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Rados DV, Falcetta MRR, Pinto LC, Leitão CB, Gross JL. All-cause mortality and cardiovascular safety of basal insulin treatment in patients with type 2 diabetes mellitus: A systematic review with meta-analysis and trial sequential analysis. Diabetes Res Clin Pract 2021; 173:108688. [PMID: 33549676 DOI: 10.1016/j.diabres.2021.108688] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 09/04/2020] [Accepted: 01/24/2021] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the risk of all-cause and cardiovascular mortality, acute myocardial infarction, and stroke associated with insulin treatment in patients with type 2 diabetes. METHODS A systematic review with meta-analysis of randomized clinical trials (RCTs) was performed. EMBASE, Cochrane, and PubMed databases were searched for RCTs reporting mortality or cardiovascular events and comparing basal insulin to any treatment in patients with type 2 diabetes. Data were summarized with Mantel-Haenzel relative risk (RR). Trial sequential analysis (TSA) was used to evaluate the reliability of the results considering a 20% relative risk difference between treatments. PROSPERO Registry: CRD42018087336. RESULTS In total, 2351 references were identified, and 26 studies (24348 patients) were included. Most studies evaluated glargine insulin (69%), compared insulin to GLP-1 analogs (57%), and evaluated add-on therapy with metformin (77%). Insulin was not associated with increased all-cause mortality (RR 0.99; 95% confidence interval (CI) 0.92-1.06), cardiovascular mortality (RR 1.01; 95% CI 0.91-1.13), myocardial infarction (RR 1.02; 95% CI 0.92-1.15), or stroke (RR 0.87; 95% CI 0.68-1.12). Insulin treatment increased severe hypoglycemia risk (RR 2.98; 95% CI 2.47-3.61). All analyses had low statistical heterogeneity. TSA confirmed these findings: optimal sample size (myocardial infarction), futility boundary (all-cause mortality, cardiovascular mortality, and stroke) and harm boundary (hypoglycemia) were reached. CONCLUSION Treatment with basal insulin of patients with type 2 diabetes does not increase the risk of cardiovascular events or death. Despite the increased risk of hypoglycemia, these findings reinforce that insulin is a safe option in the treatment of type 2 diabetes.
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Affiliation(s)
- Dimitris Varvaki Rados
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil.
| | - Mariana Rangel Ribeiro Falcetta
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil
| | - Lana Catani Pinto
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil
| | - Cristiane Bauermann Leitão
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil.
| | - Jorge Luiz Gross
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil
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Rados DV, Viecceli C, Pinto LC, Gerchman F, Leitão CB, Gross JL. Metabolic effects of antihyperglycemic agents and mortality: meta-analysis of randomized controlled trials. Sci Rep 2020; 10:12837. [PMID: 32733045 PMCID: PMC7393357 DOI: 10.1038/s41598-020-69738-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 07/06/2020] [Indexed: 12/19/2022] Open
Abstract
The effects of antihyperglycemic medications on cardiovascular events and mortality are heterogeneous and their effects on intermediate factors might explain these differences. This systematic review explores the relationship between metabolic factors, mechanism of action, and mortality effects of antihyperglycemic medications in type 2 diabetes. Randomized trials assessing the effects of antihyperglycemic medications on all-cause or cardiovascular mortality in type 2 diabetes were included. Myocardial infarction, stroke, and heart failure were secondary outcomes. The effects of medications on HbA1c, severe hypoglycemia (SH), body weight, systolic blood pressure (SBP), and mechanism of action were evaluated. Meta-analyses and meta-regressions were performed grouping studies according to the above-cited factors. All-cause mortality was lower for medications that reduced HbA1c, SH, body weight, and SBP. Decreased cardiovascular mortality was associated with lower HbA1c, SH, SBP. Myocardial infarction and stroke were also associated with favorable metabolic profile. These findings were not confirmed in meta-regression models. Medications associated with lower SH, body weight and SBP had a lower risk of heart failure. In conclusion, medications with better metabolic profile were associated with reduced all-cause and cardiovascular mortality. These findings are based on indirect comparisons and must be applied cautiously.
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Affiliation(s)
- Dimitris Varvaki Rados
- Post-Graduate Program in Medical Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2300, 2º floor, Porto Alegre, RS, 90035-903, Brazil.
| | - Camila Viecceli
- Post-Graduate Program in Medical Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2300, 2º floor, Porto Alegre, RS, 90035-903, Brazil
| | - Lana Catani Pinto
- Post-Graduate Program in Medical Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2300, 2º floor, Porto Alegre, RS, 90035-903, Brazil
| | - Fernando Gerchman
- Post-Graduate Program in Medical Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2300, 2º floor, Porto Alegre, RS, 90035-903, Brazil
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4º floor, Porto Alegre, RS, 90035-903, Brazil
| | - Cristiane Bauermann Leitão
- Post-Graduate Program in Medical Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2300, 2º floor, Porto Alegre, RS, 90035-903, Brazil
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4º floor, Porto Alegre, RS, 90035-903, Brazil
| | - Jorge Luiz Gross
- Post-Graduate Program in Medical Sciences, Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2300, 2º floor, Porto Alegre, RS, 90035-903, Brazil
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4º floor, Porto Alegre, RS, 90035-903, Brazil
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Pinto LC, Kramer CK, Camargo JL, Canani LH, Gross JL, Leitão CB. No effect of acidification or freezing on urinary metanephrine levels. J Endocrinol Invest 2020; 43:53-56. [PMID: 31228104 DOI: 10.1007/s40618-019-01076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/14/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Urinary metanephrine is a reliable method to estimate catecholamine secretion. Traditionally, urinary metanephrines are collected into chilled containers containing hydrochloric acid (HCl) and most laboratories freeze urinary samples before analysis. It is uncertain if these pre-analytic procedures alter metanephrine values. AIM To evaluate if acidifying and freezing urine samples affect the accuracy of urinary metanephrine measurements. METHODS Random urine samples from healthy individuals were collected. Urine samples were distributed into two containers: with HCl 50% homogenized with urine to obtain pH < 2, and without HCl. Each container was divided again into aliquots for immediate measurement or freezing. One aliquot with acid (group 1) and another without acid (group 2) were sent immediately to the laboratory for testing (HPLC), while the other two aliquots, one with acid (group 3) and another without it (group 4) were frozen for 3 months at - 20 °C. Bland-Altman's test was used to analyze inter-assay agreement between measurements. RESULTS A total of 15 individuals were included (mean age 27.5 ± 5.9 years, 8 male and 14 white). No difference was observed on mean urinary metanephrine/creatinine ratio between groups: group 1: 0.23 ± 0.11, group 2: 0.22 ± 0.07, group 3: 0.25 ± 0.13, group 4: 0.25 ± 0.15 mg/g creatinine; P > 0.05 for all the comparisons). Bland-Altman's analysis showed agreement between the standard method (group 1) and the experimental method (group 4). CONCLUSION Measurement of urinary metanephrines by HPLC method is not influenced by sample acidification nor freezing at - 20 °C for 3 months.
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Affiliation(s)
- L C Pinto
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4° Andar, Porto Alegre, RS, 90035-003, Brazil.
| | - C K Kramer
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Canada
| | - J L Camargo
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4° Andar, Porto Alegre, RS, 90035-003, Brazil
| | - L H Canani
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4° Andar, Porto Alegre, RS, 90035-003, Brazil
| | - J L Gross
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4° Andar, Porto Alegre, RS, 90035-003, Brazil
| | - C B Leitão
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4° Andar, Porto Alegre, RS, 90035-003, Brazil
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dos Santos ALT, Duarte CK, Santos M, Zoldan M, Almeida JC, Gross JL, Azevedo MJ, Lichtenstein AH, Zelmanovitz T. Low linolenic and linoleic acid consumption are associated with chronic kidney disease in patients with type 2 diabetes. PLoS One 2018; 13:e0195249. [PMID: 30092058 PMCID: PMC6084813 DOI: 10.1371/journal.pone.0195249] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 03/19/2018] [Indexed: 01/25/2023] Open
Abstract
Aim This cross-sectional study aimed to assess the association of the fat content in the diet with Diabetic Kidney Disease (DKD) in patients with type 2 diabetes. Methodology Patients from the Diabetes research clinic at Hospital de Clínicas de Porto Alegre (Brazil) were consecutively recruited. The inclusion criterion was the diagnosis of type 2 diabetes. The exclusion criteria were as follows: body mass index >40 kg/m2, heart failure, gastroparesis, diabetic diarrhea, dietary counseling by a registered dietitian during the previous 12 months, and inability to perform the weighed diet records (WDR). The dietary fatty acids (saturated, monounsaturated and polyunsaturated) consumption was estimated by 3-day WDR. Compliance with the WDR technique was assessed by comparison of protein intake estimated from the 3-day WDR and from the 24-h urinary nitrogen output performed on the third day of the WDR period. The presence of DKD was defined as urinary albumin excretion (UAE) ≥ 30 mg / 24 h or/and glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Urinary albumin was measured twice and eGFR was estimated by using the CKD-EPI equation. Results A total of 366 patients were evaluated; of these, 33% (n = 121) had DKD. Multivariate analysis showed that the intake of linolenic acid was negatively associated with DKD (OR = 0.57; 95% CI 0.35–0.93; P = 0.024), adjusted for gender, smoking, cardiovascular disease, ACE inhibitors and/or angiotensin receptor blocker use, systolic blood pressure, fasting plasma glucose and HDL cholesterol. In a separate model, similar results were observed for linoleic acid, adjusting to the same co-variables (OR = 0.95; 95% CI 0.91–0.99; P = 0.006). Conclusion The lower intake of polyunsaturated fatty acids, especially linolenic and linoleic acid, is associated with chronic kidney disease in patients with type 2 diabetes.
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Affiliation(s)
- Ana Luiza Teixeira dos Santos
- Medical Sciences Post-Graduate Program: Endocrinology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Camila Kummel Duarte
- Medical Sciences Post-Graduate Program: Endocrinology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Manoella Santos
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Maira Zoldan
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jussara Carnevalle Almeida
- Medical Sciences Post-Graduate Program: Endocrinology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jorge Luiz Gross
- Medical Sciences Post-Graduate Program: Endocrinology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Mirela Jobim Azevedo
- Medical Sciences Post-Graduate Program: Endocrinology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Alice Hinda Lichtenstein
- Cardiovascular Nutrition Laboratory, Jean Mayer USDA Human Nutrition Research Center, Tufts University, Boston, MA, United States of America
| | - Themis Zelmanovitz
- Medical Sciences Post-Graduate Program: Endocrinology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- * E-mail:
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Daudt LD, Musskopf ML, Mendez M, Remonti LLR, Leitão CB, Gross JL, Weidlich P, Oppermann RV. Association between metabolic syndrome and periodontitis: a systematic review and meta-analysis. Braz Oral Res 2018; 32:e35. [PMID: 29846383 DOI: 10.1590/1807-3107bor-2018.vol32.0035] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 03/14/2018] [Indexed: 01/11/2023] Open
Abstract
The aim of the present study was to evaluate the association between metabolic syndrome (MS) and periodontitis (PD), through a systematic review and meta-analysis. Original observational studies assessing the association between MS and PD in adults, published before May 11th (2017), were identified through electronic searches of MEDLINE, EMBASE and Cochrane Library databases. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was used. For studies to be included, they had to mention the criteria used to diagnose MS and to have used at least one clinical measure to diagnose PD. There was no language restriction. Three reviewers independently identified eligible studies for possible inclusion in the systematic review and meta-analysis. The quality of the studies was evaluated by the Newcastle-Ottawa scale for observational studies. A random model meta-analysis was conducted. The strategies used to investigate heterogeneity were sequential analysis, subgroup analysis, univariate meta-regression and sensitivity analysis. Thirty-three studies met the inclusion criteria for the systematic review, and 26 had enough information to be included in the meta-analysis, totaling 52,504 patients. MS and PD were associated with an odds ratio of 1.38 (95%CI 1.26-1.51; I2 = 92.7%; p < 0.001). Subgroup analysis showed that complete periodontal examination (I2 = 70.6%; p < 0.001) partially explained the variability between studies. The present findings suggest an association between MS and PD. Individuals with MS are 38% more likely to present PD than individuals without this condition. Prospective studies should be conducted to establish cause and effect relations between MS and PD.
