Agata Bronisz

Self-Monitoring of Blood Glucose in Diabetes: From Evidence to Clinical Reality in Central and Eastern Europe—Recommendations from the International Central-Eastern European Expert Group

Self-monitoring of blood glucose (SMBG) is universally considered to be an integral part of type 1 diabetes management and crucial for optimizing the safety and efficacy of complex insulin regimens. This extends to type 2 diabetes patients on intensive insulin therapy, and there is also a growing body of evidence suggesting that structured SMBG is beneficial for all type 2 diabetes patients, regardless of therapy. However, access to SMBG can be limited in many countries in Central and Eastern Europe. A consensus group of diabetes experts from 10 countries in this region (with overlapping historical, political, and social environments)--Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Serbia, Slovakia, Slovenia, and Ukraine--was formed to discuss the role of SMBG across the spectrum of patients with diabetes. The group considered SMBG to be an essential tool that should be accessible to all patients with diabetes, including those with non-insulin-treated type 2 diabetes. The current article summarizes the evidence put forward by the consensus group and provides their recommendations for the appropriate use of SMBG as part of individualized patient management. The ultimate goal of these evidence-based recommendations is to help patients and providers in Central and Eastern Europe to make optimal use of SMBG in order to maximize the efficacy and safety of glucose-lowering therapies, to prevent complications, and to empower the patient to play a more active role in the management of their diabetes.

Stress hyperglycaemia in patients with first myocardial infarction

Objective:  To investigate the incidence of stress hyperglycaemia at first acute myocardial infarction (MI) with ST‐segment elevation, occurrence of stress hyperglycaemia as a manifestation of previously undiagnosed abnormal glucose tolerance (AGT), and its relation to stress hormone levels.

Value of oral glucose tolerance test in the acute phase of myocardial infarction

BackgroundAlthough European guidelines advise oral glucose tolerance test (OGTT) in patients with acute myocardial infarction (AMI) before or shortly after hospital discharge, data supporting this recommendation are inconclusive. We aimed to analyze whether disturbances in glucose metabolism diagnosed before hospital discharge in AMI patients represents a latent pre-existing condition or rather temporary finding. Additionally, we planned to investigate the value of pre-selected glycemic control parameters as predictors of long-term glucometabolic state.MethodsWe assessed admission glycemia, glycated hemoglobin, mean blood glucose concentration on days 1 and 2 in 200 patients with a first AMI but without overt disturbances of glucose metabolism. We also performed OGTT at discharge and 3 months after discharge.ResultsThe prevalence of disturbances in glucose metabolism (as assessed by OGTT) at 3 months was significantly lower than at discharge (29% vs. 48%, p = 0.0001). Disturbances in glucose metabolism were not confirmed in 63% of patients with impaired glucose tolerance and in 36% of patients with diabetes mellitus diagnosed during the acute phase of AMI. Age >77 years, glucose ≥12.06 mmol/l at 120 minutes during OGTT before discharge and mean blood glucose level on day 2 >7.5 mmol/l were identified as independent predictors of disturbances in glucose metabolism at the 3-month follow-up.ConclusionsDisturbances in glucose metabolism observed in patients with a first AMI are predominantly transient. Elderly age, high plasma glucose concentration at 120 minutes during OGTT at discharge and elevated mean blood glucose level on day 2 were associated with sustained disturbances in glucose metabolism.

The role of intrinsic fibrinolytic system activation in pathogenesis of hemostasis disturbances in hemodialyzed patients with chronic renal failure.

