Irene Vinagre

Impact of the LDL subfraction phenotype on Lp-PLA2 distribution, LDL modification and HDL composition in type 2 diabetes

BackgroundQualitative alterations of lipoproteins underlie the high incidence of atherosclerosis in diabetes. The objective of this study was to assess the impact of low-density lipoprotein (LDL) subfraction phenotype on the qualitative characteristics of LDL and high-density lipoprotein (HDL) in patients with type 2 diabetes.MethodsOne hundred twenty two patients with type 2 diabetes in poor glycemic control and 54 healthy subjects were included in the study. Patients were classified according to their LDL subfraction phenotype. Seventy-seven patients presented phenotype A whereas 45 had phenotype B. All control subjects showed phenotype A. Several forms of modified LDL, HDL composition and the activity and distribution of lipoprotein-associated phospholipase A2 (Lp-PLA2) were analyzed.ResultsOxidized LDL, glycated LDL and electronegative LDL were increased in both groups of patients compared with the control group. Patients with phenotype B had increased oxidized LDL and glycated LDL concentration than patients with phenotype A. HDL composition was abnormal in patients with diabetes, being these abnormalities more marked in patients with phenotype B. Total Lp-PLA2 activity was higher in phenotype B than in phenotype A or in control subjects. The distribution of Lp-PLA2 between HDL and apoB-containing lipoproteins differed in patients with phenotype A and phenotype B, with higher activity associated to apoB-containing lipoproteins in the latter.ConclusionsThe presence of LDL subfraction phenotype B is associated with increased oxidized LDL, glycated LDL and Lp-PLA2 activity associated to apoB-containing lipoproteins, as well as with abnormal HDL composition.

Effect of Improving Glycemic Control in Patients With Type 2 Diabetes Mellitus on Low-Density Lipoprotein Size, Electronegative Low-Density Lipoprotein and Lipoprotein-Associated Phospholipase A2 Distribution

The aim of this study was to determine the effect of intensified hypoglycemic therapy in patients with type 2 diabetes mellitus on the distribution of lipoprotein-associated phospholipase A2 (Lp-PLA2) activity between high-density lipoprotein and low-density lipoprotein (LDL) and its relation with the lipid profile and other qualitative properties of LDL. Forty-two patients with type 2 diabetes on the basis of poor glycemic control and normal or near normal LDL cholesterol were recruited. Lifestyle counseling and pharmacologic hypoglycemic therapy were intensified to improve glycemic control, but lipid-lowering therapy was unchanged. At 4 ± 2 months, glycosylated hemoglobin had decreased by a mean of 2.1%, but the only effect on the lipid profile were statistically significant decreases in nonesterified fatty acids and apolipoprotein B concentration. LDL size increased and the proportion of electronegative LDL decreased significantly. In parallel, total Lp-PLA2 activity decreased significantly, promoting a redistribution of Lp-PLA2 activity toward a higher proportion in high-density lipoprotein. Improvements in glycemic control led to more marked changes in Lp-PLA2 activity and distribution in patients with diabetes who had not received previous lipid-lowering therapy. In conclusion, optimizing glycemic control in patients with type 2 diabetes promotes atheroprotective changes, including larger LDL size, decreased electronegative LDL, and a higher proportion of Lp-PLA2 activity in high-density lipoprotein.

Thyrotoxic Periodic Paralysis: A Case Report and Literature Review

We describe a 37-year-old man with a 4-month history of episodic muscular weakness, involving mainly lower-limbs. Hypokalemia was documented in one episode and managed with intravenous potassium chloride. Hyperthyroidism was diagnosed 4 months after onset of attacks because of mild symptoms. The patient was subsequently diagnosed as having thyrotoxic periodic paralysis associated with Graves’ disease. Treatment with propranolol and methimazol was initiated and one year later he remains euthyroid and symptom free. Thyrotoxic periodic paralysis is a rare disorder, especially among Caucasians, but it should always be considered in patients with acute paralysis and hypokalemia, and thyroid function should be evaluated.

Hypovitaminosis D in type 2 diabetes: relation with features of the metabolic syndrome and glycemic control

