences (P > 0.05) for any socio-demographic data. Regarding the FHSQ section II of the specific foot health-related QoL, the only statistically significant differences (P = 0.042) were observed for the general foot health showing a QoL impairment (lower median ± interquartile range) in patients diagnosed with type II diabetes (60.00 ± 60.00 points) compared with patients who suffered from type I diabetes (25.00 ± 72.50 points). The other domains did not show any statistically significant differences (P > 0.05). Patients with type II diabetes present a negative impact on the specific foot health-related QoL compared with patients who suffered from type I diabetes.

Age and sex differences in the incidence of diabetes mellitus in a population-based Spanish cohort

BACKGROUND

The prevalence of diabetes mellitus (DM) in Spain ranges between 10% and 20%. However, very little is known about the incidence of DM because of difficulties involved in estimating it and its apparent lack of usefulness in practice. The aim of the present study was to describe the incidence of type 1 and type 2 DM (T1DM and T2DM, respectively) in the Castilla y León diabetes cohort (CODICyL).

METHODS

New diabetes cases, were registered on a standard form that included diagnostic criteria, background, symptoms, results of clinical examination, complications, other cardiovascular risk factors, and treatment. There were 1 354 619 person-years monitored between 2000 and 2013. We estimated the incidence of DM and calculated the relative risks adjusted for age, gender, and year of diagnosis with Poisson regression models.

RESULTS

The incidence of DM in individuals aged ≥15 years was 196.9 per 100 000 person-years (95% confidence interval [CI] 188.4-205.7), whereas in those aged <15 years the incidence was 10.8 per 100 000 person-years (95% CI 7.8-14.8). Men had a 36% higher risk than women of developing T2DM (95% CI 25%-49%). The greatest incidence of T2DM was found in 55-64-year-old men and 65-69-year-old women.

CONCLUSIONS

The annual incidence of T2DM is approximately 2 per 1000 person-years, higher in men, and peaks in middle age. Although specific tests to differentiate between the two types of DM are not available in this study, the estimation of incidence in those <15 years of age (10.8 per 100 000 person-years) represents a close approximation of the incidence of T1DM.

Polyol pathway: A possible mechanism of diabetes complications in the eye

In complex diseases such as diabetes mellitus, the causative agents include various serum factors such as glucose, aldose reductase, oxygen-free radicals, advanced glycation end products, protein kinase-C and growth factors. The polyol pathway is a pathway of glucose metabolism and is regarded as an important element in the pathogenesis of refractive changes, cataract formation and diabetic retinopathy in individuals with diabetes mellitus. The focus of this review is on the role of the polyol pathway in the pathogenesis of diabetic complications in the eye. The first enzyme (aldose reductase) in the polyol pathway reduces glucose to sorbitol. The second enzyme (sorbitol dehydrogenase) converts sorbitol to fructose. The accumulation of sorbitol and fructose in the crystalline lens and retina leads to the generation of oxidative stress. Oxidative stress is the imbalance between levels of reactive oxygen species and the antioxidant defence in a biological system, and it results in tissue damage. How hyperglycaemia leads to oxidative stress is not clear but could be through a combination of increased levels of reactive oxygen species and decreased capacity of the cellular antioxidant system. Oxidative stress causes the development of diabetic complications that are seen clinically.

Diabetes in older people: Prevalence, incidence and its association with medium- and long-term mortality from all causes

OBJECTIVE

To estimate the prevalence and incidence of self-reported diabetes and to study its association with medium- and long-term mortality from all causes in persons ≥ 65 years.

DESIGN

A population-based cohort study begun in 1993.

SETTING

"Envejecer en Leganés" cohort (Madrid).

PARTICIPANTS

A random sample of persons ≥ 65 years (n=1277 in the 1993 baseline sample).

METHODS

Participants were classified as having diabetes if they so reported and had consulted a physician for this reason within the last year. Diabetes history was categorized in <10 and ≥ 10 years in 1993. Incidence density was calculated in 2-year periods in non-diabetic individuals (1965 persons/2 years). Vital status was recorded on 31 December 2011. The association between diabetes history ≥ 10 years and mortality at 6 and 18 years follow-up was studied by the Kaplan-Meier and Cox regression analyses after adjusting for age, sex, heart disease and comorbidity.