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Affiliation(s)
- Luciana Dondonis Daudt
- Universidade Federal do Rio Grande do Sul - UFRGS, Dental School, Department of Periodontology, Porto Alegre, RS, Brazil
| | | | - Marina Mendez
- Universidade Federal do Rio Grande do Sul - UFRGS, Dental School, Department of Periodontology, Porto Alegre, RS, Brazil
| | - Luciana Loss Reck Remonti
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre, Division of Endocrinology, Porto Alegre, Brazil
| | - Cristiane Bauermann Leitão
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre, Division of Endocrinology, Porto Alegre, Brazil
| | - Jorge Luiz Gross
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre, Division of Endocrinology, Porto Alegre, Brazil
| | - Patricia Weidlich
- Universidade Federal do Rio Grande do Sul - UFRGS, Dental School, Department of Periodontology, Porto Alegre, RS, Brazil
| | - Rui Vicente Oppermann
- Universidade Federal do Rio Grande do Sul - UFRGS, Dental School, Department of Periodontology, Porto Alegre, RS, Brazil
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de Souza CF, Dalzochio MB, Zucatti ATN, De Nale R, de Almeida MT, Gross JL, Leitão CB. Efficacy of an education course delivered to community health workers in diabetes control: A randomized clinical trial. Endocrine 2017. [PMID: 28646377 DOI: 10.1007/s12020-017-1352-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Community health workers are community members who provide education and care for patients for a broad range of health issues, including diabetes mellitus. However, few community health workers are trained for diabetes education and little is known about the effectiveness of their interventions. The aim of this study is to evaluate the effect of a diabetes education program delivered to community health workers in improving the metabolic control of patients with type 2 diabetes mellitus. METHODS Eight community health workers, providing care for 118 patients, were randomized in two groups to receive a 1-month diabetes education program (intervention, patients n = 62) or an education course in other health issues (control, patients n = 56). Each community health worker was responsible for transmitting the acquired knowledge to patients. Primary outcome was changed in HbA1C 3 months after the intervention. RESULTS PARTICIPANTS: Mean age was 61 ± 11 years, 35% were men and 62% were whites. HbA1c levels reduced in both groups (intervention: 9.1 ± 2.2 vs. 7.9 ± 1.9%; control: 9.1 ± 2.1 vs. 8.4 ± 2.5%, p < 0.001), but no statistically significant differences were observed between groups (p between groups = 0.13). Total cholesterol (intervention: 192 ± 43 vs. 182 ± 39 mg/dl; control: 197 ± 44 vs. 191 ± 45 mg/dl, p between groups = 0.035) and triglycerides (intervention: 158 [106-218] vs. 135 [106-215]; control: 128 [100-215] mg/dl vs. 146 [102-203] mg/dl, p between groups = 0.03) reduced overtime only in intervention group. CONCLUSIONS In this study, a significant decrease in HbA1c was observed during patients' follow-up, but it was similar in intervention and control groups. The diabetes mellitus education course delivered to community health workers was able to improve patients' lipid profile.
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Affiliation(s)
- Camila Furtado de Souza
- Primary Care Divison, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Mériane Boeira Dalzochio
- Primary Care Divison, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Rosana De Nale
- Primary Care Divison, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marília Tavares de Almeida
- Primary Care Divison, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jorge Luiz Gross
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Cristiane Bauermann Leitão
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Leiter LA, Gross JL, Chow F, Miller D, Johnson S, Ahrén B. Once weekly glucagon-like peptide-1 receptor agonist albiglutide vs. prandial insulin added to basal insulin in patients with type 2 diabetes mellitus: Results over 52 weeks. J Diabetes Complications 2017; 31:1283-1285. [PMID: 28587789 DOI: 10.1016/j.jdiacomp.2017.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/17/2017] [Accepted: 05/21/2017] [Indexed: 11/29/2022]
Abstract
We have previously reported that once-weekly albiglutide was noninferior to thrice-daily lispro for glycemic lowering, with decreased weight and risk of hypoglycemia, in patients inadequately controlled on basal insulin over 26 weeks. Findings after 52 weeks reveal similar responses to albiglutide as an add-on to insulin glargine.
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Affiliation(s)
- Lawrence A Leiter
- Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, 61 Queen St. East #6121, Toronto, Canada, M5C 2T2.
| | - Jorge Luiz Gross
- Hospital Moinhos De Vento, Rua. Ramiro Barcelos, 910, Floresta, Porto Alegre, RS, Brazil.
| | - Francis Chow
- Chinese University of Hong Kong, 30 32 Ngan Shing Street, Shatin, China.
| | - Diane Miller
- GlaxoSmithKline, 1250 S. Collegeville Road, Collegeville, PA, 19426, USA.
| | - Susan Johnson
- GlaxoSmithKline, 1250 S. Collegeville Road, Collegeville, PA, 19426, USA.
| | - Bo Ahrén
- Lund University, Biomedical Centre C11, SE-221 84 Lund, Sweden.
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Cavagnolli G, Pimentel AL, Freitas PAC, Gross JL, Camargo JL. Effect of ethnicity on HbA1c levels in individuals without diabetes: Systematic review and meta-analysis. PLoS One 2017; 12:e0171315. [PMID: 28192447 PMCID: PMC5305058 DOI: 10.1371/journal.pone.0171315] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 01/18/2017] [Indexed: 12/16/2022] Open
Abstract
Aims/Hypothesis Disparities in HbA1c levels have been observed among ethnic groups. Most studies were performed in patients with diabetes mellitus (DM), which may interfere with results due to the high variability of glucose levels. We conducted a systematic review and meta-analysis to investigate the effect of ethnicity on HbA1c levels in individuals without DM. Methods This is a systematic review with meta-analysis. We searched MEDLINE and EMBASE up to September 2016. Studies published after 1996, performed in adults without DM, reporting HbA1c results measured by certified/standardized methods were included. A random effects model was used and the effect size was presented as weighted HbA1c mean difference (95% CI) between different ethnicities as compared to White ethnicity. Results Twelve studies met the inclusion criteria, totalling data from 49,238 individuals. There were significant differences between HbA1c levels in Blacks [0.26% (2.8 mmol/mol); 95% CI 0.18 to 0.33 (2.0 to 3.6), p <0.001; I2 = 90%, p <0.001], Asians [0.24% (2.6 mmol/mol); 95% CI 0.16 to 0.33 (1.7 to 3.6), p <0.001; I2 = 80%, p = 0.0006] and Latinos [0.08% (0.9 mmol/mol); IC 95% 0.06 to 0.10 (0.7 to 1.1); p <0.001; I2 = 0%; p = 0.72] when compared to Whites. Conclusions/Interpretation This meta-analysis shows that, in individuals without DM, HbA1c values are higher in Blacks, Asians, and Latinos when compared to White persons. Although small, these differences might have impact on the use of a sole HbA1c point to diagnose DM in all ethnic populations.
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Affiliation(s)
- Gabriela Cavagnolli
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Centro Universitário FSG, Caxias do Sul, Brazil
| | - Ana Laura Pimentel
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Priscila Aparecida Correa Freitas
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Laboratory of Transplantation Immunology, Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil
| | - Jorge Luiz Gross
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Joíza Lins Camargo
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- * E-mail:
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Zucatti ATN, de Paula TP, Viana LV, DallAgnol R, Cureau FV, Azevedo MJ, Gross JL, Schaan BD, Leitao CB. Low Levels of Usual Physical Activity Are Associated with Higher 24 h Blood Pressure in Type 2 Diabetes Mellitus in a Cross-Sectional Study. J Diabetes Res 2017; 2017:6232674. [PMID: 29018827 PMCID: PMC5606041 DOI: 10.1155/2017/6232674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/28/2017] [Accepted: 08/17/2017] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
| | - Tatiana Pedroso de Paula
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Luciana Verçoza Viana
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Rafael DallAgnol
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Felipe Vogt Cureau
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Mirela Jobim Azevedo
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Jorge Luiz Gross
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Beatriz D. Schaan
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Cristiane Bauermann Leitao
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Rados DV, Pinto LC, Remonti LR, Leitão CB, Gross JL. Correction: The Association between Sulfonylurea Use and All-Cause and Cardiovascular Mortality: A Meta-Analysis with Trial Sequential Analysis of Randomized Clinical Trials. PLoS Med 2016; 13:e1002091. [PMID: 27340828 PMCID: PMC4920361 DOI: 10.1371/journal.pmed.1002091] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pmed.1001992.].
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Varvaki Rados D, Catani Pinto L, Reck Remonti L, Bauermann Leitão C, Gross JL. The Association between Sulfonylurea Use and All-Cause and Cardiovascular Mortality: A Meta-Analysis with Trial Sequential Analysis of Randomized Clinical Trials. PLoS Med 2016; 13:e1001992. [PMID: 27071029 PMCID: PMC4829174 DOI: 10.1371/journal.pmed.1001992] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 03/01/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Sulfonylureas are an effective and inexpensive treatment for type 2 diabetes. There is conflicting data about the safety of these drugs regarding mortality and cardiovascular outcomes. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyze whether the available sample was powered enough to support the results. METHODS AND FINDINGS Electronic databases were reviewed from 1946 (Embase) or 1966 (MEDLINE) up to 31 December 2014. Randomized clinical trials (RCTs) of at least 52 wk in duration evaluating second- or third-generation sulfonylureas in the treatment of adults with type 2 diabetes and reporting outcomes of interest were included. Primary outcomes were all-cause and cardiovascular mortality. Additionally, myocardial infarction and stroke events were evaluated. Data were summarized with Peto odds ratios (ORs), and the reliability of the results was evaluated with TSA. Forty-seven RCTs with 37,650 patients and 890 deaths in total were included. Sulfonylureas were not associated with all-cause (OR 1.12 [95% CI 0.96 to 1.30]) or cardiovascular mortality (OR 1.12 [95% CI 0.87 to 1.42]). Sulfonylureas were also not associated with increased risk of myocardial infarction (OR 0.92 [95% CI 0.76 to 1.12]) or stroke (OR 1.16 [95% CI 0.81 to 1.66]). TSA could discard an absolute difference of 0.5% between the treatments, which was considered the minimal clinically significant difference. The major limitation of this review was the inclusion of studies not designed to evaluate safety outcomes. CONCLUSIONS Sulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded. REVIEW REGISTRATION PROSPERO CRD42014004330.
