Prevalência de complicações micro e macrovasculares e de seus fatores de risco em pacientes com diabetes melito do tipo 2 em atendimento ambulatorial

Association of Eating Patterns and Diabetic Kidney Disease in Type 2 Diabetes: A Cross-Sectional Study

OBJECTIVE

The aim of this cross-sectional study was to evaluate the relationship between eating patterns and diabetic kidney disease in patients with type 2 diabetes.

METHODS

Outpatients underwent clinical and nutritional evaluation. Dietary information was obtained through a validated quantitative food frequency questionnaire, and eating patterns were identified by cluster analysis. Diabetic kidney disease was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m² and/or persistently elevated urinary albumin concentration (albuminuria ≥ 14 mg/L). Procedures involving patients were approved by the Hospital's Ethics Committee. Patients with type 2 diabetes treated at university hospital and tertiary referral center, southern Brazil.

RESULTS

A total of 329 patients were evaluated: mean age 62 ± 10 years, body mass index 30.9 ± 4.2 kg/m², glycated hemoglobin 8.7% ± 2.0, and 10 (5 to 19) years of diabetes duration. Four eating patterns were identified based on cluster analysis: healthy= dairy products, fruits, and vegetables; snacks= dairy products, whole breads, vegetables, and low-calorie products; processed foods= refined carbohydrates and processed meat, and red meat= red meat. Poisson regression models confirmed that snack eaters (PR = 1.48, 95% CI 1.10, 1.99; P = .010) and red meat eaters (PR = 1.93, 95% CI 1.29, 2.89; P = .001) were associated with diabetic kidney disease.

CONCLUSION

In this sample of outpatients with type 2 diabetes, the patterns of snacks and red meat were associated with diabetic kidney disease as compared to a healthy pattern.

Prevalence and incidence of diabetic peripheral neuropathy in Latin America and the Caribbean: A systematic review and meta-analysis

AIMS

The objective of this systematic review and meta-analysis is to estimate the prevalence and incidence of diabetic peripheral neuropathy (DPN) in Latin America and the Caribbean (LAC).

MATERIALS AND METHODS

We searched MEDLINE, SCOPUS, Web of Science, EMBASE and LILACS databases of published observational studies in LAC up to December 2020. Meta-analyses of proportions were performed using random-effects models using Stata Program 15.1. Heterogeneity was evaluated through sensitivity, subgroup, and meta-regression analyses. Evidence certainty was performed with the GRADE approach.

RESULTS

Twenty-nine studies from eight countries were included. The estimated prevalence of DPN was 46.5% (95%CI: 38.0-55.0) with a significant heterogeneity (I2 = 98.2%; p<0.01). Only two studies reported incidence, and the pooled effect size was 13.7% (95%CI: 10.6-17.2). We found an increasing trend of cumulative DPN prevalence over time. The main sources of heterogeneity associated with higher prevalence were diagnosis criteria, higher A1c (%), and inadequate sample size. We judge the included evidence as very low certainty.

CONCLUSION

The overall prevalence of DPN is high in LAC with significant heterogeneity between and within countries that could be explained by population type and methodological aspects. Significant gaps (e.g., under-representation of most countries, lack of incidence studies, and heterogenous case definition) were identified. Standardized and population-based studies of DPN in LAC are needed.

-866G/A and Ins/Del polymorphisms in the UCP2 gene and diabetic kidney disease: case-control study and meta-analysis

Uncoupling protein 2 (UCP2) decreases reactive oxygen species (ROS). ROS overproduction is a key contributor to the pathogenesis of diabetic kidney disease (DKD). Thus, UCP2 polymorphisms are candidate risk factors for DKD; however, their associations with this complication are still inconclusive. Here, we describe a case-control study and a meta-analysis conducted to investigate the association between UCP2 -866G/A and Ins/Del polymorphisms and DKD. The case-control study comprised 385 patients with type 1 diabetes mellitus (T1DM): 223 patients without DKD and 162 with DKD. UCP2 -866G/A (rs659366) and Ins/Del polymorphisms were genotyped by real-time PCR and conventional PCR, respectively. For the meta-analysis, a literature search was conducted to identify all studies that investigated associations between UCP2 polymorphisms and DKD in patients with T1DM or type 2 diabetes mellitus. Pooled odds ratios were calculated for different inheritance models. Allele and genotype frequencies of -866G/A and Ins/Del polymorphisms did not differ between T1DM case and control groups. Haplotype frequencies were also similar between groups. Four studies plus the present one were eligible for inclusion in the meta-analysis. In agreement with case-control data, the meta-analysis results showed that the -866G/A and Ins/Del polymorphisms were not associated with DKD. In conclusion, our case-control and meta-analysis studies did not indicate an association between the analyzed UCP2 polymorphisms and DKD.

Effects of short-term resistance training on endothelial function and inflammation markers in elderly patients with type 2 diabetes: A randomized controlled trial

PURPOSE

To evaluate the effects of 12-weeks of strength training on endothelial function and inflammatory markers in elderly individuals with T2DM.

METHODS

Forty-four elderly patients with T2DM were screened for participation. After completion of the baseline assessment, participants were randomly assigned to either the resistance training group (RT) or an active control group (AC). Inflammatory (TNF-α, IL-6, IL-1β, IL-10 and CRP) and blood lipid profiles, glycated hemoglobin, basal artery diameter and flow mediated dilation were evaluated before and after the intervention. Comparisons between groups were obtained from the generalized estimation equation and all tests were two-tailed and the alpha level for significance set at 0.05.

RESULTS

TNF-α and IL-1β were decreased in both groups, while no interactions were found for flow mediated dilation and basal artery diameter. No significant differences were found for blood lipid profile and glycated hemoglobin for both groups after the intervention period.

