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Inicio Endocrinología, Diabetes y Nutrición Relación entre hemoglobina glucosilada, tiempo en rango y variabilidad glucémi...
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Relación entre hemoglobina glucosilada, tiempo en rango y variabilidad glucémica en una cohorte de pacientes pediátricos y adultos con diabetes tipo 1 con monitorización flash de glucosa
The relationship between glycosylated hemoglobin, time-in-range and glycemic variability in type 1 diabetes patients under flash glucose monitoring
Gonzalo Díaz-Sotoa,1,
Autor para correspondencia
diazsotogonzalo@gmail.com

Autor para correspondencia.
, M. Pilar Bahíllo-Curiesesb,1, Rebeca Jimeneza, Maria de la O. Nietoa, Emilia Gomeza, Beatriz Torresa, Juan Jose López Gomeza, Daniel de Luisa
a Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Centro de Investigación de Endocrinología y Nutrición Clínica (IENVa), Universidad de Valladolid, Valladolid, España
b Servicio de Pediatría, Hospital Clínico Universitario de Valladolid, Valladolid, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La implantaci&#243;n progresiva de la monitorizaci&#243;n intersticial de glucosa &#40;MIG&#41;&#44; junto a su evoluci&#243;n tecnol&#243;gica y financiaci&#243;n&#44; han supuesto una revoluci&#243;n en la aproximaci&#243;n al control metab&#243;lico en la diabetes mellitus tipo 1 &#40;DM1&#41;&#46; A pesar de que la relaci&#243;n entre la HbA<span class="elsevierStyleInf">1c</span> y el desarrollo de complicaciones cr&#243;nicas est&#225; ampliamente demostrada&#44; la ingente cantidad de datos proporcionados por la MIG ha originado un cambio en la percepci&#243;n del control gluc&#233;mico &#171;m&#225;s all&#225; de la HbA<span class="elsevierStyleInf">1c</span>&#187;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a>&#46; De hecho&#44; son numerosos los autores que abogan por la sustituci&#243;n de los par&#225;metros de control cl&#225;sico de DM1 &#40;HbA<span class="elsevierStyleInf">1c</span> e hipoglucemias&#41; por nuevas glucom&#233;tricas derivadas de la evaluaci&#243;n de la MIG&#44; tanto medidas de centralidad &#40;tiempo en rango &#91;TIR&#93;&#41; como de variabilidad gluc&#233;mica &#40;VG&#41; &#40;coeficiente de variaci&#243;n &#91;CV&#93;&#44; desviaci&#243;n est&#225;ndar &#91;DE&#93;&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Las limitaciones aducidas para la sustituci&#243;n de la HbA<span class="elsevierStyleInf">1c</span> incluyen&#58; la falta de precisi&#243;n de su medici&#243;n en el laboratorio en situaciones cl&#237;nicas comunes &#40;hemoglobinopat&#237;as&#44; anemia&#44; uremia y embarazo&#44; entre otras&#41;&#44; su relaci&#243;n variable y no predecible con la glucosa media de manera individual&#44; as&#237; como una vida media en torno a los 3 meses&#44; que no permite ver cambios r&#225;pidos en la evaluaci&#243;n del control gluc&#233;mico<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Frente a los par&#225;metros cl&#225;sicos de control&#44; el TIR y el CV se han postulado como las m&#233;tricas preferidas&#44; en parte dada su estrecha relaci&#243;n con los niveles de HbA<span class="elsevierStyleInf">1c</span> y de hipoglucemia&#44; respectivamente<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; Adem&#225;s&#44; estudios preliminares han relacionado sus niveles con el desarrollo de complicaciones cr&#243;nicas<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a>&#46; A pesar de ello&#44; los intervalos de referencia asumidos como normales &#40;TIR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>70&#37; y CV<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>36&#37;&#41; no han sido derivados directamente de estudios prospectivos&#44; sino basados en su relaci&#243;n lineal con los par&#225;metros cl&#225;sicos&#58; HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#44;0&#37; y aumento de la incidencia de hipoglucemias graves&#44; respectivamente<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#44;7</span></a>&#46; Recientemente&#44; algunos autores han cuestionado esta correlaci&#243;n debido a la falta de precisi&#243;n de la relaci&#243;n lineal entre la HbA<span class="elsevierStyleInf">1c</span> y el TIR<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a>&#44; semejante a la existente entre la HbA<span class="elsevierStyleInf">1c</span> y la glucosa media<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a>&#46; De hecho&#44; estudios recientes en pacientes con diabetes tipo 2 y monitorizaci&#243;n continua de glucosa retrospectiva justifican la falta de correlaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span> por la influencia de la VG&#44; e insisten en la necesidad de establecer objetivos individualizados de TIR teniendo en cuenta este factor<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo del presente estudio fue evaluar la correlaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span> y su relaci&#243;n con la VG&#44; en una cohorte de pacientes pedi&#225;tricos y adultos con DM1 en tratamiento con m&#250;ltiples dosis de insulina &#40;MDI&#41; o infusor subcut&#225;neo de insulina &#40;ISCI&#41; y monitorizaci&#243;n flash de glucosa &#40;MFG&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio transversal en una cohorte de pacientes con DM1 en tratamiento intensivo con insulina &#40;ISCI o MDI&#41; y MFG &#40;Free Style Libre&#44; Abbot Diabetes Care&#44; Witney&#44; Reino Unido&#41;&#44; en seguimiento en la Unidad de Endocrinolog&#237;a Pedi&#225;trica y el Servicio de Endocrinolog&#237;a y Nutrici&#243;n de Adultos de un hospital terciario&#46; La prescripci&#243;n de la MFG se realiz&#243; siguiendo los criterios de financiaci&#243;n p&#250;blica y priorizaci&#243;n aprobados por el Sistema Nacional de Salud &#40;discapacidad visual o limitaciones funcionales graves&#44; hipoglucemias de repetici&#243;n&#44; y mujeres embarazadas o que planifiquen un embarazo&#41;&#46; Se recogieron datos cl&#237;nicos y anal&#237;ticos &#40;HbA<span class="elsevierStyleInf">1c</span>&#58; inmunoan&#225;lisis de inhibici&#243;n turbidim&#233;trico&#59; NGSP&#44; Roche Diagnostics&#44; Ginebra&#44; Suiza&#41;&#44; as&#237; como datos de control metab&#243;lico a trav&#233;s del an&#225;lisis de la descarga del dispositivo&#46; Para ello&#44; se analizaron los &#250;ltimos 15 d&#237;as de MFG previos a la consulta presencial y tras un m&#237;nimo de 3 meses de utilizaci&#243;n del dispositivo&#46; Se recogieron datos glucom&#233;tricos de MFG definidos como&#58; glucemia media&#44; TIR &#40;&#37;&#41; &#40;definido como tiempo entre 70-180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl de glucosa&#41;&#44; CV &#40;&#37;&#41;&#44; DE &#40;mg&#47;dl&#41;&#44; Glucose Management Indicator &#40;GMI&#41;&#44; tiempo por encima del rango &#40;TAR &#91;&#37;&#93;&#44; definido como tiempo<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl de glucosa&#41;&#44; tiempo por debajo del rango &#40;TBR &#91;&#37;&#93;&#44; definido como tiempo<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl de glucosa&#41;&#44; n&#250;mero de escaneos y uso de sensor<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a>&#46; Se excluyeron aquellos pacientes con menos del 80&#37; de uso del dispositivo&#46; El estudio fue aprobado por el Comit&#233; &#201;tico de Investigaci&#243;n Cl&#237;nica del centro hospitalario&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los resultados se expresaron como media y DE&#46; La distribuci&#243;n normal de las variables se analiz&#243; con el test de Kolmogorov-Smirnov&#46; Las variables cuantitativas con distribuci&#243;n normal se analizaron con una prueba t de Student bilateral&#46; Las variables no param&#233;tricas se evaluaron mediante la prueba de U de Mann-Whitney&#46; Las variables cualitativas se evaluaron mediante el test Chi al cuadrado y&#44; cuando fue necesario&#44; el test exacto de Fisher&#46; La asociaci&#243;n de variables cuantitativas se calcul&#243; utilizando el coeficiente de correlaci&#243;n lineal de Pearson&#46; Por &#250;ltimo&#44; se utiliz&#243; un modelo de regresi&#243;n m&#250;ltiple que incorporara como variables independientes el efecto del TIR&#44; el CV&#44; la edad y el tipo de tratamiento realizado&#44; as&#237; como la interacci&#243;n entre TIR y CV &#40;TIR-CV&#41;&#44; sobre la HbA<span class="elsevierStyleInf">1c</span> como variable dependiente&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Aquellos valores de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 fueron considerados estad&#237;sticamente significativos&#46; Se utiliz&#243; el paquete estad&#237;stico SPSS&#174; versi&#243;n 17&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; EE&#46; UU&#46;&#41; para el an&#225;lisis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se estudiaron 195 pacientes con DM1&#44; de los cuales 70 eran pacientes pedi&#225;tricos y adolescentes &#40;menores de 20 a&#241;os&#41; y 125 adultos &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>20 a&#241;os&#41;&#46; El 42&#44;6&#37; eran mujeres&#46; El 26&#44;2&#37; realizaban tratamiento con ISCI y el 28&#44;7&#37; presentaban un CV<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37;&#46; Dentro del grupo pedi&#225;trico&#44; la edad media fue 12&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;4 a&#241;os&#44; la evoluci&#243;n media de la diabetes 5&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;5 a&#241;os y la HbA<span class="elsevierStyleInf">1c</span> media 6&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;6&#37;&#44; realizando el 28&#44;6&#37; tratamiento con ISCI&#46; La media de escaneos diarios de MFG fue de 12&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;8&#44; con glucemia media de 150<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; DE de 63&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; CV de 42&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;6&#37; y TIR de 64&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;9&#37;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Dentro del grupo de adultos &#40;<span class="elsevierStyleUnderline">&#8805;<span class="elsevierStyleHsp" style=""></span></span>20 a&#241;os&#41;&#44; la edad media fue de 37&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;3 a&#241;os&#44; la