Aniceto Charro

A preventative foot care programme for people with diabetes with different stages of neuropathy.

The aim of this study was to assess the efficacy of a preventative foot care programme, applied in a normal outpatient setting to decrease the incidence of foot ulcers in people with diabetes diagnosed as having neuropathy by neuropathy disability score (NDS), in relation to the severity of neuropathy based on the vibration perception threshold (VPT). A structured continuous preventative foot care programme was designed to ensure proper footwear, walking foot hygiene, callus care, nailcutting, water temperature checks, use of warming devices, bathroom surgery, foot care products and self-inspection. Continual foot-care education and treatment, including podiatry, were available. Evaluation was at least every 6 months. Diabetic patients (n=308) with neuropathy (NDS > or =6), 72.3+/-10.7 years old, 45% men, 10.9+/-8.8 years duration of diabetes, and HbA(1c) 6.5+/-1.3%, without a history of foot lesions were recruited over 3 years and followed-up for 4.6 (3-6) years. A low risk group (n=124) had a VPT<25 V while 184 had a VPT > or =25 V (high risk). In all 220 patients (71%) complied with the programme, compliance being 76 and 68% in low and high risk groups. The low risk group developed nine ulcers in nine patients, and the high risk group 24 ulcers in 19 patients. Of these eight and 19 ulcers, respectively, were in the non-compliant patient group, giving relative risk of 22 and eight compared with people attending the programme. Thus compliance with a preventative foot programme reduces the incidence of foot ulceration in people with diabetes with neuropathy. This decrease is relatively greater in patients with less severity of neuropathy. The simple design should be widely generalisable.

Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients : a prospective clinic-based study

UNLABELLED To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569307 and an estimated diabetic population of 37932 (15505 men and 22427 women). The level of arterial reconstruction and associated risk factors were ascertained. RESULTS A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P<0.05) and were less frequently smokers (P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05). CONCLUSION Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Family physician and endocrinologist coordination as the basis for diabetes care in clinical practice.

BackgroundTo estimate the proportion of diabetic patients (DPts) with peripheral vascular disease treated at a primary health care site after an endocrinologist-based intervention, who meet ATP III and Steno targets of metabolic control, as well as to compare the outcome with the results of the patients treated by endocrinologists.MethodsA controlled, prospective over 30-months period study was conducted in area 7 of Madrid. One hundred twenty six eligible diabetic patients diagnosed as having peripheral vascular disease between January 2003 and June 2004 were included in the study. After a treatment period of three months by the Diabetes team at St Carlos Hospital, 63 patients were randomly assigned to continue their follow up by diabetes team (Group A) and other 63 to be treated by the family physicians (FP) at primary care level with continuous diabetes team coordination (Group B). 57 DPts from Group A and 59 from Group B, completed the 30 months follow-up period. At baseline both groups were similar in age, weight, time from diagnosis and metabolic control. The main outcomes of this study were the proportion of patients meeting ATP III and Steno goals for HbA1c (%), Cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, blood pressure, albumine-to-creatinine excretion ratio (ACR), body mass index (BMI), waist circumference (WC), anti-aggregation treatment and smoking status.ResultsAt the end of the follow up, no differences were found between the groups. More than 37% of diabetic patients assigned to be treated by FP achieved a HbA1c < 6.5%, more than 50% a ACR < 30 mg/g, and more than 80% reached low risk values for cholesterol, LDL cholesterol, triglycerides, diastolic blood pressure and were anti-aggregated, and 12% remained smokers. In contrast, less than 45% achieved a systolic blood pressure < 130 mm Hg, less than 12% had a BMI < 25 Kg.m-2 (versus 23% in group A; p < 0.05) and 49%/30% (men/women) had a waist circumference of low risk.ConclusionImprovements in metabolic control among diabetic patients with peripheral vascular disease treated at a primary health care setting is possible, reaching similar results to the patients treated at a specialized level. Despite such an improvement, body weight control remains more than poor in both levels, mainly at primary care level. General practitioner and endocrinologist coordination care may be important to enhance diabetes management in primary care settings.Trial registrationClinical Trial number ISRCTN75037597

Effect of [d-Trp6]LHRH infusion on prolactin secretion by perifused rat pituitary cells

The effect of a superactive agonistic analog of luteinizing hormone-releasing hormone (LHRH), [D-Trp6]LHRH on prolactin (PRL) secretion by perifused rat pituitary cells was investigated. Constant infusion of [D-Trp6]LHRH (0.5 ng/min) for 2-3 h elicited a significant decrease in PRL secretion by these cells. This decrease in PRL release started ca. 30 min after the beginning of the infusion with the LHRH analog and lasted up to 1.5-2 h. [D-Trp6]LHRH significantly stimulated luteinizing hormone (LH) secretion during the first 30 min of peptide infusion; thereafter, LH levels began to return to control values. In animals pretreated in vivo with 50 micrograms of [D-Trp6]LHRH (s.c.) 1 h before sacrifice, PRL secretion by the rat pituitary cell perifusion system was significantly lower than vehicle-injected controls throughout the entire [D-Trp6]LHRH infusion period. On the other hand, thyrotropin-releasing hormone (TRH)-stimulated PRL secretion was slightly, but significantly imparied by [D-Trp6]LHRH infusion, while dopamine (DA) inhibition of PRL release was unaffected by this same treatment. These results reinforce previous observations of a modulatory effect of [D-Trp6]LHRH, probably mediated by pituitary gonadotrophs, on PRL secretion by the anterior pituitary. In addition, our findings suggest that basal PRL secretion by the lactotroph may be dependent on a normal function of the gonadotroph. The collected data from this and previous reports support the existence of a functional link between gonadotrophs and lactotrophs in the rat pituitary gland.

Evaluación de dos inmunoensayos altamente sensibles para la determinación de IGF-1 y GH séricas tras sobrecarga oral de glucosa en controles sanos

OBJECTIVE To evaluate 2 highly sensitive assays for serum insulin-like growth factor-1 (IGF-1) and growth hormone (GH) determination following an oral glucose tolerance test (OGTT) in healthy controls. METHODS Nineteen healthy adults underwent a standard 75g OGTT and GH and IGF-1 were measured. Serum GH and IGF-1 levels were assayed by a sensitive immunoradiometric assay (IRMA) and a highly sensitive chemiluminescent immunometric assay (CLIA). RESULTS The mean IGF-1 concentration was 153±65ng/ml measured by IRMA and 144±56ng/ml measured by CLIA. The median (interquartile range) basal GH concentrations by IRMAvs CLIA were 0.8 (0.5-3) μg/l vs 0.5 (0.1-2.4) μg/l. The median nadir GH measured by IRMA in these subjects was 0.4 (0.3-0.5) μg/l, and the mean nadir GH by CLIA was 0.08 (0.01-0.22) μg/I. When a ratio of basal IRMA/CLIA GH was calculated in each subject, the median ratio of basal IRMA/CLIA GH concentrations in subjects overall was 1.68. Similarly, the median ratio of nadir IRMA/CLIA GH values was 4.44. One of the subjects did not achieve GH suppression into the established normal range, with a GH nadir of 1.2 μg/l by IRMA and 1 μg/l by CLIA, overlapping with the traditional cut-off defining acromegaly when GH suppression was measured by IRMA. CONCLUSIONS Highly sensitive chemiluminescent immunometric assays should be used to assess the GH/IGF-1 axis. In our opinion, there is no need for a lower GH suppression cut-off for diagnosing acromegaly. We found no significant gender-, BMI- or age-related differences in nadir GH levels and thus our results do not support different OGTT criteria for screening of acromegaly in men and women, or in younger and older subjects.OBJECTIVE To evaluate 2 highly sensitive assays for serum insulin-like growth factor-1 (IGF-1) and growth hormone (GH) determination following an oral glucose tolerance test (OGTT) in healthy controls. METHODS Nineteen healthy adults underwent a standard 75g OGTT and GH and IGF-1 were measured. Serum GH and IGF-1 levels were assayed by a sensitive immunoradiometric assay (IRMA) and a highly sensitive chemiluminescent immunometric assay (CLIA). RESULTS The mean IGF-1 concentration was 153±65ng/ml measured by IRMA and 144±56ng/ml measured by CLIA. The median (interquartile range) basal GH concentrations by IRMAvs CLIA were 0.8 (0.5-3) μg/l vs 0.5 (0.1-2.4) μg/l. The median nadir GH measured by IRMA in these subjects was 0.4 (0.3-0.5) μg/l, and the mean nadir GH by CLIA was 0.08 (0.01-0.22) μg/I. When a ratio of basal IRMA/CLIA GH was calculated in each subject, the median ratio of basal IRMA/CLIA GH concentrations in subjects overall was 1.68. Similarly, the median ratio of nadir IRMA/CLIA GH values was 4.44. One of the subjects did not achieve GH suppression into the established normal range, with a GH nadir of 1.2 μg/l by IRMA and 1 μg/l by CLIA, overlapping with the traditional cut-off defining acromegaly when GH suppression was measured by IRMA. CONCLUSIONS Highly sensitive chemiluminescent immunometric assays should be used to assess the GH/IGF-1 axis. In our opinion, there is no need for a lower GH suppression cut-off for diagnosing acromegaly. We found no significant gender-, BMI- or age-related differences in nadir GH levels and thus our results do not support different OGTT criteria for screening of acromegaly in men and women, or in younger and older subjects.

Tumor de células de Leydig en mujer posmenopáusica

La aparicion de hirsutismo clinico en mujer menopausica, de manera brusca y con poco tiempo de evolucion, junto con otros factores, como hipertension arterial, diabetes mellitus, poliglobulia, tiene que hacer pensar en un exceso de androgenos, exogeno o endogeno. Presentamos un caso de virilizacion en una mujer menopausica por un tumor de celulas del Leydig, secretor de androgenos. Se trata de una neoplasia muy infrecuente, menos del 1% de los tumores ovaricos y de presentacion muy rara en la menopausia.