Alexander Sämann

Prevalence of the diabetic foot syndrome at the primary care level in Germany : a cross-sectional study

Aims  The diabetic foot syndrome (DFS) is an important complication of diabetes mellitus resulting in amputations, disability and reduced quality of life. DFS is preventable. The aim was to investigate the prevalence of the DFS at the primary care level in Germany.

Glycaemic control is positively associated with prevalent fractures but not with bone mineral density in patients with Type 1 diabetes

Diabet. Med. 28, 872–875 (2011)

Clinical and endocrine correlates of circulating sclerostin levels in patients with type 1 diabetes mellitus

Type 1 diabetes mellitus (T1DM) increases fragility fractures due to low bone mass, micro‐architectural alterations and decreased bone formation. Sclerostin is expressed by osteocytes and inhibits osteoblastic bone formation. We evaluated serum sclerostin levels in T1DM and their association with bone mineral density (BMD), bone turnover, glycaemic control and physical activity.

A retrospective study on the incidence and risk factors of severe hypoglycemia in primary care

AIMS To investigate the incidence and risk factors of severe hypoglycemia (SH) in primary care. SH was defined as hypoglycemia with coma, or the need of glucose or glucagon injection. METHODS We performed a cross-sectional retrospective study in patients with diabetes treated in primary care in Germany. We analyzed an unselected sample of participants with type 1 (n = 373) and type 2 diabetes (n = 4481) who participated in an insurance plan from the health care insurer Deutsche BKK. Data of participants with type 1 diabetes are as follows: women, n = 155 (42%); age, 49±16 years; diabetes duration, 20+13 years; BMI, 28±6 kg/m2; GHb, 7.1+1.5%; GHb≤7%, n = 263 (71%); GHb≥8.5%, n = 48 (13%). Data of participants with type 2 diabetes: women, n = 1979 (44%); age, 66±10 years; diabetes duration, 8±7 years; BMI, 30±5 kg/m2; GHb, 6.6±1.3%; GHb≤7%, n = 3747 (84%); GHb≥8.5%, n = 360 (8%); insulin therapy, n = 1175 (26%). RESULTS The incidence of SH in type 1 diabetes: 1.3% (CI: 0.4%, 3.1%) per year; type 2 diabetes with insulin therapy: 0.9% (CI: 0.5%, 1.7%); without insulin therapy: 0.3% (CI: 0.1%, 0.6%). The event rate was 0.02 SH per patient/year in type 1 diabetes and 0.01 in type 2 diabetes, respectively. Low BMI, GHb, insulin therapy and female gender were associated with an increased risk of SH. CONCLUSIONS In primary care, patients with diabetes can achieve good glycemic control with very rare events of SH. Due to low incidence, SH would have been an inappropriate parameter to evaluate the outcome quality of diabetes therapy in primary care.

Evaluation of a treatment and teaching refresher programme for the optimization of intensified insulin therapy in type 1 diabetes.

OBJECTIVE Evaluation of an ambulatory diabetes teaching and treatment refresher programme (DTTP) for the optimization of intensified insulin therapy in patients with type 1 diabetes (refresher course). METHODS 85 outpatients took part in this prospective multicentre trial. Metabolic and psychosocial data were analyzed at baseline (V1), 6 weeks (V2) and 12 months after DTTP (V3). RESULTS In patients with baseline HbA1c>7% (88%), HbA1c decreased by 0.36% (p=0.004). The percentage of patients with HbA1c≤7% increased from 21.3 to 34.9% and with HbA1c above 10% decreased from 6.6 to 1.6% at V3. The incidence of hypoglycaemia decreased significantly: non severe hypoglycaemia from 3.31 to 1.39 episodes/pat/week (p=0.001) and severe hypoglycaemia from 0.16 to 0.03 episodes/pat/year (p=0.02). The treatment satisfaction increased by +10 of maximal ±18 points. The negative influence of diabetes on quality of life decreased from -1.93 to -1.69 points (p=0.031). CONCLUSION In a group of patients with moderately controlled diabetes type 1 who were already treated with intensified insulin therapy, metabolic control, treatment satisfaction and quality of life were improved after participation in an ambulatory DTTP without increasing insulin dosage, number of injections or insulin species. PRACTICE IMPLICATIONS This DTTP is effective for the optimization of intensified insulin therapy.

