Inzulin – skoro sto godina

Uskoro će biti sto godina od kada se upotrebljava inzulin. Prva industrijska proizvodnja inzulina počela je 1923. godine u SAD-u, nedugo poslije toga u Danskoj. Produljeno djelovanje ostvareno je 1936.god. Sljedeći veliki iskorak bila je tehnologija visokog pročišćavanja inzulinskih pripravaka, 1970-ih. Inzulin je prvi lijek dobiven tehnologijom rekombinantne DNK, taj „humani“ inzulin odobren je 1982. god. Neki nedostaci inzulinskih pripravaka (duljina djelovanja, varijabilnost) pokušavaju se riješiti inzulinskim analozima – prvi se pojavio 1996. godine. Analozi imaju učinkovitost sličnu humanom inzulinu, uz manje hipoglikemija. Kontinuirana infuzija (uglavnom potkožno) inzulina pumpom, posebno u zatvorenom sustavu povezano s kontinuiranim mjeračem glikemije, trenutno je vrhunac u supstituciji inzulina inzulinopeničnim osobama. U osoba s relativnim nedostakom inzulina (tip 2) postoje različite sheme liječenja, a potreba za inzulinom može biti i privremena. Humani inzulini potisnuti su na račun analoga (ne samo) u razvijenom svijetu. To povećava troškove, a još ima mjesta u svijetu gdje je bilo kakav inzulin luksuz. Kritično razmišljanje svakog sudionika u skrbi o šećernoj bolesti i solidarnost međunarodnih organizacija teži rješenju ovog paradoksa. Konačno, ne treba zaboraviti: inzulin je nužan, ali ne i dovoljan za dobru kontrolu šećerne bolesti. Dobra regulacija je nemoguća bez kontinuirane edukacije i potpore.

Prehrana osobe sa šećernom bolešću

Način prehrane uvelike utječe na regulaciju i tijek šećerne bolesti. Piramida zdrave prehrane osoba sa šećernom bolešću tek se neznatno razlikuje od uobičajene prehrambene piramide. Uobičajeno se preporučuje relativno visokougljikohidratna prehrana, s ne više od 30% ukupnog energijskog unosa iz masnoća, s tim da udio zasićenih masnoća ne smije prelaziti 7%, te maksimalno 200 mg kolesterola. Unos bjelančevina u osoba bez oštećenja nije drugačiji od onoga koji se preporučuje zdravim osobama. Alternativa je tzv. mediteranska dijeta: više masnoća, izrazita prevaga mononezasićenih (maslinovo ulje), uz više dijetnih vlakana. Od ostalih elemenata plana prehrane možda najvažnije je savjetovanje o adekvatnom unosu soli (6 g na dan, ili manje uz oštećenu funkciju bubrega). Ne postoji jedinstvena “dijabetička dijeta”. Kontinuiranom edukacijom osobe sa šećernom bolešću moraju steći sposobnost zdravih izbora hrane te usklađivanja prehrane s potrebnom terapijom

Prevalence of diabetes mellitus in Croatia

The aim of this study was to obtain an accurate estimate of diabetes prevalence in Croatia and additional estimates of impaired fasting glucose (IFG), undiagnosed diabetes, and insulin resistance. The study was part of the First Croatian Health Project. Field work included a questionnaire, anthropological measurements, and blood sampling. A nationally representative sample of 1653 subjects aged 18-65 years was analyzed. A total of 100 participants with diabetes were detected, among them 42 with previously unknown diabetes. The prevalence was 6.1% (95% CI: 4.59-7.64), with a significant difference by age. IFG prevalence (WHO-criteria) was 11.3%. The ratio of undiagnosed/diagnosed diabetes was 72/100, unevenly distributed by the regions. HOMA-IR was >1 in 40.4% of the subjects. This survey revealed a higher prevalence of diabetes than previously estimated, whereas that of IFG was as expected. A significant difference in the proportion of undiagnosed diabetes among the regions warrants attention

Noćna hipoglikemija – vodeća indikacija za terapiju inzulinskom crpkom u odraslih