RESULTS

The prevalence of self-reported diabetes rose from 10.3% in 1993 to 16.1% in 1999 (p ≤ 0.001) and was higher in women than men (p ≤ 0.05). Total incidence density was 2.6 cases/100 persons/2 years (95% CI: 2.0-3.3). Medium- and long-term mortality was higher in persons with diabetes history ≥ 10 years than in non-diabetic individuals (HR: 2.0; 95% CI: 1.2-3.3 and HR: 1.7; 95% CI: 1.1-2.5, respectively). In diabetics with history <10 years the HR was 1.3 (95% CI: 0.9-1.9) and HR: 1.5 (95% CI: 1.2-1.9, respectively).

CONCLUSIONS

Although diabetes is clearly associated with increased risk of mortality, it is significant only for patients with ≥ 10 years' history of diabetes.

Effectiveness of diabetes self-management education on quality of life in diabetic elderly females

INTRODUCTION

Diabetes is a chronic illness that requires continuing medical care and patient self-management education to reduce the risk of long-term and acute complications. The aim of the present study was to determine the effectiveness of diabetes self-management education on quality of life in elderly females with diabetic mellitus (type 2) in Shiraz, Iran, 2013.

METHOD

The study was conducted from January to April 2014 at the Jahandidegan center, a day center affiliated to Shiraz welfare organization. The instrument used for the study was the Quality of life Questionnaire (WHO QOL-BREF) SF26. After an explanation of the aim of the study by the researcher, 90 participants with all the required criteria and G.H.Q score ? 23 were selected as the study sample for the intervention. Participants divided into experimental and control groups, and completed WHO QOL-BREF before the intervention, 2 and 3 months after the last session of education.

RESULT

It is shown that 2 and 3 months after the intervention, QOL scores had a significant difference between the two groups. In other words, the training sessions improved the score of QOL in the intervention group (P < 0.001) versus control group (P = 0.5).

CONCLUSION

The Behavioral Intervention Program significantly improved the quality of life outcomes of the diabetic elderly females. Thus, it is concluded that the diabetic individuals can be significantly improved following instruction by health care providers.

Estimation of the economic and health impact of complications of type 2 diabetes mellitus in the autonomous community of Madrid (Spain)

OBJECTIVE

To estimate the economic and health impact of chronic complications (macrovascular and microvascular) of type 2 diabetes mellitus (T2DM) in the autonomous community of Madrid (Spain) (ACM).

METHODS

The number of expected complications was obtained from a descriptive, cross-sectional study on a cohort of 3,268 patients with T2DM from the ACM. Cost of complications (€, 2012) was assessed both at hospitals and in primary care. The number of medical visits in primary care and drug treatment for complications were collected by a panel of 21 physicians experienced in treatment of T2DM. Population and epidemiological data and healthcare costs were obtained from Spanish sources. Univariate sensitivity analyses were performed.

RESULTS

It is estimated that there are 390,944 patients with T2DM in the ACM, and that they experience 172,406 and 212,283 macrovascular and microvascular complications respectively during their lifetimes. Mean cost of T2DM complications per patient is estimated at € 4,121.54 (66% due to macrovascular complications). The economic impact of T2DM complications in the ACM would be € 1,611 million (1,065 and 545 millions from macrovascular and microvascular complications respectively). The economic impact would range from € 1,249 and 2.509 million euro depending on T2DM prevalence.

CONCLUSIONS

Complications of T2DM have a great health and economic impact in ACM.

Effect of smoking status on healthcare costs and resource utilization in patients with type 2 diabetes in routine clinical practice: a retrospective nested case-control economic study

AIM

To compare healthcare resource utilization and costs according to smoking status in patients with type 2 diabetes in clinical practice.

