Jan Brož

Health Care Provision for People with Diabetes and Postgraduate Training of Diabetes Specialists in Eastern European Countries

Background: In many eastern European countries, information is limited regarding (1) prevalence of diabetes and its complications, (2) health care provisions for diabetes, (3) diabetes management, and (4) the structure of postgraduate training in diabetes for doctors and nurses. These have been reviewed here. Methods: Source material was derived from publications and through personal communication with diabetes specialists in leading clinical centers in Bulgaria, the Czech Republic, Hungary, Poland, Romania, Russia, Slovakia, and Ukraine. Results: In many countries, information about diabetes prevalence is incomplete or inaccurate with many undiagnosed cases but varies from 7.7–9.6%. Diabetic complications and adverse outcomes (blindness, amputation, and chronic renal failure) are common, with a high mortality resulting from cardiovascular disease. State-funded and private systems often exist side by side. Diabetes care is provided by diabetologists, endocrinologists, internal medicine physicians, and general practitioners, but their involvement varies considerably between countries and some have too few specialists who are located only in large centers. Specialized dietetics and foot care services are, in general, poorly developed. Insulin is freely available although analogs may incur a cost to the patient, while newer drugs (glucagon-like peptide-1 agonists, dipeptidyl peptidase-4 inhibitors) are either expensive or unavailable. Glucose monitoring is often rationed. Postgraduate training in diabetes is now well established in most countries and specialist training for nurses is being developed. Conclusions: Continuing disparities with western European countries are related mainly to deficient economic resources and inadequate financial investment. Some countries have introduced national programs to improve diabetes care with better clinical outcomes being obtained following treatment initiatives.

Three novel mutations in MODY and its phenotype in three different Czech families

AIMS/HYPOTHESIS MODY (Maturity Onset Diabetes of the Young) is an autosomal dominant inherited type of diabetes with significant genetic heterogeneity. New mutations causing MODY are still being found. A genetically confirmed diagnosis of MODY allows application of individualized treatment based on the underlying concrete genetic dysfunction. Detection of novel MODY mutations helps provide a more complete picture of the possible MODY genotypes. MATERIALS AND METHODS We tested 43 adult Czech patients with clinical characteristics of MODY, using direct sequencing of HNF1A (hepatocyte nuclear factor 1-alpha), HNF4A (hepatocyte nuclear factor 4-alpha) and GCK (glucokinase) genes. RESULTS In three Czech families we identified three novel mutations we believe causing MODY-two missense mutations in HNF1A [F268L (c.802T>C) and P291S (c.871C>T)] and one frame shift mutation in GCK V244fsdelG (c.729delG). Some of the novel HNF1A mutation carriers were successfully transferred from insulin to gliclazide, while some of the novel GCK mutation carriers had a good clinical response when switched from insulin or oral antidiabetic drugs to diet. CONCLUSION We describe three novel MODY mutations in three Czech families. The identification of MODY mutations had a meaningful impact on therapy on the mutation carriers.

Fear of driving license withdrawal in patients with insulin-treated diabetes mellitus negatively influences their decision to report severe hypoglycemic events to physicians

Background Under current European Union legislation, two severe hypoglycemic events within 12 months is grounds for driving license withdrawal. The aim of the study reported here was to determine whether fear of such a withdrawal could lead to patients concealing severe hypoglycemia from physicians, which could negatively impact further treatment decisions. Methods A total of 663 patients with insulin-treated diabetes were anonymously surveyed about whether they would conceal severe hypoglycemic events from their physicians, if revealing them could result in driving license withdrawal. This investigation utilized an adapted and expanded questionnaire by Graveling et al. Results Of all diabetic patients surveyed, 26.17% would most likely not report hypoglycemia, and 25.86% were undecided. In a group of patients with type 1 diabetes, 31.83% would likely not report hypoglycemic events, and 25.06% were undecided. The patients least likely to report severe hypoglycemic events were those who indicated that vehicles were partly essential for work, and who also had more than two hypoglycemic events monthly. Conclusion A considerable percentage of diabetic patients would likely conceal severe hypoglycemic events from their physicians due to fear of driving license withdrawal. Patient failure to report severe hypoglycemic events can potentially lead to physicians being misinformed regarding the patient’s condition, which could lead to inadequate monitoring and treatment.

Could Continuous Glucose Monitoring Facilitate Identifying Diabetes Patients with a Higher Risk of Hypoglycemia during Driving

An extensive article about driving with diabetes mellitus by Kohrman and coauthors1 was published in Journal of Diabetes Science and Technology. The authors mentioned that a hypoglycemic episode during driving is generally considered as one of the main risk factors for driving mishaps. Furthermore, they suggested the use of continuous glucose monitoring (CGM) as one of the possible tools to prevent hypoglycemia during driving.1 A survey of 1076 adults with type 1 diabetes mellitus revealed that the distribution of severe hypoglycemia was highly skewed, with 5% of subjects accounting for 54% of all episodes.2 In almost all the studies concerning hypoglycemia during driving, information is obtained through questionnaires filled in by the patients themselves. The value of such questionnaires is limited, because patients tend to describe the occurrence of hypoglycemia in a more positive fashion.3 Moreover, unrecognized hypoglycemia remains undetected. Continuous glucose monitoring provides information about fluctuation in blood glucose levels and can also uncover asymptomatic hypoglycemia.4 Unfortunately, the use of CGM is not widespread, and it is also limited by its cost.