evoluci&#243;n media de la diabetes 18&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;8 a&#241;os y la HbA<span class="elsevierStyleInf">1c</span> media 7&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;1&#37;&#46; La media de escaneos diarios de MFG fue de 10&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;6&#44; con una glucemia media de 173<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>37<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; DE de 68&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#44;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; CV de 40&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;1&#37; y TIR de 52&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;2&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Al evaluar la relaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span> se observ&#243; una correlaci&#243;n lineal fuerte negativa &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;746&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;557&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Es decir&#44; cada aumento absoluto de TIR del 10&#37; supondr&#237;a una modificaci&#243;n del 0&#44;75&#37; en la HbA<span class="elsevierStyleInf">1c</span>&#46; Sin embargo&#44; esta correlaci&#243;n se modific&#243; al evaluarla en pacientes con baja VG &#40;CV<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37;&#41; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;852&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;836&#41;&#44; presentando una correlaci&#243;n mayor&#44; frente a aquellos con un &#237;ndice de VG elevado &#40;CV<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>36&#37;&#41; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;703&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;551&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Al evaluar la relaci&#243;n entre el TIR y el GMI se observ&#243; una correlaci&#243;n lineal fuerte negativa &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;846&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;715&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; De la misma manera&#44; esta correlaci&#243;n se modific&#243; al evaluar los pacientes con baja VG &#40;CV<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37;&#41; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;980&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;960&#41; frente a aquellos con VG elevada &#40;CV<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>36&#37;&#41; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;837&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;701&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>B&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">La correlaci&#243;n TIR-HbA<span class="elsevierStyleInf">1c</span> se mantuvo estable al evaluar de manera independiente la poblaci&#243;n pedi&#225;trica &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;724&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;525&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y adulta &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;706&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;498&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; as&#237; como al evaluar el tipo de tratamiento utilizado&#58; MDI &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;747&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;558&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e ISCI &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;711&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;506&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Al analizar la HbA<span class="elsevierStyleInf">1c</span> como variable dependiente en un modelo de regresi&#243;n m&#250;ltiple que inclu&#237;a el TIR&#44; el CV&#44; la interacci&#243;n TIR-CV&#44; la edad y el tipo de tratamiento realizado como variables independientes&#44; las &#250;nicas variables que mantuvieron la significaci&#243;n estad&#237;stica fueron el TIR &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;031&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; el CV &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;843&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; y la interacci&#243;n TIR-CV &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;017&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; se evalu&#243; la correlaci&#243;n entre las diferentes glucom&#233;tricas empleadas&#44; observ&#225;ndose una mayor correlaci&#243;n estad&#237;sticamente significativa entre aquellas variables con mayor componente de centralidad &#40;glucosa media&#44; HbA<span class="elsevierStyleInf">1c</span>&#44; GMI&#44; TIR y TAR&#41; y aquellas con mayor componente de dispersi&#243;n de los valores de glucosa &#40;DE&#44; CV y TBR&#41;&#46; Por &#250;ltimo&#44; el mayor porcentaje de uso del dispositivo &#40;n&#250;mero de escaneos y uso de sensor&#41; se correlacion&#243; con mejores valores en los par&#225;metros de control metab&#243;lico &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0075" class="elsevierStylePara elsevierViewall">La