Diabete con ecv ldlc<70.

In un uomo diabetico di 70 anni con una storia di cardiopatia ischemica, qual è il target terapeutico per il colesterolo LDL e l'emoglobina glicosilata (Hb A1c)?

[Evaluation of metabolic control targets in patients with type 2 diabetes mellitus].

To evaluate the extent to which metabolic targets in type 2 diabetes (DM-2) are achieved in the Endocrinology and Clinical Nutrition Unit of the Hospital Puerta del Mar in Cadiz (Spain) from 2005 to 2008. The database included in the computer application HP-Doctor used for all patients attended in our unit (admissions, consultations and peripheral centers) was analyzed. All patients with a principal or secondary diagnosis of DM-2 were included. Clinical characteristics, chronic complications, drug treatment and the percentage of patients who achieved annual mean targets of glycosylated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDLc) were analyzed. From 2005 to 2008, the number of DM-2 patients with computerized records increased by 108.7%. In 2008, 1,177 patients were evaluated. A total of 10.8% were active smokers, 53% had hypertension, and 51.2% and 12.6% presented with retinopathy and cardiovascular disease, respectively. During the study period, the percentage of patients with a mean HbA1c <7% was similar (2005: 31.7% 2008: 30.4%), those with LDLc <100 mg/dl increased from 19.2% to 25.6% and only 9.2% of patients achieved both targets, HbA1c <7% and LDLc <100 mg/dl. In 2008, only 30% of DM-2 patients achieved a mean HbA1c < 7% and only 25% had LDLc < 100 mg/dl. Metabolic control in DM-2 patients should be improved.

In patients with stable coronary heart disease, low-density lipoprotein-cholesterol levels < 70 mg/dL and glycosylated hemoglobin A1c < 7% are associated with lower major cardiovascular events.

In patients with stable coronary heart disease, it is not known whether achievement of standard of care (SOC) targets in addition to evidence-based medicine (EBM) is associated with lower major adverse cardiovascular events (MACE): cardiovascular death, myocardial infarction, and stroke. EBM use was recommended in the STabilisation of Atherosclerotic plaque By Initiation of darapLadIb TherapY trial. SOC targets were blood pressure (BP) <140/90 mm Hg and low-density lipoprotein-cholesterol (LDL-C) <100 mg/dL and <70 mg/dL. In patients with diabetes, glycosylated hemoglobin A1c (HbA1c) < 7% and BP of <130/80 mm Hg were recommended. Feedback to investigators about rates of EBM and SOC was provided regularly. In 13,623 patients, 1-year landmark analysis assessed the association between EBM, SOC targets, and MACE during follow-up of 2.7 years (median) after adjustment in a Cox proportional hazards model. At 1 year, aspirin was prescribed in 92.5% of patients, statins in 97.2%, β-blockers in 79.0%, and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers in 76.9%. MACE was lower with LDL-C < 100 mg/dL (70-99 mg/dL) compared with LDL-C ≥ 100 mg/dL (hazard ratio [HR] 0.694, 95% CI 0.594-0.811) and lower with LDL-C < 70 mg/dL compared with LDL-C < 100 mg/dL (70-99 mg/dL) (HR 0.834, 95% CI 0.708-0.983). MACE was lower with HbA1c < 7% compared with HbA1c ≥ 7% (HR 0.705, 95% CI 0.573-0.866). There was no effect of BP targets on MACE. MACE was lower with LDL-C < 100 mg/dL (70-99 mg/dL) and even lower with LDL-C < 70 mg/dL. MACE in patients with diabetes was lower with HbA1c < 7%. Achievement of targets is associated with improved patient outcomes.

Health coaching

Efficacy Several studies have shown health coaching to be effective in improving various aspects of health. One study on type 2 diabetes concludes that after six months, individuals who were coached showed improvement in medication adherence. Coaching had a positive effect on patients' knowledge, skill, self-efficacy and behavior change while a non-coached control group did not show any improvement. Additionally, coached participants with a hemoglobin A1C over 7% showed significant improvement in A1C. A study on coronary heart disease indicated that patients in a coaching program achieved a significantly greater change in total cholesterol of 14 mg/dl than the non-coached patients, with a considerable reduction in LDL-C. Those involved in the coaching program showed improvements in secondary outcomes such as weight loss, increased exercise, improved quality of life, less anxiety, and improvement in overall health and mood.

[Changes in metabolic parameters and microalbuminuria in patients with type 2 diabetes treated with acarbose].

To determinate the influence of the acarbosa and microalbuminuria on metabolic parameters in patients diabetics type 2. We are studied 92 patients with diabetes type 2, treated with Acarbose alone or with insuline or oral anti-diabetics We are determined the values of HbA1c, total cholesterol, HDL, LDL, triglycerides and microalbuminuria, before and after or the treatment with acarbose. The patients presented globally a statistically significant improvement in the levels of Hb A1 c, triglycerides and microalbuminuria. In the group treatise with 300 mg/day of acarbose it was observed a significant decrease of the values of Hb A1c and triglycerides independently of the associated treatment. In the group treated with 150 mg/day the improvement only it was statistically significant for the levels of Hb A1c. The treatment with acarbose produces an improvement in the levels of Hb A1c independently of the administered dose and of the triglycerides in patients treated with 300 mg/day without relation to associated treatments. Therefore, he acarbose win be considered an effective medication to improve the metabolic control to prevent the cardiovascular risk in those patients.

Diabetes management

"Perfect glycemic control" would mean that glucose levels were always normal (70–130 mg/dl, or 3.9–7.2 mmol/L) and indistinguishable from a person without diabetes. In reality, because of the imperfections of treatment measures, even "good glycemic control" describes blood glucose levels that average somewhat higher than normal much of the time. In addition, one survey of type 2 diabetics found that they rated the harm to their quality of life from intensive interventions to control their blood sugar to be just as severe as the harm resulting from intermediate levels of diabetic complications. In the 1990s the American Diabetes Association conducted a publicity campaign to persuade patients and physicians to strive for average glucose and hemoglobin A1c values below 200 mg/dl (11 mmol/l) and 8%. Currently, many patients and physicians attempt to do better than that.

Achievement of treatment goals among adults with diabetes in Colombia, 2015-2019: Results from a national registry.

To assess the achievement of essential treatment goals among patients with diabetes in Colombia. We analyzed data from a nationwide registry of all individuals with diagnosed diabetes, hypertension or CKD assisted by the health system. We explored the prevalence of treatment goals (HbA1c < 7% [<53 mmol/mol], systolic blood pressure (SBP) < 130 mmHg and LDLc < 100 mg/dL), and their variations by race and type of health insurance, between July 1, 2015, and June 30, 2019. We studied 1 352 846 patients with diagnosed diabetes. The prevalence of HbA1c < 7% (<53 mmol/mol) remained steady at 52%, systolic blood pressure (SBP) < 130 mmHg was also stable at 80-82%. Meanwhile, the prevalence of both LDLc < 100 mg/dL and non-HDLc < 130 mg/dL increased by 6 percentage points. Achievement of the triple HbA1c + SBP + LDLc goal was only 21.4% in 2015, increasing to 24.4% by 2019. Goal achievement was consistently lower among patients of black race, especially for HbA1c (5% lower than other races), but also for the SBP, LDLc and joint goals. Patients under third-party insurance reached better HbA1c, SBP, and LDLc control. Achievement of treatment goals of patients with diabetes in Colombia remains substantially low, despite improvements in LDLc control.

[New European guidelines for the management of dyslipidaemias: their aggressiveness is not legitimated by current evidence].

Le linee guida 2019 delle Società europee di cardiologia e dell'aterosclerosi sulla gestione delle dislipidemie hanno aumentato l'aggressività diagnostico-terapeutica e non distinguono prevenzione primaria e secondaria, con parziale eccezione per gli ultra75enni. Raccomandano nuovi target di cLDL: per pazienti a rischio molto alto si raccomanda una riduzione a <55 mg/dl e >=50% rispetto al basale; per pazienti a rischio alto una riduzione a <70 mg/dl e >=50% del basale; per pazienti a rischio moderato una riduzione a <100 mg/dl; per pazienti a rischio basso una riduzione a <116 mg/dl. In base alle carte SCORE e ai dati di mortalità cardiovascolare in Italia, quasi tutti i maschi dai 70 anni e le donne dai 70-75 anni risulterebbero ad alto rischio per solo effetto dell'età. Anche quasi tutti i 60enni sarebbero a rischio moderato, con target di cLDL <100, e spesso necessità di aggiungere costosi ipolipemizzanti per chi già assume statine. Le prove supportano ben poco tale aggressività. Infatti, anche negli studi randomizzati controllati (RCT) i benefici su esiti cardiovascolari non fatali subiscono esagerazioni sistematiche, quello meno distorto e di maggior interesse per gli assistiti è la mortalità totale. Questa, con terapie ipocolesterolemizzanti più intensive, non si è ridotta nelle metanalisi di RCT con pazienti con cLDL tra 80 e <100 mg/dl al basale; con inibitori di PCSK9, pazienti con questi valori mostrano persino tendenza all'aumento della mortalità totale. Dunque, abbassare il cLDL a <80 mg/dl può non giovare neppure ad anziani coronaropatici. A oggi, ciò vale ancora di più per anziani nella popolazione generale, in cui una revisione sistematica di studi di coorte ha mostrato relazioni nulle o più spesso inverse tra cLDL e mortalità. Le nuove linee guida europee forzano le prove disponibili, trascurano il principio di precauzione e non possono esser base per un equo consenso informato.

[Trends in the level of control of patients with type 2 diabetes from 2010 to 2015].

Aim: To examine the trend in the level of control of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL-cholesterol (LDL) in patients with type 2 diabetes mellitus between 2010 and 2015. Setting: 3 cut-offs in the years 2010, 2013, and 2015. Southeast area of Madrid. Descriptive and cross-sectional epidemiological study. Patients diagnosed and registered with type 2 diabetes. N=41,096 (2010), n=49,658 (2013), n=6,674 (2015) MAIN MEASUREMENTS: Measurement or not in the last year of HbA1c, BP, and LDL. Control of HbA1c (<7% individual targeting), BP (<140/90mmHg), and LDL (<100mg/dL, if cardiovascular disease <70mg/dL). Data were collected from electronic records of clinical history. The Chi-square test was used. The percentages of patients with each parameter measured in 2010, 2013 and 2015 were: HbA1c: 36.4%, 37.0%, 62.0% (P<.001); BP: 33.2%, 43.3%, 65.0% (P<.001); LDL: 32.9%, 33.2%, 43.5% (P<.001). The percentages of patients with each parameter measured and controlled in 2010, 2013, and 2015 were: HbA1c: 59.6%, 59.1%, 79.6% (P<.001); BP: 74.9%, 67.4%, 79.2% (P<.001); LDL: 41.8%, 58.3%, 58.8% (P<.001) CONCLUSION: In the 2010-2015 period, a sustained but insufficient trend of better control of HbA1c, BP and LDL was observed in patients with diabetes. The frequency of the measurements of these parameters improved more than the control of them. It seems that efforts to improve care for the patient with diabetes pay off, but they still have to be maintained.

[The OIBOH Registry (Optimal Intensification therapy in a Broad Observed High risk patient population with coronary disease): an Italian observational study of secondary prevention after a coronary event during the pandemic COVID-19 outbreak].