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Affiliation(s)
- Dimitris Varvaki Rados
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
- * E-mail:
| | - Lana Catani Pinto
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Luciana Reck Remonti
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Cristiane Bauermann Leitão
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Jorge Luiz Gross
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
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Grillo MDFF, Neumann CR, Scain SF, Rozeno RF, Beloli L, Perinetto T, Gross JL, Leitão CB. Diabetes education in primary care: a randomized clinical trial. CAD SAUDE PUBLICA 2016; 32:S0102-311X2016000500502. [DOI: 10.1590/0102-311x00097115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 03/02/2016] [Indexed: 11/22/2022] Open
Abstract
Abstract: The aim of the study was to evaluate the effect of a structured group education program administered by a primary care nurse in patients with type 2 diabetes mellitus. The sample included 137 patients with type 2 diabetes mellitus, randomized into two groups: intervention (5-week educational course and reinforcements every 4 months for one year) and control (with no structured diabetes mellitus education) with an evaluation of metabolic control, weight, blood pressure, distress scores, and knowledge on diabetes. There were no differences between the two groups in HbA1c at 4, 8, or 12 months when compared to baseline values. An increase in HbA1c was observed in the control group after adjusting for baseline HbA1c and insulin dose (p = 0.044 between groups). Knowledge scores and diabetes-related distress improved after the intervention. A structured educational program administered to type 2 diabetes mellitus patients seen at a primary care unit improved the knowledge and distress associated with the disease. The results also suggest the prevention of an increase in HbA1c.
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Affiliation(s)
| | | | | | | | - Luis Beloli
- Universidade Federal do Rio Grande do Sul, Brazil
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13
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Davies M, Sasaki T, Gross JL, Bantwal G, Ono Y, Nishida T, Tojjar D, Seino H. Comparison of insulin degludec with insulin detemir in type 1 diabetes: a 1-year treat-to-target trial. Diabetes Obes Metab 2016; 18:96-9. [PMID: 26435472 DOI: 10.1111/dom.12573] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 11/26/2022]
Abstract
The long-term safety and tolerability of insulin degludec (IDeg) was compared with that of insulin detemir (IDet), as basal treatment in participants with type 1 diabetes mellitus (T1DM). In the present multinational, 26-week core + 26-week extension, controlled, open-label, parallel-group trial, adults with T1DM were randomized to IDeg or IDet as basal insulin treatment combined with meal-time bolus insulin aspart. IDeg was administered once daily, whilst IDet was administered once or twice daily depending on patients' glycaemic control. After 1 year, IDeg provided a 33% lower rate of nocturnal hypoglycaemia compared with IDet: estimated rate ratio (IDeg : IDet) 0.67 [95% confidence interval (CI) 0.51; 0.88]; p < 0.05. IDeg improved glycated haemoglobin after 1 year of treatment, similarly to IDet, but IDeg also provided a significantly greater reduction in fasting plasma glucose compared with IDet: estimated difference (IDeg - IDet) -1.11 (95% CI -1.83; -0.40) mmol/l; p < 0.05. The present study confirmed the long-term safety and tolerability profile of IDeg in patients with T1DM. IDeg provided a lower risk of nocturnal confirmed hypoglycaemia than IDet.
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Affiliation(s)
- M Davies
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
| | - T Sasaki
- Internal Medicine, Sasaki Hospital Internal Medicine, Hokkaido, Japan
| | - J L Gross
- Centro de Pesquisas em Diabetes, Porto Alegre, Brazil
| | - G Bantwal
- Department of Endocrinology, St. Johns Medical College Bangalore, Bangalore, India
| | - Y Ono
- Internal Medicine, Yuri Ono Clinic, Hokkaido, Japan
| | - T Nishida
- Novo Nordisk Pharma Ltd, Tokyo, Japan
| | - D Tojjar
- Novo Nordisk A/S, Søborg, Denmark
| | - H Seino
- Internal Medicine, Seino Internal Medicine Clinic, Fukushima, Japan
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14
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Pinto LC, Rados DV, Remonti LR, Kramer CK, Leitao CB, Gross JL. Efficacy of SGLT2 inhibitors in glycemic control, weight loss and blood pressure reduction: a systematic review and meta-analysis. Diabetol Metab Syndr 2015. [PMCID: PMC4653505 DOI: 10.1186/1758-5996-7-s1-a58] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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15
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Vora J, Cariou B, Evans M, Gross JL, Harris S, Landstedt-Hallin L, Mithal A, Rodriguez MR, Meneghini L. Clinical use of insulin degludec. Diabetes Res Clin Pract 2015; 109:19-31. [PMID: 25963320 DOI: 10.1016/j.diabres.2015.04.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 03/27/2015] [Accepted: 04/03/2015] [Indexed: 12/25/2022]
Abstract
The limitations of current basal insulin preparations include concerns related to their pharmacokinetic and pharmacodynamic properties, hypoglycaemia, weight gain, and perception of management complexity, including rigid dosing schedules. Insulin degludec (IDeg) is a novel basal insulin with improved pharmacokinetic and pharmacodynamic properties compared to insulin glargine (IGlar) including a long half-life of ∼25 h and a duration of action >42 h at steady state, providing a flat and stable blood glucose-lowering effect when injected once daily. Evidence from phase 3a clinical trials with a treat-to-target design in patients with type 1 and type 2 diabetes has shown that IDeg has similar efficacy to IGlar, with a 9% and 26% reduction in risk of overall and nocturnal hypoglycaemia, respectively (in the pooled population) during the entire treatment period, and a 16% and 32% reduction during the maintenance period, respectively. Given its pharmacodynamic properties, IDeg offers a broad dosing window, allowing for flexible dose administration, if required. Two different formulations of IDeg are available (100 units/mL [U100] and 200 units/mL), the latter providing the same IDeg dose as the U100 formulation in half the injection volume. The unique pharmacokinetic profile of IDeg facilitates glycaemic control while minimising the risk of nocturnal hypoglycaemia.
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Affiliation(s)
- Jiten Vora
- Department of Endocrinology and Diabetes, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK.
| | - Bertrand Cariou
- Clinique d'Endocrinologie, l'Institut du Thorax, CHU Nantes, Nantes, France
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | | | - Stewart Harris
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lena Landstedt-Hallin
- Karolinska Institute, Department of Clinical Sciences, Division of Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Ambrish Mithal
- Division of Endocrinology and Diabetes, Medanta the Medicity, Gurgaon, Haryana, India
| | | | - Luigi Meneghini
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health & Hospital System, Dallas, TX, USA
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Abstract
BACKGROUND Thyroid nodules are a common finding in the general population, and their detection is increasing with the widespread use of ultrasound (US). Thyroid cancer is found in 5-15% of cases depending on sex, age, and exposure to other risk factors. Some US parameters have been associated with increased risk of malignancy. However, no characteristic seems sufficiently reliable in isolation to diagnose malignancy. The objective of this meta-analysis was to evaluate the diagnostic performance of US features for thyroid malignancy in patients with unselected thyroid nodules and nodules with indeterminate fine-needle aspiration (FNA) cytology. METHODS Electronic databases were reviewed for studies published prior to July 2012 that evaluated US features of thyroid nodules and reported postoperative histopathologic diagnosis. A manual search of references of review and key articles, and previous meta-analyses was also performed. A separate meta-analysis was performed including only nodules with indeterminate cytology. Analyzed features were solid structure, hypoechogenicity, irregular margins, absence of halo, microcalcifications, central vascularization, solitary nodule, heterogeneity, taller than wide shape, and absence of elasticity. RESULTS Fifty-two observational studies (12,786 nodules) were included. Nine studies included nodules with indeterminate cytology as a separate category, comprising 1851 nodules. In unselected nodules, all US features were significantly associated with malignancy with an odds ratio varying from 1.78 to 35.7, and microcalcifications, irregular margins, and a taller than wide shape had high specificities (Sp; 87.8%, 83.1%, 96.6%) and positive likelihood ratios (LHR; 3.26, 2.99, 8.07). Absence of elasticity was the single feature with the best diagnostic performance (sensitivity 87.9%, Sp 86.2%, and positive LHR 6.39). The presence of central vascularization was the most specific US feature in nodules with indeterminate cytology (Sp 96% and positive LHR 2.13). CONCLUSIONS US features in isolation do not provide reliable information to select nodules that should have a FNA performed. A combination of US characteristics with higher likelihood ratios and consequently with higher post-test probabilities of malignancy-microcalcifications, or a taller than wide shape, or irregular margins, or absence of elasticity-will probably identify nodules with an increased risk for malignancy. Further studies are required to standardize elastography techniques and evaluate outcomes, especially in nodules with an indeterminate cytology.
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Affiliation(s)
- Luciana Reck Remonti
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - Lana Catani F. Pinto
- Department of Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jorge Luiz Gross
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Cavagnolli G, Pimentel AL, Freitas PAC, Gross JL, Camargo JL. Factors affecting A1C in non-diabetic individuals: Review and meta-analysis. Clin Chim Acta 2015; 445:107-14. [PMID: 25818244 DOI: 10.1016/j.cca.2015.03.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 12/16/2022]
Abstract
We carried out a systematic review and meta-analyses of studies that evaluated the possible effects of anemia, variant hemoglobin, and uremia on A1C levels in individuals without diabetes (DM). Medline and Embase were searched for studies that measured A1C values in groups with and without iron deficiency anemia (IDA) and/or iron deficiency (ID), variant hemoglobin and/or uremia by standardized methods. The difference between A1C levels in the groups with and without interferences was obtained by using random-effects meta-analysis and the effect size was presented as absolute difference of means (95% CI). Ten studies fulfilled the inclusion criteria, providing data from 11,176 participants without DM. There were no statistically significant differences in A1C in the presence of IDA/ID, HbS, and uremia by HPLC and uremia by immunoassay [0.79% (95% IC -0.39; 1.97), -0.13% (95% IC -0.51; 0.26), 0.15% (95% CI -0.58; 0.88) and -0.19% (95% CI -0.78; 0.40), respectively]. The effects of HbAS and uremia on A1C levels are within the expected individual variation and should not affect A1C results to diagnose DM. However, the effects of IDA/ID remain inconclusive and further studies are needed to clarify the glycation mechanisms in individuals with IDA/ID without diabetes.
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Affiliation(s)
- Gabriela Cavagnolli
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ana Laura Pimentel
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | | | - Jorge Luiz Gross
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Joíza Lins Camargo
- Graduate Program in Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
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18
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Viana LV, Gross JL, Azevedo MJ. Dietary intervention in patients with gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials on maternal and newborn outcomes. Diabetes Care 2014; 37:3345-55. [PMID: 25414390 DOI: 10.2337/dc14-1530] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Diet is the cornerstone treatment of patients with gestational diabetes mellitus (GDM), but its role in maternal and newborn outcomes has been scarcely studied. The purpose of this study was to analyze the efficacy of dietary interventions on maternal or newborn outcomes in patients with GDM. RESEARCH DESIGN AND METHODS A systematic review and meta-analysis of randomized clinical trials (RCTs) of dietary intervention in GDM or pregnancy with hyperglycemia was performed. MEDLINE, Embase, ClinicalTrials.gov, Cochrane, and Scopus were searched through to March 2014. The main evaluated maternal outcomes were proportion of patients using insulin and proportion of cesarean delivery; the newborn outcomes were proportion of macrosomia and hypoglycemia and newborn weight. RESULTS From 1,170 studies, nine RCTs, including 884 women aged 31.5 years (28.7-33.2) with 27.4 weeks (24.1-30.3) of gestation, were eligible. We divided the RCTs according to the type of dietary intervention: low glycemic index (GI) (n = 4; 257 patients), total energy restriction (n = 2; 425 patients), low carbohydrates (n = 2; 182 patients), and others (n = 1; 20 patients). Diet with low GI reduced the proportion of patients who used insulin (relative risk 0.767 [95% CI 0.597, 0.986]; P = 0.039) and the newborn birth weight (weight mean differences -161.9 g [95% CI -246.4, -77.4]; P = 0.000) as compared with control diet. Total restriction and low carbohydrate diets did not change either maternal or newborn outcomes. CONCLUSIONS A low GI diet was associated with less frequent insulin use and lower birth weight than control diets, suggesting that it is the most appropriate dietary intervention to be prescribed to patients with GDM.
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Affiliation(s)
- Luciana Verçoza Viana
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jorge Luiz Gross
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Mirela Jobim Azevedo
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Tinahones FJ, Gross JL, Onaca A, Cleall S, Rodríguez A. Insulin lispro low mixture twice daily versus basal insulin glargine once daily and prandial insulin lispro once daily in patients with type 2 diabetes requiring insulin intensification: a randomized phase IV trial. Diabetes Obes Metab 2014; 16:963-70. [PMID: 24725616 PMCID: PMC4237554 DOI: 10.1111/dom.12303] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/19/2014] [Accepted: 04/04/2014] [Indexed: 11/28/2022]
Abstract
AIMS To compare the efficacy and safety of two insulin intensification strategies in patients with type 2 diabetes inadequately controlled on basal insulin glargine with metformin and/or pioglitazone. METHODS A multinational, randomized, open-label trial that compared insulin lispro low mixture (LM25; n = 236) twice daily with a basal-prandial regimen of insulin glargine once daily and insulin lispro once daily (IGL; n = 240) over 24 weeks in patients with HbA1c 7.5-10.5% and fasting plasma glucose ≤ 6.7 mmol/l. The primary objective was to assess non-inferiority [per-protocol (PP) population], and then superiority [intention-to-treat (ITT) population], of LM25 versus IGL according to change in HbA1c after 24 weeks (non-inferiority margin 0.4%, two-sided significance level 0.05). RESULTS Estimated change [least squares (LS) mean (95% CI)] in HbA1c after 24 weeks: -1.30 (-1.44, -1.16)% with LM25 and -1.08 (-1.22, -0.94)% with IGL. Non-inferiority was shown [LS mean (95% CI) HbA1c treatment difference -0.21 (-0.38, -0.04) (PP population)]; gated superiority assessment showed a statistically significant advantage for LM25 (p = 0.010; ITT population). Mean blood glucose, glycaemic variability, overall tolerability and hypoglycaemic episodes per patient-year did not show significant differences between treatments during the study. CONCLUSIONS In patients with type 2 diabetes inadequately controlled on once-daily basal insulin glargine and metformin and/or pioglitazone, intensification with LM25 was superior to a basal-prandial approach in terms of reduction in HbA1c after 24 weeks and did not increase hypoglycaemia episodes.
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Affiliation(s)
- F J Tinahones
- Hospital Universitario Virgen de la Victoria, Málaga and CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Malaga, Spain
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20
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Davies MJ, Gross JL, Ono Y, Sasaki T, Bantwal G, Gall MA, Niemeyer M, Seino H. Efficacy and safety of insulin degludec given as part of basal-bolus treatment with mealtime insulin aspart in type 1 diabetes: a 26-week randomized, open-label, treat-to-target non-inferiority trial. Diabetes Obes Metab 2014; 16:922-30. [PMID: 24702700 PMCID: PMC4237553 DOI: 10.1111/dom.12298] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/05/2014] [Accepted: 03/31/2014] [Indexed: 01/09/2023]
Abstract
AIMS The efficacy and safety of insulin degludec (IDeg) was compared with insulin detemir (IDet), both administered once daily (OD) as basal treatment in participants with type 1 diabetes mellitus (T1DM). The primary outcome was non-inferiority of IDeg to IDet in glycated haemoglobin (HbA1c) reduction after 26 weeks. METHODS This multinational, 26-week, controlled, open-label, parallel-group trial randomized adults with T1DM to IDeg or IDet as OD basal insulin treatment combined with mealtime bolus insulin aspart (IAsp). Participants with T1DM treated with any basal-bolus insulin regimen for ≥ 12 months prior to the trial, a mean HbA1c ≤ 10.0% (85.8 mmol/mol) and body mass index (BMI) ≤ 35.0 kg/m(2) at screening participated in the trial (IDeg: N = 302; IDet: N = 153). RESULTS After 26 weeks, HbA1c decreased 0.73% (8.0 mmol/mol) (IDeg) and 0.65% (7.1 mmol/mol) (IDet) [estimated treatment difference (ETD) IDeg-IDet: -0.09% (-0.23; 0.05)95% CI (-10.0 mmol/mol [-2.6; 0.6]95% CI ); confirming non-inferiority]. Mean fasting plasma glucose improved in both groups, and was lower with IDeg than IDet [ETD IDeg-IDet: -1.66 mmol/l (-2.37; -0.95)95% CI , p < 0.0001]. The rate of confirmed hypoglycaemia was similar with IDeg and IDet [45.83 vs. 45.69 episodes per patient-year of exposure (PYE); estimated rate ratio (RR) IDeg/IDet: 0.98 (0.80; 1.20)95% CI , p = 0.86]. The rate of nocturnal confirmed hypoglycaemia was lower with IDeg than IDet [4.14 vs. 5.93 episodes per PYE; RR IDeg/IDet: 0.66 (0.49; 0.88)95% CI , p = 0.0049]. Adverse event profiles were similar between groups. CONCLUSION IDeg administered OD in basal-bolus therapy effectively improved long-term glycaemic control in participants with T1DM with a lower risk of nocturnal confirmed hypoglycaemia than IDet.
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Affiliation(s)
- M J Davies
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
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dos Santos ALT, Weiss T, Duarte CK, Gross JL, de Azevedo MJ, Zelmanovitz T. Dietary fat composition and cardiac events in patients with type 2 diabetes. Atherosclerosis 2014; 236:31-8. [PMID: 25014032 DOI: 10.1016/j.atherosclerosis.2014.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 05/07/2014] [Accepted: 06/18/2014] [Indexed: 02/04/2023]
Abstract
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..
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Affiliation(s)
- Ana Luiza Teixeira dos Santos
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350/ Prédio 12, 4° andar, CEP 90035-003 Porto Alegre, RS, Brazil.
| | - Tanara Weiss
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350/ Prédio 12, 4° andar, CEP 90035-003 Porto Alegre, RS, Brazil.
| | - Camila Kümmel Duarte
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350/ Prédio 12, 4° andar, CEP 90035-003 Porto Alegre, RS, Brazil.
| | - Jorge Luiz Gross
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350/ Prédio 12, 4° andar, CEP 90035-003 Porto Alegre, RS, Brazil.
| | - Mirela Jobim de Azevedo
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350/ Prédio 12, 4° andar, CEP 90035-003 Porto Alegre, RS, Brazil.
| | - Themis Zelmanovitz
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350/ Prédio 12, 4° andar, CEP 90035-003 Porto Alegre, RS, Brazil.
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Viana MV, Moraes RB, Fabbrin AR, Santos MF, Torman VBL, Vieira SR, Gross JL, Canani LH, Gerchman F. Contrasting effects of preexisting hyperglycemia and higher body size on hospital mortality in critically ill patients: a prospective cohort study. BMC Endocr Disord 2014; 14:50. [PMID: 24941997 PMCID: PMC4072488 DOI: 10.1186/1472-6823-14-50] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 06/11/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Obesity and diabetes mellitus are well-defined risk factors for cardiovascular mortality. The impact of antecedent hyperglycemia and body size on mortality in critical ill patients in intensive care units (ICUs) may vary across their range of values. Therefore, we prospectively analyzed the relationship between in-hospital mortality and preexisting hyperglycemia and body size in critically ill ICU patients to understand how mortality varied among normal, overweight, and obese patients and those with low, intermediate, and high glycated hemoglobin (HbA1c) levels. METHODS Medical history, weight, height, physiologic variables, and HbA1c were obtained during the first 24 h for patients who were consecutively admitted to the high complexity ICU of Hospital de Clínicas de Porto Alegre, Brazil, from April to August 2011. The relationships between mortality and obesity and antecedent hyperglycemia were prospectively analyzed by cubic spline analysis and a Cox proportional hazards model. RESULTS The study comprised 199 patients. The overall hospital mortality rate was 43.2% during a median 16 (8-28) days of follow-up. There was a progressive risk of in-hospital mortality with higher HbA1c levels, with the relationship becoming significant at HbA1c >9.3% compared with lower levels (hazard ratio 1.74; 95% confidence interval with Bonferroni correction 1.49-2.80). In contrast, mean body mass index (BMI) was higher in survivors than in nonsurvivors (27.2 kg/m2 ± 7.3 vs. 24.7 kg/m2 ± 5.0 P = 0.031, respectively). Cubic spline analysis showed that these relationships differed nonlinearly through the spectrum of BMI values. In a Cox proportional hazards model adjusted for Acute Physiology and Chronic Health Evaluation II score and HbA1c, the risk of in-hospital mortality progressively decreased with increasing BMI (BMI <20 vs. 20-23.9 kg/m2, P = 0.032; BMI <20 vs. 24-34.9 kg/m2, P = 0.010; BMI <20 vs. ≥35 kg/m2, P = 0.032). CONCLUSIONS Our findings suggest that significant hyperglycemia prior to ICU admission is a risk factor for in-hospital mortality. Conversely, increasing BMI may confer an advantageous effect against mortality in critical illness independently of previous glycemic control.
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Affiliation(s)
- Marina Verçoza Viana
- Intensive Care Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Rafael Barberena Moraes
- Intensive Care Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Amanda Rodrigues Fabbrin
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Manoella Freitas Santos
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Vanessa Bielefeldt Leotti Torman
- Department of Statistics, Federal University of Rio Grande do Sul, and Research and Post-Graduation Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Silvia Regina Vieira
- Intensive Care Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Jorge Luiz Gross
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Luis Henrique Canani
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernando Gerchman
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Affiliation(s)
- Jorge Luiz Gross
- Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Caroline K Kramer
- Division of Endocrinology, University of Toronto and Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Luciana Reck Remonti
- Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
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Rosenstock J, Gross JL, Aguilar-Salinas C, Hissa M, Berglind N, Ravichandran S, Fleming D. Long-term 4-year safety of saxagliptin in drug-naive and metformin-treated patients with Type 2 diabetes. Diabet Med 2013; 30:1472-6. [PMID: 23802840 DOI: 10.1111/dme.12267] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 04/05/2013] [Accepted: 06/18/2013] [Indexed: 01/13/2023]
Abstract
AIMS To evaluate the safety of saxagliptin ± metformin over 4 years in patients with Type 2 diabetes mellitus. METHODS Drug-naive (n = 401; study 11) or metformin-treated (n = 743; study 14) adults with HbA(1c) of 53-86 mmol/mol (7.0-10%) were enrolled in two randomized, placebo-controlled, double-blind trials of saxagliptin 2.5, 5 or 10 mg/day. Patients rescued during or completing 24 weeks of treatment could continue in a 42-month long-term blinded phase, for which the primary goal was assessment of safety and tolerability. Between-group efficacy was not evaluated in the long-term phase of study 11. Time to rescue or discontinuation because of inadequate glycaemic control, change from baseline in HbA(1c) and percentages of patients achieving HbA(1c) < 53 mmol/mol (< 7.0%) were assessed in study 14. RESULTS No new safety findings were noted during the long-term phase. Most adverse events were mild or moderate, with slightly greater frequency of upper respiratory infections with saxagliptin. Hypoglycaemic event rates were similar with saxagliptin and placebo. In study 14, time to rescue or discontinuation because of inadequate glycaemic control was longer with saxagliptin plus metformin than for placebo plus metformin. From baseline to week 154, HbA(1c) decreased with saxagliptin but increased with placebo. CONCLUSION Saxagliptin monotherapy or add-on to metformin is generally safe and well tolerated, with no increased risk of hypoglycaemia, for up to 4 years.
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Affiliation(s)
- J Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX, USA
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Silva FM, Kramer CK, de Almeida JC, Steemburgo T, Gross JL, Azevedo MJ. Fiber intake and glycemic control in patients with type 2 diabetes mellitus: a systematic review with meta-analysis of randomized controlled trials. Nutr Rev 2013; 71:790-801. [DOI: 10.1111/nure.12076] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Flávia M Silva
- Endocrine Division; Hospital de Clínicas de Porto Alegre; Universidade Federal do Rio Grande do Sul; Porto Alegre Brazil
| | - Caroline K Kramer
- Endocrine Division; Hospital de Clínicas de Porto Alegre; Universidade Federal do Rio Grande do Sul; Porto Alegre Brazil
| | - Jussara C de Almeida
- Nutrition Course; Faculdade de Medicina; Universidade Federal do Rio Grande do Sul; Porto Alegre Brazil
| | - Thais Steemburgo
- Nutrition Course; Faculdade de Medicina; Universidade Federal do Rio Grande do Sul; Porto Alegre Brazil
| | - Jorge Luiz Gross
- Endocrine Division; Hospital de Clínicas de Porto Alegre; Universidade Federal do Rio Grande do Sul; Porto Alegre Brazil
| | - Mirela J Azevedo
- Endocrine Division; Hospital de Clínicas de Porto Alegre; Universidade Federal do Rio Grande do Sul; Porto Alegre Brazil
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26
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Canani LH, Copstein E, Pecis M, Friedman R, Leitão CB, Azevedo MJ, Triches C, Rados DRV, Moreas RS, Gross JL. Cardiovascular autonomic neuropathy in type 2 diabetes mellitus patients with peripheral artery disease. Diabetol Metab Syndr 2013; 5:54. [PMID: 24295032 PMCID: PMC3849595 DOI: 10.1186/1758-5996-5-54] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 09/17/2013] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate possible associations between cardiovascular autonomic dysfunction and peripheral artery disease (PAD) in patients with type 2 diabetes mellitus. RESEARCH DESIGN AND METHODS In this cross-sectional study, 67 patients with type 2 diabetes were included. PAD was identified by Doppler ultrasonography: systolic ankle-brachial pressure index <0.9. Cardiovascular autonomic function, besides five conventional cardiovascular autonomic function tests, was assessed by heart rate variability (HRV; 24-h ambulatory ECG recording) in time and frequency domains (spectral analyses) and three dimensional return maps. Power spectral analyses (PSA) were quantified in low frequency (LF), high frequency (HF), and very low frequency. RESULTS Patients with PAD (n = 30) had longer diabetes duration, higher systolic blood pressure (BP), waist-to-hip ratio, HbA1C test, and urinary albumin excretion (UAE) than patients without PAD. Most HRV indices in time domain were lower in patients with than without PAD. These patients also had lower PSA indices (LF=0.19±0.07 vs. 0.29±0.11 n.u.; LF/HF ratio=1.98±0.9 vs. 3.35±1.83; P< 0.001) and indices of sympathetic (three-dimensional return map: P1-night 61.7±9.4 vs. 66.8±9.7; P=0.04) and vagal (24-h P2 54.5±15.2 vs. 62.7±2.9; P< 0.02) activities (arbitrary units) than patients without PAD. Multivariate logistic regression analyses, adjusted for systolic BP, DM duration, HbA1C test, and UAE, confirmed the associations between impaired autonomic modulation and PAD, except for P1 index. CONCLUSION In conclusion, patients with type 2 diabetes with PAD had lower HRV indices than patients without PAD, reflecting a dysfunction of cardiovascular autonomic modulation.
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Affiliation(s)
- Luís Henrique Canani
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Eduardo Copstein
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Miriam Pecis
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Rogério Friedman
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Cristiane Bauermann Leitão
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Mirela Jobim Azevedo
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Cristina Triches
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Dimitris Rucks Varvaki Rados
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
| | - Ruy Silveira Moreas
- Cardiology Division of Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jorge Luiz Gross
- Endocrine Division, Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Prédio 12, 4º andar, Porto Alegre, Rio Grande do Sul, 90035-003, Brazil
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Abstract
Brazil is expected to have 19.6 million patients with diabetes by the year 2030. A key concept in the treatment of type 2 diabetes mellitus (T2DM) is establishing individualized glycemic goals based on each patient's clinical characteristics, which impact the choice of antihyperglycemic therapy. Targets for glycemic control, including fasting blood glucose, postprandial blood glucose, and glycated hemoglobin (A1C), are often not reached solely with antihyperglycemic therapy, and insulin therapy is often required. Basal insulin is considered an initial strategy; however, premixed insulins are convenient and are equally or more effective, especially for patients who require both basal and prandial control but desire a more simplified strategy involving fewer daily injections than a basal-bolus regimen. Most physicians are reluctant to transition patients to insulin treatment due to inappropriate assumptions and insufficient information. We conducted a nonsystematic review in PubMed and identified the most relevant and recently published articles that compared the use of premixed insulin versus basal insulin analogues used alone or in combination with rapid-acting insulin analogues before meals in patients with T2DM. These studies suggest that premixed insulin analogues are equally or more effective in reducing A1C compared to basal insulin analogues alone in spite of the small increase in the risk of nonsevere hypoglycemic events and nonclinically significant weight gain. Premixed insulin analogues can be used in insulin-naïve patients, in patients already on basal insulin therapy, and those using basal-bolus therapy who are noncompliant with blood glucose self-monitoring and titration of multiple insulin doses. We additionally provide practical aspects related to titration for the specific premixed insulin analogue formulations commercially available in Brazil.
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Affiliation(s)
- Marcos Antônio Tambascia
- Faculty of Medical Sciences, State University of Campinas, Brazil Rua Frei Manoel da Ressurreição 965, Campinas, SP, Brazil
| | - Márcia Nery
- Diabetes Unit - Endocrinology and Metabolism Service, Clinical Hospital of Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Jorge Luiz Gross
- Department of Internal Medicine, Faculty of Medicine of Federal University of Rio Grande do Sul, Rio Grande do Sul, Brazil
| | - Mariana Narbot Ermetice
- Diabetes Group, Eli Lilly do Brazil São Paulo, São Paulo, Brazil
- Currently at Novo Nordisk Brazil, São Paulo, Brazil
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Grillo MDFF, Neumann CR, Scain SF, Rozeno RF, Gross JL, Leitão CB. Effect of different types of self-management education in patients with diabetes. Rev Assoc Med Bras (1992) 2013; 59:400-5. [PMID: 23850026 DOI: 10.1016/j.ramb.2013.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 12/30/2012] [Accepted: 02/11/2013] [Indexed: 11/29/2022] Open
Abstract
Education plays an important role in diabetes mellitus (DM) treatment, as it enables patients to manage their disease. There is a wide range of tested educational interventions, and, to date, no universal model that can be standardized and recognized as effective for all individuals with the disease has been defined. This article aims to review the effect of different types of educational interventions for self-management of glycemic control in patients with DM type 2, in addition to define general recommendations for this treatment strategy.
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Ferreira FN, Crispim D, Canani LH, Gross JL, dos Santos KG. Association study of sorbitol dehydrogenase -888G>C polymorphism with type 2 diabetic retinopathy in Caucasian-Brazilians. Exp Eye Res 2013; 115:140-3. [PMID: 23850972 DOI: 10.1016/j.exer.2013.06.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/27/2013] [Indexed: 11/26/2022]
Abstract
Diabetic retinopathy (DR) is a common chronic complication of diabetes and remains the leading cause of blindness in working-aged people. Hyperglycemia increases glucose flux through the polyol pathway, in which aldose reductase converts glucose into intracellular sorbitol, which is subsequently converted to fructose by sorbitol dehydrogenase (SDH). The accelerated polyol pathway triggers a cascade of events leading to retinal vascular endothelial dysfunction and the eventual development of DR. Polymorphisms in the gene encoding aldose reductase have been consistently associated with DR. However, only two studies have analyzed the relationship between polymorphisms in the gene encoding SDH (SORD) and DR. In this case-control study, we investigated whether the -888G > C polymorphism (rs3759890) in the SORD gene is associated with the presence or severity of DR in 446 Caucasian-Brazilians with type 2 diabetes (241 subjects with and 205 subjects without DR). The -888G > C polymorphism was also examined in 105 healthy Caucasian blood donors, and the genotyping of this polymorphism was carried out by real-time PCR. The genotype and allele frequencies of the -888G > C polymorphism in patients with type 2 diabetes were similar to those of blood donors (G allele frequency = 0.16 in both groups of subjects). Similarly, the genotype and allele frequencies in patients with DR or the proliferative form of DR were similar to those of patients without this complication (P > 0.05 for all comparisons). Thus, our findings suggest that the -888G > C polymorphism in the SORD gene is not involved in the pathogenesis of DR in type 2 diabetes.
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Affiliation(s)
- Fábio Netto Ferreira
- Laboratory of Human Molecular Genetics, Universidade Luterana do Brasil, Canoas, Brazil
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Brondani LDA, Assmann TS, Duarte GCK, Gross JL, Canani LH, Crispim D. The role of the uncoupling protein 1 (UCP1) on the development of obesity and type 2 diabetes mellitus. ACTA ACUST UNITED AC 2013; 56:215-25. [PMID: 22790465 DOI: 10.1590/s0004-27302012000400001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 06/10/2012] [Indexed: 12/19/2022]
Abstract
It is well established that genetic factors play an important role in the development of both type 2 diabetes mellitus (DM2) and obesity, and that genetically susceptible subjects can develop these metabolic diseases after being exposed to environmental risk factors. Therefore, great efforts have been made to identify genes associated with DM2 and/or obesity. Uncoupling protein 1 (UCP1) is mainly expressed in brown adipose tissue, and acts in thermogenesis, regulation of energy expenditure, and protection against oxidative stress. All these mechanisms are associated with the pathogenesis of DM2 and obesity. Hence, UCP1 is a candidate gene for the development of these disorders. Indeed, several studies have reported that polymorphisms -3826A/G, -1766A/G and -112A/C in the promoter region, Ala64Thr in exon 2 and Met299Leu in exon 5 of UCP1 gene are possibly associated with obesity and/or DM2. However, results are still controversial in different populations. Thus, the aim of this study was to review the role of UCP1 in the development of these metabolic diseases.
