Trabajos Científicos

Problemática de la Neuroartropatía de Charcot en una unidad multidisciplinaria de pie diabético

XIX Congreso Argentino de Diabetes Mar del Plata

Introducción: la Neuroatropatía de Charcot (NC) es una de las complicaciones más raras pero más devastadora de la DM, con una prevalencia estimada de 0,4 a 13%. Se presenta con una evolución de la diabetes de más de 10 años y dos tercios de los pacientes son diabéticos tipo 2. Objetivos: determinar prevalencia de NC en una unidad multidisciplinaria de pie diabético, características clínicas, epidemiológicas y factores de riesgo asociados a su desarrollo.

Materiales y métodos: estudio observacional de corte transversal. Sobre 3.945 pacientes atendidos durante 6 años en una unidad multidisciplinaria de pie diabético se incluyeron aquellos con diagnóstico de NC. Se estudiaron los pacientes con NC agudo y crónico, las complicaciones asociadas (neuropatía, nefropatía, retinopatía, enfermedad vascular periférica) y factores de riesgo para el desarrollo de úlcera en la NC. Se utilizó el test de chi cuadrado para variables categóricas y test t de Student para variables continuas, se estableció valor de p<0,05 como estadísticamente significativo.

Resultados: se analizaron 51 pacientes con NC, el 64,5% era >50 años, con predominio del sexo masculino (74,5%); el 82,3% tenía diagnóstico de DM 2 y el 66,6% tenía más de 10 años de evolución de la DM. Casi todos los pacientes tenían sobrepeso y obesidad. La mitad era hipertenso, un 43% dislipémico, un tercio tabaquista y un 4% alcohólico. Se realizó diagnóstico de NC agudo en un 33% y crónico en un 64%. Se localizó en pie el 86%, tobillo el 13%, y un 13 % fue bilateral. Se observó como complicación frecuente la presencia de úlcera en el 58% de los pacientes y un 6% sufrió amputación. Al analizar las complicaciones crónicas, el 49% tenía retinopatía, 35% nefropatía, 72% neuropatía periférica (NP) severa, 24% moderada y 4% leve. Se encontró enfermedad vascular periférica (EVP) en el 13%. Casi todos los pacientes (93,4%) que desarrollaron úlcera sobre el pie de Charcot, padecían pérdida de la sensibilidad protectora (evaluada con monofilamento de semmes –weinstein), otorgando mayor riesgo de padecer úlcera con un OR 7 (IC: 1,28-38,2) y una p=0,014.

Conclusiones: nuestro trabajo muestra que la NP es un requisito para el desarrollo de NC y que además del factor ortopédico, la pérdida de sensibilidad protectora es el factor de riesgo más importante para padecer úlcera. A pesar de que la adecuada perfusión es indispensable en la fisiopatogenia de la enfermedad encontramos que el 13% de los pacientes tenía EVP.

Diabetes tipo 1 e insulinoresistencia: Tasa Estimada de Disposición de la Glucosa y su correlación con complicaciones crónicas

XIX Congreso Argentino de Diabetes Mar del Plata

INTRODUCCION La presencia de insulinoresistencia (IR) en individuos con diabetes tipo 1(DM1) ha sido demostrada en muchos estudios y se asocia a un mayor riesgo cardiovascular en estos pacientes. El gold standard para la medición de insulinosensibilidad es el clamp euglucémico hiperinsulinemico. Esta técnica no resulta práctica para su aplicación en el ámbito clínico. La “tasa estimada de disposición de la glucosa ó TeDG” puede calcularse utilizando mediciones clínicas de rutina (HbA1c, presencia de hipertensión y perímetro de cintura), muestra una buena correlación con la IR medida por el clamp euglucémicohiperinsulinémico y ha sido validada para la estimación de insulinosensibilidad en DM 1 OBJETIVOS: Relacionar la presencia de IR en DM1, estimada a través de la fórmula de TeDG con complicaciones macro y microvasculares. MATERIAL Y MÉTODOS: Estudio transversal que incluyó 357 pacientes con diagnóstico clínico de DM 1 atendidos en un Servicio de Diabetología. La TeDG fue calculada utilizando HbA1c, perímetro de cintura y presencia de hipertensión TeDG (mg/kg/min)= 21.158 + (0.09 x PC)+ (3.407x HTA)+ (0.551x HbA1c) Se estimo la prevalencia de complicaciones y comorbilidades por terciles de TeDG. RESULTADOS: 57% de los pacientes eran hombres, edad media de 40± 14 años y un promedio de 14 años de evolución. El Indice de Masa Corporal (IMC) fue de 25,8 ± 4,8. Los pacientes en el tercil más bajo de TeDG (>IR) tenían mayor edad, mayor tiempo de evolución, mayor IMC, mayor dosis de insulina/kg de peso, mayores niveles de TGC, menores niveles de HDL, peor control metabólico y mayor prevalencia de hipertensión. Eran más sedentarios y mostraban mayor indicación de estatinas, aspirina, IECA o ARAII. Registraba mayor prevalencia de retinopatía, nefropatía, enfermedad renal crónica, neuropatía, pie diabético y mayor enfermedad cardiovascular. En el análisis multivariado, la única complicación que mostró asociación independiente a una TeDG <6,33 fue la nefropatia diabética. CONCLUSIÓN: Una menor TeDG se asoció a mayor presencia de complicaciones y comorbilidades en comparación a los terciles superiores. La única complicación que se asoció de manera independiente a una TeDG <6.33 fue la nefropatía diabética. Esta herramienta clínica podría resultar de utilidad para identificar pacientes con mayor riesgo de complicaciones a fin de implementar estrategias más agresivas para el control de factores de riesgo.