Razionale. In Italia la pandemia COVID-19 ha determinato importanti riorganizzazioni logistiche nell'erogazione delle cure ospedaliere e di specialistica ambulatoriale. Ciò ha spinto clinici e decisori pubblico-amministrativi della Sanità ad adottare nuovi modelli organizzativi in molteplici scenari clinici. Materiali e metodi. Il registro OIBOH (Optimal Intensification therapy in a Broad Observed High risk patient population with coronary disease) è uno studio osservazionale "cross-sectional" condotto in vari centri italiani di cardiologia ambulatoriale per valutare durante la pandemia COVID-19 la capacità di identificare in breve tempo i pazienti ad altissimo rischio cardiovascolare residuo dopo un evento coronarico recente (<12 mesi). Successivamente alla valutazione clinica iniziale, venivano arruolati i pazienti ritenuti ad altissimo rischio, registrando le caratteristiche cliniche e di trattamento in una scheda di raccolta dati elettronica.Risultati. Al registro hanno partecipato 134 centri di cardiologia ambulatoriale che hanno arruolato 1428 pazienti su 3227 esaminati fra quelli che avevano avuto accesso ad una visita cardiologica durante la pandemia nel periodo ottobre 2020-marzo 2021. Il criterio di arruolamento era costituito dall'aver avuto una diagnosi di coronaropatia confermata angiograficamente negli ultimi 12 mesi, per sindrome coronarica acuta (SCA) o cronica (SCC). La SCA come evento indice era presente nel 93% dei pazienti arruolati mentre la SCC nel 7%. L'età media era 67 ± 10 anni, il 25% era di sesso femminile. Il 96.1% dei pazienti con SCA e il 67.6% dei pazienti con SCC sono stati sottoposti a rivascolarizzazione coronarica. Il 46% e 47% dei pazienti con SCA e SCC, rispettivamente, era diabetico. Oltre il 65% dei pazienti presentava una malattia coronarica multivasale. È stata osservata una importante prevalenza di arteriopatia periferica (17.5% nei pazienti con SCA e 19.6% nei pazienti con SCC). I valori di pressione arteriosa e frequenza cardiaca risultavano ben controllati (128 ± 25.2 mmHg e 65 ± 12.3 b/min nei pazienti con SCA; 127 ± 23.4 mmHg e 67 ± 13.2 b/min nei pazienti con SCC). Viceversa, è stato riportato uno scarso controllo dei livelli di colesterolemia LDL, con un valore medio di 88.8 ± 38.6 mg/dl nei pazienti con SCA e 86 ± 36.6 mg/dl nei pazienti con SCC. Solo il 16.4% dei pazienti con SCA raggiungeva i livelli raccomandati dalle attuali linee guida europee. Nonostante l'estensivo uso di statine (>90%), si è rilevato un utilizzo limitato dell'associazione statina ad alta intensità + ezetimibe (solo il 22.4% dei pazienti). Estremamente basso è stato l'utilizzo di inibitori di PCSK9 (2.5%). La duplice terapia antiaggregante piastrinica (DAPT) è risultata complessivamente ben condotta fin dalla dimissione ospedaliera. Nei pazienti in DAPT, l'inibitore P2Y12 più utilizzato è risultato il ticagrelor alla dose di 90 mg, soprattutto dopo un evento coronarico acuto (in circa l'80% dei pazienti con SCA). Nella stragrande maggioranza dei casi (>90%) i cardiologi ambulatoriali hanno posto indicazione a prosecuzione della DAPT oltre i 12 mesi con aspirina e ticagrelor 60 mg bid. Conclusioni. La gestione del paziente con coronaropatia in fase cronica stabilizzata è molto complessa. Tale complessità logistico-gestionale si è accentuata durante la pandemia COVID-19. Il registro OIBOH ha evidenziato un'ottima capacità di identificare le problematiche clinico-prognostiche delle cardiologie ambulatoriali italiane, specie nei pazienti ad altissimo rischio residuo. Rimangono importanti aree di miglioramento come uno stretto controllo della colesterolemia LDL, mentre altre raccomandazioni delle linee guida, come la prosecuzione della DAPT con ticagrelor 60 mg oltre i 12 mesi, risultano ben applicate. L'implementazione dell'assistenza con la medicina digitale e l'intelligenza artificiale potrebbe migliorare di molto la performance dei clinici.

[Which HbA1c and lipid targets in patients with type 2 diabetes?].

Patients with type 2 diabetes are at high cardiovascular risk and require a global management targeting all risk factors. Target values for blood pressure have been discussed in a previous paper. The present clinical case summarizes the most important arguments concerning the choice of the target values for glucose control (glycated haemoglobin or HbA1c) and lipid management. As far as glucose control is concerned, the objective should be individually adjusted, based on the benefits/risks ratio, with a less stringent HbA1c level in presence of coronary heart disease and risk of severe hypoglycaemia. However, in absence of these two risks factors, the objective should be reinforced (HbA1c < 7%), essentially to prevent or retard microangiopathic lesions. As far as lipid management is concerned, the most crucial goal remains LDL cholesterol lowering, with a target value < 100 mg/dL in patients at high cardiovascular risk and <70 mg/dL in patients at very high risk, according to the recent European guidelines. Dyslipidaemia related to the metabolic syndrome (hypertriglyceridaemia, low HDL cholesterol) may also represent a therapeutic target (non-HDL cholesterol), although evidence is mostly missing in the literature.

Revisiting the oral glucose tolerance test criterion for the diagnosis of diabetes.

The Expert Committee on the Diagnosis and Classification of Diabetes retained the 2-hour glucose concentration on an oral glucose tolerance test of >/=11.1 mmol/L (200 mg/dL) as a criterion to diagnose diabetes. Since glycated hemoglobin levels have emerged as the best measure of long-term glycemia and an important predictor of microvascular and neuropathic complications, we evaluated the distribution of hemoglobin A1C (Hb A1C) levels in individuals who had undergone an oral glucose tolerance test to determine how well 2-hour values could identify those with normal versus increased Hb A1C levels. A cross-sectional analysis of 2 large data sets was performed. We cross-tabulated 2-hour glucose concentrations on an oral glucose tolerance test separated into 4 intervals (<7.8 mmol/L [140 mg/dL], 7.8-11.0 mmol/L [140-199 mg/dL], 11.1-13.3 mmol/L [200-239 mg/dL], and >/=13.3 mmol/L [240 mg/dL]) with Hb A1C levels separated into 3 intervals (normal; <1% above the upper limit of normal; and greater than or equal to the upper limit of normal + 1%). Approximately two thirds of patients in both data sets with 2-hour glucose concentrations of 11.1 to 13.3 mmol/L (200-239 mg/dL) had normal Hb A1C levels. In contrast, 60% to 80% of patients in both data sets with 2-hour glucose concentrations >/=13.3 mmol/L (240 mg/dL) had elevated Hb A1C levels. Since Hb A1C levels are the best measures presently available that reflect long-term glycemia, we conclude that the 2-hour glucose concentration criterion on an oral glucose tolerance test for the diagnosis of diabetes should be raised from >/= 11.1 mmol/L (200 mg/dL) to >/= 13.3 mmol/L (240 mg/dL) to remain faithful to the concept that diagnostic concentrations of glucose should predict the subsequent development of specific diabetic complications (e.g., retinopathy).

[Evaluation and care of patients with type Ii diabetes regarding recommendations concerning cardiovascular risk factors and adherence to values in general medicine in the Grand Duchy of Luxembourg].

The objective of this study was to assess the adherence to national guidelines on cardiovascular prevention and target attainment for patients with type 2 diabetes mellitus followed-up in general practice. Non-interventional, cross-sectional survey. 606 patients have been considered in this analysis. Type 2 diabetes patients remain undertreated with statins (63% treated), even so those with a cardiovascular history (80% treated). Although more patients received antihypertensive treatment (82%) compared to hypolipidemic medication (69%), the proportion of patients attaining targets for total (35%), HDL (65%), and LDL-cholesterol (42%) exceeded far those attaining blood pressure control (13%). The primary endpoint of reaching the goal for LDL-cholesterol (<100 mg/dL) was attained by 42% of patients, of which only 13% reached the more stringent target of LDL-C <70 mg/dL. About half of the patients attained glycemic control (HbA1c <7%, 49%) and had triglycerides <150 mg/dL (55%). The majority of type 2 diabetes patients are treated for hypercholesterolemia and hypertension, although, there is still undertreatment with statins, especially in patients with CV disease. Only 42% of patients were on target for LDL-cholesterol and 13% for blood pressure. Therefore, wider implementation of process and outcome indicators, which proved to be related, and continuous evaluation of their result, is needed.

[Compliance with the 2002 consensus document of the Spanish Society of Nephrology for the control of diabetic nephropathy in Catalonia (ECCODIAB)].

To evaluate the level of compliance with the 2002 consensus document (Spanish Society of Nephrology) on guidelines for the detection, prevention and treatment of diabetic nephropathy in Catalonia. Multicenter (23 hospitals), observational, cross-sectional, descriptive study conducted in 413 diabetic patients (61.7% men, 38.3% women) with a median age of 66.2 +/-11.5 years (26-93 years). The ANOVA test (post-hoc analysis; p value< 0.05) was used to study the relationships between the stages of diabetic nephropathyand different variables. 90.3% of the patients had type 2 DM. The following anthropometric parameters were observed: BMI 29.8 +/- 5 kg/m2 (BMI > 30 kg/m2: 48.7%) and waist circumference 104.1 +/- 14 cm (48.6% men > 102 cm and 78.9% women > 88 cm). Serum creatinine 1.9 +/- 1.3 mg/dl and simplified MDRD equation 45.3 +/- 25.0 ml/min/1.73 m2 [65.8%with CKD stages 3 and 4]. 80% of patients had ophthalmologic examination and 52.8% antiplatelet treatment. Hb A1c was 7.3 +/- 1.3%, but the percentage of patients with glycated hemoglobin > 7% and 8% was 54.9 and 28.6% [only 50.2% had been seen by an endocrinologist in the last 6 months]. 52.8% of patients were treated with insulin and 44.1% with anti-diabetic drugs, although only 19.6% used the new anti-diabetic drugs. 61% of patients had an LDLc > 100 mg/dl (61% treated) and 44% had triglycerides (TG) > 150 mg/dl (72% treated). 95% of patients presented with hypertension (BP > or = 130/80 mmHg),91% were undergoing antihypertensive treatment (79.7% with angiotensin-converting enzyme inhibitors and / or angiotensin receptor blockers). 81% with microalbuminuria and 78%with established proteinuria were receiving anti-proteinuric treatment. Of the patients considered to be refractory to BP (>3 drugs), only 28.9% underwent ambulatory BP monitoring. Significant differences were observed between stages of diabetic nephropathy and glycated hemoglobin (HBA1c; p = 0.048), systolic blood pressure (SBP; p = 0.024), lipidic control (HDLc; p = 0.015 and TG; p = 0.034), anemia (Hb; p = 0.010) and CKD (creatinine and sMDRD; p = 0.000). The levels of compliance with the therapeutic objectives regarding lipid control (LDL < or = 100 mg/dl and TG< or = 150 mg/dl), BP < or = 130/80 mmHg and HbA1c < or =7% were 1 objective: 68%, 2 objectives: 21.8% and 3 objectives: only 4% of patients. According to the results of our study, only a reduced proportion of patients fulfilled the different therapeutic end-points indicated. Future measures will be directed at improving physician-patient relationships with the main aim of intensifying the therapeutic measures to attain better metabolic and blood pressure control, nephroprotection and prevention in the appearance of cardiovascular events.

[Level at which control objectives are reached in patients in different population groups with type 2 diabetes].