The aim was to determine which adult type 1 diabetic patient receiving multiple daily injection therapy is the most appropriate candidate for insulin pump therapy, while taking into consideration limited insulin pump affordability in Croatia. A total of 145 type 1 diabetic patients (52% diagnosed in adult age) were monitored at the Department of Endocrinology, Clinical Department of Internal Medicine, Zagreb University Hospital Center from 2009 to 2014. Twenty-one patients started insulin pump therapy in adulthood (seven men and 14 women, median age 27). Five patients had chronic complications (retinopathy in two, polyneuropathy in one, and both nephropathy and retinopathy in two patients). The median HbA1c at the initiation of pump therapy was 6.95% versus 6.5% after 1 year of pump therapy. Patients were stratified according to indications for insulin pump therapy (frequent and/or severe hypoglycemia, specific lifestyle, having not reached glycemic goals despite adherence/labile diabetes, and preconception). Patients could meet more than one criterion. Initially, the occurrence of hypoglycemia was analyzed by 6-day continuous glucose monitoring, while re-evaluation was done after collecting history data at 1 year ± 3 months. Initially, all patients had a median of 5 hypoglycemias/6 days (30% nocturnal) versus 1 hypoglycemia/6 days (without nocturnal) after 1 year. The Wilcoxon signed-rank test yielded a statistically significant difference in hypoglycemic events, nocturnal hypoglycemia and HbA1c. Patients commencing insulin pump therapy due to hypoglycemia initially had median HbA1c of 6.7% with 7 hypoglycemia/6 days (50% nocturnal). After one year, median HbA1c was 6% with 1 hypoglycemia/6 days (without nocturnal). In conclusion, the main indication for insulin pump therapy in adults is the frequency of hypoglycemia, especially nocturnal ones.Cilj studije bio je istražiti koji su odrasli bolesnici s tipom 1 dijabetesa liječeni s više dnevnih doza inzulina najbolji kandidati za liječenje inzulinskom crpkom, uzimajući u obzir njihovu ograničenu dostupnost u Republici Hrvatskoj. Na Zavodu za endokrinologiju Interne klinike Kliničkoga bolničkog centra Zagreb praćeno je 145 bolesnika s tipom 1 dijabetesa (kod 52% njih je bolest dijagnosticirana u odrasloj dobi) u razdoblju od 2009. do 2014. godine. Kod 21 bolesnika (7 muškaraca i 14 žena, medijan dobi 27 godina) liječenje crpkom započelo je u odrasloj dobi. Petoro bolesnika je imalo kronične komplikacije (dvoje retinopatiju, jedan polineuropatiju, a dvoje je imalo i retinopatiju i neuropatiju). Medijan HbA1c prije započinjanja liječenja inzulinskom crpkom je bio 6,95%, a nakon godine dana terapije crpkom 6,5%. Bolesnici su bili razvrstani prema indikaciji za liječenje crpkom (učestale i/ili teške hipoglikemije, specifičan stil života, nepostizanje željenih ciljeva glikemije unatoč suradljivosti/nestabilan dijabetes te pretkoncepcija). Bolesnici su mogli ispunjavati i više od jedne indikacije. Na početku liječenja učestalost hipoglikemija se analizirala kontinuiranim praćenjem glukoze tijekom 5-6 dana, a reevaluacija je učinjena iz anamnestičkih podataka nakon 1 godine ± 3 mjeseca. Na samom početku liječenja bolesnici su imali 5 hipoglikemija/6 dana (30% noćnih), a nakon godine dana 1 hipoglikemiju/6 dana (bez noćnih). Wilcoxonov signed-rank test pokazao je statistički značajnu razliku u broju i učestalosti noćnih hipoglikemija te u HbA1c. Kod onih bolesnika u kojih je liječenje započelo inzulinskom crpkom s indikacijom hipoglikemije prije crpke medijan HbA1c je bio 6,7% sa 7 hipoglikemija/6 dana (50% noćnih). Nakon godinu dana medijan HbA1c je bio 6% s 1 hipoglikemijom /6 dana (bez noćnih). Kao zaključak, vodeća indikacija za liječenje inzulinskom crpkom u odraslih bolesnika je učestalost hipoglikemija, osobito noćnih

Quaternary prevention. Prediabetes: risk, disease or overdiagnosis? The diseases which are not of great danger should not be teased by medicines (Plato, 5th century BC)

