La supresión de la educación especializada empeora el control metabólico en diabetes tipo 2

ResumenObjetivoEvaluar la posible relación entre la supresión de un programa de educación especializada en diabetes y el grado de control metabólico a largo plazo.DiseñoEstudio longitudinal prospectivo en una cohorte.EmplazamientoCentros de atención primaria en 3 comarcas de Cataluña.ParticipantesMuestra aleatorizada de 276 sujetos con diabetes mellitus tipo 2.Mediciones principalesLos pacientes se clasificaron, según el tipo de educación en diabetes (ED) recibida antes del comienzo del estudio, en 2 grupos: especializado (n=59) o convencional (n=217). En todos los sujetos se evaluó la hemoglobina glucosilada (HbA1C) en línea de base y a los 5 años de recibir únicamente educación convencional en diabetes.ResultadosEn la evaluación inicial, el grupo con educación especializada previa mostró mejores concentraciones de HbA1C (p=0,009). La evaluación final no mostró diferencias significativas entre ambos grupos (p=0,679). Comparados con la línea de base, los valores finales de HbA1C en toda la muestra aumentaron de manera significativa (p=0,001). Analizados separadamente, el grupo con educación convencional previa mostró un deterioro no significativo (p=0,058), mientras que el grupo especializado había empeorado significativamente (p=0,001).ConclusionesLos resultados indican que la supresión de niveles especializados de ED puede desempeñar un papel esencial en el deterioro del control metabólico y que la ED convencional no mejora los resultados. La política de salud en atención primaria debería considerar mejorar los niveles de ED mediante una organización más adecuada.AbstractAimsTo evaluate the possible relationships between a health policy decision, in relation to the diabetes education strategies and the metabolic control outcomes.DesignLongitudinal prospective cohort study.ParticipantsA random cohort sample of 276 type II diabetes mellitus subjects.LocationAll primary care centres in three regions of Catalonia.Principal measurementsPatients were classified as specialised (n=59) or non-specialised (n=217) groups, as regards whether having received previous diabetes education before the start of the study. HbA1c values were evaluated in all subjects at baseline and after 5 years after receiving only conventional education.ResultsBaseline evaluation showed a better metabolic control in the specialised group (P=0.009). The final evaluation showed no significant differences in outcomes between the two groups (P=0.679). When baseline and outcomes values were compared, significant differences were observed in all subjects (P=0.001), the specialised group showed significantly poorer metabolic control (P<0.001), but in the group with previous conventional education no significant differences were observed (P=0.058).ConclusionsOur results suggest that the withdrawal of higher levels of diabetes education may play a major role in poor metabolic control, and that conventional diabetes education does not improve outcomes. Health policy in Primary Care should consider improving the level of diabetes education

Marcadores de riesgo de Polineuropatía diabética en la Diabetes tipo 2

[cat] La polineuropatia diabètica és una complicació molt freqüent en la diabetis tipus 2, el factor de risc més important d'úlcera i està involucrada en la majoria d'amputacions no traumàtiques del peu. La seva evolució es lenta i silenciosa i, una vegada establerta, és substancialment irreversible. Disposar de més factor temps per una prevenció secundària de la polineuropatia diabètica realment efectiva exigeix nous enfocaments en la investigació dels seus marcadors de risc. OBJECTIUS: Investigar possibles marcadors de risc, innovadors o poc estudiats, de polineuropatia diabètica. METODOLOGIA: Es varen fer tres estudis observacionals en mostres aleatòries de persones amb diabetis tipus 2: 1) Descriptiu transversal per avaluar la relació entre els nivells circulants del Transforming Growth Factor Beta 1 (TGF-beta-1) total i la presència de polineuropatia diabètica; 2) Prospectiu de seguiment a tres anys explorant el polimorfisme ("I/D" inserció/delecció) del gen de l'enzim conversor de l'angiotensina (ACE) com a factor de risc de desenvolupar polineuropatia diabètica; 3) Prospectiu de seguiment a deu anys, analitzant la presència prèvia de malaltia cardiovascular i la seva relació amb l'aparició posterior de polineuropatia diabètica. RESULTATS: El TGF-beta-1 apareix com una molècula biomarcadora important per la detecció de polineuropatia diabètica. El genotip (D/I) del gen de l'ACE s'erigeix com un factor protector en el desenvolupament de la polineuropatia diabètica. Als deu anys de seguiment, les persones amb diabetis tipus 2 i malaltia cardiovascular a l'inici de l'estudi presentaren major risc de desenvolupar polineuropatia diabètica. CONCLUSIONS: Els tres estudis aporten resultats orientats a identificar persones susceptibles de desenvolupar polineuropatia diabètica. La possibilitat que aquesta identificació es dugui a terme abans de les seves manifestacions clíniques permetria anticipar les mesures de prevenció secundària i intensificar les actuacions envers els seus factors de risc.[eng] Diabetic Polyneuropathy (DPN) is the commonest of its microangiopathic complications. It is the main risk factor for ulcers and is involved in the majority of non-traumatic lower extremity amputations. Its natural history is silent and insidious; nevertheless, once established it substantially irreversible. Hence, new research strategies on DPN risk factors are needed to provide health practitioners with more time for a more efficient secondary prevention. OBJETIVES: To look after for novel or surrogate DPN risk factors METHODOLOGY: three observational studies were performed on randomly selected samples of patients with Type 2 Diabetes mellitus (T2DM): 1) Descriptive cross-sectional study designed to evaluate the relationship between circulating plasma Transforming Growth Factor Beta 1 (TGF-beta-1) and the presence of DPN; 2) Prospective (three years of follow-up) study exploring the Angiotensin-converting enzyme (ACE) gene single polymorphism ("I/D" insertion/ deletion) as a genetic biomarker of the risk factor for DPN development; 3) Prospective (10 years of follow-up) study assessing the relationship between DPN development and a history of previous cardio-vascular disease (CVD). RESULTS: TGF-beta-1 appears as an important biomarker molecule for DPN screening. The (D/I) genotype of the ACE gene polymorphism stands as a protective factor in the development of DPN. After ten year of follow-up, those T2DM patients with prior history of CVD disclose a higher risk of developing DPN. CONCLUSIONS: the three aforementioned studies provide results oriented at identifying potential candidates to develop DPN. This identification is likely to be performed prior to the development of DPN clinical manifestations. The latter would allow implementation of secondary prevention measures and intensify the treatment of its risk factors.[spa] La polineuropatía diabética es una complicación muy frecuente en la diabetes tipo 2, el factor de riesgo más importante de ulcera y está involucrada en la mayoría de amputaciones no traumáticas del pie. Su evolución es lenta y silenciosa y, una vez establecida, es sustancialmente irreversible. Disponer de más factor tiempo para una prevención secundaria de la polineuropatía diabética realmente efectiva requiere nuevos enfoques en la investigación de sus marcadores de riesgo. OBJETIVOS: Investigar posibles marcadores de riesgo, innovadores o poco estudiados, de polineuropatía diabética. METODOLOGIA. Se realizaron tres estudios observacionales en muestras aleatorias de personas con diabetes tipo 2: 1) Descriptivo transversal para evaluar la relación entre los niveles circulantes del Transforming Growth Factor Beta 1 (TGF-beta-1) total y la presencia de polineuropatía diabética; 2) Prospectivo de seguimiento a tres años explorando el polimorfismo ("I/D" inserción/ delección) del gen del enzima conversor de la angiotensina (ACE) como factor de riesgo de desarrollar polineuropatía diabética; 3) Prospectivo de seguimiento a diez años, analizando la presencia previa de enfermedad cardiovascular y su relación con la aparición posterior de polineuropatía diabética. RESULTADOS: El TGF-beta-1 aparece como una molécula biomarcadora importante para la detección de polineuropatía diabética. El genotipo (D/I) del gen del ACE se erige como un factor protector en el desarrollo de la polineuropatía diabética. A los diez años de seguimiento, las personas con diabetes tipo 2 y enfermedad cardiovascular al inicio del estudio presentaron mayor riesgo de desarrollar polineuropatía diabética. CONCLUSIONES: Los tres estudios aportan resultados orientados a identificar personas susceptibles de desarrollar polineuropatía diabética. La posibilidad de que dicha identificación se lleve a cabo antes de sus manifestaciones clínicas permitiría anticipar las medidas de prevención secundaria e intensificar las actuaciones sobre sus factores de riesgo

La infermeria d'atenció primària en l'atenció als problemes del peu en la diabetis tipus 2 a Catalunya

Aquesta tesi pretén respondre a la pregunta: Què pot fer la infermeria d'atenció primària i què és el què fa, en els problemes del peu en persones amb diabetis tipus 2 a Catalunya?. L'estat del tema exposa la importància de les complicacions en el peu i la possibilitat de reduir-les amb un paper rellevant de la infermeria d'atenció primària. La investigació s'ha centrat en conèixer de què disposa, les activitats que desenvolupa, i què li manca a la infermeria per desenvolupar el seu potencial. Els resultats observats són representatius i mostren clares desigualtats assistencials entre centres, regions sanitàries i tipus de gestió. Suggerint que en l'atenció primària convé organitzar i coordinar l'atenció als problemes del peu en la diabetis, millorar la formació i la capacitació infermera en el tema, fomentar i optimitzar la presència de professionals especialitzats, i potenciar l'educació en diabetis i la promoció de la salut.This doctoral thesis intends to reply to the question: what can make primary care nursing and what it makes in the problems of the foot in type two diabetic patients in Catalonia? The state the subjects sets forth the importance of the foot complications and the possibility to reduce them with a relevant role of the primary care nursing.The research has focused on knowing of what the orders, the activities that it develops and what needs the nursing to develop its potential. The observed results are representative and they show clear welfare inequalities among centers, sanitary regions and type of management. Suggesting that in primary care, it agrees on organizing and coordinating the attention in diabetic foot problems, improving the nursing training in this topic, fostering and optimizing the presence of specialized professionals and promoting the diabetes education and the health promotion

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society