There is evidence of increased macro- and micro-vascular risk in diabetic patients. The objective of this study was to determine the level of control in patients in different population groups with type 2 diabetes.  Descriptive cross-sectional study. Primary care. Madrid Health Service. Year: 2014. Patients over 14 years with type 2 diabetes. Number of patientes: n=6674. Variables on the degree of control (HbA1c, systolic blood pressure [SBP], diastolic blood pressure [DBP], LDL-c) and variables on patient characteristics (demographic, other cardiovascular risk factors, complications). The mean age of patients with controlled HbA1c was 67.8 years vs. 62.9 years in the uncontrolled (P<.001). Patients diagnosed with hypertension have a higher percentage of control with respect to the undiagnosed in HbA1c, SBP, DBP and LDL-c: 51 vs. 37%, 62 vs. 43%, 75 vs. 47% and 57 vs. 44% respectively; diagnosed with dyslipidaemia: 51 vs. 39%, 60 vs. 49%, 70 vs. 56% and 56 vs. 46%. With a diagnosis of macroangiopathy: 46 vs. 45%, 58 vs. 54%, 71 vs. 62% and 15 vs. 60%. All differences were statistically significant (P<.001). Over 50% of patients without a diagnosis of hypertension had an SBP> 140mmHg or DBP> 90mmHg. Over 25% of patients with hypertension or DL and uncontrolled levels were not receiving drug treatment. Control was improved in all groups, especially in younger patients, with particularly high cardiovascular risk by the presence of other cardiovascular risk factors or macroangiopathy. A significant percentage of patients with uncontrolled BP and cLDL were not diagnosed or receiving drug treatment.

Frazione polifenolica del bergamotto per il trattamento della sindrome metabolica nella schizofrenia: uno studio pilota.

Introduzione. La frazione polifenolica del bergamotto (BPF) ha dimostrato di possedere buona efficacia nel trattamento dei pazienti affetti da sindrome metabolica (SM) e pertanto potrebbe rappresentare una strategia promettente nel trattamento degli effetti collaterali indotti da antipsicotici di seconda generazione (SGA) in soggetti schizofrenici in trattamento con tali farmaci. Materiali e metodi. A 15 pazienti schizofrenici in trattamento stabilizzato con SGA e 15 soggetti di controllo non affetti da patologie psichiatriche, che presentavano valori ematici di colesterolo totale compresi tra 200 e 239 mg/dl, è stato somministrato un integratore contenente BPF (1000 mg) per un periodo di 60 giorni. A tutti i soggetti all'inizio e alla fine del trattamento sono state eseguite la misurazione dell'indice di massa corporea (BMI) e una serie di esami ematochimici per la valutazione degli aspetti metabolici (colesterolo totale, LDL, HDL, trigliceridi, glicemia). Risultati. In entrambi i gruppi si è evidenziata una riduzione significativa del BMI (BMI T0 vs Tfinale (media±DS)= schizofrenici: 34,5±5,7 vs 33,9±5,4, p=,041; controlli: 28,1±4,5 vs 27,3±4,1, p=,016 - BMIcambiamento schizofrenici vs controlli (media±DS)= -0,59±0.7 vs -0,72±0,8, p=,378); colesterolo totale e LDL risultano invece essere diminuiti esclusivamente nel gruppo di controllo (colesterolo totalecambiamento schizofrenici vs controlli (media±DS)= 8,2±31,5 vs -35,1±31,1, p=,003; LDLcambiamento schizofrenici vs controlli (media±DS)= 14,1±29,4 vs -9±38,9, p=,014). Discussione. La differenza di efficacia dei BPF sulla dislipidemia tra i soggetti schizofrenici e il gruppo di controllo potrebbe essere spiegata dai diversi meccanismi patogenetici che sono alla base delle alterazioni metaboliche nei soggetti in trattamento con SGA e nei pazienti che non assumono questa classe di farmaci. Conclusioni. Ulteriori studi si rendono necessari al fine di valutare in questa categoria di soggetti i possibili effetti sulla dislipidemia di dosi maggiori di BPF.

LDL-cholesterol target values and actual values in patients with type 2 diabetes (T2D) uncontrolled on oral antidiabetic monotherapy: the lipid results of the French ESCALADE survey.

While new European guidelines have recommended much lower LDL-c target values than current 2005 French HAS guidelines, it appears that even those ones are not widely implemented. This lipid-side of the ESCALADE study was designed to determine the LDL-c target values of GPs, diabetologists (DIABs) and cardiologists (CARDIOs) and the consistency of actual values in patients with type 2 diabetes (T2D) uncontrolled on antidiabetic monotherapy. ESCALADE was a national multicentre, observational, descriptive, transversal survey. One thousand and three hundred GPs and 350 specialists (DIABs and CARDIOs) agreed to include respectively three and four patients each. For each patient, the physician had to set the LDL-c target value that was compared to the calculated HAS target value. The actual LDL-c value was recorded and compared to those target values. A total of 412 GPs, 137 DIABs and 27 CARDIOs included respectively 699, 364 and 66 patients. Among them 19.6% had cardiovascular disease (CVD) and 56.9% were on lipid-lowering therapy (LLT). The physician's target value was in concordance with HAS value in 37.3% (GPs), 35.4% (DIABs) and 57.4% (CARDIOs) of the cases. Physicians overestimated the risk in respectively 42.7%, 54.1% and 21.3%. However, very high risk was underestimated in respectively 38.1%, 22.0% and 25.6% of the patients and the actual LDL-c value was in the target range (<100mg/dL) for only 28% of the very high-risk patients. Physicians tend to overestimate the CVD risk in patients with T2D and set lower LDL-c target values than HAS calculated values. Nevertheless, patients with a very high risk are largely under-treated.

Prevalence and effect of hemoglobin E disorders on Hba1c and lipid profile of diabetic patients at Surin Hospital.

To evaluate the prevalence of hemoglobin E disorders (HbE) and their characteristics in diabetic patients at Surin Hospital. Effects of HbE on HbA1c measurement and other variables in diabetic patients were also studied. A cross-sectional study was performed. One thousand nine hundred seventy eight patients were recruited randomly using a systemic random sampling method HbE screening test and Hb typing was performed HbA lc was measured by turbidimetric inhibition immunoassay. The prevalence of homozygous HbE (HbEE) and HbE trait were 7.9% and 35.3% respectively. When compared with the negative screening group, the variables that were significantly higher in the HbEE group were hemoglobin A1c (HbA1c) < 6.5% (p < 0.010), HbA1c < 7% (p < 0.010), serum cholesterol level (CHOL) < 200 mg/dl (p < 0.010), low density lipoprotein (LDL) < 100 mg/dl (p = 0.021), and anemia by Hb measurement (p < 0.010). The adjusted odds ratio and 95% confidence interval (CI) of HbA1c < 6.5% and < 7% in HbEE when compared with the negative screening group were 5.16 (3.55-7.50) and 4.60 (3.04-6.97) respectively The means of HbA1c, Hb, CHOL, and LDL in HbEE were significantly lower than the other groups (p < 0.010 in all variables). The adjusted odds ratio and 95% CI of HbA1c < 6.5% and < 7% in HbE trait when compared with the negative screening group were 1.12 (1.01-1.24) and 1.17 (1.06-1.29) respectively. Hemoglobin E disorders are highly prevalent in diabetes patients at Surin Hospital. HbA1c, CHOL, and LDL were significantly lower in diabetic patients with HbEE.

[Effect of glucose control on lipid levels in patients with type 2 diabetes].

The dyslipoproteinemia characterizing patients with type 2 diabetes is a major risk factor for atherosclerosis. Prospective studies indicate that an improved glucose control is associated with lower lipid levels. In this study we evaluated whether an improvement of the lipid status can also be observed in a routine clinical setting. Furthermore, we evaluated how many patients achieve lipid target levels by improving glucose control. In 51 type 2 diabetics (60 +/- 12 ys., 29 men, 22 women) lipid values were determined before and after improvement of glucose metabolism (6 - 12 weeks, HbA1c 7.9 +/- 1.9 % vs. 7.1 +/- 1.3 %). Patients on lipid-lowering medication or with atherosclerosis were excluded. The improved glucose control was achieved by starting/intensifying treatment with diet (n = 5), acarbose (n = 5), metformin (n = 10), sulfonylurea/glinide (n = 12) or insulin (n = 19). The decrease in HbA1c was associated with a decrease in total cholesterol (232 +/- 64 vs. 216 +/- 35 mg/dl, p < 0.05) and triglycerides (348 +/- 448 vs. 216 +/- 139 mg/dl, p < 0.01), while HDL- and LDL-cholesterol did not change significantly. Only in patients with triglycerides > 200 mg/dl did changes in HbA1c-levels correlate with changes in triglyceride-levels (r(2) = 0.32, p = 0.012). Lipid target levels were reached in seven of 51 patients (five of 51 patients before improvement of HbA1c). Although in routine clinical practice an improvement in HbA1c results in better lipid values. This improvement is small and is usually not sufficient to reach lipid target levels.

Hemoglobin

To a small extent, hemoglobin A slowly combines with glucose at the terminal valine (an alpha aminoacid) of each β chain. The resulting molecule is often referred to as Hb A1c, a glycated hemoglobin. The binding of glucose to amino acids in the hemoglobin takes place spontaneously (without the help of an enzyme) in many proteins, and is not known to serve a useful purpose. However, as the concentration of glucose in the blood increases, the percentage of Hb A that turns into Hb A1c increases. In diabetics whose glucose usually runs high, the percent Hb A1c also runs high. Because of the slow rate of Hb A combination with glucose, the Hb A1c percentage reflects a weighted average of blood glucose levels over the lifetime of red cells, which is approximately 120 days. The levels of glycated hemoglobin are therefore measured in order to monitor the long-term control of the chronic disease of type 2 diabetes mellitus (T2DM). Poor control of T2DM results in high levels of glycated

[Diabetes control in type 2 diabetic subjects treated in primary health care].

Aim of the study was to assess control of type 2 diabetes in subjects treated by general practitioners. Study was conducted in one of the primary health care centers in a big city, in which health care was provided for 27 900 inhabitants. Control of diabetes was assessed in 355 of all 936 type 2 diabetic subjects registered in the center. None of them was seen by diabetologist in the preceeding year. Mean age was 65,7 +/- 10,3 lat, diabetes duration 9,2 +/- 7,3 lat, BMI 29,9 +/- 4,9 kg/m2. Normal body weight was found in 15%, overweight in 39%, obesity in 46% of subjects. Hypertension was present in 81%, dyslipidaemia in 62% of patients. Mean HbAlc was 7,2 +/- 1,3%, fasting serum glycaemia 144 +/- 48 mg/dl, total cholesterol 204 +/- 45 mg/dL, LDL - 119 +/- 33 mg/dL, HDL - 51 +/- 13 mg/dl, triglicerides 182 +/- 108 mg/dL. Mean systolic blood pressure was 146 +/- 20 mmHg, diastolic 83 +/- 11 mmHg. Treatment goals recommended by Polish Diabetological Association in 2005 were attained as follows: HbAlc < or = 6,1% - 19,7% of subjects, fasting glycaemia < or =110 mg/dl - 24%, total cholesterol < 175 mg/dl - 26%, LDL < 100 mg/dl - 29%, triglicerides < 150 mg/dl - 46%, cholesterol HDL > 40 mg/dl in men and > 50 mg/dl in women - 65% of subjects. Recommended systolic blood pressure < 130 mmHg was found in 16 %, diastolic blood pressure < 80 mmHg - in 24%, and both values - in 8% of diabetics. In no one subject all recommended treatment goals were met. Conclusions 1. Recommended treatment goals are perceived in unacceptably low number of type 2 diabetic subjects treated by general practitioners. 2. Medical care of type 2 diabetic subjects performed in primary health care is unsatisfactory and should be essentially improved or changed.

