The Minister of Health, María Jesús Montero, who today opened the IX Congress of the Andalusian Society of Community Nursing (ASANEC) being held in Seville, was referring to the second development phase of the decree so far given to this group Professional 96 indicate the possibility of non-prescription drugs and medical devices such as catheters, sterile dressings, absorbent urinary incontinence, and test strips to measure blood glucose among others.

The new competition now allows nurses, once accredited, provided that the physician’s request and authorization, which can track drug treatment previously indicated by the doctor to patient.

“It is concerned that nurses have the ability to vary the intensity or dose of treatment to take account of developments in the patient,” said Montero, who confined the new allocation nurse, always under the protocol established for each chronic health problem.

To that nurses can begin to exercise this new competition should prove their training and experience in the various protocols for chronic health problems, in this case in the treatment of diabetes and chronic wounds are those who will start the call ‘ collaborative prescribing, “which will be extended gradually to other processes.

Therefore, Health will soon publish the first two collaborative prescribing guidelines (Diabetes Mellitus and Chronic Wounds), you will have access to all Andalusian health.

There are also plans in September to start various courses for nurses who want to update their training in the treatment of diabetes in the face of accreditation in this’ collaborative prescribing. ”

Health Quality Agency of Andalusia, organ of the Ministry of Health is responsible for certifying these issues by assessing the merits provided by the professionals.

Netherlands scientists said the results suggest that they should “seriously consider” regular monitoring of vitamin B12 levels during prolonged treatment with metformin to try to prevent deficiency and its effects.

Vitamin A is essential for maintaining nerve cells and red blood cells healthy. It is found in meat, dairy products, eggs, fish, seafood and fortified cereals, and can also be taken as a supplement.

Coen Stehouwer, Medical Center of Maastricht University in Holland, whose study was published in the British Medical Journal, said that the symptoms of B12 deficiency include fatigue, mental changes, anemia and brain damage called neuropathy.

All these symptoms can easily be misdiagnosed as arising from diabetes and its complications or aging, he said. But controlling the levels of the vitamin could help doctors evaluate and treat the real cause of the problem if it occurs.

“Our data strongly justify carrying out routine checks of vitamin B12 levels during prolonged treatment of metformin,” wrote Stehouwer.

Around 246 million people worldwide have diabetes, and rates are expected to grow along with the increase of obesity and overweight. Most have type 2 diabetes, which is linked with poor diet and lack of exercise.

Stehouwer’s team studied 390 patients with type 2 diabetes. A 194 metformin were given three times a day for more than four years and 194 showed them a placebo.

People who had taken metformin, reportedly had a 19 percent lower risk of reducing the levels of vitamin B12, compared with the other group, which almost remained unchanged.

The fall of B12 in the metformin group also persisted and became more evident over time, they added.

“Our study shows that it is reasonable to assume that some patients with low vitamin B12 levels induced by metformin suffer damage,” wrote Stehouwer.

The type 2 diabetes
Type-2 diabetes have a resistance of body cells to the biological effects of insulin. Once this so-called insulin resistance is too strong, does the injected insulin in a diabetes therapy is not effective enough. Be increased in these cases, the insulin sensitivity by insulin sensitizers. These sensitizers are firstly used for type-2 diabetes with marked insulin resistance, ie, in patients in whom insulin alone is insufficient. On the other hand in diabetic patients who are not the standard combination of insulin and metformin because of contraindications or intolerance can take.

To date, registered in Germany, two insulin sensitizers: Pioglitazone and rosiglitazone. These drugs increase insulin sensitivity of liver cells, muscle, and adipose tissue. The cells absorb more sugar by these substances, the liver, however, limits their glucose production. The result: the blood sugar level falls, both fasting and after meals.

The study
In the current study for three years more than 4000 patients taking part. All will be treated with the combination of insulin and pioglitazone. The first interim analysis of data from 2086 patients from 408 different diabetological study centers appears very positive. The blood glucose levels of the test subjects fell by nearly one percentage point. As an ultimate goal, the leaders recommend a percentage of 6.5%. In addition, the interim results showed that 22% of patients required less insulin. Blood pressure and blood lipid values of study participants also improved.

Possible side effects
The compatibility ratio of this therapy was quite good and was 97.7%, which was tolerated in most patients, the combination without major problems. One in seven patients, there was water retention in the legs. Through a diuretic these unwanted side effects, however, were already resolved during therapy. Encouraging, the researchers expressed the fact that no patient had to discontinue the therapy and already well-known complications with pioglitazone were observed.