CONCLUSIONS

No significant changes were found between the RT and AC groups, regarding inflammatory profile and endothelial function, which does not prove the superiority of this intervention model in the studied period.

Degree of risk for foot ulcer due to diabetes: nursing assessment

OBJECTIVE

To classify the level of risk for foot ulcers in people with diabetes mellitus and identify their main predictive risk factors.

METHOD

Exploratory, descriptive study, in which patients were assessed in a municipal ambulatory of São Paulo through nursing consultation, following the guidelines of the International Consensus on the Diabetic Foot. Data were descriptively analyzed.

RESULTS

The analyzed population was composed of 50 longevous and retired people, with household income of up to two minimum wages, with dermato-neurofunctional risk factors and unfavorable clinical indicators, and 66% had Risk 1; 16% Risk 2; 6% Risk 3 and 12% Risk 4. Of this analyzed total, 96% never had their feet examined with the Semmes-Weinstein monofilament.

CONCLUSION

The data found indicate the importance of careful feet examination in people with diabetes by the nursing staff to identify future risks of ulcers and, thus, prevent them.

Gut microbiota and probiotics: Focus on diabetes mellitus

The characterization of gut microbiota has become an important area of research in several clinical conditions, including type 2 diabetes (T2DM). Changes in the composition and/or metabolic activity of the gut microbiota can contribute to human health. Thus, this review discusses the effects of probiotics and gut microbiota on metabolic control in these individuals. Relevant studies were obtained from electronic databases such as PubMed/Medline and ISI Web of Science. The main probiotics used in these studies belonged to the genera Lactobacillus and Bifidobacterium. The authors found seven randomized placebo-controlled clinical trials and 13 experimental studies directly related to the effect of probiotics on metabolic control in the context of T2DM. The hypothesis that gut microbiota plays a role in the development of diabetes indicates an important beginning, and the potential of probiotics to prevent and reduce the severity of T2DM is better observed in animal studies. In clinical trials, the use of probiotics in glycemic control presented conflicting results, and only few studies have attempted to evaluate factors that justify metabolic changes, such as markers of oxidative stress, inflammation, and incretins. Thus, further research is needed to assess the effects of probiotics in the metabolism of diabetic individuals, as well as the main mechanisms involved in this complex relationship.

Low Levels of Usual Physical Activity Are Associated with Higher 24 h Blood Pressure in Type 2 Diabetes Mellitus in a Cross-Sectional Study

The aim of this study is to evaluate the association between usual physical activity and 24 h blood pressure (BP) profile in people with type 2 diabetes mellitus (DM). This is a cross-sectional study of 151 participants with type 2 DM. Usual physical activity was assessed by step counting and self-reported questionnaire. BP was measured in office and by 24 h ambulatory BP monitoring (ABPM; 24 h, daytime and nighttime). Mean participant age was 61.1 ± 8.4 years, 64% was women, and mean duration of diabetes was 14.3 ± 8.5 years. Ninety-two percent of participants had hypertension, and office BP was 138 ± 18/78 ± 10 mmHg. Inverse correlations were observed between step count and 24 h BP (systolic, r = -0.186; p = 0.022), daytime BP (systolic, r = -0.198; p = 0.015), and nighttime BP (pulse pressure, r = -0.190; p = 0.019). People were categorized into tertiles of daily step count, and the 1st tertile had higher 24 h systolic BP, daytime systolic BP, daytime mean BP, and daytime systolic BP load than those in the other tertiles, even after adjusting for age and HbA1c. Participants with type 2 DM and low levels of physical activity exhibit higher 24 h and daytime systolic ambulatory BP values as compared with those who performed more steps per day, even after adjustments for confounding factors.

Transcultural Diabetes Nutrition Algorithm: Brazilian Application

The prevalence of obesity, pre-diabetes, and type 2 diabetes (T2D) is increasing worldwide, especially in the developing nations of South America. Brazil has experienced an exponential increase in the prevalence of these chronic non-communicable diseases. The rising prevalence is probably due to changing eating patterns, sedentary living, and a progressive aging of the population. These trends and their underlying causes carry untoward consequences for all Brazilians and the future of Brazilian public health and the healthcare system. Lifestyle changes that include healthy eating (nutrition therapy) and regular physical activity (structured exercise) represent efficient inexpensive measures to prevent and/or treat the aforementioned disorders and are recommended for all afflicted patients. Regrettably, the implementation of lifestyle changes is fraught with clinical and personal challenges in real life. The transcultural Diabetes Nutrition Algorithm (tDNA) is a therapeutic tool intended to foster implementation of lifestyle recommendations and to improve disease-related outcomes in common clinical settings. It is evidence-based and amenable to cultural adaptation. The Brazilian Diabetes Association, Society of Cardiology and Ministry of Health guidelines for nutrition therapy and physical exercise were considered for the Brazilian adaptation. The resultant tDNA-Brazil and its underlying recommendations are presented and explained.

An Extended Minimal Physiologically Based Pharmacokinetic Model: Evaluation of Type II Diabetes Mellitus and Diabetic Nephropathy on Human IgG Pharmacokinetics in Rats

Although many studies have evaluated the effects of type 2 diabetes mellitus (T2DM) on the pharmacokinetics (PK) of low molecular weight molecules, there is limited information regarding effects on monoclonal antibodies. Our previous studies have reported significant increases in total (2-4 fold) and renal (100-300 fold) clearance of human IgG, an antibody isotype, in Zucker diabetic fatty (ZDF) rats. Pioglitazone treatment incompletely reversed the disease-related PK changes. The objective of this study was to construct a mechanistic model for simultaneous fitting plasma and urine data, to yield physiologically relevant PK parameters. We propose an extended minimal physiologically based PK (mPBPK) model specifically for IgG by classifying organs as either leaky or tight vascular tissues, and adding a kidney compartment. The model incorporates convection as the primary mechanism of IgG movement from plasma into tissues, interstitial fluid (ISF) in extravascular distribution space, and glomerular filtration rate (GFR), sieving coefficient and fraction reabsorbed in the kidney. The model captured the plasma and urine PK profiles well, and simulated concentrations in ISF. The model estimated a 2-4 fold increase in nonrenal clearance from plasma and 30-120 fold increase in renal clearance with T2DM, consistent with the experimental findings, and these differences in renal clearance were related to changes in GFR, sieving coefficient, and proximal tubular reabsorption. In conclusion, the mPBPK model offers a more relevant approach for analyzing plasma and urine IgG concentration-time data than conventional models and provides insight regarding alterations in distributional and elimination parameters occurring with T2DM.