Prevalence of active infection with Chlamydia pneumoniae and human cytomegalovirus in patients with type II diabetes mellitus.

By promoting the inflammatory process in the arterial wall,Chlamydia pneumoniae (CPN) and human cytomegalovirus (CMV) participate in the pathogenesis of cardiovascular disease (CVD). Since patients with diabetes mellitus (DM) are at high risk of CVD, we studied markers of CMV and CPN infection in DM patients as possible predictors of cardiovascular complications. The seroprevalence rates of CMV in 44 DM patients and matched controls were 74 and 88 %, respectively. Compared with controls, patients showed lower titers of IgG against CMV (p < 0.001) and higher titers of genus-specific IgA against CPN (p = 0.006). The titers of genus-specific IgG and prevalence rates of type-specific anti-CPN IgA, IgG or IgM were similar in both DM patients and controls. Serological markers of either active or recent CPN infection were detected in 54 % of patients and 59 % of controls. However, CPN DNA was not detected in the blood of any DM patient. CMV DNA was found in the blood of 1 (2.3 %) patient. The results do not indicate an increased rate of CMV or CPN infection in patients with type II DM.

An international, multicenter, observational survey to evaluate diabetes control in subjects using insulin for the treatment of type 1 and type 2 diabetes mellitus in the Czech Republic and Slovak Republic: study protocol for a cross-sectional survey

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Incidence of Diabetes Mellitus Narrowly Correlates with Unemployment Rate during 2000-2012 in the Czech Republic

There is a documented association between higher unemployment rates in inner cities and a higher risk of type 2 diabetes mellitus (DM) (1). Higher unemployment at regional level is also associated with a higher prevalence of diabetes mellitus (2). Possible causes for the relationship between unemployment and diabetes mellitus include, for example, limited financial resources, which can lead to underfunded support of physical activity and healthy diets (3, 4). Results from the DIAB-CORE Consortium, a study that examined, among other issues, the relationship between type 2 diabetes mellitus and various social aspects including unemployment in Germany (1, 2, 5), led us to question whether the relationship between unemployment rates and the incidence of diabetes mellitus could be confirmed for larger areas and over longer periods of time in the Czech Republic. We also wanted to determine whether previous findings of a study involving a relatively small sample of patients could be verified using a different methodology based on population data (official unemployment figures) from all 14 administrative regions of the Czech Republic.We analyzed the relationship between the incidence of diabetes mellitus and unemployment in the Czech Republic, wherein 10,509,286 inhabitants resided during 2012 and the prevalence of diabetes mellitus was 8.0%. The country is divided into 14 higher-level territorial administrative units (regions): in 2012 the least populous was inhabited by 301,726 residents, while the most populous by 1,291,816 residents (6). Data pertaining to patients with diabetes mellitus (more specifically, the number of new diabetes patients per calendar year) were obtained from a register that is maintained by the Institute of Health Information and Statistics of the Czech Republic, to which all physicians are legally obliged to annually report data for diabetes patients in their care (7). Unemployment figures were obtained from a register kept by the Ministry of Labour and Social Affairs, which is managed in accordance with Eurostat/International Labour Office methods (8). At the time this study was conducted, available data from both registers spanned the period from 2000 to 2012.Given that the unemployment rates among individual regions vary both instantaneously and continuously, we compared the relationship between unemployment rates and the incidence of diabetes mellitus, while taking into account time and inter-regional differences in both population totals and background diabetes incidence. Using the Generalized Additive Model (GAM) (9), regions were represented by i and calendar year was represented by t:(ProQuest: ... denotes formula omitted.)wherein the modeled quantity (the left side of the equation) is a proxy for the regionally-specific incidence. For this, the effect of unemployment was tested (regional and time-specific); coefficient β is estimated from the data, after an adjustment for regionallyspecific average incidence (μi) and time trend s(t) , estimated as a spline, and [varepsilon] it represents homoscedastic random error.Thus, we compared the incidence of diabetes mellitus and unemployment rate, while taking into account separate values for individual regions, over the aforementioned period of 2000-2012. The effect of unemployment on DM incidence adjusted for spatial and temporal differences was positive (the estimate of the β coefficient was 4.173.10-3, its standard error was 7.688.10-4 ) and highly statistically significant (p Unfortunately, the diabetes mellitus patient registry does not distinguish types of disease in the annual new patient reports. However, the number of patients registered according to different types of diabetes mellitus in the years 2000 and 2012 was 44,870 and 56,514 individuals, respectively, with type 1 diabetes mellitus: 8,299 and 12,128, respectively, with secondary diabetes; and 599,782 and 772,585, respectively, with type 2 diabetes mellitus. …