Treatment Information
In patients receiving the combination therapy for the first time it is very important that the physician individually reduces the insulin dose to prevent hypoglycaemia. Those in charge of the study suggest, therefore, patients in the first few weeks follow closely, especially with regard to the occurrence of Herzinsuffiziensymptomen. Particularly crucial to a problem-entry into this type of therapy is the continuous adjustment of insulin dose.

In contrast to the insulin-dependent type 1 diabetes produce humans with type 2 diabetes, even a small amount of endogenous insulin. This amount is often small, that they no longer sufficient to adequately regulate the blood sugar. In addition, the metabolism of a type-2 diabetics often speaks to the existing insulin significantly less responsive than in perfectly healthy people would be the case. In this problem, so-called “oral agents” to correct the situation. These tablets increase the effects of the existing residual insulin and stimulate the pancreas to pour out to, for example at meals sufficient endogenous insulin. In the tablets even no insulin is included because it would be destroyed by stomach acid. In Germany, a type-2 diabetes is usually treated with oral antidiabetic agents. Only when the excess of regular long-term blood sugar levels (HbA1c), despite all efforts, the level of 7% are type 2 diabetics treated with insulin.

Texas study examines the advantages and disadvantages of diabetes therapy
A team of endocrinologists in the United States had now for three years, recently published study examined the self-treatment of people with type 2 diabetes. The study involved about 58 people had taken part with a newly diagnosed diabetes who were assigned randomly to one of two groups. One group was treated during the three-year observation period with insulin and the drug metformin, the other group received a combination treatment with the antidiabetic metformin, pioglitazone, and glyburide.

Insulin and combination tablets are equally good
The result: The HbA1c of both groups differed at the end of the study, only 0.1 percent. The insulin group had reached an average of 6.1%, the tablet group had the slightly better value of 6%. Weight gain was observed in both groups. Surprisingly, participants had risen kg in the insulin group, however, only about 4.5, while the tablet group average of 7.2 kg with a lot more put on the scales. Hypoglycemia occurred during the study in both groups rarely, and usually, these were not severe hypoglycemia. The self-discipline and the satisfaction with the therapy in both groups were also roughly equal.

Results are not fully meaningful
As a result, the insulin / metformin therapy and the combination of three anti-diabetic agents also equal. However, a combination of three different anti-diabetic agents in Germany is practiced only in emergencies, because the blood glucose in most patients even with a tablet can be adjusted very well. In addition, a study with only 60 patients compared to the experience of millions of diabetics is not meaningful.

This is because during pregnancy the placenta produces hormones such as estrogen, cortisol and lactogen, which can block the work of insulin, which is responsible for regulating blood glucose. When gestational diabetes is not treated, can cause severe consequences on the health of the pregnant woman and baby, one of the most common infections are usually in the urinary tract.

You may also see preeclampsia, which is characterized by increased high blood pressure and a lot of fluid retention which can interfere with the development of the sick baby and the mom. A characteristic of babies born to mothers with gestational diabetes, is that they can grow so much and weigh more than 4 kg which is called (macrosomia), which can complicate delivery, and require much more effort the mother.

You can give these babies born with respiratory failure, poor lung development, which then has for some time in the neonatal intensive care unit until they can breathe on their own. Therefore it is necessary that the mother make the appropriate checks and if you detect gestational diabetes, observed to the letter the instructions of their doctors.

At a conference sponsored by the institute, the Network of Diabetic Retinopathy Clinical Research, reported that: “Lucentis, known generically as ranibizumab, was much more effective than single treatment with laser in various types of retinal problems.”

Lucentis is a particle called the immune system engineered monoclonal antibody that targets the blood vessels of the eye. The drug is already approved to treat macular degeneration, a condition that causes blindness and is caused by the growth of vessels in the retina and the possibility of using the drug to millions of diabetics opens a huge market.

The national network of researchers evaluated 691 patients who underwent random laser treatment, the laser or laser Lucentis with another drug called triamcinolone.
The team found that adding injections of Lucentis to stop blood vessel growth at the molecular level showed better effects.

“After a year, almost 50 percent of eyes treated with ranibizumab and laser immediate or delayed showed a substantial improvement in vision,” he wrote in a report to be published in the journal Ophthalmology.

On the other hand, only 28 percent of patients treated only with laser or triamcinolone showed this improvement. Most of the positive effects were seen after two months of injections.

