Lege Artis Medicinae

[Optimalisation of basal insulin regimen for adolescent patients with type 1 diabetes]


JANUARY 20, 2012

Lege Artis Medicinae - 2012;22(01)

[INTRODUCTION - During the total phase of type 1 (insulin-dependent) diabetes mellitus (T1DM), both the quantity and the quality of daily insulin doses must be determined to help the daily blood-glucose profile approach normoglycaemia, derived from the patient’s diet and regimen. Adolescence for young people with T1DM is a rather stressful - often shocking - psychosomatic state, due not only to the increased - but erratic - secretion of contrainsular hormones (predominantly growth hormone), but also to the special mental state of the child. Accordingly, choosing the right kind and amount of basal insulin to compensate the contrainsular effect is crucial for optimal treatment during this stage of life as well. CASE REPORT - We describe the process of optimising metabolic balance and basal insulin demand in a 11-year-old, adolescent girl with T1DM for 7.5 years using glargine insulin. In order to achieve this goal, both the dosage of glargine and the daily schedule of its administration needed to be modified. CONCLUSIONS - To achieve optimal metabolic results, both the quantity and the efficacy curve of basal insulin must and can be adapted to the actual stage of general somatic development. The demand for basal insulin during puberty may be well beyond the widely approved limit of 50%. Adapting the administration of glargine insulin to a daily schedule has the potential to counterbalance increasing contrainsular effects.]



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[Genetic background of thyroid cancers]

HALÁSZLAKI Csaba, LAKATOS Péter, KÓSA P. János, BALLA Bernadett, JÁRAY Balázs, TAKÁCS István

[Molecular genetics has become an indispensable diagnostic tool in a number of diseases. The most frequent thyroid tumours are associated with genetic alterations that might be used for diagnostic purpose in the future. Somatic mutations and rearrangements in BRAF, RAS family RET/PTC and PAX8/PPAR-gamma genes may occur in papillary and follicular thyroid carcinomas. Other mutations of the RET gene can be found in medullary carcinomas (in sporadic as well as hereditary types), whereas mutations of the genes TP53, RAS, and BRAF are associated with poorly differentiated and anaplastic carcinomas. At present, the most reliable diagnostic tool for the differential diagnosis of thyroid nodules is fine-needle aspiration cytology. However, the existing malignancy cannot be unequivocally proven in up to 10-40% of all samples. On the basis of previous results, genetic examination of fine needle aspiration samples from thyroid nodules can contribute to a more precise diagnosis and the timely removal of potentially malignant nodules.]

Lege Artis Medicinae

[How do physicians sleep and dream?]


[INTRODUCTION - Satisfying sleep is especially important for physicians. Our study analyses physicians’ sleep and dream from the point of view of continuous nightand- day duty. SAMPLE AND METHOD - Questionnaires were completed by 125 physicians among whom the proportion of night shift taking and only day-time working persons was equal. The questionnaire contained the Athens Insomnia Scale and the Dream Quality Questionnaire as well as questions about demographical characteristics and work circumstances. RESULTS - Almost each doctor mentioned sleep problems, principally daytime sleepiness (78%) and sleep deprivation (70%). Long sleep latency is reported more often by women doctors; the frequency of night awakenings increases, while daytime sleepiness decreases by age. The feeling of performance-loss is more prevalent among night shift takers. Dream characteristics differ significantly neither along demographical characteristics nor by work shifts. CONCLUSION - Although sleep problems are more frequent among physicians when comparing to the Hungarian general population, the frequency of clinical level insomnia is not higher. On the other hand, physicians can recall their dreams more often (25% vs 7%) and the emotional load of their dreams influence their daytime mood more commonly.]

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SOÓS Zsuzsanna, SALAMON Mónika, ERDEI Katalin, KASZÁS Nóra, FOLYOVICH András, SZŰCS Anna, BARCS Gábor, ARÁNYI Zsuzsanna, SKALICZKI József, VADASDI Károly, WINKLER Gábor

[Celiac disease - in its typical form - is a chronic immunemediated enteropathy with typical clinical symptoms that develops against gliadin content of cereal grains, and is often associated with other autoimmune diseases. In cases of atypical manifestation classic symptoms may be absent or mild, and extra-intestinal symptoms or associated syndromes dominate clinical picture. The authors present a longitudinal follow-up of such a case. A 63-years old woman was diagnosed with epilepsy at the age of 19, and with progressive limb ataxia at the age of 36, which was initially thought to be caused by cerebellar atrophy, later probably by stiff person syndrome. At the age 59, her diabetes mellitus manifested with type 2 diabetic phenotype, but based on GAD positivity later was reclassified as type 1 diabetes. Only the last check-up discovered the celiac disease, retrospectively explaining the entire disease course and neurological symptoms. By presenting this case, the authors would like to draw attention to the fact that one should think of the possibility of celiac disease when cerebellar ataxia, progressive neurological symptoms and diabetes are present at the same time. An early diagnosis may help to delay the progression of disease and help better treatment.]

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[Nowadays human insulins and insulin analogues are exclusively used in the clinical practice, when insulin therapy is needed. The patents of human insulins are expired and will expire soon for glargine, the first long-acting, basal insulin analogue preparation. The reliable production of biosimilar insulins is a new challenge for the pharmaceutical industry. Independently developed insulins with appreciable clinical efficacy have already become available in some countries where the quality criteria of regulatory process in place are less strict than in the European Union. The first approval for true biosimilar insulin, i.e. for biosimilar glargine was given in Europe in 2014. In this article, the characteristics of biosimilar insulins, especially the difficulties in the manufacturing process are reviewed in comparison with generic drugs. It is of note that potential efficacy and safety differences may occur due to even minor changes in the production, formulation and storage of the biological drugs. Therefore, biosimilarity should be investigated by detailed comparative pharmacokinetic and pharmacodynamic studies. Moreover, similar clinical efficacy and safety should be documented by randomized, comparative clinical trials. The potential impact of altered immunologic profile of biosimilar insulins should also be carefully monitored. ]

Lege Artis Medicinae



[Insulin detemir is a neutral, soluble, long-acting insulin analogue in which the amino acid threonineB30 has been removed and the LysB29 acylated with a 14-carbon fatty acid. The fatty acid modification allows insulin detemir to dihexamerisate and reversibly bind to human albumin upon administration. This brand new principle (self association and albumin binding) ensures slow absorption and a prolonged and consistent metabolic effect without a marked peak for up to 24 hours in patients both with type 1 and type 2 diabetes mellitus. Results of large clinical trials have shown that detemir can be efficiently used as basal insulin, supplemented with human regular insulin or aspart insulin taken before the main meals, in both type 1 and type 2 diabetes. Available data clearly demonstrate that the use of this insulin is associated with decreased variability of the fasting blood glucose values. In some of the studies the risk of (mostly nocturnal) hypoglycaemic episodes also dropped. It is important to note that patients using insulin detemir gained less or no weight compared to the group of patients treated with neutral protamine Hagedorn (NPH) insulin. Evaluation of long-term and wide-spread application of detemir needs further observations. Such trials are being conducted worldwide.]

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[Asserting basis-bolus principle by analogue insulin preparations in pre-pubertal child with diabetes]


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