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Affiliation(s)
- Letícia de Almeida Brondani
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, RS, Brazil
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Naim Younes R, Gross JL, Abrao FG, Rodrigues Pereira J. Impact of adjuvant chemotherapy in completely resected stage IIIA non-small cell lung cancer. MINERVA CHIR 2013; 68:169-174. [PMID: 23612230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
AIM Outcome of patients with locally advanced non-small-cell lung cancer (NCSLC) is generally poor, with five-year survival rate of only 23%, when patients are treated with surgery only. The presentation of positive adjuvant therapy trials in NSCLC has changed clinical practice, doubling the number of patients with completely resected NSCLC referred for adjuvant chemotherapy since 2004. Furthermore, few large studies described a large number of stage III patients in non-Asiatic patients and they showed controversial results about survival in completely resected stage IIIA NSCLC. The objective of this study was to evaluate the impact of adjuvant chemotherapy in completely resected stage IIIA NCSLC, administered on a routine basis, outside clinical trials. METHODS This is a retrospective study of patients with stage IIIA NCSLC treated between 1990 and 2008, and included in a continuous, consecutive database. Inclusion criteria were: age >18 years, complete surgical resection, and pathologically confirmed as stage IIIA. The following clinical data were obtained: age, gender, performance status, histological type, chemotherapy regimens, status at last follow-up and hospital where the treatment occurred. Kaplan-Meier's method was used to determine actuarial survival. Differences in survival were determined by Breslow and log rank analyses. RESULTS According to these inclusion criteria, 415 patients were considered for the present study. The median follow-up time of all patients was 38.2 months. The adjuvant chemotherapeutic treatment affected survival significantly (P <0.001). Also the type of chemotherapeutic treatment affected survival (P ≤0.001). CONCLUSION Cisplatin-based adjuvant chemotherapy was beneficial in patients who had a completed resected stage IIIA carcinoma.
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Affiliation(s)
- R Naim Younes
- Department of Surgery, University of Sao Paulo, Sao Paulo, Brazil.
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Gross JL, Rogers J, Polhamus D, Gillespie W, Friedrich C, Gong Y, Monz BU, Patel S, Staab A, Retlich S. A novel model-based meta-analysis to indirectly estimate the comparative efficacy of two medications: an example using DPP-4 inhibitors, sitagliptin and linagliptin, in treatment of type 2 diabetes mellitus. BMJ Open 2013; 3:e001844. [PMID: 23468467 PMCID: PMC3612798 DOI: 10.1136/bmjopen-2012-001844] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 01/31/2013] [Accepted: 02/07/2013] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To develop a longitudinal statistical model to indirectly estimate the comparative efficacies of two drugs, using model-based meta-analysis (MBMA). Comparison of two oral dipeptidyl peptidase (DPP)-4 inhibitors, sitagliptin and linagliptin, for type 2 diabetes mellitus (T2DM) treatment was used as an example. DESIGN Systematic review with MBMA. DATA SOURCES MEDLINE, EMBASE, http://www.ClinicalTrials.gov, Cochrane review of DPP-4 inhibitors for T2DM, sitagliptin trials on Food and Drug Administration website to December 2011 and linagliptin data from the manufacturer. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Double-blind, randomised controlled clinical trials, ≥12 weeks' duration, that analysed sitagliptin or linagliptin efficacies as changes in glycated haemoglobin (HbA1c) levels, in adults with T2DM and HbA1c >7%, irrespective of background medication. MODEL DEVELOPMENT AND APPLICATION: A Bayesian model was fitted (Markov Chain Monte Carlo method). The final model described HbA1c levels as function of time, dose, baseline HbA1c, washout status/duration and ethnicity. Other covariates showed no major impact on model parameters and were not included. For the indirect comparison, a population of 1000 patients was simulated from the model with a racial composition reflecting the average racial distribution of the linagliptin trials, and baseline HbA1c of 8%. RESULTS The model was developed using longitudinal data from 11 234 patients (10 linagliptin, 15 sitagliptin trials), and assessed by internal evaluation techniques, demonstrating that the model adequately described the observations. Simulations showed both linagliptin 5 mg and sitagliptin 100 mg reduced HbA1c by 0.81% (placebo-adjusted) at week 24. Credible intervals for participants without washout were -0.88 to -0.75 (linagliptin) and -0.89 to -0.73 (sitagliptin), and for those with washout, -0.91 to -0.76 (linagliptin) and -0.91 to -0.75 (sitagliptin). CONCLUSIONS This study demonstrates the use of longitudinal MBMA in the field of diabetes treatment. Based on an example evaluating HbA1c reduction with linagliptin versus sitagliptin, the model used seems a valid approach for indirect drug comparisons.
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Affiliation(s)
- Jorge Luiz Gross
- Endocrine Division, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sol, Brazil
| | - James Rogers
- Metrum Research Group, Tariffville, Connecticut, USA
| | | | | | | | - Yan Gong
- Boehringer Ingelheim, Ingelheim, Germany
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Ferreira Grillo MDF, Neumann CR, Scain SF, Rozeno RF, Gross JL, Leitão CB. Effect of different types of self-management education in patients with diabetes. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/s2255-4823(13)70494-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Viana LV, Gross JL, Camargo JL, Zelmanovitz T, da Costa Rocha EPC, Azevedo MJ. Prediction of cardiovascular events, diabetic nephropathy, and mortality by albumin concentration in a spot urine sample in patients with type 2 diabetes. J Diabetes Complications 2012; 26:407-12. [PMID: 22677793 DOI: 10.1016/j.jdiacomp.2012.04.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 04/21/2012] [Accepted: 04/23/2012] [Indexed: 11/16/2022]
Abstract
AIMS To analyze in a random urine spot the predictive value of urinary albumin concentration (UAC) for cardiovascular events, diabetic nephropathy (DN), and death in patients with type 2 diabetes. METHODS In this cohort, urinary albumin (immunoturbidimetry) was measured as 24-h urinary albumin excretion (UAE) and, in a random spot urine, as UAC and albumin:creatinine ratio (ACR). Primary outcomes were: 1) cardiovascular events, 2) DN defined as a composite outcome [macroalbuminuria and/or decreased glomerular filtration rate (GFR) <60 ml/min/1.73 m²], and 3) death. RESULTS A total of 199 type 2 diabetic patients, aged 59.9 ± 9.9 years, were followed for 6.1 ± 2.7 years. UAC ≥14.4 mg/l, as determined by ROC curve, predicted DN and prediction for this and other outcomes were compared with traditional microalbuminuria cutoffs for ACR and UAE. The outcomes frequency was: cardiovascular events = 26.4%, DN = 31.7% (23.5% decreased GFR; 13.6% macroalbuminuria) and death = 8.50%. In Cox analyses, UAC ≥14 mg/l increased the risk (hazard ratio, HR) for cardiovascular events 3.25 times (95% CI 1.43-7.38; P = 0.005), 4.30 for DN composite outcome (95% CI 2.22-8.32; P <0.001), and 5.51 for death (95% CI 1.16-26.22; P = 0.032). Corresponding HRs of ACR ≥30 mg/g were: 2.89 (95% CI 1.29-6.45; P = 0.009) for cardiovascular events, 4.67 (95% CI 2.34-9.34; P <0.001) for DN composite outcome and 5.07 (95% CI 1.01-24.88; P = 0.049) for death. HRs of UAE ≥30 mg/24-h were: 2.20 (95% CI 2.08-2.49; P = 0.030) for cardiovascular events, 6.76 (95% CI 3.32-13.77; P <0.001) for DN composite outcome, and 2.47 (95% CI 0.72-8.42; P = 0.150) for death. CONCLUSIONS In conclusion, random UAC ≥14 mg/l predicted cardiovascular events, diabetic nephropathy, and mortality just as well as ACR. UAC may be used to assess cardiovascular and renal risks in patients with type 2 diabetes.
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Affiliation(s)
- Luciana Verçoza Viana
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Souza CFD, Gross JL, Gerchman F, Leitão CB. Pré-diabetes: diagnóstico, avaliação de complicações crônicas e tratamento. ACTA ACUST UNITED AC 2012; 56:275-84. [DOI: 10.1590/s0004-27302012000500001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 07/19/2012] [Indexed: 02/06/2023]
Abstract
O diabetes melito do tipo 2 (DM2) é responsável por 90% dos casos de diabetes e está associado a complicações micro e macrovasculares de elevada morbimortalidade. Os indivíduos com maior risco de desenvolvimento de DM incluem aqueles com glicemia de jejum alterada (GJA) e tolerância diminuída à glicose (TDG) e especialmente aqueles com as duas condições combinadas. Esses indivíduos fazem parte de um grupo hoje conhecido como pré-diabetes. Aproximadamente 25% dos indivíduos com pré-diabetes desenvolverão DM2 em três a cinco anos. A hiperglicemia, na ausência de DM, também foi associada ao aumento no risco de doença cardiovascular. Estudos demonstraram que mudanças no estilo de vida e intervenções medicamentosas são efetivas em retardar ou prevenir o DM2 em pacientes com pré-diabetes. GJA e TDG estão associadas ao desenvolvimento de DM2 e, apesar das controvérsias, a maioria dos estudos epidemiológicos reforça a importância dessas duas condições também no desenvolvimento de doença micro e macrovascular. Assim, intervenções em pacientes com pré-diabetes são importantes na prevenção primária do DM2 e de suas complicações crônicas.
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Furtado de Souza C, Dalzochio MB, de Oliveira FJA, Gross JL, Leitão CB. Glucose tolerance status is a better predictor of diabetes and cardiovascular outcomes than metabolic syndrome: a prospective cohort study. Diabetol Metab Syndr 2012; 4:25. [PMID: 22682107 PMCID: PMC3441286 DOI: 10.1186/1758-5996-4-25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 05/17/2012] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND To evaluate the importance of oral glucose tolerance test (OGTT) in predicting diabetes and cardiovascular disease in patients with and without Metabolic Syndrome from a population treated in a primary care unit. RESEARCH DESIGN AND METHODS A prospective cohort study was conducted with subjects regularly attending the primary care unit of Hospital de Clínicas de Porto Alegre. Participants underwent a 75 g OGTT. Metabolic syndrome definition was based on the criteria of IDF/AHA/NHLBI-2010. RESULTS Participants mean age was 61 ± 12 years (males: 38%; whites: 67%). Of the 148 subjects included, 127 (86%) were followed for 36 ± 14 months, 21 (14%) were lost. Subjects were classified into four groups based on baseline OGTT: 29% normal (n = 43), 28% impaired fasting glucose (IFG; n = 42), 26% impaired glucose tolerance (IGT; n = 38), and 17% diabetes (n = 25). Metabolic syndrome prevalence was lower in normal group (28%), intermediate in IFG (62%) and IGT (65%) groups, and higher among subjects with diabetes (92%; P <0.001). Incidence of diabetes increased along with the stages of glucose metabolism disturbance (normal: 0%, IFG: 16%, IGT: 28%; P = 0.004). No patient with normal OGTT developed diabetes, regardless metabolic syndrome presence. Diabetes at baseline was the major determinant of cardiovascular disease occurrence (normal: 0%, IFG: 4%, IGT: 0%, diabetes: 24%; P = 0.001). In Cox-regression analysis, only the 2 h OGTT results were associated with diabetes (OR = 1.03; 95%CI 1.01-1.06; P <0.001) and cardiovascular disease development (OR = 1.013; 95%CI 1.002-1.025; P = 0.024). CONCLUSIONS In this sample of subjects undergoing diabetes screening, the OGTT predicted diabetes and cardiovascular disease more effectively than the metabolic syndrome status.
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Affiliation(s)
- Camila Furtado de Souza
- Primary Care, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
- Endocrine Division of Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4° andar, 90035-003, Porto Alegre, RS, Brazil
| | - Mériane Boeira Dalzochio
- Endocrine Division of Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4° andar, 90035-003, Porto Alegre, RS, Brazil
| | | | - Jorge Luiz Gross
- Endocrine Division of Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4° andar, 90035-003, Porto Alegre, RS, Brazil
| | - Cristiane Bauermann Leitão
- Endocrine Division of Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4° andar, 90035-003, Porto Alegre, RS, Brazil
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Gross JL, Park GR. Humidification of inspired gases during mechanical ventilation. Minerva Anestesiol 2012; 78:496-502. [PMID: 22269929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Humidification of inspired gas is mandatory for all mechanically ventilated patients to prevent secretion retention, tracheal tube blockage and adverse changes occurring to the respiratory tract epithelium. However, the debate over "ideal" humidification continues. Several devices are available that include active and passive heat and moisture exchangers and hot water humidifiers Each have their advantages and disadvantages in mechanically ventilated patients. This review explores each device in turn and defines their role in clinical practice.
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Affiliation(s)
- J L Gross
- Intensive Care Unit, North Middlesex, University Hospital, London, UK
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Greca LF, Pinto LC, Rados DR, Canani LH, Gross JL. Clinical features of patients with type 2 diabetes mellitus and hepatitis C infection. Braz J Med Biol Res 2012; 45:284-90. [PMID: 22286533 PMCID: PMC3854195 DOI: 10.1590/s0100-879x2012007500013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 10/06/2011] [Indexed: 02/07/2023] Open
Abstract
The objective of the present cross-sectional study was to assess the prevalence and the clinical and laboratory features of hepatitis C virus (HCV)-positive patients with type 2 diabetes mellitus (DM) attending either an outpatient clinic or hemodialysis units. Serologic-HCV testing was performed in 489 type 2 DM patients (303 outpatients and 186 on dialysis). A structured assessment of clinical, laboratory and DM-related complications was performed and the patients were then compared according to HCV infection status. Mean patient age was 60 years; HCV positivity (HCV+) was observed in 39 of 303 (12.9%) outpatients and in 34 of 186 (18.7%) dialysis patients. Among HCV+ patients, 32 were men (43.8%). HCV+ patients had higher serum levels of aspartate aminotransferase (0.90 ± 0.83 vs 0.35 ± 0.13 μKat/L), alanine aminotransferase (0.88 ± 0.93 vs 0.38 ± 0.19 μKat/L), gamma-glutamyl transferase (1.57 ± 2.52 vs 0.62 ± 0.87 μKat/L; P < 0.001), and serum iron (17.65 ± 6.68 vs 14.96 ± 4.72 μM; P = 0.011), and lower leukocyte and platelet counts (P = 0.010 and P < 0.001, respectively) than HCV-negative (HCV-) patients. HCV+ dialysis patients had higher diastolic blood pressure than HCV- patients (87.5 ± 6.7 vs 81.5 ± 6.0 mmHg; P = 0.005) and a lower prevalence of diabetic retinopathy (75 vs 92.7%; P = 0.007). In conclusion, our study showed that HCV is common among subjects with type 2 DM but is not associated with a higher prevalence of chronic diabetic complications.
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Affiliation(s)
- L F Greca
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Porto Alegre, RS, Brazil
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Zanatta CM, Veronese FV, Loreto MDS, Sortica DA, Carpio VN, Eldeweiss MIA, da Silva VD, Lopes TG, Gross JL, Canani LH. Endothelin-1 and endothelin a receptor immunoreactivity is increased in patients with diabetic nephropathy. Ren Fail 2012; 34:308-15. [PMID: 22250646 DOI: 10.3109/0886022x.2011.647301] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endothelin-1 (ET-1) is associated with progression of renal disease, acting as a vasoconstrictor and growth factor for mesangial cells. ET-1 and endothelin A receptor (ET-RA) might have a role in the development of diabetic nephropathy (DN). The aims of this study were to determine ET-1 and ET-RA expressions in patients with DN and to correlate these expressions with renal function and proteinuria. MATERIALS AND METHODS This is a cross-sectional study comprising 13 patients with type 2 diabetes mellitus and DN, 10 patients with proteinuric IgA nephropathy, and 13 samples of normal kidney from tumor nephrectomies. Demographic and selected data were collected from medical charts. The distribution and intensity of ET-1 and ET-RA immunostaining in renal biopsies were determined by immunohistochemistry and these correlated with the estimated glomerular filtration rate (eGFR) and proteinuria. RESULTS Patients with DN and IgA nephropathy on biopsy had markedly increased staining for ET-1 in endothelial cells of glomerular and peritubular capillaries when compared with controls (p < 0.001). ET-RA staining was also more intense and more diffuse in DN and IgA nephropathy than in controls (p = 0.019) and was restricted to tubular epithelial cells. A positive correlation was observed between ET-1 expression and proteinuria (r = 0.634, p = 0.027), but both ET-1 and ET-RA expressions did not correlate with eGFR. CONCLUSION In this preliminary report, the higher expressions of ET-1 and ET-RA found in both DN and IgA nephropathy suggest a potential role for the endothelin system in DN as well as in other nondiabetic glomerular diseases.
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Affiliation(s)
- Claudete Maria Zanatta
- Post-Graduate Endocrinology Program, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Souza BMD, Assmann TS, Kliemann LM, Gross JL, Canani LH, Crispim D. The role of uncoupling protein 2 (UCP2) on the development of type 2 diabetes mellitus and its chronic complications. ACTA ACUST UNITED AC 2012; 55:239-48. [PMID: 21779625 DOI: 10.1590/s0004-27302011000400001] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 04/29/2011] [Indexed: 11/21/2022]
Abstract
It is well established that genetic factors play an important role in the development of type 2 diabetes mellitus (DM2) and its chronic complications, and that genetically susceptible subjects can develop the disease after being exposed to environmental risk factors. Therefore, great efforts have been made to identify genes associated with DM2. Uncoupling protein 2 (UCP2) is expressed in several tissues, and acts in the protection against oxidative stress; in the negative regulation of insulin secretion by beta cells, and in fatty acid metabolism. All these mechanisms are associated with DM2 pathogenesis and its chronic complications. Therefore, UCP2 is a candidate gene for the development of these disorders. Indeed, several studies have reported that three common polymorphisms in UCP2 gene are possibly associated with DM2 and/or obesity. Only a few studies investigated these polymorphisms in relation to chronic complications of diabetes, with inconclusive results.
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Steemburgo T, de Azevedo MJ, Gross JL, Milagro F, Campión J, Martínez JA. The rs7204609 polymorphism in the fat mass and obesity-associated gene is positively associated with central obesity and microalbuminuria in patients with type 2 diabetes from Southern Brazil. J Ren Nutr 2011; 22:228-236. [PMID: 21741858 DOI: 10.1053/j.jrn.2011.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 03/03/2011] [Accepted: 03/17/2011] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Single nucleotide polymorphisms (SNPs) in the fat mass and obesity-associated (FTO) gene, especially the common rs9939609 (A/T) SNP, are associated with body mass index (BMI), diabetes, and metabolic syndrome (MetS). MetS is highly prevalent in patients with type 2 diabetes and has been associated with chronic diabetic complications. Therefore, the aim of this study was to evaluate possible associations of the scarcely investigated rs7204609 (C/T) polymorphism, as well as the rs9939609 (A/T) polymorphism, with MetS and chronic diabetic complications in type 2 diabetic patients from Southern Brazil. DESIGN This was a cross-sectional study. PATIENTS AND METHODS A total of 236 patients with type 2 diabetes (age: 60.0 ± 10.3 years; diabetes duration: 12.7 ± 8.2 years; 53.4% women) were genotyped for the FTO rs7204609 and rs9939609 polymorphisms (ABI PRISM 7000 Real-Time PCR System). Patients underwent clinical, laboratory, and nutritional evaluation. MetS was defined according to the 2009-Joint Interim Statement. RESULTS Carriers of C allele of the rs7204609 polymorphism (CT/CC genotypes, n = 35) were at increased risk for the presence of MetS (odds ratio [OR] = 4.56; 95% CI: 1.04 to 19.9), elevated waist circumference (OR = 8.66; 95% CI: 1.12 to 66.7), BMI: ≥ 30 kg/m(2) (OR = 3.71; 95% CI: 1.71 to 8.02), and microalbuminuria (OR = 2.30; 95% CI: 1.08 to 4.88), adjusted for gender and diabetes duration (P < .05 for all models). The rs9939609 polymorphism was not associated with MetS, elevated waist circumference or BMI, or diabetic complications. Daily energy and nutrient intakes did not differ according to the presence of the polymorphisms. CONCLUSIONS The C allele of the rs7204609 polymorphism in the FTO gene increased the chance for the presence of MetS, especially central obesity, and microalbuminuria, independently of energy and nutrient intakes in this sample of type 2 diabetic patients from Southern Brazil.
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Affiliation(s)
- Thais Steemburgo
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Department of Nutrition and Food Sciences, Physiology and Toxicology, University of Navarra, Navarra, Spain.
| | - Mirela Jobim de Azevedo
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jorge Luiz Gross
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Fermín Milagro
- Department of Nutrition and Food Sciences, Physiology and Toxicology, University of Navarra, Navarra, Spain
| | - Javier Campión
- Department of Nutrition and Food Sciences, Physiology and Toxicology, University of Navarra, Navarra, Spain
| | - José Alfredo Martínez
- Department of Nutrition and Food Sciences, Physiology and Toxicology, University of Navarra, Navarra, Spain
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Abstract
Topiramate was associated with weight loss in clinical trials. We summarize the evidence on the efficacy and safety of topiramate in the treatment of overweight/obesity. The databases Medline, Embase, and Cochrane were searched. Randomized controlled studies with at least 16 weeks of duration that report the effect of topiramate on weight loss and adverse events were eligible for inclusion. Ten studies were included (3320 individuals). Patients treated with topiramate lost an average of 5.34 kg (95% confidence interval [95%CI]-6.12 to -4.56) of additional weight as compared with placebo. According to meta-regression analysis, treatment duration and dosage were associated with the efficacy of topiramate treatment. Evaluating trials using topiramate 96-200 mg day(-1) , the weight loss was higher in trials with >28 weeks of duration (-6.58 kg [95%CI -7.48 to -5.68]) than in trials with ≤28 weeks (-4.11 kg [95%CI -4.92 to -3.30]). Data of 6620 individuals were available for adverse events evaluation and those more frequently observed were paraesthesia, taste impairment and psychomotor disturbances. The odds ratio for adverse events leading to topiramate withdrawal was 1.94 (95%CI 1.64-2.29) compared with the control group. In conclusion, topiramate might be a useful adjunctive therapeutic tool in the treatment of obesity as long as proper warnings about side effects are considered.
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Affiliation(s)
- C K Kramer
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Kramer CK, Ferreira N, Silveiro SP, Gross JL, Dora JM, Azevedo MJD. Pituitary gland metastasis from renal cell carcinoma presented as a non-functioning macroadenoma. ACTA ACUST UNITED AC 2011; 54:498-501. [PMID: 20694412 DOI: 10.1590/s0004-27302010000500011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Accepted: 03/29/2010] [Indexed: 11/21/2022]
Abstract
Metastatic tumors involving the pituitary gland are an uncommon finding and occur in up to 1% of all pituitary tumor resections. A 74-year-old man had progressive vision deterioration, over the 30 days prior to consultation. He did not complain of headache or polyuria, but referred to intestinal constipation. Five years ago, he underwent a right radical nephrectomy for renal cell carcinoma, followed by chemotherapy and radiotherapy for lung and parotid metastases. On ophthalmologic examination, there was a left abducens nerve palsy and bitemporal hemianopia. Magnetic resonance imaging demonstrated a sellar mass with suprasellar cistern extension compressing the optic chiasm. Endocrinological evaluation revealed central adrenal and gonadal insufficiencies. The patient underwent a transsphenoidal tumor resection that revealed renal cell carcinoma. This case illustrates that metastatic pituitary lesions can mimic typical symptoms and signs of pituitary macroadenoma. Furthermore, clinical diabetes insipidus, a common finding of pituitary metastases, can be absent.
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Affiliation(s)
- Caroline Kaercher Kramer
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Rodrigues TC, Canani LH, Schvartzman P, Gross JL. Hypertension is the metabolic syndrome component most strongly associated with microvascular complications and coronary artery calcification in Type 1 diabetes. J Endocrinol Invest 2011; 34:e58-63. [PMID: 20855932 DOI: 10.1007/bf03347077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the association of metabolic syndrome (MetS) and its individual components with microvascular complications and coronary artery calcification (CAC) in patients with Type 1 diabetes. MATERIAL/SUBJECTS AND METHODS Cross-sectional study included 261 patients with Type 1 diabetes. Patients were assessed regarding the presence of MetS according to National Cholesterol Education Program (NCEP) criteria. CAC score was measured in a subset of 100 patients without known cardiovascular disease. RESULTS The prevalence of MetS was 13.4% according to the NCEP criteria. Microvascular complications and CAC were more frequent in patients with MetS. In a multiple logistic regression analysis, MetS remained associated with nephropathy [OR: 6.33 (95% CI 2.54-15.77), p<0.001], but not with retinopathy and CAC. Among the MetS components, hypertension was associated with presence of retinopathy [OR: 4.04 (95% CI 1.65- 9.90), p=0.002], nephropathy [OR: 5.92 (95% CI 2.42-14.4), p<0.001] and CAC [OR: 2.97 (95% CI 1.06-8.30), p=0.03]. CONCLUSIONS Hypertension was the only MetS component associated with retinopathy, nephropathy and the presence of CAC. Hypertension was better associated with CAC than MetS itself.
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Affiliation(s)
- T C Rodrigues
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Abstract
AIM To analyse the performance of HbA(1c) in diagnosing Type 2 diabetes based on fasting plasma glucose and/or 2-h plasma glucose measurements after a 75-g oral glucose tolerance test. METHODS This is a study of diagnostic test accuracy in individuals referred to the Clinical Pathology Department for oral glucose tolerance testing. After fasting overnight, HbA(1c), fasting plasma glucose and 2-h plasma glucose were measured. The receiver operating characteristic curve was used to evaluate the diagnostic performance of HbA(1c). RESULTS Four hundred and ninety-eight subjects (195 male, mean age 56 years) were enrolled and 115 (23.1%) were diagnosed with diabetes according to glucose-based methods and only 56 (11.2%) individuals were identified by HbA(1c) ≥ 6.5% (48 mmol/mol) (sensitivity 20.9%, specificity 95.3%). There is poor agreement between the newly recommended criterion and the current glucose-based diagnostic criteria (κ = 0.217; P < 0.001), probably because the diagnostic methods identify different populations of patients. Adding a glucose-based method into an algorithm, as proposed by the UK Department of Health, improved HbA(1c) performance. CONCLUSIONS HbA(1c) ≥ 6.5% (48 mmol/mol) showed limited sensitivity to diabetes diagnosis, although with high specificity. The results suggest that this cut-off point would not be enough to diagnose diabetes. Its use as the sole diabetes diagnostic test should be interpreted with caution to assure the correct classification of diabetic individuals.
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Affiliation(s)
- G Cavagnolli
- Postgraduate Program in Endocrinology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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47
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Triches C, Schaan BD, Gross JL, Azevedo MJD. [Macrovascular diabetic complications: clinical characteristics, diagnosis and management]. ACTA ACUST UNITED AC 2010; 53:698-708. [PMID: 19893911 DOI: 10.1590/s0004-27302009000600002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Accepted: 06/29/2009] [Indexed: 11/21/2022]
Abstract
Diabetes mellitus (DM) is an independent risk factor for coronary heart disease, stroke, peripheral arterial disease and heart failure, which are the main causes of death in these patients. Moreover, patients with DM and cardiovascular disease have a worse prognosis than nondiabetics, present lower short-term survival, higher risk of recurrence of the disease and a worse response to the treatments proposed. In the last decades, diagnostic and therapeutic progress had already shown benefits concerning cardiovascular risk reduction in these patients, but their absolute mortality risk is still twice that of non-diabetic patients. Because of this, the adoption of intensive treatment, with strict cardiovascular risk factor control, is a priority. The present study presents the main clinical characteristics and also the practical approach for screening, diagnosis and treatment of patients with diabetic macrovascular disease.
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Affiliation(s)
- Cristina Triches
- Programa de Pós-graduação em Ciências Médicas: Endocrinologia e Metabologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
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48
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Rosenstock J, Rendell MS, Gross JL, Fleck PR, Wilson CA, Mekki Q. Alogliptin added to insulin therapy in patients with type 2 diabetes reduces HbA(1C) without causing weight gain or increased hypoglycaemia. Diabetes Obes Metab 2009; 11:1145-52. [PMID: 19758359 DOI: 10.1111/j.1463-1326.2009.01124.x] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS To assess the efficacy and safety of alogliptin added to insulin in patients with type 2 diabetes inadequately controlled with insulin alone or combined with metformin. METHODS In this 26-week, double-blind, placebo-controlled study, 390 patients were randomized to receive alogliptin 12.5 mg (n = 131), alogliptin 25 mg (n = 129) or placebo (n = 130) once daily, as add-on to stable insulin therapy with or without metformin. The primary endpoint was change in haemoglobin A(1C) (HbA(1C)) at week 26. RESULTS At week 26, mean HbA(1C) changes from the mean baseline value of 9.3% were significantly greater for alogliptin 12.5 mg (-0.63 +/- 0.08%) and alogliptin 25 mg (-0.71 +/- 0.08%) than placebo (-0.13 +/- 0.08%; p < 0.001). Significantly greater proportions of patients receiving alogliptin 12.5 or 25 mg than placebo had HbA(1C) decreases of > or =0.5, > or =1.0 and > or =1.5%. Insulin doses remained unchanged, and there were no differences in the proportions of patients experiencing hypoglycaemia among placebo (24%), alogliptin 12.5 mg (27%) and alogliptin 25 mg (27%). Mean weight increases from baseline at week 26 were similar for placebo (0.6 +/- 0.2 kg), alogliptin 12.5 mg (0.7 +/- 0.2 kg) and alogliptin 25 mg (0.6 +/- 0.2 kg). Incidences of overall adverse events, and of gastrointestinal, dermatological and infection-related events, were similar among groups. CONCLUSIONS Adding alogliptin to previous insulin therapy (with or without metformin) significantly improved glycaemic control in patients with type 2 diabetes inadequately controlled on insulin, without causing weight gain or increasing the incidence of hypoglycaemia. Further studies are warranted to explore the role of alogliptin added to optimized basal insulin regimens.
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Affiliation(s)
- J Rosenstock
- Dallas Diabetes and Endocrine Center, Dallas, TX 75230, USA.
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Kramer CK, Leitão CB, Azevedo MJ, Valiatti FB, Rodrigues TC, Canani LH, Gross JL. Diabetic retinopathy is associated with early autonomic dysfunction assessed by exercise-related heart rate changes. Braz J Med Biol Res 2009; 41:1110-5. [PMID: 19148374 DOI: 10.1590/s0100-879x2008001200011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 11/18/2008] [Indexed: 11/22/2022] Open
Abstract
Diabetic retinopathy has been associated with cardiac autonomic dysfunction in both type 1 and type 2 diabetes mellitus (DM) patients. Heart rate (HR) changes during exercise testing indicate early alterations in autonomous tonus. The aim of the present study was to investigate the association of diabetic retinopathy with exercise-related HR changes. A cross-sectional study was performed on 72 type 2 and 40 type 1 DM patients. Autonomic dysfunction was assessed by exercise-related HR changes (Bruce protocol). The maximum HR increase, defined as the difference between the peak exercise rate and the resting rate at baseline, and HR recovery, defined as the reduction in HR from the peak exercise to the HR at 1, 2, and 4 min after the cessation of the exercise, were determined. In type 2 DM patients, lower maximum HR increase (OR = 1.62, 95%CI = 1.03-2.54; P = 0.036), lower HR recovery at 2 (OR = 2.04, 95%CI = 1.16-3.57; P = 0.012) and 4 min (OR = 2.67, 95%CI = 1.37-5.20; P = 0.004) were associated with diabetic retinopathy, adjusted for confounding factors. In type 1 DM, the absence of an increase in HR at intervals of 10 bpm each during exercise added 100% to the odds for diabetic retinopathy (OR = 2.01, 95%CI = 1.1-3.69; P = 0.02) when adjusted for DM duration, A1c test and diastolic blood pressure. In conclusion, early autonomic dysfunction was associated with diabetic retinopathy. The recognition of HR changes during exercise can be used to identify a high-risk group for diabetic retinopathy.
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Affiliation(s)
- C K Kramer
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil.
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DeFronzo RA, Hissa MN, Garber AJ, Luiz Gross J, Yuyan Duan R, Ravichandran S, Chen RS. The efficacy and safety of saxagliptin when added to metformin therapy in patients with inadequately controlled type 2 diabetes with metformin alone. Diabetes Care 2009; 32:1649-55. [PMID: 19478198 PMCID: PMC2732156 DOI: 10.2337/dc08-1984] [Citation(s) in RCA: 321] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This 24-week trial assessed the efficacy and safety of saxagliptin as add-on therapy in patients with type 2 diabetes with inadequate glycemic control with metformin alone. RESEARCH DESIGN AND METHODS This was a randomized, double-blind, placebo-controlled study of saxagliptin (2.5, 5, or 10 mg once daily) or placebo plus a stable dose of metformin (1,500-2,500 mg) in 743 patients (A1C > or =7.0 and < or =10.0%). Efficacy analyses were performed using an ANCOVA model using last observation carried forward methodology on primary (A1C) and secondary (fasting plasma glucose [FPG] and postprandial glucose [PPG] area under the curve [AUC]) end points. RESULTS Saxagliptin (2.5, 5, and 10 mg) plus metformin demonstrated statistically significant adjusted mean decreases from baseline to week 24 versus placebo in A1C (-0.59, -0.69, and -0.58 vs. +0.13%; all P < 0.0001), FPG (-14.31, -22.03, and -20.50 vs. +1.24 mg/dl; all P < 0.0001), and PPG AUC (-8,891, -9,586, and -8,137 vs. -3,291 mg . min/dl; all P < 0.0001). More than twice as many patients achieved A1C <7.0% with 2.5, 5, and 10 mg saxagliptin versus placebo (37, 44, and 44 vs. 17%; all P < 0.0001). beta-Cell function and postprandial C-peptide, insulin, and glucagon AUCs improved in all saxagliptin treatment groups at week 24. Incidence of hypoglycemic adverse events and weight reductions were similar to those with placebo. CONCLUSIONS Saxagliptin once daily added to metformin therapy was generally well tolerated and led to statistically significant improvements in glycemic indexes versus placebo added to metformin in patients with type 2 diabetes inadequately controlled with metformin alone.
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Affiliation(s)
- Ralph A DeFronzo
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
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