Prediabetes, diabetes and unemployment

e read with interest the article by Rautio et al. which as been recently published online in the journal Primary are Diabetes [1]. This article objectively quantifies the relaionship between varying exposure to unemployment and mpaired glucose metabolism, suggesting a relation of unemloyment and type 2 diabetes in men. In our recent work [2] e have, through a different type of data (extensive population ata from official registers, without a longitudinal structure), etected a relationship between unemployment and the incience of diabetes in the Czech Republic. This type of data id not allow us to analyse differences between men and omen with this diagnosis. When thinking about the results f the work Rautio et al., we came up with four questions hich we would like to respectfully pose to the authors. (1) hether the authors had information on the weight gain of ndividual subjects, at least in recent years just before the tudy. It would be interesting to test whether higher weight ain is associated with the prediabetes and diabetes status weight history can be a valuable proxy or predictor for changng diabetes status, but it is certainly possible that its effect nteracts with the effect of unemployment). (2) Whether they ave data available on the nature of employment that each ubject last held before the study. Knowledge of this data ould help estimate the likely differences in physical workload etween previous employment and current unemployment. 3) Whether it would be worthwhile to study the interaction ffects of unemployment not only with gender, but also with ther explanatory variables such as physical activity level, ody mass index, smoking history, education effects interct with uneployment. (4) Whether it would be valuable to ttempt to quantify the impact of the unemployment period n more detail (e.g. via modern regression methods like GAM”). e recognize that, that in each group of “unemployed”, as they re defined in the article, there may be included individuals ith a diametrically different number of unemployed days (for nstance in the group of ≤1 year there can be an individual with day, but also 268 days spent unemployed, that is, people with ompletely different probable impact of unemployment). We

An online source of information for diabetes mellitus patients—a neglected opportunity for a developing region like Sub-Saharan Africa

The world of current e-medicine not only in advanced countries focuses on the measurable benefits of using the Internet and mobile applications with the view of diabetes mellitus (DM), in particular on their impact on diabetes metabolic compensation (HbA1c) and hypoglycemia [1]. In general, simple educational portals as elementary source of information are underestimated. Nevertheless, they are increasingly important especially in places with insufficient education. When there was a significant lack of educational materials for type 1 DM (T1DM) patients and an insufficient network of educators in the Czech Republic, we created an online informational site with the help of medical experts and educators. Between 2009 and 2013, this was widely used by our patients, even without its active promotion (30,421 individual users spent at least 30 s on the site, i.e., more than a half of all T1DM patients in the Czech Republic) [2] and continues to be similarly used. We have investigated implementation, in this respect, in Sub-Saharan African countries where there is a marked increase in DM [3] while healthcare enjoys little support; hence, the availability of medical care and professional information is very poor. Google’s keyword combinations of diabetes-Internet-education, diabetes-web-education, and diabetes-portal-education links together with BAfrica^ and individual country names were searched. The search was carried out in English, French, Portuguese, and Spanish. Except for South Africa, merely six informational sites were found (four in English, two in French). None of these, however, brings more than a little general information about diabetes; one even just promotes a nutritional supplement. There was not found any specific information for insulin-treated patients what-so-ever. The vast majority of national diabetes associations do not have their own websites. Internet access is also an important issue. Although access is limited in Sub-Saharan Africa, there is a rapid growth of its users (from 2.4% of the population in 2005 to 25.1% in 2016), just as of cellphone users (from 12.4% in 2005 increased to 80.8% in 2016), thus increasing the potential for wider use of the Internet [4]. It may, therefore, be believed that the creation of a professional information resource, which could then be modified depending on the local needs of individual countries, would provide patients with necessary information and at a low cost partly bridge the current lack of trained educators and physicians.

Hidden MODY—Looking for a Needle in a Haystack

MODY (Maturity onset diabetes of the young) is a specific type of diabetes caused by mutation in a single gene, involved in the development and function of the β-cells, inherited in an autosomal dominant manner (1). Out of fourteen, up to date discovered, MODY genes (2) the most often affected ones include GCK (gene encoding glucokinase enzyme) and HNF1A (encoding the transcription factor—hepatocyte nuclear factor 1α), which altogether account for approximately 80% of all MODY cases (3). Mutations in other genes (e.g., HNF4A or HNF1B—hepatocyte nuclear factor 4α and 1β), occur rarely (4). Although MODY represents a rather scarce diabetes type (1), searching for MODY among much more prevalent forms of diabetes is important and desirable for its clear impact on clinical practice—for appropriate diabetes management with the most suitable treatment (accompanied with improved quality of life) (5, 6), for assessing the real risk of development and progression of specific diabetic complications in each MODY type, as well as for early diagnosis in the patients relatives and offspring. Nevertheless, overwhelming majority of MODY patients worldwide remains misdiagnosed (3, 7). Moreover, no unitary and up-to-date diagnostic guidelines have been established so far, and also it is not obvious, which approach to correct identification of MODY patients is optimal. The aim of this communication is to present our experiences with searching for patients with MODY in the context of current diagnostic proceedings and actual study outputs available.