Effect of Type 2 Diabetes Mellitus and Diabetic Nephropathy on IgG Pharmacokinetics and Subcutaneous Bioavailability in the Rat

The objective of this research was to assess the effects of type 2 diabetes mellitus (T2DM) and diabetic nephropathy (DN) on the pharmacokinetics of human IgG (hIgG), an antibody isotype, in Zucker diabetic fatty (ZDF) rats. Furthermore, the specific role of T2DM in the altered disposition of hIgG was evaluated by treating diabetic rats with pioglitazone, while the role of chronic kidney disease (CKD) was assessed using 5/6 nephrectomized Sprague Dawley rats. ZDF male (lean non-diabetic control and obese diabetic) and pioglitazone-treated ZDF rats were studied at ages 12-13 weeks (only DM was present), and at ages 29-30 weeks (progression to DN). All animals were dosed with 1 mg/kg of hIgG intravenously (IV) or subcutaneously (SC). ZDF rats had significantly higher blood glucose concentrations and urinary albumin excretion compared to control rats. Significant increases in total clearance (2.5-fold) and renal clearance (100-fold) of hIgG were observed; however the major increase in total clearance was due to increased non-renal clearance. Greater changes in urinary albumin excretion and total and renal clearances of IgG (3.5-fold and 300-fold, respectively) were observed with progression to DN. SC bioavailability of hIgG in all animal groups was similar (>84%). With pioglitazone-treatment, diabetic animals remained euglycemic and treatment was able to reverse the clearance changes, although incompletely. In the CKD group, no difference in hIgG clearance was observed when compared with controls. In conclusion, the increased clearance of hIgG in ZDF diabetic animals, reversal by pioglitazone treatment and lack of effect of CKD, demonstrate the influence of T2DM on hIgG pharmacokinetics.

Implementation of physiotherapeutic shares in the prevention of diabetes complications in a Family Health Strategy

Introduction In the Family Health Strategy (FHS), the treatment of Diabetes Mellitus (DM) includes education and lifestyle change strategies. Physiotherapists have a key role in this health setting. Objectives To implement actions of evaluation and guidelines for patients with type 2 DM who attend a Family Health Strategy (FHS), regarding diabetic foot and the practice of regular physical exercise in the control and prevention of the complications of Diabetes Mellitus. Methods 17 individuals from an FHS were evaluated, with the following procedures: clinical and anthropometric parameters, inspection, a questionnaire on diabetic neuropathy, tests of vibratory and tactile sensitivity, muscle function, range of motion, functional analysis, questions about exercise practice and guidance regarding controlling blood glucose and foot care. Results Deformities, dry skin, calluses, dehydration, ulceration, cracking and brittle nails were found. Peripheral neuropathy was not observed; tactile sensitivity was altered in the heel region and the vibratory sense was absent in 5% of individuals. A decrease in functionality of ankle movements was verified. Of the participants, 76% were sedentary, 24% knew about the benefits of practicing regular exercise, 25% had undergone a medical evaluation prior to performing physical exercise and, of these, 25% were supervised by a qualified professional. Discussion The implementation of physiotherapy actions in diabetics from an FHS was important for highlighting the presence of risk factors for diabetic complications. Conclusions Individuals attending the FHS need more information and programs for the prevention of diabetic complications.

Dietary fat composition and cardiac events in patients with type 2 diabetes

OBJECTIVE

To evaluate associations of dietary fat composition with the development of cardiac events in patients with type 2 diabetes, without ischemic heart disease who were followed for at least 12 months.

METHODS

In this prospective cohort study the usual diet of patients was retrospectively assessed by a 3-day weighed diet record (WDR). Compliance with the WDR technique was assessed by comparing protein intake estimated from 3-day WDR and 24-h urinary nitrogen output. The following were considered cardiac events: myocardial infarction, myocardial revascularization procedures, congestive heart failure, new-onset angina pectoris, and sudden death.

RESULTS

A total of 227 patients with type 2 diabetes (aged 59 ± 10 years; 46.0% male), were followed during 4.6 years. In a multivariate Cox regression analysis, the intake of polyunsaturated fatty acids had a protective effect for cardiac events (HR = 0.31, 95% CI: 0.11-0.89; P = 0.03) adjusted for age, gender, duration of diabetes, smoking, compliance with WDR, using hypolipidemic agents, and the presence of hypertension and diabetic nephropathy. When the fat intake was divided into quartiles, the highest intake of α-linolenic acid (>1.25% of energy) was negatively associated with cardiac events (HR = 0.58, 95% CI: 0.39-0.85; P = 0.006), adjusted for the same covariates..

CONCLUSION

In patients with type 2 diabetes without ischemic heart disease, a high intake of polyunsaturated fatty acids, especially alpha linolenic acid, was protective for the development of cardiac events..

Economic evaluations of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in type 2 diabetic nephropathy: a systematic review

Background

Structured comparison of pharmacoeconomic analyses for ACEIs and ARBs in patients with type 2 diabetic nephropathy is still lacking. This review aims to systematically review the cost-effectiveness of both ACEIs and ARBs in type 2 diabetic patients with nephropathy.