Kvartarna prevencija suvremen je, kritički pristup moderne medicine. Usmjerena je na zaštitu pacijenata od medicinskih intervencija koje su suvišne pri zdravstvenoj zaštiti i mogu nanijeti više štete nego koristi. Kvartarna prevencija sastavni je dio svih triju prevencija: primarne, sekundarne i tercijarne. Cilj je zaštita pacijenta od mogućega suvišnog probira, suvišne dijagnoze bolesti, što pacijenta može uvesti u suvišnu medikalizaciju i postupke. Dijabetes je kronična, doživotna bolest s dijagnozom na temelju dogovorene točke razgraničenja kontinuirane varijable i pod visokim je rizikom od suvišnih postupaka. S druge strane, prepoznavanjem i intervencijom u graničnim području (u predbolesti) može se odgoditi nastanak bolesti. Izazov je prepoznati rizike i uvesti intervenciju samo ondje gdje su oni visoki, gdje je nastanak bolesti siguran, a odgovarajuća intervencija može ga odgoditi. Čini li se to za osobe niskog rizika od nastanka bolesti i komplikacija, pacijentu se ne mijenja prognoza, ali mu se dodaju suvišna dijagnoza i dodatni postupci te izaziva dodatni stres. O ovomu treba voditi računa na svim razinama zdravstvene zaštite, no poglavito u obiteljskoj medicini, što je prepoznala i Svjetska udruga obiteljskih liječnika (WONCA).Quaternary prevention is a contemporary critical approach to modern medicine. Its goal is the protection of patients from unnecessary medical intervention which can do more harm than good. Quaternary prevention is a part of all three preventions: primary, secondary and tertiary. Its aim is to protect a patient from overscreening and overdiagnosis which can lead to overmedicalization. As a life-long disease with diagnosis based on the agreed cutoff point of a continuous variable, diabetes is in a great risk of over-intervention. However, with a right intervention in pre-disease it is possible to postpone the disease. The challenge is to recognize the risks and intervene if they are high, the risk of disease progression is substantial, and appropriate intervention can diminish it. If the same is done for low risk it is a waste of energy and means, and the patient gains nothing but additional stress due to overdiagnosis. It has to be considered at all levels of health care, but mostly in primary care, which has been recognized by the international association of family physicians (WONCA)

Chronic patients: persons with diabetes frequent attenders in Croatian family practice

Chronic diseases cause high frequency visits and generate the long-term frequent attenders (FAs). The connection between frequent attendance and specific morbidities in the health care systems in transitional Europe has been underestimated. We investigated whether frequent visits of chronic patients in primary care are related to characteristic of chronic disease (diabetes mellitus) and whether this is influenced by the family practice in the transitional health care. We analyzed the number of visits a day time work for 490 persons with diabetes in the period 1997 to 2000. As the cut-off points between frequent attenders and non frequent attenders (NFAs) we used the value of the third quartile (Q3) of visits determined for the sex and age groups in the parallel study in the whole population. The analysis was performed for 23 variables: demographic characteristics of patients, disease characteristic and variables of physician. Logistic regressions were employed to identify the predictors of FAs/NFAs. 56.9% (in 1997) to 62.4% (in 2000) persons with diabetes were FAs, compared to 22.4% to 24.3% FAs patients in the whole population. Logistic regression analysis significantly differentiated the two group of visits with 68% accuracy. 4 variables are significant predictors for FAs/NFAs: diabetes as the main disease (p = 0.0005), diet-only-treatment (p = 0.0062), treatment by secondary care (p = 0.0116), and if glycated hemoglobin test (HbA1c) is determined (p = 0.0272). Understanding the similarities and differences of FAs/NFAs persons with diabetes may be important in improving the care and management of chronic diseases in family medicine in transitional health care systems

Glukagonu sličan peptid-1 različito utječe na percepciju okusa u žena: randomizirana, placebom kontrolirana ukrižena studija