InternalMed_Harrison

<7.0%c 4.4–7.2 mmol/L (80–130 mg/dL) <10.0 mmol/L (<180 mg/dL) <2.6 mmol/L (100 mg/dL)g >1 mmol/L (40 mg/dL) in men >1.3 mmol/L (50 mg/dL) in women <1.7 mmol/L (150 mg/dL) aAs recommended by the American Diabetes Association; goals should be individualized for each patient (see text). Goals may be different for certain patient populations. bHbA1c is primary goal. cDiabetes Control and Complications Trial–based assay. d1–2 h after beginning of a meal. eGoal of <130/80 mmHg may be appropriate for younger individuals fIn decreasing order of priority. Recent guidelines from the American College of Cardiology and American Heart Association no longer advocate specific LDL and HDL goals (see Chaps. 291e and 419). gGoal of <1.8 mmol/L (70 mg/dL) may be appropriate for individuals with cardiovascular disease. Abbreviation: HbA1c, hemoglobin A1c. Source: Adapted from American Diabetes Association: Diabetes Care 38(Suppl 1):S1, 2015. PATIENT EDUCATION ABOUT DM, NUTRITION, AND EXERCISE

Prediabetes

Prediabetes Screening in a Dental Setting Screening The United States Preventative Services Task Force (USPSTF) recommends adults who are overweight/obese and aged 40–70 years old to get screened during visits to their regular physician. The American Diabetes Association (ADA) recommends normal testing repeated every three years and recommends a larger range of people get tested: anyone over the age of 45 regardless of risk; an adult of any age who is obese or overweight and has one or more risk factors, which includes hypertension, a first degree relative with diabetes, a physical inactivity, high risk race/ethnicity, Asian Americans with BMI of ≥23 kg/m2, HDL < 35 mg/dL or TG > 250 mg/dL, women who have delivered child >9 lbs or with gestational diabetes, A1c ≥ 5.7%, impaired fasting glucose (IFG) or impaired glucose tolerance (IGT).

Hemoglobin

Long-term control of blood sugar concentration can be measured by the concentration of Hb A1c. Measuring it directly would require many samples because blood sugar levels vary widely through the day. Hb A1c is the product of the irreversible reaction of hemoglobin A with glucose. A higher glucose concentration results in more Hb A1c. Because the reaction is slow, the Hb A1c proportion represents glucose level in blood averaged over the half-life of red blood cells, is typically ~120 days. An Hb A1c proportion of 6.0% or less show good long-term glucose control, while values above 7.0% are elevated. This test is especially useful for diabetics. The functional magnetic resonance imaging (fMRI) machine uses the signal from deoxyhemoglobin, which is sensitive to magnetic fields since it is paramagnetic. Combined measurement with NIRS shows good correlation with both the oxy- and deoxyhemoglobin signal compared to the BOLD signal.

[Quality of care in diabetic outpatient clinics].

Type 2 Diabetes Mellitus affects an increasing number of people throughout the world. Several studies have shown that it is possible to prevent and minimize type 2 diabetes complications, be it treated appropriately over time. This study aimed to determine the quality of care provided to type 2 diabetic patients in our institution, through metabolic control and risk factors evaluation. We reviewed the medical records of 776 type 2 diabetic patients, followed at our outpatient clinic between 1998-2004. A total of 588 patients were included in the study, with a mean age of 66,8 ± 27,2 years. 58% were men. HbA1c levels averaged 7,2 ± 1,6. 57% had HbA1c = 7%. 25,3% met the target blood pressure of 130/80 mmHg; 48% met the goal LDL cholesterol level < 100 and 80% < 130 mg/dl. 6,8% of patients met the combined ADA goal for BP, LDL and HbA1c. Concerning therapeutic regimens: 71,5% used oral hypoglycaemic agents (OAD) alone (52,1% of these were using 2 or more agents); 28,5% were treated with insulin (16,2% in combination with OAD). 52,1% of the patients were anti-aggregated with aspirin. The metabolic control (HbA1c) and LDL values were favourable in our patients sample, comparing to other studies. The percentage of patients treated to the recommended BP of 130/80 mmHg is consistent with the literature. Only 6,8% of patients met the combined ADA goal for BP, LDL and HbA1c. Despite our comparable results to published data, we would like to highlight the difficulty to accomplish international recommendations to metabolic and risk factors control in clinical practice and the necessity of an aggressive approach to diabetes treatment.

[Informatori biologici per ischemia miocardica silente: approccio diagnostico e prognostico.]

Riassunto. L'ischemia miocardica silente (SMI) è un aspetto dello spettro della cardiopatia ischemica che varia dalla malattia coronarica asintomatica all'angina grave. Considerando il progressivo aumento della prevalenza di SMI e l'inaffidabilità di test diagnostici comuni, l'identificazione di biomarcatori SMI benefici è molto critica per una diagnosi rapida e un trattamento efficace della malattia. La presente revisione ha lo scopo di analizzare l'efficienza clinica di biomarcatori ben applicati e nuovi per la diagnosi e la previsione dei risultati dei pazienti con SMI. Questi biomarcatori includono cTnT, cTnI, hs-cTnT, hs-cTnI, hsCRP, NT-proBNP, sST2, GDF-15, Lp-PLA2, recettori della superficie cellulare, citochine antinfiammatorie, OPG, leptina, colesterolo totale, HDL, LDL, lipoproteine (a), omocisteina, albuminuria, microalbuminuria e miRNA circolanti. Nel database PubMed sono stati cercati rapporti scientifici (articoli originali) usando i termini "biomarcatori", "ischemia miocardica silenziosa", "biomarcatori cardiaci", "infiammatori", "marcatori", "stress ossidativo". Una migliore comprensione di vari biomarcatori SMI fornisce una migliore comprensione della sua varia patofisiologia e aspetto asintomatico, nonché dell'uso clinico di routine di questi biomarcatori.

Optimizing diabetes care regarding cardiovascular targets at general practice level: Direct@GP.

The objective of this study was to assess the adherence to national guidelines on cardiovascular (CV) prevention and target attainment for patients with type 2 diabetes mellitus followed-up in general practice. Non-interventional, cross-sectional survey. Type 2 diabetes patients remain undertreated with statins (63% treated), even so those with a cardiovascular history (80% treated). Although more patients received antihypertensive treatment (82%) compared to hypolipidemic medication (69%), the proportion of patients attaining targets for total cholesterol (TC) (35%), HDL-cholesterol (HDL-C) (65%), and LDL-cholesterol (LDL-C) (42%) exceeded far those attaining blood pressure control (13%). The primary endpoint of reaching the goal for LDL-cholesterol (<100mg/dL; 2.59 mmol/L) was attained by 42% of patients, of which only 13% reached the more stringent target of LDL-C<70 mg/dL (1.81 mmol/L). About half of the patients (49%) attained glycemic control (HbA1c<7%) and 55% had triglycerides<150 mg/dL (1.69 mmol/L). The majority of type 2 diabetes patients are treated for hypercholesterolemia and hypertension, although, there is still under treatment, especially in patients with CV disease. Only 42% of patients were on target for LDL-cholesterol and 13% for blood pressure. Therefore, wider implementation of process and outcome indicators, which proved to be related, and continuous evaluation of their result, is needed.

Obese Nondiabetic Pregnancies and High Maternal Glycated Hemoglobin at Delivery as an Indicator of Offspring and Maternal Postpartum Risks: The Prospective PEACHES Mother-Child Cohort.

We investigated whether obese pregnant women negative for gestational diabetes (GDM) still experience dysglycemia, as indicated by high glycated hemoglobin (Hb A1c) at delivery, and whether this impacts offspring and long-term maternal outcomes. Data of 462 mother-child pairs of our prospective Programming of Enhanced Adiposity Risk in Childhood - Early Screening (PEACHES) cohort study were analyzed. Of 885 obese and normal-weight pregnancies prospectively enrolled after GDM testing according to the International Association of Diabetes and Pregnancy Study Groups criteria, 462 GDM-negative mothers and their offspring were investigated. We assessed associations of maternal Hb A1c at delivery with large-for-gestational-age (LGA) birth weights, cord-blood C-peptide, and biomarkers of glucose metabolism and inflammation in obese mothers followed for 2.9 years (median) postpartum (n = 42). Cumulative distribution analysis in GDM-negative normal-weight women (n = 155) revealed that 12% had Hb A1c ≥5.7% at delivery (high Hb A1c). Among obese GDM-negative women (n = 307), 31.9% (95% CI, 26.7%-37.4%) equaled or exceeded this cutoff. In obese GDM-negative women with Hb A1c ≥5.7% (n = 98) vs <5.7% (n = 209) at delivery, newborns were more likely to be born LGA [adjusted odds ratio 3.56 (95% CI, 1.64-8.02)], and mean cordblood serum C-peptide was increased by 0.09 ng/mL (95% CI, 0.01-0.17 ng/mL). In the mothers at follow-up, mean postpartum Hb A1c, fasting glucose, high-sensitivity C-reactive protein, and fibrinogen concentrations were higher by 0.3% (95% CI, 0.1%-0.5%), 6.0 mg/dL (95% CI, 2.4-9.5 mg/dL), 6.8 mg/L (95% CI, 1.4-12.3 mg/L), and 74.9 mg/dL (95% CI, 13.6-136.2 mg/dL), respectively. Increased Hb A1c in obese GDM-negative women at delivery indicates gestational dysglycemia, potentially conferring offspring and long-term maternal health risks. These findings should raise awareness as to careful monitoring of obese pregnancies. Measurement of Hb A1c at delivery could help select women who may need closer postpartum health checks.

[Factors associated to glycaemic control in patients with type 2 diabetes].

Evaluate the factors influencing blood glucose control of type 2 diabetic patients attended at a tertiary health care center. A retrospective study by review of medical records of patients who attended the Diabetes Clinic at the University of Caxias do Sul was carried out. Patients were evaluated for glycaemic and metabolic control and divided according to glycated hemoglobin at the beginning and end of the period in question, in compensated and not compensated. The factors associated with glycaemic control were analyzed. Seventy three patients were included in the analysis. On the average, improvement of parameters related to glycaemic, pressure and lipid control during the average of 20 months of treatment was observed. In the beginning of the follow-up period, 25% of patients had glycated hemoglobin < 7%, 22.7% had LDL cholesterol < 100mg/dL, 8.7% had systolic blood pressure < 130 mmHg and diastolic < 80 mmHg and no patients had all parameters meeting the recommended goals. At the last visit the percentages were, 42.3%, 37.5%, 30.2% and 9.6% respectively. In the multivariate analysis, younger age, higher levels of LDL cholesterol and insulin use were associated with poor blood glucose control. A small part of the sample simultaneously achieved the goals for blood glucose, lipids and blood pressure control. Some factors, such as age and gender can be determinants to achieve control of diabetes. Greater efforts are still needed to achieve the goals for treatment in type 2 diabetic patients.

Green tea

Glycemic control Green tea consumption lowers fasting blood sugar but in clinical studies the beverage's effect on hemoglobin A1c and fasting insulin levels was inconsistent. Hyperlipidemia Drinking green tea or taking green tea supplements decreases the blood concentration of total cholesterol (about 3–7 mg/dL), LDL cholesterol (about 2 mg/dL), and does not affect the concentration of HDL cholesterol or triglycerides. A 2013 Cochrane meta-analysis of longer-term randomized controlled trials (>3 months duration) concluded that green tea consumption lowers total and LDL cholesterol concentrations in the blood. Inflammation A 2015 systematic review and meta-analysis of 11 randomized controlled trials found that green tea consumption was not significantly associated with lower plasma levels of C-reactive protein levels (a marker of inflammation). Weight loss There is no good evidence that green tea aids in weight loss or weight maintenance.

[Glycemic control related factors in type 2 diabetes mellitus patients].