Methods

A systematic literature search was performed in MEDLINE and EMBASE for the period from November 1, 1999 to Oct 31, 2011. Two reviewers independently assessed the quality of the articles included and extracted data. All cost-effectiveness results were converted to 2011 Euros.

Results

Up to October 2011, 434 articles were identified. After full-text checking and quality assessment, 30 articles were finally included in this review involving 39 study settings. All 6 ACEIs studies were literature-based evaluations which synthesized data from different sources. Other 33 studies were directed at ARBs and were designed based on specific trials. The Markov model was the most common decision analytic method used in the evaluations. From the cost-effectiveness results, 37 out of 39 studies indicated either ACEIs or ARBs were cost-saving comparing with placebo/conventional treatment, such as amlodipine. A lack of evidence was assessed for valid direct comparison of cost-effectiveness between ACEIs and ARBs.

Conclusion

There is a lack of direct comparisons of ACEIs and ARBs in existing economic evaluations. Considering the current evidence, both ACEIs and ARBs are likely cost-saving comparing with conventional therapy, excluding such RAAS inhibitors.

Epidemiology, management, complications and costs associated with type 2 diabetes in Brazil: a comprehensive literature review

BACKGROUND

With an estimated 74% of all deaths attributable to non-communicable diseases (NCDs) in 2010, NCDs have become a major health priority in Brazil. The objective of the study was to conduct a comprehensive literature review on diabetes in Brazil; specifically: the epidemiology of type 2 diabetes, the availability of national and regional sources of data (particularly in terms of direct and indirect costs) and health policies for the management of diabetes and its complications.

METHODS

A literature search was conducted using PubMed to identify articles containing information on diabetes in Brazil. Official documents from the Brazilian government and the World Health Organization, as well as other grey literature and official government websites were also reviewed.

RESULTS

From 2006 to 2010, an approximate 20% increase in the prevalence of self-reported diabetes was observed. In 2010, it was estimated that 6.3% of Brazilians aged 18 years or over had diabetes. Diabetes was estimated to be responsible for 278,778 years of potential life lost for every 100,000 people. In 2013, it is estimated that about 7% of patients with diabetes has had one or more of the following complications: diabetic foot ulcers, amputation, kidney disease, and fundus changes. The estimated annual direct cost of diabetes was USD $3.952 billion in 2000; the estimated annual indirect cost was USD $18.6 billion. The two main sources of data on diabetes are the information systems of the Ministry of Health and surveys. In the last few years, the Brazilian Ministry of Health has invested considerably in improving surveillance systems for NCDs as well as implementing specific programmes to improve diagnosis and access to treatment.

CONCLUSIONS

Brazil has the capacity to address and respond to NCDs due to the leadership of the Ministry of Health in NCD prevention activities, including an integrated programme currently in place for diabetes. Strengthening the surveillance of NCDs is a national priority along with recognising the urgent need to invest in improving the coverage and quality of mortality data. It is also essential to conduct regular surveys of risk factors on a national scale in order to design effective preventive strategies.

Gender-related differences in critical limb ischemia due to peripheral arterial occlusive disease

BACKGROUND: Mortality from cardiovascular disease has declined among men and increased among North American women. Recent studies have revealed differences between genders in the epidemiology of atherosclerotic disease. OBJECTIVE: To study possible differences between male and female patients with critical limb ischemia (CLI) according to risk factors of atherosclerosis and clinical characteristics of lower limbs with peripheral arterial occlusive disease (PAOD). METHODS: The study included 171 male and female patients treated for CLI due to infrainguinal PAOD and compared clinical characteristics (Rutherford category and PAOD territory), risk factors for atherosclerosis (diabetes, age, smoking and hypertension) and number of opacified arteries on digital angiograms of the leg. The EPI-INFO software was used for statistical analysis, and the level of significance was set at p<0.05. RESULTS: Mean age was 70 years, and 88 patients were men (52%). For most patients (both genders), Rutherford category was 5 (82 % of men and 70% of women; p=0.16). The group of women had higher mean age (73 vs. 67 years; p=0.0002) and greater prevalence of diabetes (66% vs. 45%; p=0.003) and hypertension (90% vs. 56%; p=0.0000001). Among men, the prevalence of smoking was higher (76% vs. 53%; p=0.0008). The analysis of digital angiograms revealed that opacification of only one artery in the leg was found for 74% of women (vs. 50% of men). CONCLUSION: The prevalence of risk factors for atherosclerosis and the characteristics of PAOD are different between male and female patients with CLI.

The effect of chinese herbal medicine on albuminuria levels in patients with diabetic nephropathy: a systematic review and meta-analysis

To evaluate the effect of Chinese herbal medicine (CHM) on albuminuria levels in patients with diabetic nephropathy (DN), we performed comprehensive searches on Medline database, Cochrane Library, CNKI database, CBM database, Wanfang database, and VIP database up to December 2012. A total of 29 trials including 2440 participants with DN met the selection criteria. CHM was tested to be more effective in reducing urinary albumin excretion rate (UAER) (MD −82.95 μg/min, [−138.64, −27.26]) and proteinuria (MD −565.99 mg/24 h, [−892.41, −239.57]) compared with placebo. CHM had a greater beneficial effect on reduction of UAER (MD −13.41 μg/min, [−20.63, −6.19]) and proteinuria (MD −87.48 mg/24 h, [−142.90, −32.06]) compared with angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). Combination therapy with CHM and ACEI/ARB showed significant improvement in UAER (MD −28.18 μg/min, [−44.4, −11.97]), urinary albumin-creatinine ratio (MD −347.00, [−410.61, −283.39]), protein-creatinine ratio (MD −2.49, [−4.02, −0.96]), and proteinuria (MD −26.60 mg/24 h, [−26.73, −26.47]) compared with ACEI/ARB alone. No serious adverse events were reported. CHM seems to be an effective and safe therapy option to treat proteinuric patients with DN, suggesting that further study of CHM in the treatment of DN is warranted in rigorously designed, multicentre, large-scale trials with higher quality worldwide.

