SEMNIFICAIA SCORULUI REAVEN N CAZUL PACIENILOR CU DIABET ZAHARAT NOU DIAGNOSTICAT A. Nicoar, C. Pencea, D. Licroiu, R. Nafornita, R. Lichiardopol Institutul de Diabet, Nutriie i Boli Metabolice N. Paulescu, Bucureti, Romnia

Obiectiv: Obiectivul acestui studiu a fost acela de a identifica relaia dintre Scorul Reaven i caracteristicile clinice si metabolice ale pacienilor nou descoperii cu diabet zaharat tip 1 (DZ tip 1) si diabet zaharat tip 2 (DZ tip 2). Material si metod: Lotul studiat a inclus 200 pacieni cu DZ tip 1 si DZ tip 2, nou descoperii, nregistrai n ultimele 2 luni la Institutul de Diabet, Nutriie si Boli Metabolice N.Paulescu, Bucureti, dintre care 98 au fost barbai (49%) si 102 au fost femei (51%). Pe lotul studiat, pacienii au fost grupai n funcie de tipul de diabet zaharat (DZ) n 2 loturi : lotul 1 incluznd pacienii cu DZ tip 1 (n=13) i lotul 2 incluznd pacienii cu DZ tip 2 (n=187). Pentru fiecare lot au fost colectate date clinice si antropometrice (nalime, greutate, indexul masei corporale-IMC, circumferina abdominal i valorile tensiunii arteriale sistolice i diastolice), dar i parametrii metabolici (HbA1c i profilul lipidic), date privind statusul de fumtor/nefumtor i antecedente heredocolaterale de DZ.Pentru interpretarea rezultatelor, am utilizat criteriile ATP III pentru definirea parametrilor sindromului metabolic i Scorul Reaven (raportul TG/HDLcol3) pentru estimarea insulinorezistenei.Analiza statistic a datelor s-a efectuat utiliznd SPSS 15.0. Rezultate: Prevalena obezitii abdominale a fost de 30.7% n cazul lotului de pacieni cu DZ tip 1 i de 47.05% n cazul lotului de pacieni cu DZ tip 2. Valori crescute ale tensiunii arteriale sistolice s-au constatat la 74.2% dintre subieci, 23.1% dintre acetia aparinnd lotului 1 de pacieni cu DZ tip 1, iar 77.2% aparinnd lotului 2 de pacieni cu DZ tip 2. Valoarea medie a HbA1c a fost de 10.62.84% la pacienii cu DZ tip 1, respectiv 9.082.54% la pacienii cu DZ tip 2. Valoarea medie a Scorului Reaven a fost de 2.591.35 la lotul de pacieni cu DZ tip 1 i respectiv 6.443.98 la lotul de pacieni cu DZ tip 2. Valorile medii ale IMC au fost 23.76kg/m la pacienii cu DZ tip 1, respectiv 30.16kg/m la pacienii cu DZ tip 2.La pacienii cu DZ tip 1 nou diagnosticat, raportul TG/HDLcol s-a corelat direct i puternic cu circumferina taliei (rs=0.670, p=0.012, CD=44.89), astfel c 44% dintre subieci au prezentat o corelaie pozitiv ntre cei doi parametri.La pacienii cu DZ tip 2 nou diagnosticat, Scorul Reaven s-a corelat pozitiv cu circumferina abdominal (rs=0.740, p=0.001, CD=54.76%), cu valorile HbA1c (rs=0.552, p=0.006, CD=30.47%) i cu tensiunea arteriala (p=0.001). Nu am constatat diferene statistic semnificative ntre pacienii din cele 2 loturi n ceea ce privete stratificarea lor n funcie de sex, antecedente de DZ i statusul de fumtor. Concluzii: In cazul DZ tip 1 nou diagnosticat, Scorul Reaven se asociaz cu circumferina taliei pacienilor. n cazul DZ tip 2, Scorul Reaven se asociaz cu circumferina taliei, cu majoritatea parametrilor sindromului metabolic i cu gradul de

1

control metabolic al DZ. Circumferina taliei, fiind un parametru uor de msurat, poate fi uzitat ca punct de plecare n screeningul insulinorezistenei.

THE SIGNIFICANCE OF REAVENS SCORE IN PATIENTS WITH DIABETES MELLITUS NEWLY DIAGNOSED A.Nicoara, C.Pencea, D. Licaroiu, G. Stan, R. Lichiardopol N.Paulescu Institute of Diabetes, Nutrition and Metabolic Disease, Bucharest, Roumania

Background and Aims: The objective of this study was to identify the relationship between the Reaven`s Score which is an indicator for insulin resistance and the clinical and metabolic features of patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) newly diagnosed. Materials and Methods: The study group included two hundred patients newly diagnosed T1DM and T2DM registrated at N. Paulescu Institute of Diabetes, Nutrition and Metabolic Disease, Bucharest during the last two month, 98 men (49%) and 102 women (51%). Depending on the type of diabetes mellitus (DM), the subjects were selected in two groups: group 1 included the patients with T1DM newly diagnosed (n=13) and group 2 included the patients with T2DM newly diagnosed (n=187). In each group, we assessed the clinical and a few anthropometric data (heigh, weight, body mass index - BMI, waist circumference and sistolic and diastolic blood pressure) as well as metabolic parameters (HbA1c and lipid profiles), history of DM data and smoking/no smoking status data.The ATP III criteria for metabolic syndrome (MetS), Reaven`s Score (TG/HDL chol) 3 for estimation of insulin resistance have been used to interpret the results.Statistical analysis was carried out using SPSS 15.0. Results: The prevalence of large waist was 30.77% for T1DM group and 47.05% for T2DM group. High sistolic blood pressure was found in 74.2% of the subjects, in 23.1% of the patients with T1DM and in 77.2% of the patients with T2DM. The mean HbA1c level was 10.62.84% in T1DM patients group and 9.082.54% in T2DM patients group. The mean values of Reaven`s Score was 2.591.35 in T1DM patients and 6.443.98 in T2DM patients. The mean values of BMI was 23.76kg/m in newly diagnosis T1DM patients and 30.16kg/m in newly diagnosis T2DM patients. In patients with newly diagnosed T1DM there was proved the existence of a positive correlation between Reaven`s Score and waist circumference (rs=0.670, p=0.012, CD=44.89): in 44% of the patients with newly diagnosed T1DM has been shown a positive correlation between the TG/HDL chol. ratio values and the waist circumference values. In patients with newly diagnosed T2DM there was proved the existence of a positive correlation between Reaven`s Score and waist circumference values (rs=0.740, p=0.001, CD=54.76%) as well as between Reaven`s Score and HbA1c values (rs=0.552, p=0,006, CD=30.47%) and 2

between the Reaven`s Score and high blood pressure (p=0,001). We have not found semnificative statistical differences between the patients of the two groups regarding the sex stratification (p=0.832), history of DM (p=0.267) and smoking status (p=0.225). Conclusions: The Reaven`s Score is related to waist circumference in newly diagnosed T1DM patients. In T2DM, The Reaven`s Score is related to anthropometric and most parameters of metabolic syndrome and with the degree of metabolic control. Based on the frequency and easy-to-determine waist circumference, it could be use as starting point to screen for insulin resistance.

INSTRUMENT INFORMATIC APLICAT IN EDUCATIA PENTRU O ALIMENTATIE SANATOASA Calinici M.A.*, Pavel N.**, Pavel C.**, Calinici T.*** *Spitalul Judetean de Urgenta Zalau **SC. Alfasoftware. SA Zalau *** Universitatea de Medicina si Farmacie Iuliu Hatieganu, Cluj Napoca

In conditiile in care excesul ponderal ameninta sa dobandeasca proportii epidemice, am considerat util sa testam eficienta utilizarii instrumentelor informatice in educatia pentru o alimentatie sanatoasa. Obiectivul aplicatiei este sensibilizarea persoanelor sanatoase cu privire la importanta unei ratii calorice rezonabile si a unei structuri armonioase in principii nutritive. Grupul tinta e definit ca alcatuit din navigatori pe internet, grup caracterizat printr-un anume segment de varsta, coeficient intelectual si preocupari specifice. Site-ul www.anchetainfarfurie.ro are incorporata o aplicatie de tip Flash, ce permite alcatuirea unui jurnal alimentar prin intermediul unui site web (internet). Colectand date de la utilizator, aplicatia calculeaza I.M.C. si ratia calorica ideala si cea realizata. In serverul aplicatiei este inregistrata o baza de date cuprinzand peste 7500 de alimente, cu parametrii acestora. Aceste alimente se pot include in jurnalul fiecarui untilizator printr-o interfata simpla si prietenoasa. Serverul ce ruleaza aplicatia este in incinta Societatii Romane de Informatica Medicala Aplicata (SRIMA), baza de date cuprinzand alimentele provine de la The Nutricut Data Laboratory si este recomandata de catre Center for Food Safety and Applied Nutrition, din cadrul U.S. Food and Drink Administration. Programul Ancheta in farfurie este agreat de Societatea de Nutritie din Romania.