To describe metabolic, lipidic and blood pressure control and to identify blood glucose control predictive factors in patients with type 2 diabetes. Retrospective cohort study. Ambulatory type 2 diabetic patients were selected from 2/1/00 to 14/11/01 if they had been visited yearly at least three years previously. They were classified into three groups: a) initial and final treatment with diet and/or oral glucose-lowering drugs; b) insulinized patients during follow-up; and c) initial and final therapy with insulin. BODY MASS INDEX: (BMI), blood pressure, HbA1c and lipid profile were determined at start and at the end of the study. A multiple regression model was used to predict mean HbA1c through follow-up. 320 patients were selected, 199 women (62.2%) and 121 men (37.8%) with mean age of 69 years (SD: 9). Mean follow-up was 5.2 years (SD: 1.1). 106 patients (33.8%) were included into A group, 70 patients (22.4%) into B group and 137 (43.8%) into C group. 63% of patients had values of HbA1c > 7.5%, 36% blood pressure > 140/85 mmHg and 8.5% LDL values > 155 mg/dl. HbA1c mean through follow-up was of 8.2% and its independent predictors were baseline HbA1c (0.37; IC 95% 0.31-0.43; p < 0.001), baseline BMI (0.023; IC 95% 0.004-0.042; p = 0.017), baseline treatment with insulin (0.67; IC 95% 0.45-0.88; p < 0.001) and insulinization during follow-up (0.46; IC 95% 0.21-0.71; p < 0.001). It's difficult to achieve an acceptable blood glucose control. Mean HbA1c predictive factors include baseline HbA1c and BMI and insulin therapy.

Glycated Albumin for the Diagnosis of Diabetes in US Adults.

There is growing interest in using glycated albumin for the diagnosis of diabetes, especially when standard tests (glucose and hemoglobin A1c [Hb A1c]) are unavailable. However, it is unknown how well glycated albumin identifies diabetes in the general population. We measured glycated albumin in stored serum samples from the 1999-2004 National Health and Nutrition Examination Survey. We evaluated the ability of glycated albumin to identify undiagnosed diabetes in US adults aged ≥20 (n = 4785), overall and at thresholds corresponding to clinical cut points for Hb A1c and fasting plasma glucose (FPG). We assessed 4 reference definitions for undiagnosed diabetes: increased FPG (≥126 mg/dL) [≥6.99 mmol/L), increased Hb A1c (≥6.5%), either FPG or Hb A1c increased, or both FPG and Hb A1c increased. Among US adults, glycated albumin had excellent diagnostic accuracy across all 4 definitions of undiagnosed diabetes, with the area under the receiver operating characteristic curve (AUC) ranging from 0.824 to 0.951. Performance was generally consistent across patient demographic and clinical characteristics. Glycated albumin cut points of 16.5% and 17.8% were equivalent to an FPG of 126 mg/dL (6.99 mmol/L; 97th percentile) and Hb A1c of 6.5% (98th percentile) and had low to moderate sensitivity (0.273 to 0.707) but high specificity (0.980 to 0.992) for detecting undiagnosed diabetes. The excellent diagnostic performance of glycated albumin to identify diabetes defined by either FPG or Hb A1c suggests that glycated albumin may be useful for identifying adults with undiagnosed diabetes when standard tests are unavailable.

Metabolic control and chronic complications during a 3-year follow-up period in a cohort of type 2 diabetic patients attended in primary care in the Community of Madrid (Spain).

Our aim was to analyze both metabolic control and chronic complications of type 2 diabetes mellitus (T2D) patients regularly attended in primary care during a 3 years of follow-up in the Community of Madrid (Spain). From 2007 to 2010 we prospectively included 3268 patients with T2D attended by 153 primary care physicians from 51 family health centers. An prospective cohort study with annual evaluation over 3 years to the same population was performed. We measured the goals of control in diabetic patients and the incidence of chronic complications of diabetes during the study period. A significant decrease in serum glucose levels (143±42mg/dl vs 137±43mg/dl, p<0.00), HbA1c (7.09±1.2% vs 7.02±1.2%, p<0.00), total cholesterol (191.4±38mg/dl vs 181.5±36mg/dl, p<0.00), LDL cholesterol (114.7±31mg/dl vs 105.5±30mg/dl, p<0.00) and triglyceride levels (144.5±93mg/dl vs 138±84mg/dl, p<0.00) during study period was documented. On the contrary, a significant elevation in HDL cholesterol levels was observed (49.2±14mg/dl vs 49.9±16mg/dl, p<0.00). The incidence of diabetic complications throughout the study period was low, with a incidence of coronary heart disease of 6.2%, peripheral arterial disease 3%, ischemic stroke 2.8%, diabetic foot 11.2%, nephropathy 5.9%, retinopathy 4.5%, and neuropathy 3%. Metabolic control in T2D patients attended in primary care in the Community of Madrid throughout 3 years is adequate and is accompanied by low percent of chronic diabetic complications during this period of follow-up.


Ci vengono presentati molti dati analitici, ma dobbiamo considerarne solo due: i livelli delle frazioni C3 e C4 del complemento sono bassi. Tra le opzioni indicate, solo la glomerulonefrite membranoproliferativa si presenta con ipocomplementemia (opzione 4 corretta).

Ci vengono presentati molti dati analitici, ma dobbiamo considerarne solo due: i livelli delle frazioni C3 e C4 del complemento sono bassi. Tra le opzioni indicate, solo la glomerulonefrite membranoproliferativa si presenta con ipocomplementemia ([HIDDEN]).

Uomo di 25 anni senza precedenti noti. Da 2 mesi soffre di urine schiumose e piene, senza altri sintomi. Esame fisico privo di reperti. Urine elementari: pH 5; glucosio negativo; emoglobina ++; proteine ++; esterasi leucocitaria negativa; proteinuria 1,5 g/24 ore; Na urinario 60 mEq/L; K urinario 30 mEq/L; Cl urinario 100 mEq/L. Biochimica del sangue: creatinina 1,6 mg/dL; urea 80 mg/dL; Na 140 mEq/L; K 3,8 mEq/L. Studio immunologico: anti-DNA negativo; ANCA negativo; anti-MBG negativo, fattore reumatoide negativo; C3 20 mg/dL (normale 60-120); C4 10 mg/dL (normale 20-40). Viene eseguita una biopsia renale. Quale di queste diagnosi ritenete sia più probabile trovare nella biopsia?

InternalMed_Harrison

A 44-year-old woman was referred from a local hospital after presenting with flaccid paralysis. Severe hypokalemia was documented (2.0 meq/L), and an infusion containing KCl was initiated. PART 2 Cardinal Manifestations and Presentation of Diseases Sodium 140 meq/L Potassium 2.6 meq/L Chloride 115 meq/L Bicarbonate 15 meq/L Anion gap 10 meq/L BUN 22 mg/dL Creatinine 1.4 mg/dL pH 7.32 U PaCO2 30 mmHg HCO3− 15 meq/L Rheumatoid factor positive, anti-Ro/SS-A positive, and anti-La/SS-B positive pH = 6.0, normal sediment without white or red blood cell casts and no bacteria. The urine protein-to-creatinine ratio was 0.150 g/g. Urinary electrolyte values were: Na+ 35, K+ 40, Cl− 18 meq/L. Therefore, the urine anion gap was positive, indicating low urine NH4+ excretion.

Osmol gap

Osmol gap in medical science is the difference between measured serum osmolality and calculated serum osmolality. Calculation The osmol gap is typically calculated as: OG = measured serum osmolality − calculated osmolality Calculated osmolality = 2 x Na + Glucose + Urea. (all values in mmol/L) In non-SI laboratory units: Calculated osmolality = 2 x [Na mmol/L] + [glucose mg/dL] / 18 + [BUN mg/dL] / 2.8 + [Ethanol/3.7] (note: the values 18, 2.8 and 3.7 convert mg/dL into mmol/L) A normal osmol gap is < 10 mOsm/kg . The molecular weight of ethanol is 46, but empiric data shows that it does not act as an ideal osmole in solution and the appropriate divisor is 3.7

Ranson criteria

Acute pancreatitis not secondary to gallstones At admission: Blood glucose > 11.11 mmol/L (> 200 mg/dL) Age > 55 years Serum LDH > 350 IU/L Serum AST > 250 IU/L WBC count > 16000 cells/mm3 Within 48 hours: Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit decreased by > 10% Oxygen (hypoxemia with PaO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L Acute pancreatitis secondary to gallstones At admission: Glucose > 220 mg/dl Age > 70 years LDH > 400 IU/L AST > 250 IU/ 100 ml WBC count > 18000 cells/mm3 Within 48 hours: Serum calcium < 8 mg/dL Hematocrit decreased by > 10% Base deficit > 4 mEq/L BUN increased by > 2 mg/dL Sequestered fluid > 6L

[Urinalysis in chronic kidney disease].

Chronic kidney disease (CKD) is defined by glomerular filtration rate (GFR) below 60 mL/min/1.73 m2 and/or renal abnormalities including proteinuria and/or hematuria beyond 3 months. Urinalysis is an important screening test to find out CKD subjects earlier. In health check examination, proteinuria was detected in 2.3% of male population over 18 years old. The prevalence of lower estimated GFR below 50 mL/min/1.73 m2 increased to 8.9% of subjects with 1+ proteinuria and 31.8% of subjects with 2+ or more proteinuria as compared with 2.0% of subjects with negative proteinuria (p < 0.0001). To detect CKD stage IV or V, the sensitivity and the specificity of proteinuria were 0.68 and 0.978, respectively, and the positive likelihood was 30.9 (95% CI, 8.3-114.9, p < 0.0001).

Anion gap

Sample calculations Given the following data from a patient with severe hypoalbuminemia suffering from postoperative multiple organ failure, calculate the anion gap and the albumin-corrected anion gap. Data: [Na+] = 137 mEq/L; [Cl−] = 102 mEq/L; [HCO] = 24 mEq/L; [Normal Albumin] = 4.4 g/dL; [Observed Albumin] = 0.6 g/dL. Calculations: Anion Gap = [Na+] - ([Cl−] + [HCO]) = 137 - (102 + 24) = 11 mEq/L. Albumin-Corrected Anion Gap = Anion Gap + 2.5 x ([Normal Albumin] - [Observed Albumin]) = 11 + 2.5 x (4.4 - 0.6) = 20.5 mEq/L. In this example, the albumin-corrected anion gap reveals the presence of a significant quantity of unmeasured anions. See also Osmol gap Delta ratio References External links Clinical Physiology of Acid-Base and Electrolyte Disorders Anion Gap Calculator (includes a correction for the albumin concentration) Metabolic acidosis by Merck More information about the Figge-Jabor-Kazda-Fencl equation

[Renal histological lesions in patients with type II diabetes mellitus].

Diabetic glomerulosclerosis is the most frequent cause of renal disease in patients with type II diabetes mellitus (DM), sometimes accompanied by vascular lesions. However, other glomerular pathologies are important in these patients. The aim of this study was to evaluate the prevalence of non-diabetic nephropathy (NDN) in selected patients with type II DM, and to identify clinical markers that may predict its presence in this population. We reviewed 20 renal biopsies performed on twenty patients with type II DM. Nine of them showed diabetic nephropathy (DN) (45%), whereas eleven showed NDN (55%): 1 IgA nephropathy, 3 vasculitis and 7 membranous nephropathy. We found no differences between the two groups with regard to sex, duration of DM, insulin therapy, glycosylated haemoglobin, proteinuria, presence of nephrotic syndrome, hypertension, serum IgA level or renal size. The NDN group had haematuria in 63.6%, whereas the patients with NDN had it in 44.4% (NS). Body mass index was higher in NDN patients (30 +/- 6.7 vs 22 +/- 2.9; p < 0.01), The same was true for creatinine clearance (82.2 +/- 51.4 ml/m vs 40.4 +/- 19.6 ml/m; p < 0.05). The age at the moment of diagnosis was higher in ND patients (67 +/- 11.2 vs 54.3 +/- 4.6; p < 0.05). The 3 patients who had diabetic retinopathy were found to have DN on renal biopsy (diagnostic specificity = 100%), although 66.7% of the patients with diabetic glomerulopathy had no retinopathy. We conclude that patients with type II DM with renal findings suggesting non-diabetic renal disease frequently it have NDN, and a renal biopsy must be performed. The presence of retinopathy has a predictive value of 100% in predicting DN, therefore its existence may make this diagnostic procedure unneccesary.