In the hemodialysis patient, hemostasis changes may occur. The contribution of fibrinolysis in pathogenesis of these disorders is unclear. The aim of the study was to estimate intrinsic fibrinolysis pathway in patients treated with hemodialysis (HD) because of chronic renal failure caused by chronic glomerulonephritis. The study was performed with 43 patients; the control group consisted of 51 healthy volunteers chosen by sex and age. The following parameters were determined: concentration of the urokinase plasminogen activator antigen (uPA:Ag), plasmin–antiplasmin complexes (PAP), fibrin and fibrinogen degradation products (FDP), activity of prekallikrein (PK) and C1‐inhibitor (C1‐INH) and also euglobulin clot lysis time (ELT). The above parameters were assessed in the patients before and after HD and were compared with the control group. In the HD patients, in comparison with the control group, prolonged statistically ELT [153 (125;215) vs. 105 (75;142) min.; p < 0.001], with increase of PAP (508.6 ± 274.7 vs. 184.7 ± 69.4. µg/L; p < 0.001) and FDP concentrations [5 (5;15) vs. 2.5 (0;0.3), µg/mL; p < 0.05] before the procedure were determined. It suggests increased plasmin production and fibrin digestion despite determination of decreased general fibrinolytic activity. The C1‐INH activity before HD was also significantly increased as compared with the control group [157 (136;171) vs. 107 (100;124), %; p < 0.001], and its significant decreased after the HD is [157.7 ± 23.9 vs. 122.3 ± 20.3, %; p < 0.001], as it seems to be a nondirect proof of intrinsic pathway contribution in fibrinolysis activation in the HD patients. The remaining examined parameters did not change significantly after the dialysis procedure.

The influence of a ten-week Nordic walking training-rehabilitation program on the level of lipids in blood in overweight and obese postmenopausal women

[Purpose] The aim of this study was to evaluate the effect of a ten-week Nordic Walking (NW) rehabilitation program on chosen anthropometric parameters and the level of basic lipids in overweight and obese postmenopausal women’s blood. [Subjects and Methods] The subjects were 32 women aged 50–68 (average: 59.7 ± 5.9 years). The study was carried out following a non-randomized model and entailed NW rehabilitation 5 times a week, which lasted for 10 weeks, as well as a low-calorie 1,500 kcal diet. The therapeutic results of the study were measured through changes in anthropometric and biochemical parameters. The results were subjected to a statistical analysis. [Results] After 10 weeks of NW rehabilitation it was observed that participants lost weight and their body mass index dropped. Additionally, whereas levels of total cholesterol, LDL and triglycerides dropped, and the level of HDL increased. [Conclusion] Rehabilitation carried out according to the NW model resulted in statistically significant changes in basic lipids in blood which, considerably increased the percentage of persons who achieved the recommended level of blood lipids. Obese persons were characterised by a smaller rehabilitation weight loss. More intense workouts and cooperation with a dietician are required.

Infection caused by Aeromonas sobria, complicated by lower extremity paraplegia and the cauda equine syndrome in a patient with well-controlled type 2 diabetes

Aeromonas species are Gram-negative anaerobes with the natural habitat of fresh and seawater watercourses and have also been found in stagnant and flowing water reservoirs, water tanks as well as moist soil [1]. The literature primarily describes cases of alimentary tract infections [2] and occasionally sepsis or inflammation of the fascia and muscles [3]. A 75-year-old woman was admitted to the Neurology Department of the University Hospital in Bydgoszcz because of lower extremity muscle weakness developing for 2 weeks and was accompanied by bilateral foot drop and lumbosacral pain irradiating along the posterior surface of both thighs. Approximately 7 days before admission urinary and faecal incontinence as well as an increase of body temperature up to 38.5°C were observed. Type 2 diabetes was diagnosed a year ago, treated with a diet, and with a well-controlled glycaemia. The patient has a negative family history of neoplastic and haematological diseases without addictions. A neurological examination at admission revealed that the patient suffered from cauda equine syndrome accompanied by lower extremity flaccid paresis and multiple neuritis syndrome accompanied by reduced sensation of gloves-socks type. Aberrations discovered during additional examinations were as follows: C-reactive protein (CRP) 56 mg/l, white blood cells (WBC) 12.25 × 103/µl, hyperglycaemia 19.8 mmol/l, hypoalbuminaemia 19.2 g/l. A general urine analysis revealed presence of acetone, protein, glucose and microscopic haematuria. Whereas the concentration of total bilirubin in the blood serum was increased to 124 µmol/l, aspartate transaminase, alanine transaminase and alkaline phosphatase were normal, γ-glutamyl transpeptidase level was slightly increased (97 U/l). Spine magnetic resonance imaging with contrast showed as follows: presence of fluid collections resembling abscesses on various levels of the vertebral canal, in the right iliopsoas muscle, where the suspicion of abscesses was additionally intensified by the presence of gas bubbles. Gas bubbles were also visible in the left iliopsoas muscle, vertebral canal as well as L4 and L5 vertebral bodies. A small amount of pathological tissue not enhanced by contrast was visible instead of fat in the sacral canal, on the S1 level with sacral bone defects in front of it. Empirical antibiotic therapy was introduced through intravenous administration of amoxicillin with clavulanic acid (2 × 1.2 g). Gradual normalization of the WBC and the total bilirubin level were observed. In spite of the antibiotic therapy the patient suffered from fever of over 38°C. Aeromonas sobria was cultured in one of three blood samples. The antibiotic therapy that had been used hitherto was changed according to the antibiogram and ceftazidime was administered intravenously (3 × 750 mg). Human immunodeficiency virus (HIV) infection, hepatitis B, hepatitis C, tuberculosis, syphilis, toxoplasmosis and Lyme disease were all excluded. A fragment of the L4 vertebral body was collected and histological examination revealed small fragments of bone tissue without any pathological changes. A microbiological examination of a bone fragment and swabs from surrounding tissue indicated A. sobria presence in both cases. Due to occasional hyperglycaemia exceeding 11.1 mmol/l human insulin (4-6 units) was introduced. The 24-hour glycaemic profile gradually normalized up to the level where subcutaneous injections of insulin were no longer necessary. After 12 days of treatment a control X-ray computed tomography scan showed that the size and the number of hypodense areas that could stand for abscesses with gas bubbles in iliopsoas muscles and vertebral bodies decreased and all the changes in the vertebral canal were absorbed. During the patients hospitalization lasting over a month, improvement of general feeling and condition, normalization of body temperature, lowering of the inflammation index (CRP 68 mg/l), increase of albumin concentration, slight return of lower extremity motor activity, and return of normal urethral and alimentary system sphincter activity were achieved. The patient was advised to continue antibiotic therapy commenced during hospitalization with oral administration of ciprofloxacin (2 × 750 mg) and a check-up visit at the Neurosurgery and Neurology Department after 8 weeks of treatment. Aeromonas sobria is a rare human pathogen. The most frequently described cases of bacterial infections concerning humans referred to diarrhoea [4] and were usually in a good clinical condition. The bacteria were also found in preparations from appendectomy [2, 5] and it was suggested that they are an aetiological factor of acute cholangitis [6, 7]. There were no descriptions of the cauda equine syndrome or paraplegia caused by the said bacteria. The publications in English only describe a single case of inflammation of the nervous system in the form of purulent meningitis secondary to bacteraemia [8]. A severe course of A. sobria was connected with a weakened immune response such as in cases of HIV, acute leukaemia [9], neutropenia during the course of a neoplastic disease [7, 10] and liver cirrhosis [7]. There were descriptions of two cases of acute necrotic skin and fascia inflammation that ended with the patients’ death [3]. In both described cases the infection was preceded by an injury. It seems that mild gastrointestinal infection (reported as a diarrhoea a few days before admission) was the primary infection site. Jaundice as well as a fever present on admission implies that A. sobria bacteraemia was secondary to acute cholangitis. Biliary tract infection is the most common primary infection site of A. sobria secondary bacteraemia [7]. We cannot explain why the course was so severe because the patient did not have any diseases predisposing to A. sobria inflammation [9, 10]. The only disease was type 2 diabetes diagnosed a year ago, based on periodic health examinations without hyperglycaemia symptoms. The patient had been treated only with a diet. Glycated haemoglobin (HbA1c) level amounting to 5.3% indicated well-controlled glycaemia. We would like to draw attention to the possibility of A. sobria being an etiological factor not only with regard to persons with weakened immunity, chronically ill or wasted, but also to persons with well-controlled type 2 diabetes.

Lactic acidosis occurrence during exercises in the smoke chamber in a 53-year-old firefighter with no significant medical history

Lactic acidosis is a form of metabolic acidosis with a high anion gap, reduced rate of arterial blood pH under 7.35 mmol/l, and lactic acid concentration over 7 mmol/l. In the literature we can find some descriptions of the cases of lactic acidosis in patients with severe systemic diseases (cancer, acquired immunodeficiency syndrome, sepsis, diabetes with cardiovascular disease and after organ transplantations). We present the case of lactic acidosis in a patient with no chronic disease — a firefighter in whom lactic acidosis has developed during standard exercises in the smoke chamber.