MIG ha supuesto una revoluci&#243;n en la aproximaci&#243;n al control metab&#243;lico en DM1&#46; De hecho&#44; algunos autores han promulgado la sustituci&#243;n de la HbA<span class="elsevierStyleInf">1c</span> como &#250;nico par&#225;metro de control&#44; cuya determinaci&#243;n examina de manera casi exclusiva la distribuci&#243;n central de los valores de glucosa<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a>&#46; Si bien es cierto que la HbA<span class="elsevierStyleInf">1c</span> presenta ciertas limitaciones bien conocidas que pueden dificultar su interpretaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a>&#44; es a su vez el par&#225;metro con mayor evidencia cient&#237;fica relacionada con el desarrollo de complicaciones a largo plazo<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a>&#46; Por ello&#44; resulta prometedora su sustituci&#243;n por nuevos par&#225;metros glucom&#233;tricos que permitan una valoraci&#243;n m&#225;s completa del perfil gluc&#233;mico sin las limitaciones de la HbA<span class="elsevierStyleInf">1c</span>&#58; centralidad &#40;TIR&#41;&#44; hipoglucemia &#40;TBR&#41;&#44; hiperglucemia &#40;TAR&#41; y VG &#40;CV&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">La relaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span>&#44; ambos par&#225;metros de centralidad&#44; resulta de especial inter&#233;s a la hora de plantear la sustituci&#243;n de la HbA<span class="elsevierStyleInf">1c</span> o la complementariedad entre ambas variables&#46; Estudios recientes han descrito la fuerte relaci&#243;n lineal existente entre la HbA<span class="elsevierStyleInf">1c</span> y el TIR<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#44;7</span></a>&#46; De hecho&#44; aquellos autores que respaldan esta sustituci&#243;n se basan en su estrecha correlaci&#243;n&#46; Sin embargo&#44; parece razonable pensar que aquellos pacientes con mayor VG deber&#237;an presentar &#237;ndices menores de TIR incluso ante la misma HbA<span class="elsevierStyleInf">1c</span>&#44; por lo que el objetivo de control del TIR deber&#237;a individualizarse teniendo en cuenta la VG de cada individuo o incluso su tipo de diabetes&#46; Hasta el momento&#44; tan solo un estudio en pacientes con diabetes tipo 2 y monitorizaci&#243;n continua de glucosa retrospectiva durante 72<span class="elsevierStyleHsp" style=""></span>h ha valorado la influencia de la VG en la correlaci&#243;n entre GMI y TIR<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a>&#46; El presente estudio es&#44; hasta donde sabemos&#44; uno de los primeros en valorar la relaci&#243;n entre estas glucom&#233;tricas en poblaci&#243;n con DM1 en tratamiento con MDI o ISCI y con diferentes rangos de edad&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; al evaluar globalmente la relaci&#243;n entre la HbA<span class="elsevierStyleInf">1c</span> plasm&#225;tica y el TIR&#44; se observa una correlaci&#243;n lineal fuerte semejante a aquellas previamente descritas en estudios anteriores &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;746&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;557&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Es decir&#44; cada aumento absoluto de TIR del 10&#37; supondr&#237;a una reducci&#243;n del 0&#44;75&#37; en la HbA<span class="elsevierStyleInf">1c</span>&#46; Sin embargo&#44; esta correlaci&#243;n lineal se ve claramente modificada dependiendo de la VG y del valor de TIR&#46; De hecho&#44; ambas rectas de regresi&#243;n estratificadas seg&#250;n el CV se cortan en una HbA<span class="elsevierStyleInf">1c</span> en torno a 7&#44;7&#37;&#44; semejante al estudio publicado por Lu et al&#46; en diabetes tipo 2<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a>&#46; Por lo tanto&#44; el comportamiento de la relaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span> plasm&#225;tica depende directamente del CV&#46; Es decir&#44; con HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>7&#44;8&#37;&#44; a mayor CV&#44; mayor ser&#237;a el TIR&#59; y al contrario&#44; con HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#44;8&#37;&#44; a mayor CV&#44; menor TIR &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>A&#41;&#46; Esta dependencia entre las 3 variables &#40;TIR&#44; HbA<span class="elsevierStyleInf">1c</span> y CV&#41; es similar a la encontrada al evaluar el TIR frente al GMI &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;846&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;715&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; vi&#233;ndose modificada por el CV de manera similar a la relaci&#243;n entre HbA<span class="elsevierStyleInf">1c</span> plasm&#225;tica y TIR para un punto de corte de GMI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#44;1&#37;&#46; Adem&#225;s&#44; resulta especialmente significativo como la correlaci&#243;n entre TIR y GMI en aquellos pacientes con baja VG es cercana a 1&#44; es decir&#44; pr&#225;cticamente perfecta &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;980&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;960&#41;&#46; Este resultado no deber&#237;a ser