Flexible intensive versus conventional insulin therapy in insulin-naive adults with type 2 diabetes: an open-label, randomized, controlled, crossover clinical trial of metabolic control and patient preference.

Improving metabolic control can reduce complications in type 2 diabetes (1–4). Conventional insulin therapy (CIT) and flexible intensive insulin therapy (FIT) are treatment options in insulin-dependent type 2 diabetic patients. In CIT, participants inject premixed human insulin (30% regular insulin, 70% NPH insulin) before breakfast and dinner and follow individually adjusted diet plans with fixed amounts of carbohydrates (5). In FIT, human regular insulin is adjusted before main meals according to current blood glucose readings and desired carbohydrate intake. When necessary, NPH insulin is added at bedtime. CIT can be easy to handle and requires less active diabetes self-management. In FIT, patients benefit from dietary freedom and improvement in quality of life (6). In pilot studies, FIT has shown good metabolic control and low risk of hypoglycemia (7). FIT may have additional advantages due to better postprandial blood glucose control (8). We tested the hypothesis that FIT and CIT in insulin-naive adults with type 2 diabetes are equally effective in regard to metabolic outcomes. We hypothesized that younger participants, in employment, would prefer FIT. The trial was designed as a clinical, prospective, randomized, open-label, single-center, crossover study. The primary end point was glycosylated hemoglobin A1c (GHb); secondary end points were mild and severe hypoglycemia, insulin dosage, blood pressure, BMI, and therapy preference. Participants started insulin therapy either with CIT (group A) or FIT (group B), randomly. Individual insulin dosage and carbohydrate intake were determined …

Flexible, intensive insulin therapy and dietary freedom in adolescents and young adults with Type 1 diabetes: a prospective implementation study

Aims  To assess the outcome of a Diabetes Treatment and Teaching Programme (DTTP) on glycated haemoglobin (HbA1c), severe hypoglycaemia (SH) and severe ketoacidosis (SKA) in adolescents and young adults with Type 1 diabetes.

Flexible Intensive Insulin Therapy in Adults With Type 1 Diabetes and High Risk for Severe Hypoglycemia and Diabetic Ketoacidosis: Response to Pennant et al.

OBJECTIVE Diabetes treatment and teaching programs (DTTPs) for type 1 diabetes, which teach flexible intensive insulin therapy to enable dietary freedom, have proven to be safe and effective in routine care. This study evaluates DTTP outcomes in patients at high risk for severe hypoglycemia and severe ketoacidosis. RESEARCH DESIGN AND METHODS There were 96 diabetes centers that participated between 1992 and 2004. A total of 9,583 routine-care patients with type 1 diabetes were examined before and 1 year after a DTTP. History of repeated severe hypoglycemia/severe ketoacidosis was an indication for DTTP participation. Before-after analyses were performed for subgroups of patients with three or more episodes of severe hypoglycemia or two or more episodes of severe ketoacidosis during the year before a DTTP. Main outcome measures were GHb, severe hypoglycemia, severe ketoacidosis, and hospitalization. RESULTS A total of 341 participants had three or more episodes of severe hypoglycemia the year before a DTTP. Mean baseline GHb was 7.4 vs. 7.2% after the DTTP, incidence of severe hypoglycemia was 6.1 vs. 1.4 events x patient(-1) x year(-1), and hospitalization was 8.6 vs. 3.9 days x patient(-1) x year(-1). In mixed-effects models taking effects of centers and diabetes duration into account, mean difference was -0.3% (95% CI -0.5 to -0.1%; P = 0.0006) for GHb and -4.7 events x patient(-1) x year(-1) (-5.4 to -4; P < 0.0001) for severe hypoglycemia. A total of 95 patients had two or more episodes of severe ketoacidosis. GHb was 9.4% at baseline versus 8.7% after DTTP; incidence of severe ketoacidosis was 3.3 vs. 0.6 events x patient(-1) x year(-1), and hospitalization was 19.4 vs. 10.2 days x patient(-1) x year(-1). In linear models with diabetes duration as the fixed effect, the adjusted mean difference was -2.7 events x patient(-1) x year(-1) (95% CI -3.3 to -2.1; P < 0.0001) for severe ketoacidosis and -8.1 days (-12.9 to -3.2; P = 0.0014) for hospitalization. CONCLUSIONS Patients at high risk for severe hypoglycemia or severe ketoacidosis may benefit from participation in a standard DTTP for intensive insulin therapy and dietary freedom.