Abstract Aim: To assess the association of hypovitaminosis D with clinical and biochemical characteristics of type 2 diabetic patients and to determine the effect of glycemic control optimization on 25-hydroxyvitamin D (25(OH)D) concentrations. Methods: Cross-sectional study of 63 patients with type 2 diabetes (mean age 60 ± 9.8 years, 69.8% men). Twenty of the 63 patients were also studied before and after glycemic control optimization. Results: Mean 25(OH)D concentrations were 63.64 ± 25.51 nmol/L and 74.6% of patients had hypovitaminosis D. Compared with patients with vitamin D sufficiency, patients with hypovitaminosis D had higher prevalence of overweight or obesity (72.3% versus 37.5%; p = 0.012) and higher VLDL cholesterol (VLDL-c) (0.71 (0.24–3.59) versus 0.45 (0.13–1.6) mmol/L; p = 0.011) and C-reactive protein (3.28 (0.36–17.69) versus 1.87 (0.18–17.47) mg/L; p = 0.033) concentrations. The composition of HDL particles also differed in both groups, with higher relative content of triglycerides and lower of cholesterol in patients with hypovitaminosis D. After adjustment for age, seasonality and BMI, differences remained significant for VLDL-c and triglyceride content of HDL. No differences were found regarding other diabetes characteristics. Improvement of glycemic control (HbA1c 9.4 (7.6–14.8) versus 7.3 (6.2–8.7)%; p = 0.000) was accompanied by a decrease in 25(OH)D concentrations (72.7 ± 33.3 to 59.0 ± 21.0 nmol/L; p = 0.035). Correlation analysis revealed that changes in 25(OH)D concentrations were negatively associated to changes in HbA1c (r − 0.482; p = 0.032). Conclusion: Hypovitaminosis D is associated with features of the metabolic syndrome in type 2 diabetes and improvement of glycemic control decreases 25(OH)D concentrations.

Switching to basal-bolus insulin therapy is effective and safe in long-term type 2 diabetes patients inadequately controlled with other insulin regimens

AIM To assess in standard clinical practice the feasibility, efficacy, and safety of switching patients with long-standing type 2 diabetes (T2DM) and poor or unstable blood glucose control to basal-bolus insulin therapy. MATERIAL AND METHODS This was a prospective, single center study including 37 patients with T2DM (age 65±8 years, 62.2% men, body mass index 28.8±6.2 kg/m2, diabetes duration 18±8 years) with poor or unstable glycemic control, who were switched to a basal-bolus insulin regimen with glargine and rapid-acting insulin analogue at the discretion of their physicians. After a group-structured outpatient diabetes training program, patients were followed in a clinical practice setting for 6 months. Clinical and biochemical variables were collected before switching and at 3 and 6 months. RESULTS After switching to basal-bolus therapy, glycosylated hemoglobin (HbA1c) decreased from 9±1.2% to 8.1±1.2% (p<0.001) at 3 months and to 8.0±1.2% at 6 months (p<0.001) without changing total daily insulin dose. The proportion of patients with HbA1c ≥ 9% decreased from 51% to 13.8% at 3 months and to 18.9% at 6 months respectively. There was a single episode of severe hypoglycemia. No changes were seen in body weight and quality of life. The size of LDL (low density lipoprotein) particles significantly increased at 3 and 6 months, while all other lipid parameters remained unchanged. CONCLUSIONS Our study confirmed that basal-bolus insulin therapy is feasible, effective, and safe in patients with long-standing T2DM, and does not impair their quality of life.

Evaluación de la utilización de las prestaciones específicas de los sistemas de infusión subcutánea de insulina y su relación con el control metabólico en pacientes con diabetes tipo 1

BACKGROUND AND OBJECTIVE Patients with type 1 diabetes (T1DM) treated with continuous subcutaneous insulin infusion (CSII) have available several specific features of these devices. The aim of this study was to evaluate the relationship between real use of them and the degree of glycemic control in patients using this therapy. PATIENTS AND METHODS Forty-four T1DM patients on CSII therapy with or without real-time continuous glucose monitoring (CGM) were included. Data from 14 consecutive days were retrospectively collected using the therapy management software CareLink Personal/Pro(®) and HbA1c measurement performed at that period. The relationship between the frequency of usie of specific features of insulin pumps (non-sensor augmented or sensor-augmented) and glycemic control was analyzed. RESULTS Mean HbA1c in the group was 7.5 ± .8%. Mean daily number of boluses administered was 5.1 ± 1.8, with 75.4% of them being bolus wizards (BW). Daily number of boluses was significantly greater in patients with HbA1c <7.5% than in those with HbA1c>7.5% (5.3 ± 1.6 vs. 4.3 ± 1.6, P=.056). There was a trend to greater use of BW in patients with better control (82.8 ± 21.4% vs. 69.9 ± 29.1%, P=.106). HbA1c was lower in patients using CGM (n=8) as compared to those not using sensor-augmented pumps (7.6 ± .8 vs 7.1 ± .7, P=.067), but the difference was not statistically significant. CONCLUSIONS More frequent use of BW appears to be associated to better metabolic control in patients with T1DM using pump therapy. In standard clinical practice, augmentation of insulin pump with CGM may be associated to improved glycemic control.