Impact of an Educational Intervention on Foot Care among Low-Literacy and Unemployed Diabetic Patients

73th Scientific Sessions. American Diabetes Association. Chicago, USA.

Abstract: Low-Educated and Unemployed (UE) patients are susceptible of developing foot lesions. A prospective longitudinal observational study designed to determine the impact of education on DM and foot care, metabolic control, number of ulcers, healing and amputations, adherence to scheduled appointments and comparing results between patients with low (LLL) and high (HLL) literacy levels and between the employed and the UE within the framework of a Public Hospital. Patients recruited: 291. Men: 51%; Mean age: 54 years. LLL (up to primary school completion): 46%. UE: 49%. A first Survey 1 (S1) on baseline knowledge was conducted. Educational intervention: interactive lecture on DM and foot care and foot examination followed by risk stratification. Assessment of acquired skills through Survey 2 (S2). Follow-up: 1 year. Significant p<.05. The overall survey scores improved significantly in reference to both LLL (p=.014) and HLL (p=.001) patients. S1 and S2 scores were lower for LLL (p=.001 and p<.0001 respectively). The study also showed an improvement among the working population (p=.003) which was not evidenced among the UE. LLL and UE presented higher ulcer and prior amputation rates against the HLL and employed and after the intervention the number dropped for new ulcers as well as for amputations but without statistical significance. Ulcers healed reached 58%. Baseline A1C fell during follow-up among LLL (9.39±2.34 vs 7.83±1.53%; p=.0001) and UE (8.91±2.45 vs 7.96±1.85%; p=.0126). Patients attending scheduled appointments amounted to 34.36%. Education improved significantly the level of knowledge and skills as well as metabolic control among all participants. LLL patients and the UE presented a larger number of foot lesions. The rate of ulcer healing was high showing a trend of decreasing number of ulcers and amputations. Adherence to scheduled appointments proved low; hence the need to regard education as a continuous process, especially in reference to vulnerable populations.

Influence of Obesity on Chronic Complications and Cardiovascular Risk Factors among a Cohort of 360 Type 1 Diabetic Patients

73th Scientific Sessions. American Diabetes Association. Chicago, USA.

Abstract: Obesity among T1DM patients is a rising phenomenon. A cross sectional study was conducted to establish its impact on the prevalence of chronic complications and cardiovascular risk factors, which included T1DM patients ages 16 and older who visited the Diabetes Service of a Public Hospital between 1/2007 and 12/2012. The number of study participants was 360 (59.4% male, mean age 39 years, duration of DM 15 ±10 years). Obesity and overweight affected 45.56% of patients (15.56% and 30% respectively) and 41.94% had central obesity. When comparing obese and nonobese patients, the former were older (p=0.0004) and had higher prevalence of hypertension (HTN) (p=0.005) and dyslipidemia (p=0.0107). Prevalence of smoking, sedentary lifestyle and A1c averages did not differ significantly between both groups. Obesity was associated with greater macrovascular complications (p=0.0019); ischemic cardiopathy proved the most frequent (p=0.0002), followed by cerebrovascular disease (p=0.0068). Peripheral vascular disease did not differ significantly between both groups. Prevalence of microvascular complications between obese and nonobese patients did not vary significantly. In the multiple logistic regression analysis, obesity did not show an independent relationship with chronic complications, while duration of disease (OR: 1.15; 95% IC 1.10-1.19), A1c levels (OR: 1.20; 95% IC 1.06-1.36) and HTN (OR: 3.78; 95% IC 1.82-7.83) showed an independent relationship with microvascular complications as well as did age (OR: 1.05; 95% IC 1.02-1.08) and HTN (OR: 5.89; 95% IC 2.33-14.89) with macrovascular complications. Thus, obesity was associated with a greater prevalence of macrovascular complications, mainly ischemic cardiopathy and higher prevalence of HTN and dyslipidemia. There was no independent relationship between obesity and chronic complications.

Development of Chronic Complications in Relation to Risk Factors for Vascular Disease Progression in Type 1 Diabetics

73th Scientific Sessions. American Diabetes Association. Chicago, USA.

Abstract: T1DM carries early morbidity and mortality due to microvascular (MiV) and macrovascular (MaV) complications. A cross-sectional study on T1DM patients ages 16 and older who visited a Public Hospital was conducted to determine the prevalence of such complications and possible related factors. From 1/2007 to 12/2012, 360 patients were studied with a mean age of 39 yrs, 59.4% male with a 15-yrs average DM duration; 25.6% were hypertensive, 52.2% dyslipidemic, 31.5%, smokers, 41% sedentary and 45.5% obese or overweight. One or more chronic complications were found in 55.8% of patients. Out of these, 53.05% had MiV complications, 11.3% MaV complications and 8.61% both. Patients with MiV complications showed higher prevalence of dyslipidemia (p=0.0012), hypertension (HTN) (p<0.0001) and larger waist perimeter (WP) (p=0.021). They were also older with longer disease duration (p<0.0001 for both). Duration of T1DM (OR 1.15; 95% IC 1.10-1.19), A1c (OR 1.20; 95% IC 1.06-1.36) and HTN (OR 3.78; 95% IC 1.82-7.83) showed independent relation to the presence of microangiopathy. Our study found that the risk of MiV complications increased by 15% with each year of T1DM duration and by 20% for each A1C unit increase. Type 1 diabetics with HTN had a 3.8 fold increased risk of having MiV complications versus nonhypertensives. Patients with MaV complications had higher prevalence of HTN (p<0.0001), obesity (p=0.0031) and larger WP (p=0.0003), were older and had longer diabetes duration (p<0.0001 for both). Independent variables associated to macroangiopathy were age (OR 1.05; 95% IC 1.02-1.08) and HTN (OR 5.89; 95% IC 2.33-14.89). Thus, each additional year increases the risk of MaV complications by 5%. Hypertensive patients were 6 times more likely to have these complications than nonhypertensives. In brief, more than half of T1DM patients present some chronic complication, mostly MiV

Frequency of Risk Foot among Type 2 Diabetic Patients with Apparent Healthy Foot

73th Scientific Sessions. ADA,Chicago, USA.

Abstract: Lower limb amputation is perhaps the most feared complication among DM patients. At diagnosis, 8% of T2DM patients present diabetic neuropathy and 7.8% of neuropathic patients develop foot lesions each year. However, risk foot frequency has not yet been established. A cross-sectional study was conducted to determine risk foot frequency among asymptomatic T2DM patients without foot lesions, and assisted at the multidisciplinary healthcare unit between July 2011 and November 2012. An educational activity with audiovisual support, graphic material delivery and neurological (Neuropathy Symptom Score, modified Neurological Disability Score), vascular (symptoms evaluation, peripheral pulses and ankle-brachial index), orthopedic and infectious assessment (Infectious Diseases Society of America guidelines) was conducted. Risk foot was defined as the presence of peripheral vasculopathy, neuropathy associated or not to orthopedic disorders or mixed pathology. Patients: 256 (63% oral antidiabetics, 35% insulin, 2% lifestyle modifications) 56% male, age 56±7 yrs, 55% <5 yrs from diagnosis. HBP 69.5%, dyslipidemia (DLP) 48%, smoking 24 %, micro/macrovascular complications 21.4% /26%. Risk foot rate: 74% (39% neuropathy + orthopedic alterations, 17% neuropathy, 15% mixed condition, 3% vasculopathy). Frequency was higher in those with longer diagnosis periods (<5 yrs vs >15 yrs p=0.04). Around 85% never received education on foot care, and from these 71% presented risk foot (p=0.04). A statistically significant relationship between vasculopathic risk foot and either DLP (p=0.01) or macrovascular complications (p<0.0001) was found. A high risk foot frequency was found among patients with apparent healthy foot. Those T2 diabetic patients with longer time from diagnosis and no previous education on foot care were the most affected. We consider that an early education focused on the incorporation of foot care habits and intensified multifactorial treatment is priority to prevent future lesions.