Gastrointestinal tract is an important connector between food intake and body weight, it senses basic tastes in a similar manner as the tongue. The aim of the study was to find out how gut hormone glucagon-like peptide-1 (GLP-1) influences taste preference. Fourteen healthy participants (six male and eight female) were included in this double-blind, placebo-controlled crossover study. After overnight fast and salty fluid (oral sodium load), participants were randomized to receive placebo (500 mL of 0.9% saline) or GLP-1 infusion (1.5 pmol/kg/min) over a 3-hour period. At the end of infusion, participants chose food preferences from illustrations of food types representing 5 tastes. After 7 days, the protocol was repeated, this time those that had received placebo first got GLP-1 infusion, and those having received GLP-1 first got placebo. Change of taste preference after GLP-1 infusion but not after placebo was reported as response, and non-response was reported in case of taste persistence. A statistically significant difference in response type was found between genders, with women being more likely to change their taste preference after GLP-1 than men. The change of taste upon GLP-1 infusion observed in women might be ascribed to estrogen weight-lowering effects accomplished by receptor-mediated delivery.Probavni sustav povezuje unos hrane i tjelesnu masu razlikujući osnovne okuse sličnim mehanizmima kao i jezik. Cilj ove studije bio je istražiti kako glukagonu sličan peptid-1 (GLP-1) utječe na sklonost određenom okusu. Četrnaestoro zdravih ispitanika (šest muškaraca i osam žena) uključeno je u randomiziranu, placebom kontroliranu ukriženu studiju. Ispitanicima koji su bili natašte dana je slana tekućina (oralno opterećenje solju), nakon čega su randomizirani za placebo (500 mL 0.9% fiziološke otopine) ili infuziju GLP-1 (1.5 pmol/kg/min) tijekom 3 sata. Na kraju infuzije ispitanicama su predočene slike hrane koje predstavljaju 5 osnovnih okusa pa su birali okus kojem su najviše skloni. Nakon 7 dana postupak se ponovio; onima kojima je prvi puta dan placebo primijenjen je GLP-1, a onima koji su prvi put dobili GLP-1 primijenjen je placebo. Promjena sklonosti određenom okusu nakon infuzije GLP-1, no ne i nakon placeba, smatrala se pozitivnim odgovorom, a negativan je bila nepromijenjena sklonost okusu. Analizirajući ispitanike prema spolu nađeno je da žene imaju veću vjerojatnost promjene sklonosti okusa nakon GLP-1 nego muškarci, što je bilo statistički značajno. Navedeno opažanje promjeni okusa nakon infuzije GLP-1 u ispitanica može se objasniti učinkom estrogena na gubitak tjelesne mase koji se objašnjava receptorski posredovnim prijenosom

QUATERNARY PREVENTION AS A BASIS FOR RATIONAL APPROACH TO THE PATIENT IN FAMILY PRACTICE

Kvartarna prevencija definirana je kao postupak identificiranja pacijenta rizičnog podlijeganju prekomjernoj medikalizaciji ali i zaštite pacijenta od nove medicinske invazije te predlaganja takvom pacijentu etički prihvatljivih intervencija. Njeno primarno mjesto je u obiteljskoj medicini zbog pozicije obiteljskog liječnika koji predstavlja prvu liniju kontakta s pacijentom te »voditelja« pacijenta kroz zdravstveni sustav. Veliko umijeće liječnika obiteljske medicine je odrediti kojem tjelesnom sustavu pripada simptom kojega prezentira pacijent, te odrediti optimalni daljnji postupak s pojedinim pacijentom. To je posebno složeno u situaciji kada pacijent ima tegobe, a liječnik ne nalazi bolest. U tim situacijama individualni pristup pacijentu, dobra komunikacija, balans između indiciranja odgovarajućih pretraga i utvrđivanja nužnih postupaka uz oslanjanje na medicinu temeljenu na dokazima čine kvartarnu prevenciju, koja postaje nužnost u vođenju pacijenta kroz suvremeni sustav zdravstvene zaštite.Quaternary prevention is an action taken to identify a patient at risk of overmedicalisation, to protect him from new medical invasion, and to suggest to him interventions which are ethically acceptable. It belongs mostly to family medicine because of the family physician’s position who is the first contact to the patient and »leader« of patient through health care system. Family physician must have a skill to locate the patient’s symptom to the proper organ system and also to find the appropriate procedure for the patient. This is very complex in a situation when the patient has symptoms and complaints and the physician doesn’t find the disease. In these situations individual approach to the patient, good communication, balance between finding appropriate procedures and defining neccessary procedures together with evidence based medicine make quaternary prevention, which becomes a neccessity in the process of leading the patient through modern health care system