[Electrolyte abnormalities and metabolic acidosis in two Duchenne muscular dystrophy patients with advanced congestive heart failure].

We experienced two Duchenne muscular dystrophy patients with advanced congestive heart failure, who showed abrupt severe hyponatremia, hyperkalemia and metabolic acidosis. Two patients received respiratory management, parenteral nutrition, and drugs including angiotensin converting enzyme inhibitors (ACEI). The patient 1 who was 19 years old showed abdominal pain, hematuria, diarrhea and disorientation. Laboratory findings were as follows; Na 120 mEq/L, K 7.3 mEq/L, BUN > 140 mg/dl (scale over), ACTH 20.2 pg/ml, cortisol 25 micrograms/dl, renin 40.7 ng/ml/hr and aldosterone 203 ng/dl. Arterial blood gas analysis (ABG) showed metabolic acidosis (pH 7.232). Combination therapy with hydrocortisone, glucose-insulin therapy (GIT) and NaHCO3 successfully rescued this patient. The patient 2 (28 years of age) was admitted to our hospital because of congestive heart failure. Laboratory findings were as follows; Na 129 mEq/L, K 5.5 mEq/L, BUN 60 mg/dl, cortisol 21 micrograms/dl, renin 36 ng/ml/hr and aldosterone 47 ng/dl. He complained abdominal discomforts from the next day of admission. Ten days after the admission Na, K and BUN were 111 mEq/L, 6.2 mEq/L and 154 mg/dl, respectively. ABG showed compensated metabolic acidosis. He fell into shock during GIT therapy. Laboratory findings at that time were as follows; Na 108 mEq/L, K 3.2 mEq/L, ACTH 77.6 pg/ml, cortisol 24 micrograms/dl, renin 58 ng/ml/hr and aldosterone 24 ng/dl. Although hydrocortisone was introduced, he could not recover and died. There are some reports about life-threatening electrolyte abnormalities and metabolic acidosis in the patients receiving ACEI. These phenomena were more frequent in patients with renal dysfunction and/or congestive heart failure. Hyponatremia, hypovolemia, combination therapy with nonsteroidal anti-inflammatory drugs (NSAID) and/or potassium sparing diuretics were reported as risk factors. We could not prove the correlation between the acute changes in our cases and ACEI. However ACEI is suspicious, because many of these risk factors were observed in our cases. Aldosterone was extremely elevated in the patient 1 when potassium was severely elevated. On the other hand, the patient 2 showed lower aldosterone level after correction of potassium than that on admission. Potassium is regarded as a major secretion factor of aldosterone for patients receiving ACEI. The fact the patient 2 fell into shock during GIT, tells us that we should use steroid simultaneously when we try to correct potassium quickly in severe cases, because acute reduction of potassium may decrease aldosterone. Today, ACEI is a common drug for CHF, so we should pay attentions that ACEI could cause such acute changes. To prevent such acute changes, excessive restriction of water and sodium intake should be avoided. If possible, NSAID and potassium sparing diuretics also should be avoided. Steroid therapy must be introduced rapidly when needed.

[Evaluation of microalbuminuria in children].

Microalbuminuria has been shown to be important for the diagnosis and prognosis of glomerular nephropathy. A few studies in normal healthy children were performed. The concentration of albumin was determined in 171 samples of the first morning urine by an immunoturbidimetric method. Microalbumin/creatinine ratio values were 4.07 +/- 0.11 mg/mmol, 1.16 +/- 0.10 mg/mmol and 0.88 +/- 0.11 mg/mmol in children of ages 4 days-1 year, 1-7 years and 7-15 years, respectively. We found a negative inverse correlation (r = 0.31; p < 0.05) between age and microalbumin/creatinine ratio.

Hyperosmolar hyperglycemic state

Diagnosis Criteria According to the American Diabetes Association, diagnostic features include: Plasma glucose level >30 mmol/L (>600 mg/dL) Serum osmolality >320 mOsm/kg Profound dehydration, up to an average of 9L (and therefore substantial thirst (polydipsia)) Serum pH >7.30 Bicarbonate >15 mEq/L Small ketonuria (~+ on dipstick) and absent-to-low ketonemia (<3 mmol/L) Some alteration in consciousness BUN > 30 mg/dL (increased) Creatinine > 1.5 mg/dL (increased) Imaging Cranial imaging is not used for diagnosis of this condition. However, if MRI is performed, it may show cortical restricted diffusion with unusual characteristics of reversible T2 hypointensity in the subcortical white matter.

[Type 1 diabetes mellitus and nephropathy. Predicting factors in pediatric age].

To find the existence of early relationships between alterations in the glucidic metabolism and the glomerular and tubular basal function in diabetic insulin-dependent children without clinical evidence of diabetic nephropathy (DN). We determined blood pressure, basal plasma concentrations of glucose, glycosilated hemoglobin and total proteins, glomerular filtration rate (GFR), and the glucose, proteins, calcium, phosphorus, uric acid, sodium, potassium and chloride excretions in diurnal, nocturnal and 24-hour urine samples in 43 diabetic children and 13 healthy controls. The microproteinuria mean value in all urine samples (always less than 15 micrograms/min/1.73 m.2), the GFR and blood pressure were similar in both groups. In the diabetic children, we found an inverse correlation between age and 24-hour urine microproteinuria (r-0.33; p less than 0.05) and between age and nocturnal urine microproteinuria (r-0.35; p less than 0.05). There was also a highly significant correlation between microproteinuria and the albumin/creatinine ratio in urine samples (r = 0.94, p less than 0.0001). Diabetic children showed a greater nocturnal excretion of calcium (p less than 0.05) and phosphorus (p less than 0.05). Our results suggest that microproteinuria, GFR and blood pressure have not served as predictors of DN in pediatric patients.

Acute pancreatitis

At admission age in years > 55 years white blood cell count > 16000 cells/mm3 blood glucose > 11.1 mmol/L (> 200 mg/dL) serum AST > 250 IU/L serum LDH > 350 IU/L At 48 hours Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall >10% Oxygen (hypoxemia PO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L The criteria for point assignment is that a certain breakpoint be met at any time during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both gallstone and alcoholic pancreatitis. Alternatively, pancreatitis can be diagnosed by meeting any of the following:[2] Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT)

[Effect of irbesartan in proteinuric non-diabetic renal disease].

This randomized, prospective, two-arm clinical study evaluated the antiproteinuric and nephroprotective effects and the safety of treatment with an angiotensin II receptor antagonist (irbesartan) in patients with chronic glomerulonephritis (CGN) as compared to angiotensin-converting enzyme inhibitors (ACEIls). A total of 50 patients with CGN diagnosed by renal biopsy and protein levels in 24-hour urine higher than 1 g were enrolled. All patients received treatment for at least 24 months, 27 in group 1 (irbesartan) and 23 in group 2 (ACEs). A significant decrease in proteinuria (p < 0.001) was seen in both groups (49.2% in group, 1, and 44.8% in group 2) since the third month, and confirmed at 12 and 24 months of follow-up (58.1% and 62.7% in group 1, and 56.8% and 55.4% in group 2, respectively), with no significant differences being seen between the two groups. No differences were found in blood pressure control. No significant decrease was found in any of the groups in the glomerular filtration rate, but this showed higher values in the group treated with ACEIs (2.98 +/- 7.77 vs 1.64 +/- 6.84 ml/min/year), though the difference with irbersartan was not statistically significant. No side effects occurred among patients treated with irbesartan, whereas three patients initially treated with ACEIs showed intolerance (cough). In conclusion, irbesartan showed in our study an antiproteinuric and nephroprotective effect similar to ACEIs in patients with chronic glomerulonephritis, and its administration was also shown to be safe.

InternalMed_Harrison

Abbreviations: P, plasma; RC, red cells; S, serum; WB, whole blood. Electrolytes Sodium 137–145 mmol/L 137–145 meq/L Potassium 2.7–3.9 mmol/L 2.7–3.9 meq/L Calcium 1.0–1.5 mmol/L 2.1–3.0 meq/L Magnesium 1.0–1.2 mmol/L 2.0–2.5 meq/L Chloride 116–122 mmol/L 116–122 meq/L CO2 content 20–24 mmol/L 20–24 meq/L PCO2 6–7 kPa 45–49 mmHg pH 7.31–7.34 Glucose 2.22–3.89 mmol/L 40–70 mg/dL Lactate 1–2 mmol/L 10–20 mg/dL Total protein: Lumbar 0.15–0.5 g/L 15–50 mg/dL Cisternal 0.15–0.25 g/L 15–25 mg/dL Ventricular 0.06–0.15 g/L 6–15 mg/dL Albumin 0.066–0.442 g/L 6.6–44.2 mg/dL IgG 0.009–0.057 g/L 0.9–5.7 mg/dL IgG indexb 0.29–0.59 Oligoclonal bands (OGB) <2 bands not present in matched serum sample

Hypercalcaemia

The normal range is 2.1–2.6 mmol/L (8.8–10.7 mg/dL, 4.3–5.2 mEq/L), with levels greater than 2.6 mmol/L defined as hypercalcaemia. Moderate hypercalcaemia is a level of 2.88–3.5 mmol/L (11.5–14 mg/dL) while severe hypercalcaemia is > 3.5 mmol/L (>14 mg/dL). ECG Abnormal heart rhythms can also result, and ECG findings of a short QT interval suggest hypercalcaemia. Significant hypercalcaemia can cause ECG changes mimicking an acute myocardial infarction. Hypercalcaemia has also been known to cause an ECG finding mimicking hypothermia, known as an Osborn wave. Treatments The goal of therapy is to treat the hypercalcaemia first and subsequently effort is directed to treat the underlying cause.

[Alpha 1-microglobulin in the urine and serum in proteinuria and kidney insufficiency].

Alpha-1-microglobulin (alpha-1-m) is a low molecular weight glycoprotein (mw 25-33 KD) that is filtered through the glomeruli and reabsorbed in the proximal parts of the renal tubules where it is catabolized. Normal ranges were established for alpha-1-m (100 healthy controls) in serum (20-42 mg/l) and urine (3.5-8 mg/l). Alpha-1-m was then measured in 341 urine samples whose protein pattern had been classified as "pathologic" and "normal" according to microelectrophoresis. Increased alpha-1-m concentrations were found in 266 out of 280 pathologic urines (5% false negative) and in 3 out of 61 normal urines (4% false positive). Beta-2-microglobulin (beta-2-m), total protein or protein test strips showed a poorer correlation to the electrophoretic results. Measurement of alpha-1-m is, therefore, the most sensitive of these methods for the detection of proteinuria. In 90 patients with low molecular weight proteinuria and either with or without renal insufficiency alpha-1-m concentrations were determined in both urine and serum. While all patients had elevated urinary alpha-1-m concentrations, increased serum values were only found in renal insufficiency (Ccrea less than 100 ml/min). Independently of these results, we were also able to establish that increased alpha-1-m levels are found at decreased glomerular filtration rates (Ccrea less than 70 ml/min). Pathologic alpha-1-m concentrations therefore only allow the conclusion of isolated tubular impairment when the GFR is greater than 70 ml/min.(ABSTRACT TRUNCATED AT 250 WORDS)

Nabumetone-associated interstitial nephritis.

An 84-year-old woman was admitted to the hospital for progressive edema and decreased urine output. She had been taking nabumetone for 6 months, but had discontinued the agent 2 weeks before admission due to progressive edema. On admission she had 2-3+ pitting edema. Her serum electrolytes were sodium 122 mEq/L, potassium 5.9 mEq/L, chloride 93 mEq/L, and carbon dioxide 19 mEq/L. A urinalysis was significant for protein 3061 mg/dl, ketones 15 mg/dl, blood 2+, leukocytes 26-50/high-power field, and a protein:creatinine ratio 24.9. The serum creatinine and blood urea nitrogen concentrations were 2.7 mg/dl and 70 mg/dl, respectively. Throughout hospitalization the patient underwent aggressive diuresis. She developed congestive heart failure, and hemodialysis was initiated. A renal biopsy specimen on hospital day 9 showed tubular damage with minimal glomerular changes consistent with a diagnosis of nonsteroidal agent-induced nephropathy. On day 13, a 24-hour urine collection had a protein excretion of 3151 mg. Although the patient recovered from her renal failure (creatinine clearance 43 ml/min), the nephrotic syndrome persisted (13 g protein/day). The patient developed infectious complications and died on hospital day 32.