Postpartum metabolic control in a cohort of women with type 1 diabetes

BACKGROUND AND OBJECTIVE Pregnancy in women with type 1 diabetes (T1D) involves greater risks as compared to non-diabetic women, but less information is available about blood glucose and weight control after delivery. Our aim was to evaluate the postpartum metabolic profile (blood glucose and weight control) of women with T1D and the factors related to those metabolic outcomes. METHODS A retrospective, observational study of 36 women with T1D during pregnancy and for up to one year after delivery. RESULTS Fifty percent of patients attended a preconceptional planning program (PPP), and 44.4% of women were treated with continuous subcutaneous insulin infusion. Mean preconceptional HbA1c and body mass index (BMI) were 7.2±1.2% and 23.8±5.0 respectively. In the total cohort, blood glucose control significantly worsened one year after delivery (HbA1c: 7.2±1.2 vs 7.6±1.2%, P<0.001). Lower preconceptional HbA1c values were found in patients who attended PPP (6.6±0.5 vs. 7.8±1.4%; P=0.02), and were maintained for one year after delivery. No differences were found in body mass index (BMI) from the pregestational period to one year after delivery in any of two groups (No PPP 22.5±4.6 vs 23.2±4.8, P=0.078; PPP 25.4±3.4 vs 25.5±3.4 kg/m(2), P=0.947). Preconceptional HbA1c was shown to be the most important determinant of metabolic control (β=0.962, p<0.001) and weight one year after delivery (β=0.524, p=0.025) and weight gain during pregnancy (β=0.633, p=0.004). CONCLUSIONS Pregnant women with T1D return to prepregnancy body weight one year after delivery, especially those with lower HbA1c levels and BMI before pregnancy. However, blood glucose control deteriorates after delivery, suggesting the need for changes in clinical practice after delivery.

Detailed description of a prepregnancy care program and its impact on maternal glucose control, weight gain, and dropouts.

The aim of this study was to analyze the clinical and metabolic changes observed during a prepregnancy care (PPC) program.

Situación clínica de una cohorte de pacientes con diabetes tipo 1 más de 2 décadas después del inicio. Resultados de un programa específico de seguimiento en una unidad de referencia

BACKGROUND AND OBJECTIVE The clinical course of type 1 diabetes mellitus (T1DM) has changed in recent decades. The aim of our study was to assess the long-term (> 20 years) clinical status of a patient cohort with T1DM under a specific treatment and follow-up program. PATIENTS AND METHODS A single center, observational, cross-sectional study was conducted of a patient cohort diagnosed with T1DM in the 1986-1994 period at our tertiary university hospital. Clinical characteristics, metabolic parameters, and occurrence of chronic complications and comorbidities after > 20 years of follow-up were collected. All subjects entered our specific program for patients with newly-diagnosed T1D and were followed up using the same clinical protocol. Data are shown as mean (standard deviation) or as number of patients and percentage. The appropriate test was used to compare quantitative and qualitative data. A P value <0.05 was considered statistically significant. RESULTS A total of 279 patients were recorded, of whom 153 (53.6% women; mean age 46.6±8.6 years; age at onset 23.3±8.8 years; disease duration, 23.3±2.6 years) continued to attend our diabetes unit at the time of the analysis. Of these patients, 24.8% were administered continuous subcutaneous insulin infusion (CSII). Mean HbA1c in the past 5 years and in the last year were7.8±0.9% and 7.7±1.1% respectively (7.3±1.5% in those given CSII). Smoking was reported by 19.6% of patients, while 15.7% had high blood pressure and 37.9% dyslipidemia. Diabetic retinopathy was diagnosed in 20.4%, and 11.3% of the total cohort had nephropathy. Only 1.3% of our patients had a history of CVD. CONCLUSIONS Data collected from a cohort of patients with T1DM for more than 2 decades regularly followed up with a specific program in a tertiary university hospital suggest a remarkably low prevalence of diabetic complications.

Unusual characteristics and fatal outcome of a malignant struma ovarii. Case report and literature review

Struma ovarii is an uncommon teratoma of the ovary that contains over 50% of thyroid tissue. This tumor accounts for 0.2-1.3% of all ovarian tumors and for 2-4% of all teratomas. Malignancy is reported in 5% to 37% of patients with struma ovarii, with metastases occurring in few cases. 1—3 This article reports a patient with some unusual features, including malignancy, metastases, hormone production, and a fatal outcome. Literature is reviewed, and significance of appropriate treatment and follow-up of these patients is emphasized. A 38-year-old woman was referred to our hospital in 1994 for a second opinion regarding management of a struma ovarii. The disease had been diagnosed at another center in 1981, when she was 25 years old, after right salpingectomy and partial oophorectomy for a right ovarian cyst. At that time, pathological study showed a struma ovarii with no signs of malignancy. In 1993 (at the age of 37 years), patient underwent a left salpingo-oophorectomy and completion of right oophorectomy because of detection of an 8-cm left ovarian mass. Multiple peritoneal nodules were found during surgery, and pathological study found a struma ovarii with positive immunohistochemistry for thyroglobulin. A 131 I scan revealed physiological accumulation of iodine in the thyroid gland and pathological deposits in abdomen. Total thyroidectomy and 131 I ablation therapy were proposed, but the