1. Some common types of medications are listed below and are taken orally or injected.
2. Biguanides (Metformin) tell the liver that produce less glucose and help you adipocytes and muscle cells and the liver to absorb more glucose from the bloodstream, which lowers blood sugar levels.
3. The sulfonylureas (like glimepiride, glyburide, and tolazamide) trigger the pancreas to produce more insulin. Are taken by mouth.
4. Thiazolidinediones (such as rosiglitazone) help adipocytes and muscle and liver cells to absorb more blood sugar when insulin is present. Rosiglitazone may increase the risk of heart problems, so consult your doctor.
5. Injectable medications (including exenatide and pramlintide) can lower blood sugar.
6. Meglitinides (including repaglinide and nateglinide) trigger the pancreas to produce more insulin in response to glucose in the blood.
7. Inhibitors of alpha-glucosidase (such as acarbose) decrease the absorption of carbohydrates from the digestive tract to lower glucose levels after meals.

If you continue to have poor glycemic control despite changes in lifestyle and taking medicines by mouth, your doctor will prescribe insulin. It is also possible that the prescription if you have had an adverse reaction to other drugs. Insulin must be injected under the skin using a syringe or insulin pen, and can not be taken by mouth.

Insulin preparations are different in how quickly they start to work and the duration of its effect. The doctor will determine the appropriate type of insulin to use and tell you what time of day to.

More than one type may be mixed together in one injection to achieve better control of blood glucose. Usually injections are needed one to four times a day. Your doctor or diabetes educator will show you how to give yourself an injection.

Some people with type 2 diabetes find they no longer need medication if they lose weight and increase activity. When they reach their ideal weight, their own insulin and a careful diet can control their blood sugar levels.

It is not known whether hypoglycemia medications taken by mouth are safe for use in pregnancy. Women with type 2 diabetes taking these medications may be switched to insulin during pregnancy and while breastfeeding.

Glycemic control is to maintain glycosylated hemoglobin (HbA1c) between normal limitted, because we know that good glycemic control reduces the long-term risk of microvascular complications in both types of diabetes, 1 and 2. Researchers at ADVANCE and ACCORD studies examined the effect of glycemic control on the evolution of patients with type 2 diabetes and macrovascular and microvascular disease. Both studies failed to demonstrate that good glycemic control is associated with reduced cardiovascular risk.

Reports of a potential increase in mortality rates associated with intensive glycemic control resulted in a debate on the recommendations for the treatment of type 2 diabetes, specifically aiming to establish an optimal HbA1c. Researchers have suggested that in diabetics, hypoglycemia is a possible increased risk of mortality. Because intensive glycemic control increases the risk of hypoglycemia, with some drugs than with others, it is important to assess the risks associated with the various schemes to lower blood sugar. In two meta-analysis, researchers pooled data from several major works and concluded that intensive glycemic control has a positive effect on cardiovascular outcomes. However, these meta-analysis were limited by the limitations of clinical trials analyzed.

In this retrospective cohort study, the objective was to evaluate the association between mortality from all causes and HbA1c in type 2 diabetic patients seen at primary care and establish the existence of any apparent association that was independent of treatment regimen diabetes.

Test of HbA1c of approximately 7.5% was associated with lower mortality from all causes and a lower progression to disease events of the great vessels. An increase or decrease the lower value of HbA1c was associated with increased risk of adverse outcomes. The lower pattern is the association of risk was sufficiently similar in both treatment groups as to suggest that the risk of mortality for HbA1c was independent of treatment regimen. On the other hand, observed that the risk of mortality in two cohorts of treatment was different, showing that treatment with insulin was associated with higher mortality. This pattern of association remained consistent with time-dependent HbA1c as a covariate. The results, say, support the evidence of the ACCORD study. In this study, the results showed that mortality increased (RR 1.22, 95% CI 1.01 -1 46) in patients with cardiovascular disease or had at least two risk factors for cardiovascular disease or atherosclerosis severe and HbA1c 7.5%, subject to intensive glycemic control (target HbA1c <6.0% vs. 7.0 -7 * 9%). However, these data are in contradiction with the monitoring data from the UK Prospective Diabetes Study (UKPDS) showed that intensive treatment was associated with a reduced risk for all outcomes related to diabetes. However, less than 15% of UKPDS patients achieved an HbA1c level below 6.5%.