METHODS

A retrospective cohort nested case-control study was designed. Cases were current smokers, while 2 types of controls (former smokers and never smokers) were matched (2 controls per case) for age, sex, duration of diabetes and burden of comorbidity using data from medical records. Noninstitutionalized diabetics of both genders, aged>18 years and seen consecutively over a 5-year period before the index date, were enrolled. Analysis compared healthcare resource utilization, loss of productivity due to sick leave and corresponding costs.

RESULTS

In total, 2,490 medical records were analyzed, i.e. 498 cases, 996 former smokers and 996 never smokers. Mean age was 63.4 years (64.9% male). Smokers had higher glycosylated hemoglobin levels (7.4 vs. 7.2 and 7.2%, respectively; p=0.013) and a lower degree of metabolic control (49.2 vs. 54.7 and 55.8%; p=0.036). Smokers had higher average annual costs (EUR 3,583) than former smokers (EUR 2,885; p<0.001) and never smokers (EUR 2,183; p<0.001).

CONCLUSIONS

Diabetic smoker patients had lower metabolic control, higher health resource utilization and more sick leave, resulting in higher healthcare costs and lost productivity compared with both former and never smoker diabetics.

[Screening for ophthalmic disease in the diabetic patient: eye fundus examination by non-mydriatic retinography with or without examination of visual acuity and intraocular pressure]

OBJECTIVE

To screen for eye disease in diabetic patients by performing only an eye fundus examination with non-mydriatic retinography, or a more extensive ophthalmological examination including visual acuity (VA) and ocular tonometry.

DESIGN

A cross-sectional multicentre study with cohort comparison.

SUBJECTS

Diabetic patients who attended 6 Primary Health Care Centres (PCC).

INTERVENTIONS

complete ophthalmological examination of patients in 3 PCC: VA examination, intraocular pressure (IOP) measurement and eye fundus examination with non-mydriatic retinography (egphNMC). Partial examination of patients of the other 3 PCC: only an eye fundus examination with non-mydriatic retinography. Patients with a suspicion of eye disease were referred to the Ophthalmology Department.

RESULTS

A complete ophthalmological examination was carried out on 938 patients (71%) and a partial examination in 383 (29%).

DIAGNOSIS

a) suspicion of diabetic retinopathy (DR): 123 cases (9.3%), with no differences between the complete examination (9.1%) and partial examination (9.3%); b) suspicion of glaucoma: 89 cases (8.1% in complete examination and 3.4% in partial (suspicion due to papillary alteration in egphNMC)); c) VA changes: 169 cases (18%) in complete examination. Referral to ophthalmology service was made in 41% of patients with complete examination and 18% in patients with partial examination.

CONCLUSIONS

Using only back of the eye examination with a non-mydriatic camera, a high percentage of diabetic patients were not diagnosed with an eye disease distinct to diabetic retinopathy (VA and IOP alterations), which are probably associated to a higher percentage of cataracts and glaucoma in this group.

Costs, outcomes and challenges for diabetes care in Spain

BACKGROUND

Diabetes is becoming of increasing concern in Spain due to rising incidence and prevalence, although little information is known with regards to costs and outcomes. The information on cost of diabetes in Spain is fragmented and outdated. Our objective is to update diabetes costs, and to identify outcomes and quality of care of diabetes in Spain.

METHODS

We performed systematic searches from secondary sources, including scientific literature and government data and reports.

RESULTS

Diabetes Type II prevalence is estimated at 7.8%, and an additional 6% of the population is estimated to be undiagnosed. Four Spanish diabetes cost studies were analyzed to create a projection of direct costs in the NHS and productivity losses, estimating €5.1 billion for direct costs along with €1.5 billion for diabetes-related complications (2009) and labour productivity losses represented €2.8 billion. Glycemic control (glycolysated hemoglobin) is considered acceptable in 59% of adult Type II cases, in addition to 85% with HDL cholesterol ≥40mg/dl and 65% with blood pressure <140/90 mmHg, pointing to good intermediate outcomes. However, annual figures indicate that over half of the Type II diabetics are obese (BMI >30), 15% have diabetic retinopathy, 16% with microalbuminuria, and 15% with cardiovascular disease.