Neuroprotective properties of aucubin in diabetic rats and diabetic encephalopathy rats

In this study, we determined the neuroprotective effect of aucubin on diabetes and diabetic encephalopathy. With the exception of the control group, all rats received intraperitoneal injections of streptozotocin (STZ; 60 mg/kg) to induce type 1 diabetes mellitus (DM). Aucubin (1, 5, 10 mg/kg ip) was used after induction of DM (immediately) and diabetic encephalopathy (65 days after the induction of diabetes). The diabetic encephalopathy treatment groups were divided into short-term and long-term treatment groups. Treatment responses to all parameters were examined (body weight, plasma glucose, Y-maze error rates and proportion of apoptotic cells). In diabetic rats, aucubin controlled blood glucose levels effectively, prevented complications, and improved the quality of life of diabetic rats. In diabetic encephalopathy, aucubin significantly rescued neurons in the hippocampal CA1 subfield and reduced working errors during behavioral testing. The significant neuroprotective effect of aucubin could be seen not only in the short term (15 days) but also in the long term (45 days), which was a highly encouraging finding. These data suggest that aucubin may be a potential neuroprotective agent.

Reno-protective effects of renin-angiotensin system blockade in type 2 diabetic patients: a systematic review and network meta-analysis

AIMS/HYPOTHESIS

This meta-analysis aimed to compare the renal outcomes between ACE inhibitor (ACEI)/angiotensin II receptor blocker (ARB) and other antihypertensive drugs or placebo in type 2 diabetes.

METHODS

Publications were identified from Medline and Embase up to July 2011. Only randomised controlled trials comparing ACEI/ARB monotherapy with other active drugs or placebo were eligible. The outcome of end-stage renal disease, doubling of serum creatinine, microvascular complications, microalbuminuria, macroalbuminuria and albuminuria regression were extracted. Risk ratios were pooled using a random-effects model if heterogeneity was present; a fixed-effects model was used in the absence of heterogeneity.

RESULTS

Of 673 studies identified, 28 were eligible (n = 13-4,912). In direct meta-analysis, ACEI/ARB had significantly lower risk of serum creatinine doubling (pooled RR = 0.66 [95% CI 0.52, 0.83]), macroalbuminuria (pooled RR = 0.70 [95% CI 0.50, 1.00]) and albuminuria regression (pooled RR 1.16 [95% CI 1.00, 1.39]) than other antihypertensive drugs, mainly calcium channel blockers (CCBs). Although the risks of end-stage renal disease and microalbuminuria were lower in the ACEI/ARB group (pooled RR 0.82 [95% CI 0.64, 1.05] and 0.84 [95% CI 0.61, 1.15], respectively), the differences were not statistically significant. The ACEI/ARB benefit over placebo was significant for all outcomes except microalbuminuria. A network meta-analysis detected significant treatment effects across all outcomes for both active drugs and placebo comparisons.

CONCLUSIONS/INTERPRETATION

Our review suggests a consistent reno-protective effect of ACEI/ARB over other antihypertensive drugs, mainly CCBs, and placebo in type 2 diabetes. The lack of any differences in BP decrease between ACEI/ARB and active comparators suggest this benefit is not due simply to the antihypertensive effect.

Clinical features and outcomes in patients with diabetes mellitus undergoing coronary artery bypass graft in a reference center in southern Brazil

OBJECTIVE

To describe clinical/laboratory features of patients undergoing coronary artery bypass graft (CABG) in a cardiology reference center.

METHODS

Cohort study; data from patients undergoing CABG (January 2004 to February 2006, n = 717) were evaluated for clinical/laboratory features before, during and after surgery (infections, duration of hospital stay, deaths).

RESULTS

Patients were 61.9 ± 11 years old, 67.1% males, 29.6% diabetics. Intraoperatively, diabetics had a central venous catheter placed for a longer period (p < 0.001), but extracorporeal circulation, aortic clamping and total surgery times were similar to those for non-diabetics. Infection occurred in 19.1% of patients (40.1% diabetics vs. 10.3% non-diabetics, p < 0.001). The duration of hospital stay was longer for patients with diabetes vs. non-diabetic patients, but there was no difference in deaths between the two groups (p = 0.797).

CONCLUSION

Patients with diabetes undergoing CABG develop more infectious diseases and stay longer in hospital than non-diabetics.

[Family health strategy in the treatment of chronic-degenerative diseases: achievements and challenges]

This retrospective, exploratory, quantitative study was carried in a team of heath care unit (ESF) in the municipalitie of Maringá, Paraná, Brasil, to evaluate the effectiveness of ESF in the treatment of chronic diseases. Data were collected between May, 2006 and September, 2009, among 94 patients with hypertension and/or diabetes, through the analysis of the records of registration of the monitoring system of hypertensive and diabetics and charts. Despite changes in the pharmacotherapy of patients and home care, it was found a slight increase in the number of individual with blood pressure (p = 0.773) and fasting glucose levels (p = 0.745) considered appropriate, in the reporting period. It was concluded that changes in the pharmacotherapy prescribed are insufficient for an adequate control of these diseases, being necessary the development of interventions of the health team that promote the practice of self-care in individuals and their families.

[Profile of patients submitted to amputation related to diabetes mellitus]

Retrospective study that aimed at describing the clinic and socio- demographical characteristics of 141 individuals which were interned in Teaching Hospital of Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil, who were submitted to amputations related to diabetes and compare the number of amputations considering the variables sex, age, co-morbidity, the type of treatment and then associated the number of amputations with the duration of internments and diagnosis. Data were collected from patient health records, totalizing 208 amputations. Major percentage of masculine individuals (58,9%), and a major occurrence of amputation among the elderly (70.2%); the cause: diabetic foot (35.7%); the most of patients (75.0%) went through internment at least twice; most frequent co-morbidity: arterial hypertension (74.0%); median in the number of amputations was two. It was not observed any significant difference between the variables of study.

Diabetes mellitus na adolescência: experiências e sentimentos dos adolescentes e das mães com a doença

O aumento de doenças crônicas entre crianças e adolescentes, especialmente a Diabetes mellitus, requer conhecimentos que integrem os cuidados à saúde e a integração do indivíduo ao seu meio social. O objetivo foi compreender as experiências e os sentimentos de adolescentes e de suas mães sobre a condição de ser diabético, o tratamento e os cuidados à saúde. Realizamos entrevista semiestruturada com oito adolescentes e sete mães em um serviço público de Barbalha - Ceará - Brasil. A análise dos discursos resultou nas categorias: Sentimentos expressos diante da descoberta da doença; A convivência com a doença e as implicações psicossociais; Mudanças no estilo de vida. As dificuldades dos adolescentes induzem à reflexões sobre comportamentos e adaptações ao novo modo de ser e ao autocuidado. Há necessidade de um cuidado integrando as dimensões físicas e psicossociais de modo a melhorar a assistência ao adolescente e à sua família.

Complicações crônicas dos diabéticos tipo 2 atendidos nas Unidades de Saúde da Família, Recife, Pernambuco, Brasil

OBJETIVOS: analisar as complicações associadas ao diabetes tipo 2 em pacientes atendidos pelas Unidades de Saúde da Família. MÉTODOS: estudo realizado nas Unidades de Saúde da Família dos seis distritos sanitários de Recife, Pernambuco, Brasil, com uma amostra de 1374 prontuários de diabéticos cadastrados no Programa de Saúde da Família. As variáveis utilizadas foram: ocorrência de complicações macro e microvasculares, idade, sexo, anos de estudo, consumo de álcool, tabagismo, primeira e última glicemia registrada. RESULTADOS: observou-se uma freqüência de complicações mais elevada em mulheres (71,5%) quando comparada a dos homens (29,5%). Do total, 58,9% apresentava pelo menos uma complicação. As complicações macrovasculares corresponderam a 95,6%. A doença vascular periférica foi responsável por 92,1%, quando considerada como complicação única. Verificou-se associação entre a faixa etária de 66 anos a mais e complicações macrovasculares, com uma prevalência de 37,8%. As complicações microvasculares nas mulheres correspondem à metade daquelas encontradas para os homens (3,6 x 6,4), sendo significante esta diferença (p=0,04). O tabagismo mostrou-se associado a complicações microvasculares (p<0,001). CONCLUSÕES: os resultados apontam para necessidade de se reforçar, junto aos serviços básicos de saúde, medidas preconizadas pelo Ministério da Saúde, visando reduzir os fatores de risco e o impacto de suas complicações.

[Waist measure and waist-to-hip ratio and identification of clinical conditions of cardiovascular risk: multicentric study in type 2 diabetes mellitus patients]

Abdominal obesity is associated with cardiovascular disease. This study aims to compare two measures of abdominal obesity [waist and wais-to-hip ratio (WHR)] in patients with DM2 to identify cardiovascular risk factors: ischemic cardiopathy, hypertension, dislipidemia, obesity and diabetic nephropathy. A multicentric study was performed in 820 patients with type 2 DM. Waist circumference strongly correlated with body mass index (BMI), for men (r= 0.814; P< 0.05) and women (r= 0.770; P< 0.05). On the other hand, WRH was weakly correlated (r= 0.263, P< 0.05 for men; r= 0.092, P< 0.05 for women). Only waist circumference correlated with systolic pressure (r= 0.211, P< 0.05 for men; r= 0,224, P< 0.05 for women). ROC curve analysis demonstrated the superiority of waist circumference measurement compared to WHR regarding obesity and hypertension for men and women, and dyslipidemia for men. In conclusion, waist circumference is better correlated with cardiovascular risk factor than WRH.

Predictors of development and progression of microvascular complications in a cohort of Brazilian type 2 diabetic patients

AIMS

Microvascular complications are associated with increased mortality in diabetes. The objective of this study was to investigate the predictors of microvascular complication development and progression in a prospective study of Brazilian type 2 diabetic patients.

METHODS

A prospective follow-up study was carried out with 471 type 2 diabetic outpatients. Primary end points were the development or progression of retinopathy, peripheral neuropathy, and clinical nephropathy. Predictors were assessed for each individual microvascular complication and also as a composite outcome by Kaplan-Meier estimation of survival curves and by uni- and multivariate Cox analysis.

RESULTS

During a median follow-up of 57 months (range 2-84 months), 196 patients (41.6%) developed or had a progression in microvascular disease. Retinopathy occurred in 22.5%, nephropathy in 19.1%, and neuropathy in 15.5% of the patients. In Cox multivariate analysis, increased echocardiographic left ventricular mass (LVM) and longer diabetes duration were selected as predictors for all end points. Higher mean fasting glycemia was a predictor for retinopathy and neuropathy, lower serum high-density lipoprotein (HDL) cholesterol for neuropathy, and higher total cholesterol for nephropathy. Increased LVM [hazard ratio (HR): 1.39, 95% CI: 1.23-1.56], higher fasting glycemia (HR: 1.19, 95% CI: 1.04-1.36), and longer diabetes duration (HR: 1.28, 95% CI: 1.11-1.47) were the predictors of the composite end point.

CONCLUSIONS

Development and progression of microvascular complications in Brazilian type 2 diabetic patients are associated with worse hypertension and metabolic control. Additional studies are necessary to show if modification of these risk factors can reduce the burden of morbidity and mortality related to microvascular disease in type 2 diabetes.

Risk factors in patients with type 2 diabetes mellitus

This study was carried out to evaluate the risk factors of type 2 diabetic patients through sociodemographic data, habits of health, anthropometric and biochemist profiles, assisted at a basic public health care unit in Maringá, Paraná. Sixty-six patients, 56 women aged over than 50 years-old were interviewed. High prevalence factors for cardiovascular risk were observed, such as: overweight and obesity, hypertension, dyslipidemia, sedentariness and inadequate diet. Data suggested the need for multidisciplinary intervention programs in health care units associated to educative programs, adjusted diet intake and regular physical activity for these diabetic patients.

[Influence of body weight excess and central adiposity in glycemic and lipid profile in patients with type 2 diabetes mellitus]

The purpose of the present study was to evaluate, in diabetic type 2 patients, the influence of body weight excess assessed by BMI and the central adiposity assessed by the waist circumference in the lipid and glycemic profile. One hundred and forty five individuals assisted in a unit of health, aged >or= 20 years old, were appraised. The female frequency was 61.4%. Among men, the weight excess was correlated with HDL (r = -0.34, p < 0.05), with the total cholesterol (r = 0.35, p < 0.01), and with the triglycerides (r = 49, p < 0.0001), and among women there was correlation just with the triglycerides (r = 0.24, p < 0,05). Waist circumference was correlated with the fast glycemia women's group (r = 0.3, p < 0.01), with the total cholesterol among men (r = 0.33, p < 0.05) and with triglycerides in both genders (F: r = 0.22, p < 0.05; M: r = 0.49, p < 0.001). Highest glycemic and triglycerides levels were present in patients with excess body weight and central adiposity and lower HDL levels were present in patients with body weight excess. In conclusion, there is association between inadequate metabolic profile and the excess of body weight and/or central obesity, evidencing the need for a nutritional and clinical intervention in the diabetic type 2 patients, in order to reduce the risk of future chronic complications.

[Risk factors of stroke among Congolese black hypertensive diabetics]

BACKGROUND

The relationship between diabetes mellitus and risk of stroke is well established. This risk is more elevated for hypertensive diabetics men.

OBJECTIVE

To determine the incidence and the risk factors of stroke among hypertensive diabetics.

METHODS

This prospective study has considered baseline demographic, behavioural and biological parameters collected in 2002 among black Congolese hypertensive diabetics from Kinshasa till the onset of stroke or not in 2006.

RESULTS

Out of 492 followed-up patients (279 women, 213 men, 57+/-10 years), 41.9% were old of age > or = 60 years, and 16.5% experienced acute stroke. In univariate analysis, a significant association between age > or = 60 years, cigarette smoking, excessive alcohol intake, diabetes duration > or = 2 years, pulse pressure > or = 60 mmHg, acute bacterian pneumonia, left ventricule hypertrophy, hypertensive retinopathy, diabetic retinopathy, diabetic foot, diabetic neuropathy, congestive heart failure, chronic renal failure, lack of diabetic treatment compliance and the occurrence of acute stroke. However, multivariate analysis identified only acute bacterian pneumonia, diabetic retinopathy, diabetic neuropathy, chronic renal failure and pulse pressure > or = 60 mmHg as the independent risk factors of stroke onset among these black congolese hypertensive diabetics with the following and respective values of relative risk (hazard ratio): 6,2 (IC 95%: 3.2 to 11.9; P<0.0001), 2,2 (IC 95%: 1.2 to 4.1; P<0.01), 3.6 (IC 95%: 1.9 to 6.8; P<0.0001), 6.4 (IC 95%: 2.9 to 14.1; P<0.01) and 4.1 (IC 95%: 1.6 to 10.3; P<0.0001).

CONCLUSION

The rate of stroke onset is high among these hypertensive diabetics. This is the consequence of independent and respective action of infection, diabetic retinopathy, diabetic neuropathy, chronic renal failure and arterial stiffness.

[Low-dose aspirin in patients with diabete melitus: risks and benefits regarding macro and microvascular complications]

Aspirin is recommended as cardiovascular disease prevention in patients with diabetes mellitus. Due to the increased risk of bleeding and because of the hypothesis that there could be a worsening of microvascular complications related to aspirin, there has been observed an important underutilization of the drug. However, it is now known that aspirin is not associated with a deleterious effect on diabetic retinopathy and there is evidence indicating that it also does not affect renal function with usual doses (150 mg/d). On the other hand, higher doses may prove necessary, since recent data suggest that diabetic patients present the so called "aspirin resistance". The mechanisms of this resistance are not yet fully understood, being probably related to an abnormal intrinsic platelet activity. The employment of alternative antiplatelet strategies or the administration of higher aspirin doses (150-300 mg/d) should be better evaluated regarding effective cardiovascular disease prevention in diabetes as well as the possible effects on microvascular complications.