[Detection and classification of chronic kidney disease in Primary Care and importance of albuminuria].

Chronic kidney disease (CKD) is a public health problem, and Primary Care (PC) plays a key role in its detection and classification based on estimated glomerular filtration rate (eGFR), as well as the level of albuminuria for its proper management. The aim of this study was to analyse the prevalence and classification of CKD in patients attended in PC. An analysis was made of CKD prevalence and classification according to the Kidney Disease-Improving Global Outcomes guidelines in PC patients. All biochemical analyses requested from PC on patients 18 years and older over a 5-year period were collected. When several analyses were available on a patient, the biochemistry result with the best eGFR was selected. Between 2010 and 2014, PC requested 304,523 biochemical analyses on 97,470 adult patients, with a mean age of 53.4±19.4 years, of which 57.2% were women. CKD prevalence was 7.6%. Urine protein results were present in only 16.6% of analyses, and only 15.2% patients had a urine protein result. Urine albumin was measured 15.4% of biochemical controls with eGFR≥60mL/min/1.73m<sup2</sup, in 27.1% of patients with eGFR between 30-59mL/min/1.73m<sup2</sup (G3a-3b stages), and in 23.4% of patients with eGFR<30mL/min/1.73m<sup2</sup (G4-5 stages). Urine albumin was tested in 37.7% of diabetics and in 23.5% of impaired fasting glucose. Requests for the measurement of urine proteins/albumin in PC patients are low, leading to only one in 6 PC patients being classified correctly. The measurement of urine proteins/albumin is higher in CKD and diabetic patients.

[Quantification of proteinuria by measurement of the protein/creatinine ratio].

Accurate quantification of urinary protein excretion is difficult due to problems in 24-hour urine collection. We have evaluated the value of the protein/creatinine ratio in one single urine sample. There was an excellent correlation between this ratio and the protein content of a 24-hour urine collection [Pu (g/24 h) = 11.7 Pu (g/l) Cr (mmol/l); r = 0.96; P less than 0.001]. The best correlation was found with the sample collected after the first voided morning specimen. In our experience the ratio is more accurate for the quantification of urinary protein excretion than measurement of protein excretion in the same urine sample and also determination of protein excretion in 24-hour urine collected under the usual ambulatory conditions. We suggest that the protein/creatinine ratio should be used in ambulatory and hospitalized patients, especially for multicentric clinical trials in nephrology.

Spironolactone

It is recommended that alternatives to spironolactone be considered if serum creatinine is greater than 2.5 mg/dL (221 μmol/L) in males or greater than 2 mg/dL (176.8 μmol/L) in females, if glomerular filtration rate is below 30 mL/min or with a serum potassium of greater than 5.0 mEq/L given the potential for adverse events detailed elsewhere in this article. Doses should be adjusted according to the degree of kidney function as well.

[Clinical value of urinary biochemical parameters].

Twelve of the urine parameters, namely sodium, potassium, chloride, urea, creatinine, uric acid, calcium, phosphate, protein, microalbumin, amylase and glucose, routinely measured in a biochemistry laboratory were chosen to revalue their interest in clinical practice. For each parameter, urinary collection method, physiologic review and specific indications were set out. The clinical interest of chloride, urea, phosphate or uric acid measurement seem limited to specific pathological conditions. The measurement of urine amylase is out of interest.

Effects of dietary cation-anion difference on intake, milk yield, and blood components of the early lactation cow.

Early lactation Holsteins cows (15 primiparous and 18 multiparous) were offered rations with dietary cation-anion difference, calculated as mEq (Na + K - Cl - S)/100 g of feed dry matter (DCAD:S), of 20, 35, or 50 mEq from d 0 (calving) to 42 d postpartum (August 20, 2000 to January 9, 2001) to determine the effects of increasing DCAD:S on dry matter intake (DMI), milk yield, and blood metabolites. For DCAD:S of 20, 35, and 50, DMI was 3.30, 3.38, 2.96 kg/100 kg of body weight (BW); milk yield was 25.5, 24.2, and 22.4 kg/d, respectively. No differences were observed for concentration or yield of milk fat or milk protein. Serum Ca, P, Mg, Na, K, Cl, cation-anion difference, insulin, and glucose did not differ with DCAD. Serum HCO3- was 26.07, 25.88, and 27.64 mEq/L for 20, 35, and 50 DCAD:S. Serum Ca, Mg, Na, and K concentrations were greater for primiparous cows (9.52 mg/dL, 2.35 mg/dL, 140.03 mEq/L, 4.66 mEq/L, respectively) than for multiparous cows (9.27 mg/dL, 2.12 mg/dL, 137.63 mEq/L, 4.46 mEq/ L, respectively). A DCAD:S between 23 and 33 mEq/100 g of dry matter (DM) appears to be adequate during cool weather for the milk yield that occurred in the present study based on DMI (kg/100 kg of BW), whereas DCAD:S of 50 mEq/100 g of DM may be excessive and could be too alkaline or unpalatable, resulting in decreased DMI (kg/100 kg of BW).

[Familial and hereditary mesangial glomerulonephritis with IgA deposits (author's transl)].

Idiopathic mesangial glomerulonephritis with IgA deposits was observed in two relatives, father and son, in a family of 5 members. In the father the disease started at age 43 with relapsing macroscopic hematuria, proteinuria, renal failure and hypertension, with a progressive course in the ensuing four years. The affected son, the oldest of three brothers, developed relapsing macroscopic hematuria at age 16; two years later renal function was normal and there was no hypertension, but microhematuria persisted without proteinuria. The mother and the other two brothers had no clinical or biological signs of renal disease. Serum immunoglobulins (IgG, IgA, and IgM) and complement (C3, C4, C3 proactivator) were normal in the patients and their relatives. Histocompatibility typing demonstrated the presence of HLA-Bw35 in the father and the two unaffected sons, being negative in the mother and the affected son. The analysis of HLA-Bw35 in 23 patients with IgA mesangial glomerulonephritis gave positive results in 30% of them, while the control group had a positivity of 15% (p non significant with the X2 test). The present observations suggest that IgA mesangial glomerulonephritis is a potentially familial and hereditary renal disease. HLA-Bw35 antigen appears not to be a genetic marker of the disease in our geographical area.

Evaluation of Term Newborn Patients With Hypernatremic Dehydration.

We aimed to evaluate the demographic, clinical, and laboratory findings and the management of newborns with hypernatremic dehydration (HDH). A total of 85 term newborns with serum sodium (Na) levels higher than 145 mEq/L who admitted to our hospital between January 2011 and December 2018 were included in this study. Among all cases, 54.1% were female infants with the mean birth weight, weight loss ratio, and median age at diagnosis of 3095 ± 540 g, 13.6 ± 10%, and 8 (2-24) days, respectively. The most common presenting complaints were breastfeeding difficulties (90.5%), fever (63.5%), decreased urination (43.5%), jaundice (22.3%), and convulsion (15.3%). The mean sodium and potassium, and median blood urea and creatinine levels on admission were 167.9 ± 13.4 mEq/L, 5.4 ± 2.8 mmol/L, 213 mg/dL (11-476 mg/dL), and 2.4 mg/dL (0.52-9.96 mg/dL), respectively. There was metabolic acidosis in 67% and acute renal failure in 74.4% of patients, while peritoneal dialysis was performed in 12 of them. There was a positive correlation between weight loss ratio and admission age, serum urea, and creatinine levels; there was a negative correlation between weight loss and blood pH. Eight patients died (9.4%). In our study, serum urea, creatinine, potassium, metabolic acidosis levels, convulsion, and dialysis requirements at the time of admission of the newborns with HDH were found to be higher in those who died compared to those who survived. Convulsion was a presenting complaint, and it was also observed during the treatment.

[Incidence and early detection of glomerulonephritis].

Within of a for the first time performed aimed study of the early recognition and frequency of the glomerulonephritis in 1,425 males the findings of an "asymptomatic proteinuria" were proved in 5.26% of the affected persons. As a result of a comprehensive investigation, the close of which was in every case the biopsy of the kidney with the histological examination of the renipuncture cylinder, a frequency of glomerulonephritis of 2.8% was found. Within this investigation the findings of an "asymptomatic proteinuria" proved to be the decisive parameter independent of the size of excretion and the reproducibility. The serological investigations did not show any specifity and proved to be insignificant for the early recognition. The results confirm that the diagnosis of "physiological proteinuria" may be made only then when there is an inconspicuous histological finding. In lacking renal histology every form of the proteinuria should at first be attributed to glomerular process.

Tumor lysis syndrome

Cairo-Bishop definition In 2004, Cairo and Bishop defined a classification system for tumor lysis syndrome. Laboratory tumor lysis syndrome: abnormality in two or more of the following, occurring within three days before or seven days after chemotherapy. uric acid > 8 mg/dL or 25% increase potassium > 6 meq/L or 25% increase phosphate > 4.5 mg/dL or 25% increase calcium < 7 mg/dL or 25% decrease Clinical tumor lysis syndrome: laboratory tumor lysis syndrome plus one or more of the following: increased serum creatinine (1.5 times upper limit of normal) cardiac arrhythmia or sudden death seizure A grading scale (0–5) is used depending on the presence of lab TLS, serum creatinine, arrhythmias, or seizures.

[Tubular kidney function in patients with type 2 diabetes mellitus, microalbuminuria and proteinuria].

Diabetes mellitus (DM) and hypertension are the most frequent causes of kidney function damage. Many different tests are developed to detect reversible functional kidney changes (detection of microalbuminuria and selective urinary enzymes). The aim of our study was to examine tubular kidney function in type 2 DM patients with different proteinuria levels, and to compare these results with healthy people. The patients with type 2 DM and creatinine clearance >80 ml/min were included in the study. According to the levels of proteinuria, the patients were classified in three groups: group I--patients with proteinuria <300 mg/24 h, and no microalbuminuria; group II--the patients with proteinuria <300 mg/24 h and microalbuminuria >20 mg/24 h; and group III--the patients with proteinuria >300 mg/24 h. The control group consisted of healthy subjects. The study revealed that in type 2 DM patients and normal global kidney function, fractional excretions of sodium, potassium, and phosphates as well as renal phosphate concentrations were not adequately sensitive markers to detect damage in tubular kidney function in DM. There were some changes of urate fractional excretion in these patients: this value was significantly lower in patients with microalbuminuria compared with those with proteinuria >300 mg/24 h, as well as in the control group (p < 0.05). Hormone dependent tubular kidney activity, urinary osmolarity, and urea fractional excretion in all patients were within normal ranges. It is evident that routine laboratory analyses are not sensitive markers to detect early changes of kidney function in type 2 DM.

Blood and urine physiological values in farm-cultured Rana catesbeiana (Anura: Ranidae) in Argentina.

A total of 302 samples of healthy farm-cultured Rana catesbeiana specimens (9-21 months-old, 50-350 g liveweight, 50% each sex) from the north-east of Argentina, were analyzed through spectrophotometry, electrophoresis, densitometry, refractometry and microscopy in order to obtain blood and urine normal values. Confidence intervals (p<0.05) for PCV (28.6-31.6%), RBC (0.40-0.44 T/L), MCV (686-732 fL), hemoglobin (6.41-7.20 g/dL), MCH (151-164 pg), MCHC (22.6-24.0%), WBC (18.7-22.3 G/L), neutrophils (58.4-63.4%), lymphocytes (23.9-29.8%), monocytes (2.1-3.8%), eosinophils (4.6-7.0%), basophils (2.9-4.1%), bleeding time (289-393s), coagulation time (452-696s), prothrombin time (76-128s), urinary density (1.0061-1.0089 g/mL), urinary pH (6,38-6.96)., fibrinogen (0.59-0.99 g/dL), total protein (4.19-4.49 g/dL), albumin (1.49-1.67 g/dL), alpha-1 globulin (0.20-0.24 g/dL), alpha-2 globulin (0.48-0.54 g/dL), beta globulin (0.68-0.77 g/dL), gamma globulin (1.28-1.42 g/dL), albumin/globulin ratio (0.50-0.58), creatinine (4.09-5.56 mg/L). urea (76.1-92.4 mg/L), uric acid (11.5-15.4 mg/L), triglycerides (0.34-0.52 g/L), total cholesterol (0.56-0.67 g/L), HDL-C (0.03-0.05 g/L), LDL-C (0.34-0.44 g/L), alpha lipoprotein (6.01-8.67%). beta lipoprotein (91.3-93.9%), glucose (0.45-0.54 g/L), Na (116-121 meq/L), K (3.42-3.81 meq/L), Cl (100-116 meq/L), Ca (7.98-8.61 mg/dL). P (8.319.36 mg/dL), Mg (2.26-2.55 mg/dL), Fe (105-178 ug/dL), ALP (144-170 [U/L), ALT (10.0-14.8 IU/L), AST (42.8-53.4 IU/L), GGT (7.8-10.6 IU/L), LDH (99-135 IU/L), CHE (151-185 lU/L) and CPK (365-500 IU/L), were obtained. Some parameter ranges were similar to those obtained in amphibians, birds or mammals; others were very different. These parameters are useful to evaluate sanitary, metabolic and nutritional state on captive bullfrogs.

Glomerulonephritis -- Evaluation -- Urine

The urine is usually dark, and the specific gravity is more than 1.020 with RBCs and RBC casts. The 24-hour urinary protein excretion and creatinine clearance may help establish the degree of renal impairment and proteinuria. [34] The following parameters are usually helpful: Microscopy, culture, and sensitivity Bence Jones protein Albumin to creatinine or protein to creatinine ratio RBC casts

Effects of high-dose furosemide and small-volume hypertonic saline solution infusion in comparison with a high dose of furosemide as a bolus, in refractory congestive heart failure.

Diuretics, have been accepted as first-line treatment in refractory heart failure, but a lack of response is a frequent event. A randomised single blind study was performed to evaluate the effects of the combination of high-dose furosemide and small-volume hypertonic saline solution (HSS) infusion in the treatment of refractory NYHA class IV congestive heart failure (CHF). Sixty patients (21 F/39 M) with refractory CHF (NYHA class IV) of different etiologies, unresponsive to high oral doses of furosemide, ACE-inhibitors, digitalis, and nitrates, aged 65-90 years, were enrolled. They had to have an ejection fraction (EF) <35%, serum creatinine <2 mg/dl, BUN </=60 mg/dl, a reduced urinary volume and a low natriuresis. The patients were randomised in two groups (single blind): group 1 (11 F/19 M) received an i.v. infusion of furosemide (500-1000 mg) plus HSS (150 ml of 1.4-4.6% NaCl) b.i.d. in 30 min. Group 2 (10 F/20 M) received an i.v. bolus of furosemide (500-1000 mg) b.i.d., without HSS, during a period lasting 6-12 days. Both groups received KCl (20-40 mEq.) i.v. to prevent hypokalemia. All patients underwent at entry a physical examination, measurement of body weight (BW), blood pressure (BP), heart rate (HR), evaluation of signs of CHF, and controls of serum Na, K, Cl, bicarbonate, albumin, uric acid, creatinine, urea and glycemia and daily during hospitalization, as well as the daily output of urine for, Na, K and Cl measurements. Chest X-ray, ECG and echocardiogram were obtained at entry during and at the discharge. During the treatment and after discharge the daily dietary Na intake was 120 mmol with a drink fluid intake of 1000 ml daily. An assessment of BW and 24-h urinary volume, serum and urinary laboratory parameters, until reaching a compensated state, were performed daily, when i.v. furosemide was replaced with oral administration (250-500 mg/day). After discharge, patients were followed as outpatients weekly for the first 3 months and subsequently once per month. The groups were similar for age, sex, EF, risk factors, treatment and etiology of CHF. All patients showed a clinical improvement. Six patients in both groups had hyponatremia (from 120 to 128 mEq./l) at entry. A significant increase in daily diuresis in both groups was observed (from 390+/-155 to 2100+/-626, and from 433+/-141 to 1650+/-537 ml/24 h, P<0.05). Natriuresis (from 49+/-15 to 198+/-28 mEq./24 h) was higher in group 1 vs. group 2 (from 53.83+/-12 to 129+/-39 mEq./24 h, P<0.05). Serum Na (from 135.9+/-6.8 to 142.2+/-3. 8 mEq./l, P<0.05) increased in the group 1 and decreased in the group 2 (from 134.7+/-7.9 to 130.1+/-4.3 mEq./l). Serum K was decreased (from 4.4+/-0.6 to 3.9+/-0.6, and 4.6+/-9 to 3.6+/-0.5 mEq. /l, P<0. 05) in both groups. BW was reduced (from 73.8+/-9.1 to 63. 8+/-8.8, and from 72.9+/-10.2 to 64.5+/-7.5 kg, P<0. 05) in both groups. Group 2 showed more patients in NYHA class III than group 1 (18 vs. 2 patients, P<0.05). Group 2 showed an increase of serum creatinine. Serum uric acid increased in both groups. BP values decreased, and HR was corrected to normal values in both groups. Group 2 showed a longer hospitalization time than group receiving HHS infusion (11.67+/-1.8 vs. 8.57+/-2.3 days, P<0.001). In the follow-up (6-12 months), none of the patients from group 1 were readmitted to the hospital and they maintained the NYHA class achieved at the discharge. Group 2 showed 12 patients readmitted to hospital and a higher class than at discharge. Our data suggest that the combination of furosemide with HSS is feasible and it appears that this combination produces an improvement of hemodynamic and clinical parameters, reduces the hospitalization time and maintains the obtained results over time in comparison with those receiving high-dose furosemide as bolus.

[Role of nocturnal blood pressure in the onset of diabetic nephropathy].

The aim of this study was to assess the responsibility of night-time blood pressure in the onset of nephropathy in diabetic patients. This study included 98 diabetic patients (mean age: 54 +/- 15 years, diabetes duration: 15 +/- 10 years). An evaluation of diabetes and a 24-h ambulatory blood pressure were performed at the initial evaluation (Y0) and about five years later (Y5). At Y0, all patients had normal urinary albumin excretion (UAE) (<30 mg/24h). They were separated into two groups according to urinary albumin excretion at Y5: group (N +): UAE>30 mg/24h and group (N-): UAE<30 mg/24h. Twenty four hours ambulatory blood pressure, clinical and biological parameters recorded at Y0 were compared in both. At Y5, there was 18 patients in group (N +) and 78 in group (N-). Patients of group (N +) were older than those of group (N-): 62.9 +/- 9.5 vs. 52.6 +/- 15.7 years, p<0.01, and their BMI was higher (28 +/- 5 vs. 25 +/- 4 kg/m2, p<0.03). Diabetes duration and Hb A1c levels did not differ from significant manner in both. At Y0, UAE was significantly higher in group (N +) than in group (N-): 13 +/- 7 vs. 8 +/- 6 mg/24h, p<0.01. At the initial evaluation, daytime systolic and diastolic blood pressures did not differ from significant manner in both. Systolic and diastolic BP night-time were higher in diabetic patients who developed microalbuminuria (SBP: 122 +/- 19 vs. 113 +/- 13 mmHg, p<0.05 and DBP: 70 +/- 6 vs. 65 +/- 10 mmHg, p<0.03). UAE collected at Y5 was correlated to night-time BP recorded at Y0 (SBP: r=0.381, p=0.001 and PAD: r=0.294, p=0.004) and night-time systolic BP explained 12.3% of the UAE variance. Progression of UAE between the two evaluations was found to be correlated to the night-time systolic BP recorded at Y0 (r=0.335, p=0.0008) and night-time systolic BP explained 11.7% of the progression variance. There was a negative correlation between UAE at A5 and the difference between daytime and night-time BP recorded during the same evaluation (r=- 0.230, p=0.024 with SBP and r=- 0.243, p=0.017 with DBP). The results underlign the resposability of night-time blood pressure, and more especially of nighttime systolic blood pressure, for the onset of nephropathy in diabetic patients.

Nephrotic syndrome

The main signs of nephrotic syndrome are: A proteinuria of greater than 3.5 g /24 h /1.73 m2 (between 3 and 3.5 g/24 h /1.73 m2 is considered to be proteinuria in the nephrotic range) or greater than 40 mg/h/m2 in children. The ratio between urinary concentrations of albumin and creatinine can be used in the absence of a 24-hour urine test for total protein. This coefficient will be greater than 200–400 mg/mmol in nephrotic syndrome. This pronounced loss of proteins is due to an increase in glomerular permeability that allows proteins to pass into the urine instead of being retained in the blood. Under normal conditions a 24-hour urine sample should not exceed 80 milligrams or 10 milligrams per decilitre. A hypoalbuminemia of less than 2.5 g/dL, that exceeds the liver clearance level, that is, protein synthesis in the liver is insufficient to increase the low blood protein levels.

Hay to reduce dietary cation-anion difference for dry dairy cows.

Timothy grass has a lower dietary cation-anion difference [DCAD = (Na + K) - (Cl + S)] than other cool-season grass species. Growing timothy on low-K soils and fertilizing it with CaCl2 could further decrease its DCAD. The objective of this study was to evaluate the effects of feeding low-DCAD timothy hay on dry dairy cows. Six nonpregnant and nonlactating cows were used in a replicated 3 x 3 Latin square. Treatments were as follows: 1) control diet (control; DCAD = 296 mEq/kg of dry matter); 2) low-DCAD diet based on low-DCAD timothy hay (L-HAY; DCAD = - 24 mEq/kg of dry matter); and 3) low-DCAD diet using HCl (L-HCl; DCAD = - 19 mEq/kg of dry matter). Decreasing DCAD with L-HAY had no effect on dry matter intake (11.8 kg/d) or dry matter digestibility (71.5%). Urine pH decreased from 8.21 to 5.89 when L-HAY was fed instead of the control. Blood parameters that decreased with L-HAY were base excess (- 0.4 vs. 3.8 mM) and HCO3- (23 vs. 27 mM), and blood parameters that increased were Ca2+ (5.3 vs. 5.1 mg/dL), Cl- (30.5 vs. 29.5 mg/dL), and Na+ (60.8 vs. 60.1 mg/dL). Compared with the control, L-HAY resulted in more Ca in urine (13.4 vs. 1.2 g/d). Comparing L-HAY with L-HCl, cow dry matter intake tended to be higher (11.5 vs. 9.8 kg/d), and blood pH was higher (7.37 vs. 7.31). Urine pH; total dry matter; Ca, K, P, and Mg apparent absorption; and Ca, K, Na, Cl, S, P, and Mg apparent retention were similar. Absorption as a percentage of intake of Na and Cl was lower for L-HAY as compared with L-HCl. In an EDTA-challenge test, cows fed L-HAY regained their initial level of blood Ca2+ twice as quickly as the control treatment (339 vs. 708 min); there were no differences between L-HAY and L-HCl. This experiment confirms that feeding low-DCAD hay is an effective means of decreasing the DCAD of rations and obtaining a metabolic response in dry dairy cows.