CONCLUSIONS

The direct health care costs (8% of the total National Health System expenditure) and the loss of labour productivity are high. The importance of a multi-sectoral approach in prevention and improvements in management of diabetes are discussed, along with policy considerations to help modify the disease course.

[Bariatric surgery for the treatment of type 2 diabetes mellitus]

Weight loss can improve metabolic control in patients with type 2 diabetes mellitus but the results of conventional therapy in this respect have been discouraging. Besides achieving significant and sustained weight loss, bariatric surgery can improve or resolve type 2 diabetes mellitus in the majority of patients. Anatomical modifications and changes in the secretion of intestinal hormones can explain the superiority of malabsorptive techniques. Currently, bariatric surgery offers a therapeutic alternative for type 2 diabetes patients with severe obesity and poor metabolic control under conventional therapy. Ongoing research will provide insights regarding the effect of intestinal hormones, new surgery techniques and the possible benefits of bariatric surgery in non-obese patients.

Quality of care of patients with type-2 diabetes in Galicia (NW Spain) [OBTEDIGA project]

AIMS

The aim of this study was to describe the degree of compliance of agreed practices with reference to primary care patients with Type 2 diabetes of 40 years old and older in Galicia (NW Spain).

METHODS

A total of 108 primary care physicians were selected at random from the totality of doctors. Each physician selected 30 patients at random from their patients suffering from diabetes of 40 years old or older. External observers gathered information from each patient's medical record regarding their characteristics, condition and degree of compliance of selected indicators of good practice.

RESULTS

Group of physicians participated in this study had a mean age of 50 years (standard deviation = 3.9); 48% of them were females; and 17.5% involved in medical residents training. A total of 3078 diabetic patients were included in the study: mean age = 69 years (SD = 10.9), 47.6% women, presence of high blood pressure (72%), hypercholesterolaemia (56%), and regular smokers (10.3%). Compliance with selected indicators such as foot examination (14%), ophthalmological examination (30.6%), abdominal circumference measurement (6.1%), measurement of total or LDL-cholesterol (78.1), blood pressure measurement (84.8), glycosylated haemoglobin measurement < 7% (54.3%) was observed. Adequate monitoring in cases of high blood pressure and hypercholesterolaemia were 34.2% and 27.4%, respectively. Variability between physicians differs according to the different indicators, with interquartile range for compliance of between 16.4 and 66%.

CONCLUSIONS

There is a wide margin for improvement in the adaptation of clinical practice to recommendations for diabetic patients. The large variation existing in certain indicators would suggest that certain control objectives are less demanding than advisable in those that comply least, while low compliance and low variability in other indicators point to structural problems or unsatisfactory training of doctors.

[Capillary HbA1c determination on type 2 diabetes patients in a primary health centre]

OBJECTIVE

To determine the reliability and practicability of the point-of-care- test (POCT) analyzer, Afinion, for capillary HbA1c testing. To assess the benefits of its implementation on the intra-annual follow up of type 2 diabetic patients.

DESIGN

Descriptive cross-sectional study. Analytical validation of the Afinion reader.

SETTING

Primary Health Care (CAP Carmel and Bon Pastor Clinic Laboratory).

PARTICIPANTS

A total of 94 type 2 diabetic patients selected according to their previous HbA1c value.

METHODS

We performed one capillary puncture and one venous extraction on each visit. The capillary sample was assessed in real time on the Afinion in the Primary Health Care Centre and the venous sample was sent to Bon Pastor Clinic Laboratory for assessment on an Afinion analyzer and by a high performance liquid chromatrography (HPLC) reference method. Practicability was assesses by both by the operators of the Afinion and the patients using an 11 question questionnaire. The efficiency in terms of process timings was also evaluated.

RESULTS

Intra-serial coefficient of variation (CV) was lower than 1% and inter-serial lower than 3%. The regression analysis showed: Afinion capillary sample=0.95 Afinion venous+0.21. No systematic or proportional error was detected in the 95% confidence interval (95% CI). The comparison between venous HPLC and Afinion showed: Afinion capillary sample=0.80 HPLC+1.14. A statistically significant difference was shown for these values at the 95% CI. Practicability was valued by users from 7 to 9.2 (professionals) and from 7.7 to 9.2 (patients). Implementation of the Afinion capillary method for intra-annual testing in follow up of diabetic patients could result in the saving of 600-900 professional hours/year.

CONCLUSIONS

Afinion seems to be a good choice for the intra-annual determination of HbA1c when compared to the traditional process due to its accessibility, practicability and efficiency. Professionals should know the limitations of the POCT method in order to consider the validity of the results.

Incidence of complications and mortality in a type 2 diabetes patient cohort study followed up from diagnosis in a primary healthcare centre

AIMS

To determine the microvascular and macrovascular complications and mortality incidence rates and to identify the related factors in patients recently diagnosed with type 2 diabetes between 1991 and 2000 and followed until 2006.

METHODS

Retrospective longitudinal study in a primary healthcare center. Patients without any measure of glycaemia in the 3 years previous to diabetes diagnosis were excluded. Annual incidence rates for microvascular and macrovascular complications and mortality were estimated. Analysis of KaplanMeier survival curves and Cox proportional risk models by gender were done.

RESULTS

Of 469 patients [mean age: 60.4 (SD 10.7) years, 53.9% women], 80 died principally of tumoral (38.7%) and cardiovascular (30%) causes. The mean follow-up period was 8.81 years. (SD 3.21). The complication rates per 1000 patients/year (95% CI) were: microvascular complications 29.11 (22.97-36.38), macrovascular complications 24.10 (19.05-30.08) and mortality 19.23 (15.25-23.93), all of those being significantly greater in males except for cerebrovascular disease. Complications and mortality were associated with age, HbA1c, HDL-cholesterol, blood pressure and smoking with a different significance for each gender. HbA1c was related to microvascular complications in both sexes and to macrovascular complications only in women.

CONCLUSION

The annual rates for death and complications in a Mediterranean type 2 diabetic patient cohort followed from diagnosis were lower than those published in Anglo-Saxon countries. Males showed higher death and complication rates except in terms of cerebrovascular disease. Predictors of complication and death were different depending on gender. In terms of mortality, unlike in other studies, only one-third of the deaths were for cardiovascular causes.

Multifactorial control and treatment intensity of type-2 diabetes in primary care settings in Catalonia

BACKGROUND

Many studies on diabetes have demonstrated that an intensive control of glycaemia and the main associated risk factors (hypertension, dislipidaemia, obesity and smoking) reduce cardiovascular morbi-mortality. Different scientific societies have proposed a multifactorial approach to type 2 diabetes.The objective of this study was to identify the degree of control of glycosylated haemoglobin (HbA1c) and of cardiovascular risk factors in type 2 diabetic patients, using the GedapS 2004 guidelines, and to analyse the type and intensity of drug treatment.

METHODS

This cross-sectional, multicentre, epidemiological study was conducted in a primary care setting in Vallès Occidental South, Catalonia. Data were collected of 393 patients aged 18 and above who were diagnosed with diabetes mellitus type 2. Biodemographic and clinical data, cardiovascular risk factors, associated cardiovascular disease, and treatment were assessed. Descriptive and multivariable analysis with logistic regression was realized.

RESULTS

A total of 392 patients with a mean age of 66.8 years (SD = 10.6) (45.4% male patients) were analyzed. The duration of diabetes was 8.4 years (SD = 7.6). The degree of multifactorial control of risk factors was only 2.6%, although in more than 50% individual cardiovascular risk factor was controlled, except for LDL cholesterol (40.6%) and systolic blood pressure (29.6%). Furthermore, only 13.0% of subjects had an optimal BMI, 27.5% an optimal waist circumference. Treatment for diabetes was prescribed in 82.7% of patients, for hypertension 70.7%, for dyslipidaemia 47.2% and 40.1% were taking antiplatelets.

CONCLUSION

Over 50% of type 2 diabetic patients presented optimal control of the majority of individual cardiovascular risk factors, although the degree of multifactorial control of diabetes was insufficient (2.6%) and should be improved. Drug treatment can be intensified using a larger number of combinations, particularly in patients with target organ damage and associated clinical cardiovascular disease.

[Effects of a revision program on the control of type 2 diabetics followed at the primary care level. Diabetes First program]

BACKGROUND AND OBJECTIVE

To analyze the evolution of the glycosylated hemoglobin and other parameters after performing a control program and follow-up by nurses to improve the control of the patients with type 2 diabetes mellitus (Diabetes First).

PATIENTS AND METHOD

Intervention study in type 2 diabetes mellitus patients from Murcia. The inclusion criterium was to be a type 2 diabetes mellitus patient badly controlled on diabetes parameters (glycosylated haemoglobin > or = 7%). We included 831 patients from 8 primary care centers. The program consisted of three visits (first one, after three months and after six months), where the patients received diabetic education.

RESULTS

The mean initial glycosylated haemoglobin value was 8.1% +/- 1.3%, after 3 months it decreased to 7.5% +/- 1.1%, and after 6 months from the first visit its value was 7.5% +/- 2.6%. There was a statistically significant (p < 0.001) difference between the initial glycosylated haemoglobin and the values three months later. There was not such a difference between the second and third visit. Total and low-density liporpotein cholesterol decreased significantly after 3 months (p < 0.05). High-density lipoprotein cholesterol and triglycerides showed no difference. Systolic and diastolic blood pressure significantly decreased after three months (p < 0.0001 and p < 0.005).

CONCLUSIONS

A simple nursing intervention program performed in primary care centers has a very positive impact on the control and treatment of patients with type 2 diabetes mellitus.

Profile of central corneal thickness in diabetics with and without dry eye in a Saudi population

PURPOSE

The aim of this study was to determine the impact of diabetes in patients with and without dry eyes (DE) on central corneal thickness (CCT) measurements.

METHODS

Eighty-six subjects (51 diabetics and 35 controls) participated in the study. Ultrasound pachymetry was used to measure the CCT, whereas tear break-up time (TBUT) and Schirmer tests were conducted for tear assessments. The participants were divided into group 1 (diabetics without DE), group 2 (diabetics with DE), and group 3 (nondiabetics controls). The measurements were compared using analysis of variance.

RESULTS

The mean (95% confidence interval [CI]) of CCT was 610 (599 to 620), 601 (582 to 618), and 583 (576 to 589) mum, respectively, in diabetics without DE, with DE, and the control groups. There was significant difference in mean CCT between diabetics without DE and controls (P < 0.0001), but no significant difference in diabetics with DE versus controls (P > 0.05). The mean (95% CI) values for TBUT and Schirmer tests were 14 (13 to 15), 6 (4 to 6), 14 (14 to 15) seconds, and 21 (19 to 23), 7 (6 to 8), and 20 (19 to 21) mm, respectively, for diabetics without DE, with DE, and the nondiabetic groups.

CONCLUSIONS

DE affects the CCT in diabetic subjects, having a predilection for lower values in those exhibiting DE. In addition, the results also support the view that diabetics tend to present with higher CCT values when compared with nondiabetic patients.

The conjunctival bacterial pattern of diabetics undergoing cataract surgery

PURPOSE

To ascertain the conjunctival bacterial pattern of diabetics undergoing cataract operation to reduce the risk of postoperative endophthalmitis (PE).

METHODS

An observational retrospective study of the conjunctival bacteria of consecutive patients undergoing cataract surgery from July 2005 to November 2008. Records of patients having eye surgical prophylaxis in the 6 months before the culture and those patients having cataract operation combined with other surgical procedures were excluded. Aerobic and microaerobic cultures were carried out. Dade-Behring panels were used for bacterial identification. The database containing the isolated bacteria was linked to another Access database containing demographic and clinical data such as diabetes presence and baseline blood glucose and creatinine levels. The conjunctival bacteria of diabetics were compared with those of the non-diabetics. Epidat 3.1 program was used for statistical calculations.

RESULTS

From 5922 selected patients, 1325 (22.37%) knew they were diabetics (higher prevalence than expected). Among self-reported non-diabetics, 900 (15.2%) could be 'unknown' diabetics; another 274 had an impaired renal function; and 3423 non-diabetics joined the control group. Diabetics have a significantly higher prevalence of Staphylococcus aureus, Enterococci, certain Streptococci, and Klebsiella sp. than non-diabetics. Diabetics and non-diabetics having a blood creatinine level above 105.2 mumol/l had an increased conjunctival bacterial prevalence; these groups had a higher mean age and men predominated.

CONCLUSIONS

Diabetics have a conjunctival flora pattern whose increased bacteria are a predominant cause of many diabetic infections. An abnormally high blood creatinine level is an indicator of increased conjunctival colonisation in diabetics and non-diabetics.

The transmembrane transport of metformin by osteoblasts from rat mandible

Previous studies have demonstrated that metformin, one of systemic antihyperglycemic drugs, can slow bone loss caused by diabetes mellitus and has an osteogenic action on osteoblasts in vitro. It is tempting to speculate that metformin would be transported into bone tissues around dental implant by topical administration to improve the bone-implant contact in diabetic patients. In this study, the osteoblasts from rat mandible were cultured with 5.5 mM (control) or 16.5 mM d-glucose, then the uptake of metformin by osteoblasts was detected with high performance liquid chromatography (HPLC). Rat organic cation transporter (rOct) expression was characterized by immunocytochemistry, RT-PCR and Western blotting. It was found that, the uptake of metformin was saturable, Na(+)-dependent, affected by extracellular pH and inhibited by both phenformin and cimetidine (an inhibitor of Octs). rOct1 but no rOct2 was expressed extensively in osteoblasts and the protein level of rOct1 could be up-regulated by metformin. The uptake of metformin and phosphorylated-rOct1 at hyperglycaemic cell culture (16.5 mM d-glucose) significantly increased versus 5.5 mM control (p < 0.05). In conclusion, rat osteoblasts have the ability to transport the metformin intra-cellularly, the uptake of metformin by osteoblasts is a secondary active transportation mediated by rOct1 and high-glucose can improve the uptake of metformin by osteoblasts through phosphorylation of rOct1. The current results suggest that metformin could be used for dental implant topically in type 2 diabetic patients to increase the bone formation, therefore, to enhance the success rate of dental implants clinically.

Mortality risk in spanish adults with diagnosed diabetes, undiagnosed diabetes or pre-diabetes. The Asturias study 1998-2004

INTRODUCTION AND OBJECTIVES

Although type-2 diabetes is a well-known cause of death, the mortality associated with undiagnosed diabetes and early-stage dysglycemia has not been clearly determined.

METHODS

This study included 1015 individuals aged 30-75 years who took part in the first phase of the Asturias study (1998-1999). Participants completed a questionnaire and underwent a physical examination and an oral glucose tolerance test (OGTT). All deaths that occurred in the cohort within 6 years of follow-up (i.e. December 1998 to December 2004) were recorded.

RESULTS

Participants were divided into four groups according to the condition indicated by their OGTT result in the first phase of the study: normoglycemia, pre-diabetes, undiagnosed diabetes or diagnosed diabetes (World Health Organization 1999 criteria). A total of 42 deaths were recorded during follow-up. With normoglycemic individuals acting as a control group, multivariate analysis showed that the relative risk of mortality was 2.5 (95% CI, 1-6.3) in the group with diagnosed diabetes, 2.7 (95% CI, 1.1-6.7) in the group with undiagnosed diabetes and 1.6 (95% CI, 0.7-4) in the group with pre-diabetes.

CONCLUSIONS

Both individuals with diagnosed diabetes and those with undiagnosed diabetes had a risk of mortality around 2.5-3 times greater than individuals with normoglycemia. Those with pre-diabetes also had increased mortality relative to the control group, though the difference was not significant.

Socioeconomic inequalities in diabetes mellitus across Europe at the beginning of the 21st century

AIMS/HYPOTHESIS

The aim of this study was to determine and quantify socioeconomic position (SEP) inequalities in diabetes mellitus in different areas of Europe, at the turn of the century, for men and women.