Análise dos critérios de definição da síndrome metabólica em pacientes com diabetes melito tipo 2

O objetivo deste estudo é comparar em pacientes com diabetes melito tipo 2 (DM2) a proporção de síndrome metabólica de acordo com a definição da Organização Mundial de Saúde (OMS) e a do National Cholesterol Education Program (NCEP), e analisar qual se associa mais à presença das complicações do DM2. Foram avaliados 753 pacientes com DM2 em atendimento ambulatorial, quanto a parâmetros étnicos, antropométricos, laboratoriais e presença das complicações: nefropatia diabética, cardiopatia isquêmica, acidente vascular cerebral, retinopatia diabética e vasculopatia periférica. A resistência insulínica foi estimada através do HOMA-IR. A síndrome metabólica esteve presente em 671 (89%) e 657 (87%) dos pacientes utilizando a definição da OMS e do NCEP, respectivamente. No grupo total, houve uma concordância moderada entre as duas definições (k= 0,54; IC 95% 0,490,59), porém foi melhor para negros (k= 0,69; IC 95% 0,60,78) do que para brancos (k= 0,54; IC 95% 0,480,6) e mulatos (k= 0,26; IC 95% 0,090,43). Pacientes com síndrome metabólica pela definição do NCEP apresentaram valores de HOMA-IR maiores que os pacientes sem síndrome metabólica (p= 0,001). Esta diferença não foi encontrada utilizando a definição da OMS (p= 0,152). A proporção das complicações do DM2 foi semelhante nas duas definições. Em conclusão, em relação ao risco de complicações, as duas definições são equivalentes. Entretanto, existe variação na concordância entre as duas definições de acordo com a etnia.

[Blood pressure homeostasis and microvascular complications in diabetic patients]

The retinopathy and nephropathy are among the most prevalent and disabling complications associated to microvascular damage in diabetes mellitus. The severity of hyperglycaemia and the presence of arterial systemic hypertension are among the main risk factors for these complications. The ambulatory blood pressure provided a better understanding of patterns of blood pressure in diabetic patients. There is a growing number of evidence relating diabetic patients with abnormal 24 h blood pressure patterns. Even subtle modifications of these patterns, frequently shown by patients diagnosed as normotensives in office blood pressure measurings, may be implicated in an increased risk of microvascular complications. Hyperglycaemia and these abnormal pressure patterns appear to have a synergistic effect on promoting and aggravating diabetic retinopathy. Impairment of the normal retinal autoregulation is one of the implicated physiopathological mechanisms. Probably, ABP may be useful in predicting an increased risk of microvascular complications on diabetic normotensive patients. The objective of this paper is to provide an updated and clinically oriented review in blood pressure homeostasis and diabetes mellitus.

[Fundoscopic alterations and diabetic foot in patients of Hospital Universitário Onofre Lopes/UFRN]

PURPOSE

To identify diabetic foot abnormal changes caused by microvascular events and fundoscopy eye lesions due to diabetic retinopathy.

METHODS

A survey was performed with 76 diabetic patients from the Hospital Onofre Lopes out-patient department of ophtalmology and vascular surgery. To evaluate the diabetic foot the patients were submitted to an individual interview using Fontaine classification. The vascular test used was Semmes-Weinstein monofilament. Refraction and eye fundoscopy were acomplished in all patients to arrange the diabetic retinopathy. The study results consisted in characterized the group as age,time of disease and glicose level. The second analyse was performed with association tests among the selected secondary study results. "Statística Versão 5,1997" was the software available.

RESULTS

From 76 diabetics patients 97% had age higher than 40 years. 65% had more than 10 years of time disease. 72.72% obtained glicose level > 100 mg/dl. 55.5% had some degree of diabetic retinopathy against 44.74% had not. About the diabetic foot abnormalities, 59.93% had ischemic damages and 41.07% had not signs. 58.82% had neuropathic foot and there were 41,18% patients without diabetic neuropathy signs. Talking about the diabetic retinopathy population, 78.,57% had ischemic foot and 47.62% had neuropathic foot. It was seen 80% of no proliferative diabetic retinopathy in all diabetics foot (isquemic and neuropathic). The patients with retinopathy 60.46% of them had foot biomechanics abnormalities.

CONCLUSION

Light no proliferative diabetic retinopathy was most common in patients with ischemic diabetic foot. The severe no proliferative diabetic retinopathy was most common in patients with neuropathic diabetic foot.

Evaluation of tests for microalbuminuria screening in patients with diabetes

BACKGROUND

The first step in the diagnosis of diabetic nephropathy is to measure albumin in a spot urine sample. The aim of this study was to assess the accuracy of urinary albumin concentration (UAC), urinary albumin-to-creatinine ratio (UACR), and the Micral-Test II in a random urine specimen (RUS) for microalbuminuria screening in diabetes mellitus.

METHODS

Two hundred and seventy-eight patients collected 24 h timed urine specimens followed by RUS. Albumin (immunoturbidimetry) and creatinine were measured in protein-negative (Combur-Test) urine samples. Samples were classified as normoalbuminuric [24 h urinary albumin excretion rate (UAER) <20 microg/min; n = 189] and microalbuminuric (UAER =20-199 microg/min; n = 89). Micral-Test II readings were performed in 130 RUS. Receiver operating characteristics (ROC) curves were constructed using UAER as the reference standard.

RESULTS

The areas under the ROC curves were similar for UAC (0.934+/-0.032) and UACR (0.920+/-0.035; P = 0.626), but the Micral-Test II had lower accuracy to diagnose microalbuminuria (area = 0.846+/-0.047) than UAC (P = 0.014). The first cutoff point with 100% sensitivity for UAC was 14.4 mg/l (specificity =77.2%), and 15.7 mg/g for UACR (specificity =73.0%). Concerning the Micral-Test II, sensitivity and specificity for the 20 mg/l cutoff point were 90.0 and 46.0%, respectively. The agreement between UAER and the Micral-Test II for microalbuminuria diagnosis was 55.8% (kappa = 0.22; P < 0.001). The cost of diagnosing microalbuminuria was 1.74 dollars(UAC), 2.00 dollars (UACR) and 4.09 dollars (Micral-Test II) per patient.

CONCLUSIONS

Measurement of UAC in a RUS was the best choice for the diagnosis screening of microalbuminuria in diabetic patients, considering cost and accuracy.