[A 64-year-old female patient with recurring hypoglycaemia. Difficult aspects of diagnosis].

ZusammenfassungDas Insulinom ist einer der bekanntesten hormonaktiven Pankreastumoren und durch seine unkontrollierte Insulinproduktion und die daraus resultierenden Hypoglykämien charakterisiert. Die Diagnosesicherung erfolgt in der Regel durch den Nachweis der Hyperinsulinämie während einer Fastenperiode. Wir berichten über eine Patientin mit einem Insulinom, welches nicht durch den Nachweis einer Hyperinsulinämie demaskiert werden konnte. Eine Sekretion eines Split-Insulins bzw. von Proinsulin muss diskutiert werden. Die Diagnosesicherung gelang mittels endosonographisch gestützter Biopsie und immunhistochemischem Nachweis von Chromogranin in den atypischen Zellen. Bei Hypoglykämien ohne Nachweis erhöhter Insulinspiegel kann die Endosonographie Tumoren aufzeigen, welche Proinsulin oder Split-Insulin bilden; diese können mit den modernen Assays nicht nachgewiesen werden.AbstractInsulinomas are the most common pancreatic islet cell tumours and are characterised by uncontrolled insulin secretion even in the presence of hypoglycaemia. Diagnosis is usually made by the detection of endogenous hyperinsulinism over a period of fasting. We report the case of a patient with insulinoma without hyperinsulinaemia. A secretion and overexpression of split insulin has to be discussed. The diagnosis was made by endoscopic ultrasound-guided fine-needle aspiration and the immunohistochemical detection of chromogranine. In conclusion, the present report demonstrates that insulinomas should be considered and searched for in every case of hypoglycaemia, even when associated with normal insulin levels. It also confirms the essential role of endoscopic ultrasonography in the diagnosis of insulin-secreting tumors.

64-jährige Patientin mit rezidivierenden Hypoglykämien@@@A 64-year-old female patient with recurring hypoglycaemia: Schwierige Diagnosestellung@@@Difficult aspects of diagnosis

ZusammenfassungDas Insulinom ist einer der bekanntesten hormonaktiven Pankreastumoren und durch seine unkontrollierte Insulinproduktion und die daraus resultierenden Hypoglykämien charakterisiert. Die Diagnosesicherung erfolgt in der Regel durch den Nachweis der Hyperinsulinämie während einer Fastenperiode. Wir berichten über eine Patientin mit einem Insulinom, welches nicht durch den Nachweis einer Hyperinsulinämie demaskiert werden konnte. Eine Sekretion eines Split-Insulins bzw. von Proinsulin muss diskutiert werden. Die Diagnosesicherung gelang mittels endosonographisch gestützter Biopsie und immunhistochemischem Nachweis von Chromogranin in den atypischen Zellen. Bei Hypoglykämien ohne Nachweis erhöhter Insulinspiegel kann die Endosonographie Tumoren aufzeigen, welche Proinsulin oder Split-Insulin bilden; diese können mit den modernen Assays nicht nachgewiesen werden.AbstractInsulinomas are the most common pancreatic islet cell tumours and are characterised by uncontrolled insulin secretion even in the presence of hypoglycaemia. Diagnosis is usually made by the detection of endogenous hyperinsulinism over a period of fasting. We report the case of a patient with insulinoma without hyperinsulinaemia. A secretion and overexpression of split insulin has to be discussed. The diagnosis was made by endoscopic ultrasound-guided fine-needle aspiration and the immunohistochemical detection of chromogranine. In conclusion, the present report demonstrates that insulinomas should be considered and searched for in every case of hypoglycaemia, even when associated with normal insulin levels. It also confirms the essential role of endoscopic ultrasonography in the diagnosis of insulin-secreting tumors.