sorprendente&#44; ya que el GMI surge del c&#225;lculo matem&#225;tico a trav&#233;s de la glucemia media de los &#250;ltimos 15 d&#237;as de la descarga&#44; por lo que es l&#243;gico que aquellos pacientes sin pr&#225;cticamente amplitud en sus excursiones&#44; determinada por VG&#44; se acerquen a un perfil gluc&#233;mico &#171;plano y sin fluctuaciones&#187;&#44; haciendo coincidir TIR y GMI de una manera lineal perfecta &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>B&#41;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a>&#46; De hecho&#44; recientemente se han relacionado las divergencias entre el GMI y la HbA<span class="elsevierStyleInf">1c</span> por el &#237;ndice de glucosilaci&#243;n m&#225;s que por otros factores biol&#243;gicos<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Por otro lado&#44; nuestro estudio encontr&#243; esta relaci&#243;n entre las variables evaluadas&#44; independientemente de la edad de la poblaci&#243;n estudiada &#40;adultos o pediatr&#237;a&#41; y del tipo de tratamiento utilizado &#40;MDI o ISCI&#41;&#46; Es decir&#44; la relaci&#243;n entre la HbA<span class="elsevierStyleInf">1c</span>&#47;GMI y el TIR se ve modificada por el CV en las diferentes poblaciones estudiadas&#44; y no por la edad o el tipo de tratamiento utilizado&#44; tal y como apoya el an&#225;lisis de regresi&#243;n m&#250;ltiple&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se recogen las correlaciones entre los diferentes par&#225;metros glucom&#233;tricos m&#225;s utilizados en la pr&#225;ctica cl&#237;nica diaria seg&#250;n los consensos internacionales<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a>&#46; Resulta muy clarificadora la relaci&#243;n estad&#237;sticamente significativa existente entre pr&#225;cticamente todas las variables evaluadas&#46; Esta relaci&#243;n refleja la estrecha dependencia entre los diferentes par&#225;metros y la dificultad de modificar alguno de ellos de manera independiente al resto&#44; tal y como se ha descrito recientemente<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a>&#46; Obviamente&#44; esta relaci&#243;n es especialmente estrecha entre aquellas variables que miden el mismo patr&#243;n de distribuci&#243;n&#44; como centralidad &#40;HbA<span class="elsevierStyleInf">1c</span>&#44; GMI&#44; glucosa media&#44; TIR&#41; y VG-amplitud de las excursiones gluc&#233;micas &#40;DE&#44; CV&#44; TAR y TBR&#41;&#44; adem&#225;s de la relaci&#243;n entre el uso intensivo del dispositivo &#40;porcentaje de uso y n&#250;mero de escaneos&#41; y el mejor control metab&#243;lico&#46; Esta interrelaci&#243;n apoya el uso de las nuevas glucom&#233;tricas como variables descriptivas del control metab&#243;lico a utilizar de manera conjunta&#44; y no como sustituci&#243;n de los par&#225;metros cl&#225;sicos de control&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">El presente estudio es uno de los primeros en evaluar la relaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span> y su relaci&#243;n con la VG&#44; en una cohorte de pacientes con DM1 y MFG en edad adulta y pedi&#225;trica en tratamiento con MDI o ISCI en pr&#225;ctica cl&#237;nica real&#46; Si bien el relativamente reducido tama&#241;o muestral puede considerarse una de sus principales limitaciones &#40;especialmente en comparaci&#243;n con estudios de Big Data&#41;&#44; su desarrollo en una cohorte de DM1 en seguimiento en un centro de tercer nivel asegura la evaluaci&#243;n global de las caracter&#237;sticas cl&#237;nicas y variables anal&#237;ticas de control metab&#243;lico de los pacientes&#44; cl&#225;sicamente ausentes en este tipo de estudios&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; el CV modifica la relaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span>&#47;GMI y debe tenerse en cuenta a la hora de individualizar objetivos de TIR independientemente de la edad o el tipo de tratamiento utilizado&#46; La estrecha interrelaci&#243;n entre las diferentes glucom&#233;tricas como variables del control metab&#243;lico respalda su uso de manera conjunta y no como sustituci&#243;n de los par&#225;metros cl&#225;sicos de control&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicto de intereses</span><p id="par0110" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La monitorizaci&#243;n flash de glucosa en pacientes con diabetes tipo 1 proporciona nuevos datos glucom&#233;tricos que permiten evaluar el control gluc&#233;mico m&#225;s all&#225; de la HbA<span class="elsevierStyleInf">1c</span>&#46; El objetivo del presente estudio fue evaluar la relaci&#243;n de la HbA<span class="elsevierStyleInf">1c</span>&#44; el tiempo en rango &#40;TIR&#41; y la variabilidad gluc&#233;mica en una cohorte de pacientes pedi&#225;tricos y adultos con diabetes tipo 1 y monitorizaci&#243;n flash de glucosa&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal en 195 pacientes con diabetes tipo 1 &#40;42&#44;6&#37; mujeres&#44; 70 pedi&#225;tricos&#44; 26&#44;2&#37; infusor subcut&#225;neo de insulina&#44; 28&#44;7&#37; coeficiente de variaci&#243;n &#91;CV&#93;<span class="elsevierStyleUnderline"><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37;&#41; en tratamiento