The results of the initial phase of the UKPDS randomization showed a significant reduction in relative risk of myocardial infarction of 14% for every 1% reduction HbA1c.Los results of this analysis confirmed a weak association between HbA1c and reduced risk of sick pictures of the great vessels, with HbA1c values above 7.5%, but, unlike the results of the UKPDS, we found an increased mortality to a level of HbA1c less than 6.5 % in patients with and without large vessel disease recorded.

THE ADVANCE study evaluated the effects of intensive control of blood pressure and blood sugar (HbA1c HbA1c <7.5%) on micro and macrovascular complications in patients treated with oral hypoglycemic regimens. After an average of 5 years of follow up, a good glycemic control was associated with less frequent microvascular events, but not macrovascular events. Improved glycemic control was not associated with higher mortality. The difference between the observations of the ADVANCE study and this work could be partly due to statistical power issues, a low cardiovascular risk profile in the ADVANCE study or, as the authors, their results are not representative.

Both the ACCORD study and the Veterans Affairs study raised reservations about the safety for patients with type 2 diabetes receiving intensive insulin therapy. Moreover, the study’s researchers EDIC (Epidemiology of Diabetes Interventions and Complications) of patients with type 1 diabetes reported cardiovascular benefits in patients with intensive glycemic control, but not in those with evidence of less than 6.5% HbA1c . The mechanisms that could explain this finding is unknown. The first reports of the ACCORD trial were unable to identify the causes of death among both groups studied, mortality rates were higher for the extreme values of HbA1c, regardless of treatment regimen and some cardiovascular risk factors. The decrease in survival in patients achieving low percentages of the average HbA1c could be related to hypoglycemia, a common complication of intensive control of blood glucose. In this study, patients with severe hipooglucemia mortality was 3 times higher than those who did not experience severe hypoglycemia, both in patients treated conventionally and intensively. Moreover, in the Veterans Affairs study, the occurrence of more than 1 episode of severe hypoglycemia was associated with an increase of 88% of the risk of sudden death.

Hypoglycemia is associated with different consequences. For example, a relationship between the manifestations of sympathomimetic (adrenergic) or hypokalemic of hypoglycemia and the onset of cardiac arrhythmia, including long QT syndrome in diabetic patients with established cardiovascular disease. Intensive glycemic control associated with hypoglycemia may enhance the variability of glucose, which contributes to oxidative stress and vascular inflammation. This result may predispose to atherosclerotic plaque destabilization and vascular disfuncióln.

The lower survival in the group treated with insulin may be that insulin may increase the risk of mortality in patients with type 2 diabetes. Margolis et al. reported that the use of insulin is associated with an increased risk of serious ischemic cardiac complications. One possible explanation, as it is derived from an evaluation conducted diabetics undergoing coronary bypass surgery is that the insulin-treated patients were older and had more comorbidities as well as a longer duration of diabetes patients in group treated with oral hypoglycemic agents. In this study, the reference frequency of comorbidities such as renal failure was greater in those who used insulin. There was no evidence to support the idea that insulin has a direct toxic effect in patients with type 2 diabetes without cardiovascular disease or autonomic, however, this disorder has been reported the existence of a link between insulin use and progression and mortality of cancer.

The authors state that differences between cohorts at baseline could have affected the results. Compared with patients in group 1, more patients in group 2 had experienced a prior cardiovascular table and had a creatinine greater than 1.50 mg/100 ml. Tables previous cardiovascular and renal initial cardiovascular risk factors that herald poor outcomes in patients with atherosclerosis or diabetes. However, when we excluded patients without documented the large vessels, the Cox analysis showed that those treated with insulin had an increased risk of macrovascular disease progression than patients treated with oral agents combined.

In this study, adjustments were made for different morbidities between cohorts and gave a detailed sensitivity analysis comparing the two cohorts, as the adjustment of duration of diabetes. The differences in survival and the frame rate of disease of large vessels between the cohorts persisted under all conditions of analysis. For the authors, another plausible idea is that the causes of death and the underlying pathology in the extreme values of HbA1c were of different categories among the study’s limitations CPRD mentions that collects data from routine practice, therefore Some data is lost, there may be imperfections in encoding and HbA1c determinations are not standardized.

The normal range of HbA1c vary among centers and biochemical determinations could have been done with different periodicity. By using techniques such as linear interpolation of values, the authors measured the total exposure to the risk parameters unreliable. The variability in the frequency of the measurement of HbA1c could have created a bias. However, the bias was tested by three different methods and findings remain the same. Moreover, the study was not randomized. Although standardized when possible confounding factors recognized, it is possible that some effects have not yet been detected. Also you may not have appeared other confounding factors because other variables that might have been important were not recorded or included in the model. In addition, HbA1c groups differed systematically, although the survival models may have taken account of some of these differences.

As for the details of the cause of death, they were considered too imprecise to be informed and in this study. No data are available to characterize ethnic origin. Other limitations are that its not made a separate analysis of cases to assess the duration of response or the effect of severe hypoglycemia in mortality due to insufficient data. One possible source of confusion was the difference in prescription rates for cardiovascular prophylaxis in deciles of HbA1c. Although these data are not shown, the researchers concluded that patients with higher HbA1c received less treatment for cardiovascular prophylaxis.

The decision by the authors to include cases of dual membership cohort is an argument that can influence litigation for and against. Although this factor could have introduced bias into the study, the authors made a sensitivity analysis by introducing an indicator covariance members of both groups for the parameter of insulin regimen. These data, therefore, still need to be interpreted with caution. However, the large number of patients represents what actually took place in clinical practice. Given these limitations, the authors say, “We believe that the resultant force of our evidence suggests that this association is reliable, although these findings need further confirmation.” “Our study, together with evidence of ACCORD, could have important implications care of people with type 2 diabetes. Both in our data and the ACCORD study findings, these results are applicable to type 1 diabetic patients is unclear and needs to be investigated. “These data imply that for a broad range of HbA1c, combined oral treatment is safe with respect to mortality from all causes and pictures of the great vessels, but for insulin-based therapy, it is desirable to establish tighter limits. This involvement does not mean that there is unquestionable value in achieving the current glycemic targets to reduce microvascular disease. Still require more research and evaluation of overall risk assessment to determine whether intensification of glycemic control by insulin therapy increases the risk of death in the dibéticos. The findings suggest that it may be necessary to revise the guidelines for diabetes and include a definition of a minimum value of HbA1c.

Join the club of small things!

Why? Because it has been shown that small changes are more realistic, easier and more effective, since they are just naturally incorporated into the routine of daily life. I’ll give you some examples:

1. Take one hundred calories less a day.

Reduce intake of 100 calories each day can hardly notice it at meals, but it is effective in the long term. With no sense of hunger will be easier to do this.

Some tips for this:

* Come on small plates. If you’re hungry and you will stand up for more, but do not fill your plate to overflowing. In addition, once you serve, remove the pan instead of staying with her before.
* Pour yourself a glass of fruit with a scoop of ice cream, instead of a cup of ice cream with pieces of fruit.
* Choose half the usual serving desserts and foods high in fat.
* Make use of oil aerosols that can dispense fair. Once you’ve seasoned the salad, remove the oil.
* No monks bread in the sauce.

2. Do not throw anything from your diet

Prohibiting certain foods make your power of suggestion is much older. Occasionally you can take energy dense foods, but try to lighten. How?

* Reduce the ration.
* Add half of cheese pizza.
* Do not impregnate butter sandwiches
* Snacks, best of lettuce and tomato, cheese and chorizo.

3. Aleja temptations

The farther you have a food, the less likely they go after him. So it’s good then remove the pan to serve you and so is ideal not have home high-energy products such as candy or bakery products. Of them, better be on that top shelf all that you do not get no lean on the chair. Like it’s hard to believe, but the reality is that the greater the effort you have to do an individual to obtain a food, the lower their consumption.

4. Exercise

At the moment I’m not going to ask you notes to the gym (which would not be bad), but does include some activity in your daily life, just walking 15 minutes a day. Not so much right?

Aggressively treated patients had a much lower level of blood glucose (but still slightly above normal) than patients less medicated. After 3 years and 6 months, there were no differences between the two groups in the development of cardiovascular disease (one of the major complications of diabetes). Incredibly, those in the aggressively treated group had a 22 percent increase in risk of mortality.

Obviously, there was a lot of hands waving in the conference to try to explain these results. After all, it is well known that the reduction of blood glucose levels due to caloric restriction leads to a longer life cycle and greater overall health. So, in the opinion of Dr. Barry Sears, the answer is that the drugs used to lower blood glucose levels in diabetics involves a long-term toxicity. This is the sad part of modern medicine, especially in the treatment of diabetics, where drugs have become powerful treatment of the disease.

This is almost the opposite of the past when the diet was used as the main treatment for diabetes. Today, patients can eat what they want and just take more drugs.