Analysis of hypoglycemic events in unemployed patients

74th Scientific Sessions. ADA, San Francisco, USA.

Hypoglycaemia In Vulnerable Patients Within A Public Hospital Framework

75th Scientific Sessions. American Diabetes Association. Boston, USA

Abstract: Much has been written about the characterization of hypoglycaemia (H) but its behavior within minority groups and socioeconomically vulnerable populations (VP) is not well known. A prospective longitudinal observational study was conducted to characterize H within a public hospital population. Follow-up 1 yr. Significant p<.05. Diabetic patients recruited: 393. Men 57%. Age 50±14. A1c 8.6±2.6%. T2D 45%. IRT2D 38%. T1D 17%. Mean DM duration 7 yrs. Low literacy (LL) (primary school completed) 44.8%. Unemployed (UE) 46%. Overall prevalence of self-reported H: 38.9%. Mild episodes 91.1%, asymptomatic 7.2%, severe 1.6%. Patients with H proved younger (46 vs 52 yrs p<.005), had lower BMI (28 vs 31 p<.0001), higher insulinization (81 vs 37 % p<.0001 [OR= 5.8]), higher previous DSME/T (61 vs 43% p<.006 [OR= 1.9]) and longer DM duration (9 vs 4 yrs p 10 yrs of disease had OR= 2.2. For each additional yr of DM duration risk rose by 6% (OR= 1.06). Only 39.9% had a stable job against 51.5% event-free (p<.04. [OR 1.7]). There were no significant LL-related differences. Significant comorbidities associated to H development: neuropathy (p<.03), diabetic foot (p<.03) and retinopathy (p<.004). Triggering events most frequently associated: lack of food intake (52%) and drug overdose (28%). No immediate consequences reported: 57%, additional reactive strips required: 33%, social consequences: 23%. In short, studied VP presented a high prevalence of H, risk being higher the longer the DM duration, higher association with chronic complications, and risk was 6 times higher among those insulinized. Unexpectedly, UE patients were 70% more likely to present H, being food intake omission the triggering event most commonly associated. No significant differences in relation to H were observed in LL patients, so H seem to be more related to economic inability to afford treatment -mainly food intake- than to education level, even with high previous DSME/T %. These unconventional risk factors in the development of H in VP should be considered.

Analysis Of Unemployment And Low Literacy Level As Non-conventional Risk Factors For The Development Of Hypoglycemia

75th Scientific Sessions. ADA, Boston, USA.

Abstract:

In many developing countries patients often are poorly educated, unemployed (UE) and suffering from food insecurity. A prospective longitudinal observational study was conducted to characterize hypoglycemia (H) and their impact on UE, low-literacy patients (LL) measured against working, more educated ones. Follow-up: 1 yr. Significant p<.05. Patients recruited: 393 diabetics within the framework of a Public Hospital. Men: 57%. Age: 50±14 yr. A1c: 8.6±2.6%. T2D: 45%.IRT2D: 38%. T1D: 17%. LL (primary school completed): 44.8%. UE: 46%. Among patients reporting H only 39.9% had a permanent job measured against 51.5% who were reportedly event-free (p<.04 OR 1.7 [1.1-2.5]) Occurrence of H showed an increasing trend among the UE. Among said patients, most were female (57 vs 34% p<.02), younger (44 vs 48 yr), more sedentary (57 vs 24% p<.002) and presented a higher insulinization rate (90 vs 64% p<.0004). Predictive factors most frequently associated were lack of food intake (57%) and drug overdose (30%). Out of the surveyed population, 59% reported no immediate consequences, 36% required use of additional reactive strips and 22% reportedsocial consequences. No statistically significant differences in relation to H events were observed in LL patients compared to educated ones. Among patients who reported H 39% had LL levels, were older on average (55 ± 11 vs 40 ± 17 p <.0001), fewer T1DM (7 vs 44% p<.0001) and lower rates of insulinization (68 vs 86% p <.015). No differences concerning comorbidities were found between both groups: UE and LL. In short, UE patients are 70% more likely to present H when measured against the employed population; food intake omission being the triggering event most commonly associated. No differences in relation to H were observed in LL patients, so H seem to be more related to economic inability to afford treatment especially as regards nutrition than to education level. New approaches for the care concerning this vulnerable patient group prove necessary.