METHODS

We analysed data from ten representative national health surveys and 13 mortality registers. For national health surveys the dependent variable was the presence of diabetes by self-report and for mortality registers it was death from diabetes. Educational level (SEP), age and sex were independent variables, and age-adjusted prevalence ratios (PRs) and risk ratios (RRs) were calculated.

RESULTS

In the overall study population, low SEP was related to a higher prevalence of diabetes, for example men who attained a level of education equivalent to lower secondary school or less had a PR of 1.6 (95% CI 1.4-1.9) compared with those who attained tertiary level education, whereas the corresponding value in women was 2.2 (95% CI 1.9-2.7). Moreover, in all countries, having a disadvantaged SEP is related to a higher rate of mortality from diabetes and a linear relationship is observed. Eastern European countries have higher relative inequalities in mortality by SEP. According to our data, the RR of dying from diabetes for women with low a SEP is 3.4 (95% CI 2.6-4.6), while in men it is 2.0 (95% CI 1.7-2.4).

CONCLUSIONS/INTERPRETATION

In Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

[Diabetic autonomic neuropathy diagnosed in primary care in patients with type 2 diabetes]

OBJECTIVE

To determine the prevalence of diabetic autonomic neuropathy (DAN) in patients with type 2 diabetes using a cardiovascular test.

DESIGN

Observational, descriptive, cross-sectional study.

SETTING

Primary care clinics in Fronteras de Torrejón de Ardoz Health Centre, Area 3, Madrid, Spain.

PARTICIPANTS

Of the 361 diabetics assigned to 3 participating patient quotas, 317 patients had type 2 diabetes. Of those, 104 were excluded due to being immobile, cardiac arrhythmia, and/or on treatment with chronotropic drugs. Of the 213 patients included, 169 had the test and 44 were lost.

INTERVENTIONS

Performing of the orthostatic response test.

MAIN MEASUREMENTS

Age, sex, years since diagnosed with diabetes (measured by patient anamnesis), treatment (hygiene-diet measures, oral antidiabetics, insulin) were recorded, along with the R-R'30:15 ratio (classified as normal: 31.04, borderline: 1.01 to 1.03, and pathological: pound1.00).

RESULTS

The prevalence of DAN using the orthostatic response test was 56.2% (95 patients with a pathological R-R'30:15 index) out of a total of 169 patients with type 2 diabetes. The definitive diagnosis of DAN found in the clinical histories reviewed was 1.8%.

CONCLUSIONS

DAN goes unnoticed in our evaluation of the patient with diabetes. The improvement in diagnosing this complication and incorporating cardiovascular autonomic dysfunction tests in primary care follow-up protocols, would enable closer metabolic control and improve the prognosis of the disease.

Incidence of type 2 diabetes in southern Spain (Pizarra Study)

BACKGROUND

Few European studies have used an oral glucose tolerance test (OGTT) to examine the incidence of type 2 diabetes. We determined the incidence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes in a population from southern Spain.

MATERIAL AND METHODS

A population-based cohort study was undertaken in Pizarra, Spain. Baseline data were recorded on age, sex, weight, height, waist and hip circumferences, and diabetes status for 1051 persons, of whom 910 were free of type 2 diabetes (at-risk sample). Of these, 714 completed the 6-year follow-up study. Body mass index, waist-to-hip ratio and weight increase since baseline were calculated. The homeostasis model assessment equations were used to estimate the indices of insulin resistance and beta-cell function. Each person received an OGTT at baseline and after 6 years.

RESULTS

Type 2 diabetes developed in 81 people for a total of 4253 person-years, representing an incidence of 19.1 cases per 1000 person-years (95% confidence interval, 15.3-23.6). Age and the presence of obesity, central obesity and carbohydrate metabolism disorders [IFG (cut off = 100 mg dL(-1), capillary blood glucose level), IGT or both] at baseline were significant markers for the onset of type 2 diabetes during follow-up. After adjusting for these variables, multivariate analysis showed weight increase, waist-to-hip ratio and the indices of insulin resistance and beta-cell function were significantly associated with the risk for type 2 diabetes.

CONCLUSIONS

The incidence of type 2 diabetes in a population from southern Spain is high. It is probably associated with the high prevalence of obesity and weight increase in this population.