3

INFORMATICAL INSTRUMENT APPLIED IN THE EDUCATION FOR A HEALTHY NUTRITION Calinici M.A.*, Pavel N.**, Pavel C.**, Calinici T.*** *The Emergency County Hospital Zalau **SC Alfasoftware SA, Zalau ***The Iuliu Hatieganu University of Medicine and Pharmacy, , Cluj Napoca

In the circumstances in which excessive ponderosity threatens to gain epidemical proportions, we considered it usefull to test the eficiency of some informatical instruments in the education for a healthy nutrition. The aim of the application is to make healthy people more sensitive to the importance of a reasonable caloric intake and of a structure that is harmonious in what concerns the nutritive principles. The target group is defined as being made of internet navigators. The group is characterized by a certain age segment, IQ or specific concerns. The site www. Anchetainfarfurie.ro has incorporated a FLASH application that allows the creation of an alimentary diary through a web (internet) site. Gathering data from the user, the application calculates the B.M.I. and the ideal and the achieved caloric intake. A database is registered inside the application server, containig over 7500 aliments and their parameters. These aliments can be included in each and every users diary, through a simple and friendly interface. The server that supports the application is inside The Romanian Society for Applied Medical Informatics (RSAMI), the database containing the aliments coming from The Nutricut Data Laboratory and is recommended by The Center for Food Safety and Applied Nutrition in the U.S. Food and Drink Administration. The program Ancheta in farfurie (investigation in your plate) is supported by The Romanian Society For Nutrition.

EDUCATIA TERAPEUTICA IN ROMANIA Adina Snpetreanu, Gina Vrnceanu Centrul Clinic de DNBM Cluj-Napoca, Centrul Clinic de DNBM Iai

Lucrarea de fata isi propune sa prezinte structura organizatorica a centrelor de diabet din tara in ceea ce priveste numarul existent de educatori specializati in diabet , dieteticieni , precum si organizarea programului educational .Metodele de abordare a educatiei pacientilor cu diabet zaharat sunt de asemenea parte importanta a acestei lucrari.

4

TERAPEUTIC EDUCATION IN ROMANIA Adina Snpetreanu, Gina Vrnceanu

Diabetes demographic and epidemic data. Diabetes care network in Romania. Therapeutic Education in Romania; network, methods , achievements , barriers.

FACTORI DE RISC AI EXCESULUI PONDERAL LA COPIL SI ADOLESCENT Adriana Cosmescu, Doina Felea, Liliana Barbacariu, Antoneta Petroaie, Ana-Maria Slnin, Otilia Novac, Mihaela Manole Disciplina Medicin de Familie U.M.F. "Gr. T. Popa" Iai

Introducere: Obezitatea la copil reprezint o problem de sntate major deoarece studiile efectuate au artat ca 20 25% din populaie devine supraponderal nainte de vrsta de 20 de ani. Scopul acestui studiu a fost prezentarea aspectelor epidemiologice, clinico-anamnestice i etiologice n apariia excesului ponderal la copil. Material i metod: Studiul a fost efectuat pe un lot de 33 de copii i adolesceni dignosticai cu suprapondere sau obezitate ntr-un cabinet de pediatrie din cadrul Ambulatoriului de Specialitate al Spitalului "Sf. Spiridon" din Iai, n perioada ianuarieiunie 2008. La aceti pacieni, examenul clinic general i msurtorile antropometrice au fost completate cu o anamnez amanunit privind antecedentele heredo-colaterale, antecedentele personale fiziologice i patologice, ancheta alimentar, activitatea fizic efectuat, afeciunile asociate. Rezultate: Din cei 33 de pacieni, 23 de copii i adolesceni, reprezentnd 69,7%, au fost diagnosticai cu obezitate ( IMC peste percentila 95 dup vrsta i sex) i 10 cazuri cu supraponderalitate ( IMC peste percentila 85 ). Repartiia dup sex a artat o predominen a sexului feminin (19 fete, respectiv 57,6%), fa de sexul masculin ( 14 baieti 42,4% ). Mediul de provenien a fost urban n 66,7% din cazuri i rural la 33,3% dintre pacieni. Istoric familial pozitiv la unul sau ambii prini ( obezitate, diabet zaharat de tip 2 ) s-a ntlnit la 14 pacieni. n ce privete greutatea la natere, la 3 pacieni a fost peste 4000 de grame i n 3 cazuri sub 2700 de grame ( subponderalitate ). n toate cazurile, principala cauza a excesului ponderal a fost dieta dezechilibrat, 5

hipercaloric, pe baza surplusului de dulciuri, fainoase i grsimi. Doar 8 dintre pacieni practicau o activitate fizic corespunztoare, respectiv orele de educaie fizic dar i un sport n afara colii. n celelalte cazuri, copiii fie erau scutii de sport, fie se prezentau la orele de educaie fizic dar fr a participa efectiv. Dintre afeciunile asociate menionam: diabetul de tip 2 ntr-un caz, HTA la 2 pacieni, scderea toleranei la glucoz n 4 cazuri i dislipidemie la 10 pacieni. Concluzii Obezitatea copilului este o problem de sntate public att prin creterea prevalenei ct i prin efectele pe termen lung asupra sntii. Prevenirea obezitii se realizeaz prin diet adecvat, activitate fizic i modificarea stilului de via. Depistarea supraponderii i obezitii precum i factorii de risc ai acestora reprezint cel mai important rol profilactic al medicului de familie.

RISK FACTORS OF OVERWEIGHT IN CHILDREN AND TEENAGERS Adriana Cosmescu, Doina Felea, Liliana Barbacariu, Antoneta Petroaie, Ana-Maria Slanina, Otilia Novac, Mihaela Manole Discipline Family Medicine U.M.F. Gr. T. Popa Iasi

Introduction: Obesity in children is a major condition of health as the carried out studies have shown that 20 25% of people become overweight before they reach 20. The purpose of this study was to present the epidemiological, clinical, anamnestic and etiological aspects in the occurrence of overweight in children. Material and method: The study was performed on 33 overweight or obese children and teenagers in a pediatrics office of the Out-patient Clinic of Sf. Spiridon Hospital from January to June 2008. In these patients, the general clinical exam and the anthropometric measuring were completed by a minute anamnesis with respect to the heredo-collateral history, the pathological and physiological personal history, the food survey and the carried out physical activity. Results: Of the 33 patients, 23 children and teenagers, i.e. 69,7% were diagnosed with obesity (IMC over 95 percentile according to age and sex) and 10 cases of overweight (IMC over 85 percentile). The division according to sex showed a predominance of the female sex (19 girls, i.e. 57,6%) as opposed to the male sex (14 boys 42,4%). Their environment was an urban one in 66,7% of the cases and a rural one in 33,3% of the patients. The positive family history with one or both affected parents (obesity, type 2 diabetes mellitus) was discovered in 14 patients. The birth weight was over 4000 grams in 3 patients and below 2700 grams in 3 cases. In all cases, the main cause of overweight was an unbalanced hyper caloric diet based on excessive sweets, pastry and fats. Only 8

6

of the patients were practicing an extra sport and were participating at the physical education hours at school. The other children were exempted from physical education classes or they were present without taking any part in the activities. From the associated diseases, we mention the following: type 2 diabetes mellitus in one case, hypertension in 2 patients, impaired glucose tolerance in 4 cases and dyslipidemia in 10 patients. Conclusions Children obesity is a public health matter both due to the increase of prevalence and the long term effects on health. Obesity prevention is achieved by an adequate diet, physical activity and change of the life style. The diagnoses of overweight and obesity along with their risk factors are the most prophylactic role of the family medicine. INFLUENTA HIPERGLICEMIEI POSTPRANDIALE ASUPRA INTERVALULUI QT LA PACIENTII CU DIABET ZAHARAT TIP 2 Adriana Rusu1, Cristina Ni1,2, Ramona tefan2, Adriana Filimon2, Ildiko Kicsi Matyus2, Nicolae Hncu1,21 2

Universitatea de Medicin i FarmacieIuliu Haieganu, Cluj Napoca Centrul de Diabet , Nutriie i Boli Metabolice, Cluj-Napoca

Introducere i obiective. Intervalul QT prelungit reflect alungirea repolarizrii isau creterea heterogenitii repolarizrii miocardice, situaii asociate cu un risc crescut de aritmii i moarte subit. Studii recente au confirmat valoarea intervalului QT ca predictor al mortalitii att n cazul pacienilor cu diabet zaharat, ct i n cazul persoanelor fr diabet. Obiectivul acestei cercetri a fost investigarea relaiei ntre glicemia postprandial i durata intervalului QT, precum i identificarea valorii glicemiei postprandiale de la care crete riscul de apariie a intervalului QT prelungit. Subieci i Metod. Au fost analizate date provenite de la 47 de pacieni cu diabet zaharat tip 2 (66% femei), cu vrste cuprinse ntre 30 i 79 ani. S-au nregistrat istoricul personal, caracteristicile clinice i antropometrice, precum i rezultatele determinrilor de laborator: A1c, profil lipidic. De asemeanea, a fost nregistrat electrocardiograma (ECG) n repaus, att preprandial ct i la 2h postprandial, fr controlul frecvenei i profunzimii respiraiei. Intervalul QT a fost msurat n derivaiile II, V2, V5, iar valoarea medie a fost corectat pentru frecvena cardiac utiliznd formula lui Hodges. Prelungirea intervalului QTc > 440 ms a fost considerat patologic. Rezultate. Postprandial, durata intervalului QTc a fost semnificativ mai mare dect n condiii preprandiale (410.727.1ms vs. 403.323.03ms, p=0.03). n 59.6% din cazuri s-a constatat creterea postprandial a duratei intervalului QTc, iar dintre aceti pacieni

7

(14.9%) au prezentat prelungirea intervalului QTc > 440 ms. Pentru predicia prezenei intervalului QTc prelungit, utiliznd ROC, s-a determinat c o valoare a glicemiei postprandiale de 173.5 mg/dl poate detecta prezena intervalului QTc prelungit cu o sensibilitate de 86% i o specificitate de 51%. Valoarea predictiv negativ (VPN) a fost de 95%, iar valoarea predictiv pozitiv (VPP) de 24%. Concluzii. Alungirea intervalului QTc este frecvent asociat cu hiperglicemia postprandial i poate reprezenta un factor de risc adiional pentru evenimentele cardiovasculare. Reducerea excursiilor glicemice postprandiale ar putea preveni prelungirea intervalului QTc i ulterior apariia unor aritmii potenial fatale.

THE INFLUENCE OF POSTPRANDIAL HYPERGLYCEMIA ON QT INTERVAL IN PATIENTS WITH TYPE 2 DIABETES Adriana Rusu1, Cristina Ni1,2, Ramona tefan2, Adriana Filimon, Ildiko Kicsi Matyus2, Nicolae Hncu1,21 2

Iuliu Haieganu University of Medicine and Pharmacy, Cluj Napoca Clinical Center of Diabetes, Nutrition, Metabolic Diseases, Cluj-Napoca

Background and Aims. Ventricular myocardial depolarization and repolarization are reflected in QT interval. Prolonged QTc reflects cardiac repolarization prolongation and/or increased repolarization inhomogenity known to be associated with increased risk of arrhythmias and sudden death. In recent years, studies have confirmed the value of QT interval as a predictor of total mortality in both diabetic and non-diabetic subjects. The objective of this study was to investigate the relationship between postprandial glycemia and the duration of QT interval and to identify cutoff values of postprandial glycemia from which QT interval is prolonged. Subjects and Methods. A number of 47 persons (66% women) with type 2 diabetes, aged between 30-79 years were included in the study. A complete medical history and physical examination was performed. Blood samples were collected in the overnight fasting state, and A1c, total cholesterol, HDL-cholesterol, triglycerides were assessed. Pre- and 2 h-postprandial 12-lead resting ECG were recorded without controlling for depth and rate of respiration. QT interval was measured in II, V2, V5, and the mean value was corrected for heart rate using the Hodges` formula. QTc >440 ms was considered as abnormally prolonged. Results. In postprandial state QTc duration was significantly longer than preprandial (410.727.1 ms vs. 403.323.03 ms, p=0.03). 28 patients (59.6%) presented a

8

prolongation of QTc interval in the postprandial state compared with preprandial QTc duration. From these patients, 7 (14.9%) had a QTc interval > 440 ms. A cut-off point of 173.5 mg/dl for postprandial glycemia detected the presence of prolonged QTc interval with a sensitivity of 86% and a specificity of 51%. Negative predictive value (NPV) was 95%, and positive predictive value (PPV) was 24% when referring to the presence of prolonged QTc interval. Conclusions. Prolongation of QTc occurs frequently during postprandial state in type 2 diabetes. Postprandial hyperglycemia alters myocardial ventricular repolarization in patients with type 2 diabetes and might be an additional risk factor for cardiovascular events. Limiting meal related glucose excursions over 173.5 mg/dl could prevent QTc prolongation and possible could prevent the occurrence of arrhythmias.

COGNIII DEZADAPTATIVE DESPRE TRATAMENTUL CU INSULIN. CONSTRUCIA I VALIDAREA UNEI SCALE CARE S ORIENTEZE INTERVENIILE CARE VIZEAZ SCDEREA REZISTENEI PSIHOLOGICE LA INSULIN.1, 2 1 2

Drd. Psih. Amfiana Gherman, 2Prof. Univ. Dr. Daniel David

Centrul Clinic de Diabet, Nutriie i Boli Metabolice Catedra de Psihologie Clinic i Psihoterapie, Universitatea Babe-Bolyai

ASPECTE TEORETICE. Rezistena psihologic la insulin se refer la refuzul din partea pacientului sau a medicului de a iniia insulino-terapia atunci cnd ar fi necesar n controlul diabetului de tip 2. n literatura de specialitate nu sunt disponibile instrumente validate tiinific care s msoare acest concept din punct de vedere psihologic. Cu alte cuvinte, nu exist instrumente care s aib n spate o teorie validat tiinific pentru factorii psihologici implicai n refuzul tratamentului cu insulin i care s aib n acelai timp caliti psihometrice bune. Astfel, este nevoie de un asemenea instrument care s ghideze interveniile psihologilor clinicieni pentru scderea rezistenei psihologice la insulin. Pornind de la teoria cognitiv a emoiilor, la baza consecinelor emoionale i comportamentale dezadaptative (cum ar fi refuzul tratamentului cu insulin sau emoiile disfuncionale de tip anxietate, deprimare, frustrare, furie) stau procese cognitive de tip evaluativ, cum ar fi cerinele absolutiste fa de sine, lume i via, catastrofarea unui eveniment, tolerana sczut la frustrare, evaluarea global negativ a propriei persoane sau a altora. OBIECTIVE: Construirea i validarea unei scale care s msoare cogniiile dezadaptative specifice n rezistena psihologic la insulin.

9

METODOLOGIE: Participani 50 de pacieni cu diabet zaharat de tip 2 din evidena Centrului de Diabet, Nutriie i Boli Metabolice, Cluj-Napoca. Instrumente: Scala de cogniii despre insulin (SCI), Scala de atitudini i convingeri II (ABS II DiGiuseppe, Leaf, Exner i Robin, 1988), Chestionarul gndurilor automate (ATQ Hollon i Kendal, 1980) i Profilul distresului afectiv (Opri i Macavei, 2005), Interviu clinic pentru investigarea tulburrilor de tip depresiv sau anxios. Procedur: S-a construit (prin consultul experilor i al pacienilor) scala care msoar cogniiile dezadaptative despre tratamentul cu insulin (SCI), iar apoi scalele de mai sus s-au aplicat participanilor la studiu pentru a aduna date legate de fidelitatea i validitatea acestei scale. Rezultate: Analiza datelor a evideniat faptul c SCI are o consisten intern ridicat; validitatea de coninut a fost analizat de un grup de experi n teoriile cognitiv-comportamentale ale emoiilor. SCI a fost astfel construit nct coninutul su s reflecte principiile teoriei raional-emotive i cognitiv-comportamentale, iar forma sa s fie asemntoare altor teste similare deja existente i care i-au dovedit utilitatea. Validitatea de construct se refer la msura n care scala reflect constructul pe care l msoar; astfel, s-au corelat itemii acestui nou instrument cu itemii altor scale existente care i-au dovedit deja validitatea i fidelitatea (ABS II, ATQ i PDA). Datele arat o bun validitate de construct a acestei scale. n ceea ce privete validitatea convergent, cogniiile evaluative dezadaptative coreleaz cu emoiile negative disfuncionale, iar cele adaptative cu emoiile negative funcionale i cu cele pozitive. CONCLUZII: SCI are coeficieni de fidelitate i validitate ridicai, putnd discrimina cu succes ntre persoanele care refuz i cele care accept tratamentul cu insulin. Aceast scal este un instrument de tip evidence-based n evaluarea factorilor cognitivi care influeneaz refuzul/acceptarea insulino-terapiei.

MALADAPTIVE BELIEFS ABOUT INSULIN THERAPY. THE CONSTRUCTION AND VALIDATION OF A SCALE USEFUL FOR THE INTERVENTIONS THAT AIM TO DECREASE THE PSYCHOLOGICAL INSULIN RESISTANCE.1,2 1 2

Amfiana Gherman, M.A., PhD candidate, 2 Univ. Prof. Daniel David, PhD

Clinic of Diabetes, Nutrition and Metabolic Diseases Department of Clinical Psychology and Psychotherapy, Babe-Bolyai University

THEORETICAL ASPECTS. The psychological insulin resistance refers to the reluctance of both patients and medical staff to initiate insulin therapy when it would be beneficial for the control of the type 2 diabetes. In the literature there arent available evidence-based instruments to measure this concept from a psychological point of view. Therefore, there are no instruments based on an empirical theory for the psychological factors involved in the refusal of the insulin treatment and that has good psychometric 10

qualities at the same time. Therefore, we need such an instrument to guide the interventions of the clinical psychologists to decrease the psychological insulin resistance. Starting from the cognitive theory of emotions, at the basis of the maladaptive emotional and behavioral consequences (such as the refusal of the insulin treatment or the dysfunctional emotions such as anxiety, depression, anger) there are evaluative cognitive mechanisms, such as demandingness towards self, life and others, awfulinsing the negative character of an event, low frustration tolerance and negative global evaluation. OBJECTIVES: The development and the validation of a scale that measures the maladaptive believes about insulin treatment. METHOD: Participants 50 patients with type 2 diabetes from the Clinic of Diabetes, Nutrition and Metabolic Diseases, Cluj-Napoca. Instruments The Insulin Beliefs Scale (IBS), The Attitudes and Beliefs Scale II(ABS II DiGiuseppe, Leaf, Exner & Robin, 1988), Automatic Thoughts Questionnaire (ATQ Hollon & Kendal, 1980) and Emotional Distress Profile (Opri i Macavei, 2005), SCID (Semistructured Clinical Interview after DSM-IV) for investigating depressive or anxiety disorders. Procedure: The scale was constructed with the agreement of the experts and of the patients (IBS), and then all the other scales were applied in order to compute the psychometric coefficients of the scale. Results: The data analysis showed that IBS has a good intern consistency; the content validity was analyzed by a group of experts in the rationalemotional and cognitive behavioral theories of emotions. IBS was constructed so that its content reflects the cognitive theories of emotion and its wording is similar to other tests that already prove their utility. Its construct validity was measured by correlating the IBS items with the items of other scales that already prove their validity (ABS II, ATQ and EDP). The data show good construct validity. In what the convergent validity is concerned, the maladaptive evaluative cognitions correlate with the negative dysfunctional beliefs, and the adaptive ones with the negative and positive adaptive emotions. CONCLUSIONS: IBS has high fidelity and validity coefficients, being able to discriminate between the persons that refuse and those who accept the treatment with insulin. This scale is an evidence-based instrument in the evaluation of the cognitive factors that influence the refusal or the acceptance of the insulin therapy.

PROPUNEREA UNUI GHID CLINIC PENTRU PSIHOLOGII CLINICIENI CARE LUCREAZ CU PACIENI CU DIABET SAU OBEZITATE1,2 1 2

Drd. Psih. Gherman Amfiana, 1 Psih. Andreia Mocan, 2 Prof. Univ. Dr. Daniel David

Centrul Clinic de Diabet, Nutriie i Boli Metabolice Catedra de Psihologie Clinic i Psihoterapie, Universitatea Babe-Bolyai

11

Pentru a oferi cele mai bune i cele mai eficiente tratamente pacienilor, ne bazm pe principiul interveniilor validate tiinific (evidence-based). Astfel, pentru ca o intervenie s fie validat tiinific, este nevoie ca att teoria care st n spatele ei s fie validat, ct i procedura de intervenie n sine. De aceea, se propune un ghid de intervenie pentru psihologii clinicieni, consilieri psihologici i psihoterapeuii care lucreaz cu persoane cu diabet care s satisfac n primul rnd acest principiu, att ct este posibil avnd n vedere cercetrile existente n literatura de specialitate. Ghidul va urma elementele principale ale unei proceduri de intervenie: psihodiagnostic i evaluare clinic, conceptualizare clinic, relaie terapeutic i tehnici de intervenie. Psihodiagnostic i evaluare clinic: utilizarea interviului clinic semi-structurat dup DSM-IV sau IDC-10, utilizarea de scale care s msoare mecanismele psihologice etiopatogenetice generale i specifice i care au caliti psihometrice bune (evidencebased). Scopul evalurii este acela de a stabili un diagnostic nosologic, ali factori psihologici care influeneaz condiia medical, precum i stabilirea unei liste de probleme specifice pentru situaia de consiliere psihologic sau de psihoterapie specific. Conceptualizarea clinic trebuie s rspund la urmtoarele ntrebri: (1) Ce probleme de natur psihologic sunt (care influeneaz factorii medicali)?; (2) De ce au aprut aceste probleme? i (3) Ce se poate face pentru a remedia aceste probleme? Relaia terapeutic este unul din factorii foarte importani, care explic pn la 30% din mecanismele schimbrii psihologice i presupune cteva caracteristici majore pe care trebuie s le aib psihologul: empatie, congruen, acceptare necondiionat i colaborare. Tehnicile de intervenie recomandate vor fi n funcie de categoriile de probleme psihologice care se pot regsi la pacienii cu diabet sau obezitate. Acestea vor fi abordate din perspectiva modelelor validate tiinific ABC cognitiv i comportamental; n acelai timp, se vor avea n vedere aspectele pozitive i punctele forte ale pacienilor. De asemenea, n ceea ce privete tulburrile psihologice cuprinse n manualele de diagnostic (DSM-IV sau ICD), cum ar fi tulburrile depresive, de tip anxios, tulburrile de comportament alimentar ghidul va oferi trimiterile necesare spre cele mai eficiente (evidence-based) protocoale de intervenie existente.

THE PROPOSAL OF A CLINICAL GUIDE FOR THE CLINICAL PSYCHOLOGISTS THAT WORK WITH DIABETIC OR OBESE PATIENTS1,2

Amfiana Gherman, M.A., PhD candidate, 1 Psih. Andreia Mocan 2 Univ. Prof. Daniel David, PhD1 2

Clinic of Diabetes, Nutrition and Metabolic Diseases Chair of Clinical Psychology and Psychotherapy, Babe-Bolyai University

12

In order to offer the best and the most efficient treatments, we are based on the principle of evidence-based interventions. Therefore, in order to be scientifically based, a psychological intervention needs to have its theory as well as the intervention protocol tested. As a consequence, we propose an intervention guide for the clinical psychologists, counselors and psychotherapists that work with diabetic and obese persons, that satisfies this criterion, according to the literature. The guide will follow the principal elements of an intervention procedure: the psycho-diagnosis and clinical evaluation, the clinical conceptualization, the therapeutic relationship and the intervention techniques. Psycho-diagnosis and clinical evaluation: the use of the SCID (Semistructured Clinical Interview after DSM-IV) for investigating depressive, anxiety disorders, and others, the use of scales that measure the general and specific ethio-pathogenetic mechanisms, scales that have good psychometric qualities (are evidence-based). The goal of the evaluation is to establish a nosologic diagnosis, the factors that influence the medical condition and a list of specific problems. The clinical conceptualization must answer to the following questions: (1) What are the psychological problems that influence the medical factors? (2) Why did these problems appear? (3) What can be done in order to solve these problems? The therapeutic relationship is one of the most important factors that explain 30% of the psychological mechanisms of change and that implies a few characteristics that the psychologist must have: empathy, congruence, unconditional acceptance and collaboration. The intervention techniques will be recommended according to the specific psychological problems of the diabetic or obese patients. These problems will be approached with the cognitive and behavioral ABC models; at the same time, the positive characteristics of the patients will be used and reinforced. Regarding the ICD-10 psychological disorders, such as the depressive or anxious disorders, the guide will make the necessary references to the most efficicent (evidence-based) intervention protocols.

CUM ESTE APRECIAT PROGRAMUL GUVERNAMENTALCORNUL I LAPTELE" DE CTRE ELEVII DE GIMNAZIU DINTR-O COAL DIN MEDIUL RURAL Crciun Anca-Elena*, Streulea Ioana*, Crciun Cristian-Ioan**, Costiuc Cristina Valentina***, Anca Todoran *- medic rezident an III diabet zaharat, nutriie, boli metabolice, Centrul Clinic de Diabet i Nutriie Cluj-Napoca; **- medic rezident an IV farmacologie clinic, ClujNapoca; ***- medic rezident an III sntate public i management, Cluj-Napoca

13

Introducere: Programul guvernamental Cornul i laptele a fost lansat n 16 septembrie 2002. Iniial au beneficit de el doar elevii claselor primare. De curnd de acest program beneficiaz i elevii de gimnaziu. Material i metod: Pentru a afla ct de apreciat este programul guvernamental Cornul i laptele n rndul elevilor de gimnaziu, am aplicat un chestionar elevilor claselor V-VIII ai colii Generale nr.1 din comuna Cricior, judeul Hunedoara. Chestionarul a fost aplicat n ultima or de Educaie pentru sntate din anul colar 2007-2008. Rezultate: Au rspuns la chestionar 85 de elevi, dintre care 27 (31,8%) au fost n clasa a Va, 18 (21,2%) n clasa a VIa, 18 (21,2%) n clasa a VIIa i 22 (25,8%) n clasa a VIIIa. Dintre acetia, 39 (45,9%) au fost fete i 46 (54,1%) au fost biei. 60,2% dintre elevii chestionai nu mannc deloc cornul primit prin programul guvernamental, iar 63,8% nu beau laptele sau iaurtul. n ciuda acestor rezultate, mai bine de jumtate dintre elevii chestionai (59,5%) sunt ncntai de ideea de a primi corn i lapte la coal, iar la 3,6% dintre respondeni le displace aceast msur. Mai bine de o treime (37%) ar dori s primeasc i altceva pe lng corn i lapte sau acestea s fie nlocuite. Dintre propuneri fac parte fructele, eugeniile, biscuiii, coca-cola, brnza topit, iar n lunile de var, ngheata. Aproape 85% dintre copii au zilnic, sau aproape zilnic, pachet la coal, iar aproape 88% dintre ei primesc bani s-i cumpere ce doresc de mncat sau de but. Concluzii: n coala din mediul rural unde am aplicat chestionarul, 60,2% dintre elevi nu mnnc deloc cornul primit prin programul guvernamental, iar 63,8% nu beau laptele sau iaurtul. Cu toate acestea, majoritatea copiilor doresc n continuare s primeasc corn i lapte la coal.

THE EXTENT TO WHICH COUNTRYSIDE SECONDARY SCHOOL CHILDREN APPRECIATE THE GOVERNMENTAL PROGRAM CROISSANT AND MILK Craciun Anca-Elena*, Streulea Ioana*, Craciun Cristian-Ioan**, Costiuc Cristina Valentina***, Anca Todoran *resident doctor in Sugar Diabetes, Nutrition and Metabolic Diseases, 3rd year, at the Clinical Centre of Diabetes and Nutrition, Cluj-Napoca;**resident doctor in Clinical Pharmacology, 4th year, Cluj-Napoca; ***resident doctor in Public Health and Management, 3rd year , Cluj-Napoca

Introduction: The governmental program Croissant and Milk was launched on September 16, 2002. Initially, only the primary school children benefited from it, but recently, it was introduced to secondary school pupils as well. Materials and methods: In order to determine the extent to which the governmental program Croissant and Milk is appreciated among the secondary school children, we have applied a questionnaire to pupils of 5th-8th grade from the No.1 Secondary School, in Criscior, the district of Hunedoara. The questionnaire was applied during the last Education for Health class, at the end of the school year 2007-2008. 14

Results: From a total of 85 students who answered the questionnaire, 27(31.8%) were in the 5th grade, 18(21.2%) in the 6th grade, 18(21.2%) in the 7th grade, and 22(25.8%) were in the 8th grade. Among all these 39(45.9%) were girls, and 46(54.1%) were boys. 60.2% from the questioned pupils never eat the croissant given to them through this governmental program, and 63.8% dont drink the milk or the yoghurt. Despite these results, more than a half of the students who were questioned (59.5%) were delighted by the idea of receiving milk and croissants at school, and 3.6% from those who answered were discontented with this practice. More than one third of the pupils (37%) expressed their wish to get other products together with the milk and the croissant, or, to replace these with something else. Among the suggestions we encountered fruit, Eugenia biscuits, crackers, Coca-Cola, processed cheese, and, during the warm season, ice-cream. Almost 85% of the children have a daily, or almost daily home-packed lunch with them, and almost 88% receive money from their parents in order to buy anything they wish to eat or drink. Conclusions: In the countryside school where the questionnaire was applied, 62.2% of the pupils never eat the croissant given to them through this governmental program, and 63.8% dont drink the milk. Despite this fact, the majority of children are still in favor of receiving milk and croissants at school.

DIMENSIUNEA PSIHOLOGIC I PSIHOPATOLOGIC A SINDROMULUI METABOLIC I A DIVERSELOR SALE COMPONENTE Anca Frunz*, Radu L. Dumitru**, Prof.Dr. C-tin Ionescu-Trgovite* *Institutul de Diabet, Nutriie i Boli Metabolice Prof. Dr. N.C. Paulescu **Institutul Clinic Fundeni

Scop: Studiul de fa i propune construirea unui profil al pacientului cu sindrom metabolic care s conin caracteristicile de ordin psihologic i psihopatologic ale acestuia, profil care s furnizeze datele necesare unui management eficient al bolii i care s vin n sprijinul abordrii terapeutice de ctre medicii practicieni. De asemenea, studiul ii dorete stabilirea gradului n care fiecare component a sindromului metabolic contribuie la caracteristicile de ordin psihologic i psihopatologic ale bolnavilor cu sindrom metabolic, n special gradul n care hipertensiunea arterial este implicat n existena acestor caracteristici. Material i metod: 30 de pacieni diagnosticai cu sindrom metabolic, internai n Institutul de Diabet, Nutriie i Boli Metabolice Prof. Dr. N.C. Paulescu au fost comparai cu 60 de pacieni hipertensivi i cu 40 de pacieni normotensivi. Datele demografice i clinice, comorbiditile la momentul internrii i tratamentul urmat au fost obinute prin anamnez, examen clinic i investigaii paraclinice. Pentru evaluarea statusului psihologic am utilizat Symptom Checklist 90, Scala de Evaluare a Depresiei Hamilton, Scala funcionalitii globale i Scala funcionalitii sociale. 15

Rezultate:26% dintre subiecii inclui n studiu au fost diagnosticai cu sindrom metabolic. Pacienii hipertensivi cu sau fr sindrom metabolic au nregistrat scoruri crescute la parametrii psihologici studiai, cu rezultate statistic semnificative( pvalue0,05). Numrul evenimentelor hipoglicemice a fost similar pentru cele dou loturi: 4,121,03 vs. 3,961,22/lun, p>0,05). Evoluia pragului sensibilitii vibratorii este descris n Tabelul 1, cu valori diferite semnificativ statistic la 3 luni (p12%) nsoit fiind de semne ale deficitului insulinic.

Timp/ Unit. JND

Grup A

Grup B

Grup A Signf* (MS Vib T*) p0,05 7,283,19 p0.05). After three monts the computed vibratory threshold was 8.102.26JND Units for Group A and 10.262.52JND Units for Group B(p140 mg/dl at 2 hours after the meal), corrected for sex and treatment in 122 consecutive patients with T2DM attending the outpatient clinic from Clinical Center of Diabetes, Nutrition and Metabolic Diseases Cluj-Napoca, Romania. These patients were included in a larger epidemiological study aiming to assess the impact of postprandial hyperglycemia on cardiovascular risk in persons with type 2 diabetes. A complete medical history, physical examination (weight, height, waist circumference, and blood pressure) was performed. Blood samples were collected in the overnight fasting state, and A1c, total cholesterol, HDL-cholesterol and triglycerides were assessed. A six points blood glucose profile (before and 2 h after meals) measured by patients at home, together with a meal questionnaire was performed for each patient. To determine variables associated with higher postprandial glycemic levels, factor analysis followed by linear regression model was performed. Results: The study group had a median age of 58 years (min 29, max 77 years), 59.8% were males. The median duration of diabetes was 6 years (min 0, max 37 years). By factor analysis we have extracted 4 factors that explained 73% of the variance of postprandial glycemia [Factor 1 with positive loadings of weight and body mass index, Factor 2 with positive loadings of total cholesterol and LDL-cholesterol, Factor 3 with

52

positive loadings of diabetes duration and age, Factor 4 with positive loadings of triglycerides and HDL-cholesterol]. In an unadjusted linear regression, model which included the four factors identified was significantly associated with postprandial glycemia (p=0.002).Within the model, Factor 2 displayed a p value of 0.593 and was removed from the analysis. A second regression included Factor 1, 3 and 4, and the model remained statistically significant (p=0.001, F change=6.123, significance of F change= 0.001). After adjustment for the sex and treatment, only Factor 1 and Factor 4 remained significantly associated with postprandial glycemic values (p=0.025, and 0.004) Conclusion The results of our study shows that weight, body mass index, triglyceride level and HDL-cholesterol are independently associated with postprandial glucose excursion.

RISCUL DEZVOLTARII NASH LA PACIENTII DIABETICI E.C. Rezi1, R. Mihil2, L. Nedelcu3, O. Fril4, C. Domnariu5, M. Deac21 2 3 4 5

Spitalul Clinic Judetean de Urgenta, Sibiu Facultatea de Medicina, Universitatea Lucian Blaga Sibiu Facultatea de Medicina, Universitatea Transilvania, Brasov Facultatea de Medicina, Universitatea Oradea Centru de Sanatate publica, Sibiu

Introducere: Stetohepatitta non-alcoolica se asociaz frecvent cu sindromul metabolic, un grup de tulburri metabolice - obezitate central, diabet zaharat tip 2, rezisten la insulin, dislipidemie, hipertensiune arterial. Scopul studiului nostru a fost de a determina riscul dezvoltarii NASH la pacientii diabetici si posibilele corelatii ale nivelului glicemiei cu gradul fibrozei hepatice. Material si metoda: Au fost luai n studiu toi bolnavii deplasabili internai n clinicile medicale ale Spitalelor Judeene din Braov, Oradea i Sibiu n perioada 15.10.2006 31.12.2006, care au fost examinai ecografic. Cei fr ficat hiperecogen i fr citoliz hepatic au constituit lotul martor (812 pacienti) iar lotul de studiu a fost format din toti pacientii (68) la care s-a pus diagnosticul de steatohepatita non-alcoolica (NASH). Fibroza hepatica a fost evaluata prin scorul Forns. Rezultatele au fost analizate statistic folosind testul Pearson, testul t Student i riscul relativ (RR).

53

Rezultate: Repartitia pe genuri a pacientilor cu NASH a fost de 41.17% femei fata de 58.83% barbati. Varsta medie a lotului a fost de 54.47 12.84 ani. Glicemia medie a pacinetilor cu NASH a fost de 132.85 mg/dl fata de 100.13 mg/dl la pacientii din lotul martor, diferenta fiind inalt semnificativa statistica (p=0.00000008). Riscul relativ de a dezvolta NASH la pacientii cu diabet zaharat a fost de 3.33. Indicele de corelatie Pearson intre nivelul glicemiei si scorul Forns de fibroza hepatica a fost r = -0.005; deci nu s-au gasit corelatii intre nivelul glicemiei si scorul fibrozei hepatice. De asemenea, nivelul glicemiei nu s-a corelat cu gradul de citoliza (r = 0.007, pentru TGO, respectiv r = -0.0003 pentru TGP). Concluzii:Valorile glicemice sunt semnificativ mai mari la pacientii cu NASH decat la cei din lotul martor. Pacientii cu diabet zaharat de tip 2 sunt de trei ori mai expusi riscului de a dezolta steatohepatita non-alcoolica decat restul populatiei. Nu exista corelatii intre nivelul mediu al glicemiei si nivelul citolizei hepatice sau gradul fibrozei.

THE RISK OF DEVELOPING NASH AT THE DIABETIC PATIENTS E.C. Rezi1, R. Mihil2, L. Nedelcu3, O. Fril4, C. Domnariu5, M. Deac21 2 3 4 5

Spitalul Clinic Judetean de Urgenta, Sibiu Facultatea de Medicina, Universitatea Lucian Blaga Sibiu Facultatea de Medicina, Universitatea Transilvania, Brasov Facultatea de Medicina, Universitatea Oradea Centru de Sanatate publica, Sibiu

Introduction: Non-alcoholic steatohepatitis (NASH) is frequently associated with the metabolic syndrome, a group of metabolic disorders like central obesity, diabetes mellitus type 2, insuline resistance, dyslipidemy and arterial hypertension. Our aim was to determine the risk of developing NASH at the diabetic patients and the possible correlations between the level of glycemia and the degree of liver fibrosis. Material and method:We took in consideration a group formed by the patients who were hospitalize in the Medical Departments of the Clinical Hospitals from Brasov, Oradea and Sibiu during 15.10.2006 31.12.2006, who were ultrasonografically examined. The ones without hyperecougenous liver and without liver cytolysis formed 54

the controlled group (812 patients) and 68 patients to whom the NASH diagnosis was established formed the studied group. The liver fibrosis was evaluated using the Forns index of correlation. Results:The gender repartition of the NASH patients was 41.17% women and 58,83% men. The medium age of the lot was 54.47 12.84 years of age. The medium level of glycemia at the NASH patients was 132.85 mg/dl comparing with 100.13 mg/dl at the patients from the control group, the difference being very statistically significant (p=0.00000008). The relative risk of developing NASH at the diabetic patients was 3.33. The Pearson index of correlation between the glicemic level and the Forns index of liver fibrosis was r =-0.005; so there were no correlations found between the glycemic level and the liver fibrosis index. No correlations were found between the level of glycemia and the level of transaminases (r =0.007 for TGO and r =-0.0003 for TGP). Conclusions:The values of gycemia are significantly higher at the patients with NASH comparing with the control group. The patients with diabetes mellitus are three times more likely to develop NASH than the rest of the population. There are no correlations between the medium level of glycemia and the degree of liver cytolysis of liver fibrosis.

CORELAII CLINICO-BIOLOGICE N HEPATOPATIA ADIPOAS NONALCOOLIC :DIABETUL ZAHARAT TIP 2 SI INSULINOREZISTENA COMORBIDITAI OMIPREZENTE ALE ACESTEI PATOLOGII DASCLU DACIANA NICOLETA - medic specialist medicina interna Spital Gen. CF Sibiu

Ficatul gras non-alcoolic (FGNA) sau hepatopatia adipoasa non-alcoolica se ncadreaza intr-un spectru de boli hepatice caracterizate in principal prin degenerescenta grasoasa macroveziculara ce apare in lipsa consumului semnificativ de alcool , respectiv sub 20-30 g alcool pur/zi sau sub 200g alcool pur/saptamana. Cu toate dificultatile in interpretarea rezultatelor studiilor privind prevalenta FGNA, aceasta pare a fi cea mai frecventa afectare hepatica in populatia generala, estimarile cele mai recente si elaborate apreciind o prevalenta hepatopatiei adipoase de 20% si a steatohepatitei non-alcoolice de 2-3%. In contextul importantei majore ca problema de sanatate publica mai ales prin prisma comorbiditatilor si complicatiilor pe care le implica hepatopatia adipoasa nonalcoolica , scopul lucrarii este acela de a evidentia corelatiile clinico-biologice dar mai ales particularitatile afectiunii in randul pacientilor din aria noastra geografica . Am realizat un studiu-ancheta prospectiv pe pacienti care prezinta aspect ecografic de steatoza hepatica , fara consum semnificativ de alcool si neinfectati cu virus hepatitic B

55

sau C. Am urmarit gradul steatozei hepatice , afectiunile asociate, prezenta afectiunilor considerate clasic ca fiind premegatoare sau concomitente cu aparitia ficatului gras nonalcoolic (insulinorezistenta , diabetul zaharat de tip 2 , sindromul metabolic , obezitatea abdominala, etc.) incercand evidentierea unor posibile corelatii intre aspectele clinice si examinarile paraclinice . Datele obtinute au fost analizate comparativ cu un lot martor de pacienti . Am realizat calcule de semnificatii statistice si indice de corelatie intre valorile obtinute la cele doua loturi si am constatat existenta de corelatii pozitive intre valorile IL6 si taliei , PCR talie, TNF-IMC , IL6-TNF , IL6 -PCR si PCR-TNF la pacientii cu FGNA. Din analiza rezultatelor partiale prezentate mai sus se desprind cateva concluzii referitoare la pacientii studiati cum ar fi procentul important dintre subiecti care prezinta patologie cardiovasculara ( HTA , CIC ) fiind astfel clasificabili ca pacienti cu mare risc cardio-vascular , valorile medii ale IMC , indice talie/sold si circum-ferinta taliei care sunt mult crescute fata de limitele maxim admise , valorile medii calculate ale TNF , PCR , IL6 si IL8 fiind si ele mai mari decat limitele maxim normale (semnificand implicarea acestor citokine in procesul inflamator care produce si insoteste boala). Calculul FLI (Fibrosis Liver Index) confirma aplicabilitatea acestui test bazat pe valorile trigliceridelor , IMC , GGT si circumf. taliei in predictia steatozei hepatice .Calculul noninvaziv gradului de fibroza hepatica utilizand formule brevetate pentru alte patologii hepatice cronice a avut rezultate usor diferite functie de formula utilizata: APRI , FIB-4 scor Forns , raport ASAT/ALAT , ASPRI. Aceste concluzii confirma datele din literatura de specialitate conform carora ficatul gras non-alcoolic este o boala mult mai frecvent intalnita in populatia adulta decat se credea initial , fiind insotita de multiple comorbiditati, sindromul metabolic fiind cea mai importanta constelatie de patologie intalnita la acesti pacienti, iar hepatopatia adipoasa componenta hepatica a acestui sindrom.

CLINICAL CORRELATIONS CONCERNING NON-ALCOHOLIC FATTY LIVER DISEASE- DIABETES MELLITUS AND INSULINRESISTANCE AS OMNIPRESENT CO-MORBIDITIES

Non-alcoholic fatty liver disease (NAFLD) is a broad spectrum liver disease produced in the absence of alcohol ingestion and described as a macrovesicular fatty degenerescence of the hepatocites , with a prevalence of 20% in the general population. We present a prospective study on pts. with NAFLD comparing them with a set of healthy people concerning the weight , body mass index (BMI) , waist circumference, waist to hip ratio , IL6 , TNF , PCR , and searching for co-morbidities

56

like DM , insulinresistance , metabolic syndrome , ischemic heart disease , high blood pressure or obesity. We also calculated the grade of liver fibrosis using non-invasives formulas like Forns score , APRI , ASPRI , FIB-4 , FLI (Fibrosis Liver Index) , ASAT/ALAT. The conclusions are not optimistic since we proved a high correlation of NAFLD with cardio-vascular diseases , DM and Metabolic syndrome , a moderate degree of liver fibrosis in pts. with normal transaminases and positive correlations between IL6 -waist , PCR waist, TNF-BMI , IL6-TNF , IL6 -PCR si PCR-TNF in patients with non-alcoholic fatty liver disease. Metabolic syndrome is a broad constellation of pathologies with a high prevalence in the general population, NAFLD being just the hepatic branch of this dangerous syndrome.

PROFILUL LIPIDIC LA DZ TIP 1 I 2 NOU DESCOPERIT COHORTA 2007 Daniela Licroiu,Elena Ungurau, Alexandra Secrieru, C. Ionescu Trgovite INDNBM N.C. Paulescu Bucureti

Scop: Analiza elementelor profilului lipidic la pacienii nou diagnosticai cu diabet i relaia acestora cu parametrii controlului glicemic (glicemie a jeun i HbA1c) i IMC. Material si metoda: n studiu au fost nrolai 2787 pacieni nou diagnosticai cu DZ n perioada ianuarie decembrie 2007, grupai n dou loturi n funcie de tipul DZ: a) 204 pacieni cu DZ tip I - 117 brbai (57.4%) i 87 femei (42.6%), cu vrsta medie 31.09 ani (limite 4-76 ani) i b) 2583 pacieni cu DZ tip II, din care 1272 brbai (49.2%) i 1311 femei (50.8%), cu vrsta medie de 58.86 ani (limite 1487 ani). Datele studiului (vrst, sex, IMC, glicemie a jeun, HbA1c, colesterol total, HDL-colesterol i TG) provin din fiele CAD ale pacienilor, prelucrarea statistic realizndu-se cu S.P.S.S 15.0, folosind testele: 2, Mann-Whitney, KruskalWallis i coeficientul de corelaie Sperman, cu un prag de semnificaie statistic p 0.05. Rezultate: media (min max) IMC (kg/m2) Glicemie a jeun (mg/dl) DZ tip I 22.32 (13.5 39.45) 275.11 (43 990) 57 DZ tip II 30.30 (15.62 55.86) 223.54 (120 p P = 0.0001 P = 0.0001

1332) HbA1c (%) Colesterol total (mg/dl) HDL-colesterol (mg/dl) TG (mg/dl) 11.93 (5.10 18.20) 197.06 (100 604) 39.13 (20 98) 209.63 (39 3380) 9.28 (4 20.3) 220.76 (190 1936) 41.42 (30 216) 222.68 (90 4611) P = 0.0001 P = 0.0001 NS P = 0.0001

Prezena hipercolesterolemiei (colesterol total > 200 mg/dl) a fost la pacienii cu DZ tip 1 de 23.5% i la DZ tip 2 de 41,6 %. S-a gsit corelaie semnificativ statistic ntre valoarea colesterolului, IMC (rs1 = 0.229, rs2 = 0.073) i glicemie (rs1=0.215, rs2=0.100). Hipertrigliceridemia ( TG>150 mg/dl ) a fost prezent la 23% din pacienii cu DZ tip 1 i la 45.2% din pacienii cu DZ tip 2. La ambele loturi, valorile TG au fost corelate direct cu valorile IMC (rs1=0.515, rs2=0.179) i ale glicemiei (rs1=0.242, rs2=0.174), doar la pacienii cu DZ tip 2 acestea fiind corelate i cu valorile HbA1c (rs2 = 0.105). Semnificativ statistic, s-a ntlnit corelaie negativ la HDLc, unde la femeile cu DZ tip 1 HDLc a fost corelat invers proporional cu valorile IMC (rs1=0.529) i HbA1c (rs1=0.414), iar la femeile cu DZ tip 2, HDLc a fost corelat invers proporional cu valorile HbA1c (rs2=-0.121) i ale glicemiei (rs2=-0.115). La pacienii de sex masculin, HDLc a fost corelat invers proporional cu valorile IMC, att la cei cu DZ tip 1 (rs1=-0.326), ct i la cei cu DZ tip 2 (rs2=- 0.087) unde a fost corelat i cu valorile HbA1c (rs2=-0.160). Concluzii: La pacienii nou diagnosticai cu DZ tip 2, factorii de risc pentru bolile cardiovasculare ca: dislipidemia cu hipercolesterolemie i/sau hipertrigliceridemie, au fost mai frecvent prezente dect la pacienii cu DZ tip1 (p=0.0001), deoarece pacientii cu DZ tip 2 sunt mai in varsta si cu comorbiditati ( obezitate, HTA, IMA,, BCI, insulinoresistenta) .

LIPID PROFILE AT NEWLY DIAGNOSED T1DM AND T2DM, COHORT(2007) Daniela Licroiu, Elena Ungurau, Alexandra Secrieru, C. Ionescu Trgovite (National Institute of Diabetes, Nutrition and Metabolic Diseases N.C. Paulescu, Bucharest, Romania Background and Aims: To analyze lipid profile at newly diagnosed T1DM and T2DM and the correlation of the lipid profile with fasting blood glucose, HbA1C and BMI. Material and Methods: A cohort of 2787 diabetic patients was analyzed between January December, 2007 in Bucharest: 1389 (49.8 %) man, 1398 (50.2 %) woman 58

average age was 56, 82 years; BMI average was 29, 9Kg/m2. The two groups 204 (7, 3%) T1DM, 117(57.4%) men and 87 (41.6%) women and 2583 (92.7%) T2DM, 1272 (49.2%) men and 1311 (50.8%) women, average age 58.86 were studied depending on T1DM and T2DM.The following parameters were recorded: age, sex, BMI, fasting blood glucose, HbA1C, cholesterol, triglycerides, HDLc. The statistic program was SPSS 15.0; we used 2, Mann-Whitney, Kruskal Wallis, Spearman coefficient, with statistical significant p 0.05. Results: T1DM Parameters Mean (min max) 22.32 (13.5 39.45) 275.11 (43 990) 11.93 (5.10 18.20) 197.06 (100 604) 39.13 (20 98) 209.63 (39 3380) T2DM Mean (min max) 30.30 (15.62 55.86) 223.54 (120 1332) 9.28 (4 20.3) 220.76 (190 1936) 41.42 (30 216) 222.68 (90 4611) P for difference between T1 and T2 P = 0.0001 P = 0.0001 P = 0.0001 P = 0.0001 NS P = 0.0001

BMI (kg/m2) Fasting blood glucose (mg/dl) HbA1c (%) Cholesterol (mg/dl) HDL-c (mg/dl) Triglycerides

Hypercholesterolemia (cholesterol>200mg/dl) was presented in 23.5% patients with T1DM and 41.6% patients with T2DM. We found a positive correlation between the following parameters: total cholesterol and BMI and fasting blood glucose with total cholesterol. Hypertriglyceridemia (triglyceride>150mg/dl) was present in 23% patients with T1DM and 45.2% patients with T2DM. In both groups was positive correlation between TG level, BMI and glycemia, at T2DM was correlated also with HbA1C. In T1DM female patients, there was significant negative correlation with HDLc and inversely proportional with BMI, HbA1c and glycemia. In male patients, HDLc was correlated inversely proportional with BMI in T1DM and in T2DM patients. HDLc also correlated with HbA1C. Conclusions: In newly diagnosed T2DM patients, risk factors for cardiovascular diseases such as dyslipidemia with hypercholesterolemia +/- hypertriglyceridemia were more frequently present than in T1DM patients (p=0.0001) because T2DM patients are older

59

with more co morbidities (obesity, hypertension, heart attack, cardiovascular diseases, insulin resistance).

COMPLICATIILE CRONICE ALE DZ TIP 1 SI 2 NOU DESCOPERIT COHORTA 2007 Daniela Licaroiu, Elena Ungurasu, Luminita Dospinoiu, Corina Nedelcu, C. Ionescu-Trgoviste INDNBM N.Paulescu, Bucuresti

Scop : De obicei la descoperire diabetul este asimptomatic, dar cteodata pot fi prezente complicaii micro i macrovasculare. Scopul acestui studiu a fost s evalueze prevalena complicaiilor cronice la pacienii cu DZ nou descoperit n 2007, nregistrai n INDNBM N. Paulescu. Materiale i metode: In studiu au fost nrolai 2787 de pacieni nou diagnosticai cu DZ n perioada ianuarie decembrie 2007: 1389 (49.8%) brbai i 1398 (50.2 %) femei, cu vrsta medie de 56.82 ani (limite ntre 4 i 87 ani), i un IMC mediu de 29.9Kg/m2 (limite ntre 13 si 56 kg/m2). Cele 2 loturi au fost studiate n funcie de tipul DZ: 204 pacieni (7.3%) cu DZ tip 1, barbati 117 (57.4%) si 87 (42.6%) femei i respectiv 2583 pacieni (92.7%) cu DZ tip 2, 1272 (49.2%) barbati si 1311 (50.8%) femei; prezena/absena complicaiilor diabetului. Datele folosite n studiu provin din fiele CAD ale pacienilor, prelucrarea lor statistic realizndu-se cu ajutorul softului SPSS 15.0, semnificaia statistic a diferenelor dintre cele dou loturi realizndu-se pe baza testului Chi-patrat pentru un prag de semnificaie p 0.05.

Rezultate : Nr. Total pacieni Complicaii microvasculare Complicaii macrovasculare IMA 1 (0.1%) 53 (1.8%) 54 AVC 1 (0.1%) 97 (3.4%) 98

Retinopatie Neuropatie Arteriopatie T1DM T2DM Total 204 (7,3%) 2583 (92.7) 2787 3 (0.1%) 50 (1.8%) 53 (1.9%) 9 (0.2%) 137 (5%) 146 (5.2%) 4 (0.1%) 92 (3.3%) 96 (3.4%)

60

(100%)

(1.9%)

(3.5%)

Majoritatea pacienilor 2370 (84,1%), din care 187 (5,8%) cu DZ tip 1 i 2183 (78.3%) cu DZ tip 2, nu au prezentat complicaii, acestea fiind evideniate numai la 417 pacieni (15,9%), din care 17 pacieni (0,6%) cu DZ tip I si 400 pacieni cu DZ tip 2 (15,3%).

Concluzii : Pacienii nou diagnosticai cu DZ tip 1 i DZ tip 2 cel mai frecvent nu au complicaii, dar sunt mai frecvente la pacientii cu DZ tip 2, datorita factorilor de risc vasculari prezenti, cum ar fi: HTA, dislipidemia, hiperinsulinismul, obezitatea. Cel mai frecvent complicaiile macrovasculare afecteaza un singur teritoriu vascular, acesta fiind fie teritoriul cerebral, fie cel periferic, aceste teritorii fiind de aproximativ 4 ori mai frecvent afectate dect teritoriul coronarian. La pacienii cu complicaii microvasculare, neuropatia este mai frecvent dect retinopatia (p = 0.0001). Complicaiile cronice ale diabetului nou descoperit sunt mai frecvente la DZ tip 2 fa de DZ tip 1 datorita perioadei mai mari de prediagnostic (p= 0.038).

CHRONIC COMPLICATIONS AT NEWLY DIAGNOSED T1DM AND T2DM, COHORT 2007 Daniela Licaroiu, Elena Ungurasu, Luminita Dospinoiu, Corina Nedelcu, C. Ionescu-Trgoviste National Institute of Diabetes, Nutrition and Metabolic Diseases N.C. Paulescu, Bucharest, Romania

Background and Aims: Diabetes mellitus usually is asymptomatic at diagnosed, but sometimes micro- and macrovascular complications might be present. The aim of this study was to evaluate the prevalence of chronic diabetes complications in newly diagnosed diabetic patients registered in the outpatient Department of Institute N. Paulescu in 2007. Material and Methods: A cohort of 2787 diabetic patients was analyzed between January December, 2007 in Bucharest: 1389 (49.8 %) man, 1398 (50.2 %) woman average age was 56, 82 years; BMI average was 29, 9Kg/m2. The two groups 204 (7, 3%) T1DM, 117 (57.4%) man and 87 (41.6%) woman, 2583 (92.7%) T2DM 1272 (49.2%) man and 1311 (50.8%) woman were studied depending on present/absent off diabetic complications. The statistic program was SPSS 15.0; we used Chi-Square tests with statistical significant p 0.05.

61

Results: Total patient s Microvascular complications Retinopath y 3 (0.1%) 50 (1.8%) 53 (1.9%) Neuropath y 9 (0.2%) 137 (5%) 146 (5.2%) Macrovascular complications Miocardica l infarction 1 (0.1%) 53 (1.8%) 54 (1.9%)

Arteriopathy 4 (0.1%) 92 (3.3%) 96 (3.4%)

Stroke 1 (0.1%) 97 (3.4%) 98 (3.5%)

T1DM T2DM Total

204 (7,3%) 2583 (92.7) 2787 (100%)

Most patients 2370 (84.1 %) had no complications: 187 (6.7%) T1DM and 2183 (78.3%) T2DM, only 417 patients (15.9 %) had complications, from which 17 patients T1DM (0. 6 %) and 400 patients T2DM (15.3%). Conclusions: Obviously at diagnosis T1DM patients and T2DM patients are mostly free of complications, but if they have it, the most common ones are macrovascular complications in T2DM patients due to the presence of additional vascular risk factors as: hypertension, dyslipidemia, hyperinsulinism, obesity. Most frequent diabetic macrovascular complications affects only one vascular territory, this is the cerebral territory or peripheral territories, affected 4 times more frequent than coronaries territory (p = 0.0001). The lower frequencies of cardiac lesions are probably due to different diagnosis criteria. In patients with microvascular complications neuropathy is more frequent then retinopathy (p= 0.0001). Newly diagnosed chronic complications are higher in T2DM than in T1DM patients (p = 0.038) due to a longer pre diagnosis period.

PREVALENTA COMPLICATIILOR MICROVASCULARE LA PACIENTII CU DZ TIP 1 SI TIP 2 CU SINDROM METABOLIC Dovan D, Institutul de Diabet, Nutritie si Boli MetaboliceProf. N.C. PaulescuBucuresti, Romania

62

Introducere : Sindromul metabolic reprezinta un important factor de risc pentru diabet zaharat tip 2, putine date exista insa, despre importanta acestuia la pacientii cu diabet zaharat tip 1. Obiective : Evaluarea prevalentei complicatiilor microvasculare la pacientii cu diabet zaharat tip 1(DZ1) si tip 2(DZ2) cu sindrom metabolic(SM). Material si metoda : Au fost inclusi in studiu 1429 pacienti, internati in perioada 01.01.2006-31.12.2006 la IDNBM N.Paulescu,dintre care 270 cu DZ1 (136 barbati, 134 femei, varsta medie 42,5414,36 ani), iar 1159 cu DZ2 (518 barbati, 641 femei, varsta medie 60,1710,48 ani). SM a fost prezent la 50 (18,51%) dintre pacientii cu DZ1, respectiv 970 (83,69%) dintre cei cu DZ2, restul pacientilor nu au intrunit criteriile de diagnostic . S-au analizat urmatorii parametri prezenti in fisele de observatie ale pacientilor : varsta, sex, talie, HbA1c, istoric de HTA, colesterol total (CT), HDL, LDL, trigliceride (TG), raport TG/HDL, complicatii microvasculare: neuropatie diabetica (neuropatie diabetica senzitiva periferica, neuropatie vegetativa), retinopatie diabetica (retinopatie diabetica proliferativa, retinopatie diabetica neproliferativa). SM a fost definit conform criteriilor IDF. La pacientii cu DZ tip 1, glicemia nu a constituit citeriu de diagnostic. Rezultate : Pacientii cu DZ1 si SM, fata de cei cu DZ2 si SM au avut valori medii ale varstei semnificativ mai mici (49.1613.24vs.60.2510.33, p