intensivo y monitorizaci&#243;n flash de glucosa&#46; Se evaluaron datos cl&#237;nicos&#44; anal&#237;ticos y glucom&#233;tricos&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La relaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span> mostr&#243; una correlaci&#243;n lineal fuerte negativa &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;746&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;557&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; modificada en pacientes con CV<span class="elsevierStyleUnderline"><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;852&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;836&#41; frente a aquellos con un CV<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>36&#37; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;703&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;551&#41;&#46; Esta misma correlaci&#243;n se observ&#243; al evaluar el TIR y el Glucose Management Indicator&#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;846&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;715&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; tanto en pacientes con CV<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;980&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;960&#41; como en aquellos con CV<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>36&#37; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;837&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;701&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; Ambas correlaciones se mantuvieron estables al ser evaluadas de manera independiente en poblaci&#243;n pedi&#225;trica &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;724&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;525&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; adultos &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;706&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;498&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y por tipo de tratamiento&#58; m&#250;ltiples dosis de insulina &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;747&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;558&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e infusor subcut&#225;neo de insulina &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;711&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;506&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; En un modelo de regresi&#243;n multivariante adoptando la HbA<span class="elsevierStyleInf">1c</span> como variable dependiente&#44; exclusivamente el TIR &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;031&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; el CV &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;843&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; y la interacci&#243;n TIR-CV &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;017&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; mantuvieron la significaci&#243;n estad&#237;stica&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La variabilidad gluc&#233;mica definida por el CV modifica la relaci&#243;n entre el TIR y la HbA<span class="elsevierStyleInf">1c</span>&#47;Glucose Management Indicator y debe tenerse en cuenta a la hora de individualizar objetivos de TIR&#44; independientemente de la edad o el tipo de tratamiento utilizado&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Flash glucose monitoring in patients with type 1 diabetes provides new glucometric data that allow for the assessment of glycemic control beyond HbA<span class="elsevierStyleInf">1c</span>&#46; The objective of the study was to evaluate the relationship between HbA<span class="elsevierStyleInf">1c</span>&#44; time-in-range &#40;TIR&#41; and glycemic variability in a cohort of pediatric and adult patients with type 1 diabetes and treatment with flash glucose monitoring&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This was a cross-sectional study in 195 patients with type 1 diabetes &#40;42&#46;6&#37; females&#44; 70 pediatric&#44; 26&#46;2&#37; continuous subcutaneous insulin infusion&#44; 28&#46;7&#37; coefficient of variation &#91;CV&#93;<span class="elsevierStyleUnderline"><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37;&#41; in intensive treatment and flash glucose monitoring&#46; Clinical&#44; analytical and glucometric data were evaluated&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The relationship between the TIR and HbA<span class="elsevierStyleInf">1c</span> showed a strong negative linear correlation &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;746&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;557&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; modified in those patients with CV<span class="elsevierStyleUnderline"><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;852&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;836&#41; compared to CV<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>36&#37; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;703&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;551&#41;&#46; A similar correlation was found when evaluating the TIR and the Glucose Management Indicator &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;846&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;715&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#59; in patients with CV<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#8804;<span class="elsevierStyleHsp" style=""></span></span>36&#37; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;980&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;960&#41; versus CV<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>36&#37; &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;837&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;701&#41;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#46; Both correlations remained stable in the pediatric population &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;724&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;525&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and adults &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;706&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;498&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and by type of treatment&#58; multiple doses of insulin &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;747&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;558&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and continuous subcutaneous insulin infusion &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;711&#59; R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;506&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; In a multiple regression analysis evaluating HbA<span class="elsevierStyleInf">1c</span> as dependent variable&#44; the only parameters that maintained statistical significance were the TIR &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;031&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; CV &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;843&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41; and TIR-CV interaction &#40;&#946;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#44;017&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The glycemic variability defined by the CV modifies the relationship between the TIR and HbA<span class="elsevierStyleInf">1c</span>&#47;Glucose Management Indicator and should be taken into account when individualizing TIR targets&#44; regardless of age or the type of treatment used&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0040"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">GDS y MPBH han colaborado a este manuscrito por igual&#46;</p>"
        "identificador" => "fn0005"
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      0 => array:7 [
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        "etiqueta" => "Figura 1"
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        "mostrarFloat" => true
        "mostrarDisplay" => false
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          0 => array:4 [
            "imagen" => "gr1.jpeg"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Correlaci&#243;n entre HbA<span class="elsevierStyleInf">1c</span> plasm&#225;tica y tiempo en rango&#46;</p>"
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Correlaci&#243;n de la HbA<span class="elsevierStyleInf">1c</span> plasm&#225;tica &#40;A&#41; y la GMI &#40;B&#41; con respecto al tiempo en rango estratificado por coeficiente de variaci&#243;n&#46;</p>"
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      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CV&#58; coeficiente de variaci&#243;n&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; GMI&#58; Glucose Management Indicator&#59; HbA<span class="elsevierStyleInf">1c</span>&#58; hemoglobina glucosilada plasm&#225;tica&#59; ISCI&#58; infusor subcut&#225;neo de insulina&#59; ns&#58; no significativo&#59; TAR&#58; tiempo por encima del rango&#59; TBR&#58; tiempo por debajo del rango&#59; TIR&#58; tiempo en rango&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#60;<span class="elsevierStyleHsp" style=""></span>20 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Evoluci&#243;n media diabetes &#40;a&#241;os&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">5&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">18&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujeres &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">48&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">ISCI &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">28&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">24&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">ns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">HbA1c &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">GMI &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Glucemia media &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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ISSN: 25300164
Idioma original: Español
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es en pt

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Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos