Diabetes and covid-19: more than the sum of two morbidities

ABSTRACT The coronavirus disease 2019 (covid-19) pandemic has caused a public health emergency worldwide. Risk, severity and mortality of the disease have been associated with non-communicable chronic diseases, such as diabetes mellitus. Accumulated evidence has caused great concern in countries with high prevalence of this morbidity, such as Brazil. This text shows the picture of diabetes in Brazil, followed by epidemiological data and explanatory hypothesis for the association between diabetes and covid-19. We emphasized how the burden of these two morbidities in a middle-income country has aggravated this pandemic scenario. The comprehension of this association and biological plausibility may help face this pandemic and future challenges.

The Effects of Trimetazidine on QT-interval Prolongation and Cardiac Hypertrophy in Diabetic Rats / Os Efeitos da Trimetazidina no Prolongamento do Intervalo QT e na Hipertrofia Cardíaca em Ratos Diabéticos

Abstract Background: Trimetazidine (TMZ) is an anti-ischemic drug. In spite of its protective effects on cardiovascular system, there is no scientific study on the usefulness of TMZ treatment for prolonged QT interval and cardiac hypertrophy induced by diabetes. Objectives: To evaluate the effects of TMZ on QT interval prolongation and cardiac hypertrophy in the diabetic rats. Methods: Twenty-four male Sprague-Dawley rats (200-250 g) were randomly assigned into three groups (n = 8) by simple random sampling method. Control (C), diabetic (D), and diabetic administrated with TMZ at 10 mg/kg (T10). TMZ was administrated for 8 weeks. The echocardiogram was recorded before isolating the hearts and transfer to a Langendorff apparatus. Hemodynamic parameters, QT and corrected QT interval (QTc) intervals, heart rate and antioxidant enzymes were measured. The hypertrophy index was calculated. The results were evaluated by one-way ANOVA and paired t-test using SPSS (version 16) and p < 0.05 was regarded as significant. Results: The diabetic rats significantly indicated increased hypertrophy, QT and QTc intervals and decreased Left ventricular systolic pressure (LVSP), Left ventricular developed pressure (LVDP), rate pressure product (RPP), Max dp/dt, and min dp/dt (±dp/dt max), heart rate, superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase in the heart. Treatment with TMZ in the diabetic animals was significantly improved these parameters in comparison to the untreated diabetic group. Conclusions: TMZ improves QTc interval prolongation and cardiac hypertrophy in diabetes.

Resumo Fundamento: A trimetazidina (TMZ) é uma droga anti-isquêmica. Apesar de seus efeitos protetores sobre o sistema cardiovascular, não há estudos científicos sobre a utilidade do tratamento com TMZ para o intervalo QT prolongado e a hipertrofia cardíaca induzida pelo diabetes. Objetivo: Avaliar os efeitos da TMZ no prolongamento do intervalo QT e na hipertrofia cardíaca em ratos diabéticos. Métodos: Vinte e quatro ratos machos Sprague-Dawley (200-250 g) foram distribuídos aleatoriamente em três grupos (n = 8) pelo método de amostragem aleatória simples. Controle (C), diabético (D) e diabético administrado com TMZ a 10 mg/kg (T10). A TMZ foi administrada por 8 semanas. O ecocardiograma foi registrado antes de isolar os corações e transferir para um aparelho de Langendorff. Foram medidos os parâmetros hemodinâmicos, intervalo QT e intervalo QT corrigido (QTc), frequência cardíaca e enzimas antioxidantes. O índice de hipertrofia foi calculado. Os resultados foram avaliados pelo one-way ANOVA e pelo teste t pareado pelo SPSS (versão 16) e p < 0,05 foi considerado significativo. Resultados: Os ratos diabéticos indicaram hipertrofia aumentada, intervalos QT e QTc e diminuição da pressão sistólica no ventrículo esquerdo (PSVE), pressão desenvolvida no ventrículo esquerdo (PDVE), duplo produto (DP), Max dp/dt e min dp/dt (± dp/dt max), frequência cardíaca, superóxido dismutase (SOD), glutationa peroxidase (GPx) e catalase no coração. O tratamento com TMZ nos animais diabéticos melhorou significativamente esses parâmetros em comparação com o grupo diabético não tratado. Conclusões: A TMZ melhora o prolongamento do intervalo QTc e a hipertrofia cardíaca no diabetes.

Prevalencia de complicaciones de la diabetes y comorbilidades asociadas en medicina familiar del Instituto Mexicano del Seguro Social / Prevalence of complications of diabetes and associated comorbidities in family medicine of the Mexican Institute

Resumen Introducción: La prevalencia de complicaciones crónicas y comorbilidades en pacientes con diabetes tipo 2 (DT2) se han incrementado en el mundo. Objetivo: Comparar la prevalencia de complicaciones y comorbilidades crónicas en pacientes con DT2 en 36 unidades de medicina familiar de cinco delegaciones del Instituto Mexicano del Seguro Social (IMSS). Métodos: Conforme los códigos de la Décima Revisión de la Clasificación Internacional de Enfermedades se identificaron las complicaciones (hipoglucemia, pie diabético, enfermedad renal, retinopatía, enfermedad cardiaca isquémica, enfermedad cerebrovascular y falla cardiaca) y comorbilidades (enfermedad hepática, cáncer, anemia) de DT2. Se compararon por delegación, edad, sexo y tiempo de evolución. Resultados: Las complicaciones y comorbilidades fueron más comunes en personas ≥ 62 años. De 297 100 pacientes, 34.9 % presentó cualquier complicación; microvasculares en el norte industrial (32 %), macrovasculares en el este rural (12.3 %) y comorbilidades (5 %) en el sur de la Ciudad de México; estas complicaciones predominaron en los hombres (cualquier complicación 30.2 %). La falla cardiaca y las comorbilidades fueron más comunes en mujeres (5.6 y 4.9 %). Conclusiones: Las complicaciones y comorbilidades de DT2 mostraron diferencias geográficas y de sexo y fueron mayores con la edad y el tiempo de evolución. Urge reforzar estrategias para la prevención de las complicaciones y comorbilidades en los pacientes con DT2.

Abstract Introduction: The prevalence of chronic complications and comorbidities in patients with type 2 diabetes (T2D) has increased worldwide. Objective: To compare the prevalence of complications and chronic comorbidities in patients with T2D at 36 family medicine units of five chapters of the Mexican Institute of Social Security (IMSS). Method: Complications (hypoglycemia, diabetic foot, kidney disease, retinopathy, ischemic heart disease, cerebrovascular disease and heart failure) and comorbidities (liver disease, cancer and anemia) were identified according to codes of the International Classification of Diseases, 10th Revision. Comparisons were made by chapter, age, gender and evolution time. Results: Complications and comorbidities were more common in subjects aged ≥ 62 years. Out of 297 100 patients, 34.9 % had any complication; microvascular complications (32 %) prevailed in the industrial North, whereas macrovascular complications (12.3 %) did in the rural East, and comorbidities (5 %) in southern Mexico City. Complications predominated in men (any complication, 30.2 %). Heart failure and comorbidities were more common in women (5.6 % and 4.9 %, respectively). Conclusions: T2D complications and comorbidities showed geographic and gender differences, and were greater with older age and longer evolution time. It is urgent for strategies for the prevention of complications and comorbidities to be reinforced in patients with T2D.

Risk for acute kidney injury in primary health care / Riesgo de lesión renal aguda en la atención primaria de salu / Risco para lesão renal aguda na atenção primária à saúde

ABSTRACT Objective: To identify hypertensive and diabetic patients at risk for developing acute kidney injury in the primary health care setting. Method: Observational, longitudinal, prospective study. Sample of 56 diabetic and hypertensive individuals. A semi-structured questionnaire was adopted for data collection. For the description of results, were calculated dispersion measures and the Spearman test was used for statistical analysis. The result was considered significant when p <0.05. Results: Of the total sample, 23.2% of users evolved with renal impairment, of which 19.6% with risk for renal injury, and 3.6% with kidney injury itself. Age and body mass index were associated with worsening of renal function (p = 0.0001; p = 0.0003), respectively. Conclusion: A quarter of the health system users, hypertensive and diabetic, evolved with impaired renal function, more specifically to stages of risk for renal injury and kidney injury according to the RIFLE classification.

RESUMEN Objetivo: Identificar los pacientes hipertensos y diabéticos con riesgo para desarrollar lesión renal aguda en el escenario de la atención primaria de salud. Método: Estudio observacional, longitudinal y prospectivo. Casuística compuesta de 56 individuos diabéticos e hipertensos. Un cuestionario semiestructurado fue adoptado para la recolección de datos. Para la descripción de los resultados, se calcularon medidas de dispersión, y para el análisis estadístico se usó la prueba de Spearman. El resultado se consideró significativo cuando p < 0,05. Resultados: Del total de la muestra, el 23,2% de los usuarios evolucionaron con deterioro renal, siendo el 19,6% con riesgo para lesión renal y el 3,6% con lesión renal. La edad y el índice de masa corporal tuvieron asociación con el empeoramiento de la función renal (p = 0,0001; p = 0,0003), respectivamente. Conclusión: Se identificó que un cuarto de los usuarios del sistema de salud, hipertensos y diabéticos, evolucionaron con alteración de la función renal, más específicamente en las etapas de riesgo y de lesión renal según la clasificación RIFLE.

RESUMO Objetivo: Identificar pacientes hipertensos e diabéticos com risco para desenvolver lesão renal aguda no cenário da atenção primária à saúde. Método: Estudo observacional, longitudinal, prospectivo. Casuística composta de 56 indivíduos diabéticos e hipertensos. Adotou-se questionário semiestruturado para coleta de dados. Para descrição dos resultados foram calculadas medidas de dispersão e o teste de Spearman para análise estatística. O resultado foi considerado significativo quando p < 0,05. Resultados: Do total, 23,2% dos usuários evoluíram com comprometimento renal, sendo 19,6% com risco para lesão renal e 3,6% com lesão renal, propriamente dita. A idade e o índice de massa corporal mostraram associação com a piora da função renal (p=0,0001; p=0,0003), respectivamente. Conclusão: Identificou-se que um quarto dos usuários do sistema de saúde, hipertensos e diabéticos evoluíram com comprometimento da função renal, mais especificamente nos estágios de risco e de lesão renal segundo a classificação RIFLE.

Systemic diseases and other painful conditions in patients with temporomandibular disorders and migraine

Abstract Temporomandibular disorders (TMD) are a highly prevalent, painful musculoskeletal condition affecting the masticatory system, and are frequently associated with migraines (M) and other diseases. This study aimed to investigate the association between painful TMD and M with other painful conditions and systemic diseases, such as cervicalgia, body pain (BP), ear-nose-throat disorders, musculoskeletal disorders, diabetes, cardiopulmonary diseases and gastritis/peptic ulcer. Methods: This was a cross-sectional study conducted in a sample of 352 individuals. Participants were stratified into three groups according to the presence of painful TMD and M: controls [individuals free of TMD and any headache (HA)]; TMD only (presence of painful TMD, but free of any HA); and TMD+M (presence of painful TMD and M). TMD was classified according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) - Axis I. Nonspecific physical symptoms (NSPS) were assessed by RDC/TMD - Axis II. The International Classification of Headache Disorders - II criteria, second edition, were applied to identify and classify primary HA. Other painful conditions and systemic diseases were assessed by volunteers' self-report. The prevalence of all assessed conditions was higher in the TMD+M group. Multiple regression models showed that cervicalgia was associated with the TMD only group (p<0.05), whereas gender (p<0.05), cervicalgia (p<0.05), BP (p<0.05) and NSPS (p<0.05) were significantly associated with the TMD+M group. Our results suggest that individuals with a comorbidity (TMD associated with M) have a more severe condition than those presenting only painful TMD.

Endothelial dysfunction in children with type 1 diabetes mellitus

ABSTRACT Objective The purpose of this study was to verify the presence of endothelial dysfunction and initial structural atherosclerotic changes in children with Type 1 diabetes mellitus (T1DM). Subjects and methods The study population comprised 31 diabetic children aged 6 to 12 years, divided into two subgroups according to the duration of the T1DM diagnosis: subgroup 1, with less than 5 years elapsed since diagnosis, and subgroup 2, with more than 5 years elapsed since diagnosis. The control group comprised 58 age-matched healthy children. Ultrasonographic techniques were used to measure the flow-mediated dilatation (FMD) of the brachial artery and the intima-media thickness (IMT) of the carotid arteries. Results Children with T1DM with longer disease duration showed significantly decreased mean values of FMD compared with those in the control group. No significant differences between the groups were found in relation to IMT. The FMD percentage presented a moderate negative correlation with glycated hemoglobin (HbA1c) and fasting glucose levels. Conclusion Our findings suggest that endothelial dysfunction may be already present in children with 5 years or more elapsed since diagnosis, even in the absence of atherosclerotic structural changes. The decreased vasodilation response correlated with hyperglycemia.

Estimation of cardiovascular risk and detection of subclinical carotid atheromatosis in patients with diabetes without a history of cardiovascular disease

ABSTRACT Objectives Cardiovascular risk estimated by several scores in patients with diabetes mellitus without a cardiovascular disease history and the association with carotid atherosclerotic plaque (CAP) were the aims of this study. Materials and methods Cardiovascular risk was calculate using United Kingdom Prospective Diabetes Study (UKPDS) risk engine, Framingham risk score for cardiovascular (FSCV) and coronary disease (FSCD), and the new score (NS) proposed by the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol. Ultrasound was used to assess CAP occurrence. A receiver operating characteristic (ROC) analysis was performed. Results One hundred seventy patients (mean age 61.4 ± 11 years, 58.8% men) were included. Average FSCV, FSCD and NS values were 33.6% ± 21%, 20.6% ± 12% and 24.8% ± 18%, respectively. According to the UKPDS score, average risk of coronary disease and stroke were 22.1% ± 16% and 14.3% ± 19% respectively. Comparing the risks estimated by the different scores a significant correlation was found. The prevalence of CAP was 51%, in patients with the higher scores this prevalence was increased. ROC analysis showed a good discrimination power between subjects with or without CAP. Conclusion The cardiovascular risk estimated was high but heterogenic. The prevalence of CAP increased according to the strata of risk. Understanding the relationship between CAP and scores could improve the risk estimation in subjects with diabetes.

Diabetes mellitus and sensorineural hearing loss: is there an association? Baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

OBJECTIVES: Although several studies have investigated the effects of diabetes on hearing loss, the relationship between these two conditions remains unclear. Some studies have suggested that diabetes may cause sensorineural hearing loss, whereas others have failed to find an association. The biggest challenge in investigating the association between diabetes and hearing loss is the presence of confounding variables and the complexity of the auditory system. Our study investigated the association between diabetes and sensorineural hearing loss. We evaluated the influence of time from diabetes diagnosis on this association after controlling for age, gender, and hypertension diagnosis and excluding those subjects with exposure to noise. METHODS: This cross-sectional study evaluated 901 adult and elderly Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) participants from São Paulo, Brazil who underwent audiometry testing as part of ELSA-Brasil’s baseline assessment. RESULTS: Hearing thresholds and speech test results were significantly worse in the group with diabetes than in the group without diabetes. However, no significant differences were found between participants with and without diabetes after adjusting for age, gender, and the presence of hypertension. Hearing thresholds were not affected by occupational noise exposure in the groups with and without diabetes. In addition, no association between the duration of diabetes and hearing thresholds was observed after adjusting for age, gender, and hypertension. CONCLUSION: We found no association between the duration of diabetes and worse hearing thresholds after models were adjusted for age, gender, and the presence of hypertension.

Stages of hyperglycemia and common mental disorders in adults - The Brazilian Study of Adult Health (ELSA-Brasil) / Estágios de hiperglicemia e transtornos mentais comuns em adultos - Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil)

ABSTRACT CONTEXT AND OBJECTIVE: Diabetes mellitus and depressive disorders frequently coexist. However, this relationship has been little evaluated across stages of hyperglycemia and for a broad range of common mental disorders (CMDs). The objective here was to investigate the association between CMDs and stages of glycemia. DESIGN AND SETTING: Cross-sectional study conducted among civil servants aged 35-74 years participating in the ELSA-Brasil cohort. METHODS: CMDs were classified using the Clinical Interview Schedule - Revised (CIS-R). Glycemia was classified in stages as normal, intermediate hyperglycemia, newly classified diabetes or previously known diabetes, based on oral glucose tolerance testing, glycated hemoglobin (HbA1c), self-reported diabetes and medication use. Blood glucose control was assessed according to HbA1c. RESULTS: CMDs were most prevalent in individuals with previously known diabetes. After adjustments, associations weakened considerably and remained significant only for those with a CIS-R score ≥ 12 (prevalence ratio, PR: 1.15; 95% confidence interval, CI: 1.03-1.29). Intermediate hyperglycemia did not show any association with CMDs. For individuals with previously known diabetes and newly classified diabetes, for every 1% increase in HbA1c, the prevalence of depressive disorders became, respectively, 12% and 23% greater (PR: 1.12; 95% CI: 1.00-1.26; and PR: 1.23; 95% CI: 1.04-1.44). CONCLUSION: Individuals with previously known diabetes had higher CIS-R scores. Among all individuals with diabetes, worse blood glucose control was correlated with depressive disorder. No relationship between intermediate hyperglycemia and CMDs was observed, thus suggesting that causal processes relating to CMDs, if present, must act more proximally to diabetes onset.

RESUMO CONTEXTO E OBJETIVO: Diabetes mellitus e transtornos depressivos frequentemente coexistem. No entanto, essa relação tem sido pouco avaliada nos estágios hiperglicêmicos e em uma amplitude maior de transtornos mentais comuns (TMCs). O objetivo foi investigar a associação entre TMCs e estágios de glicemia. TIPO DE ESTUDO E LOCAL: Estudo transversal realizado com funcionários públicos com idade entre 35-74 anos participantes da coorte ELSA-Brasil. MÉTODOS: TMCs foram classificados usando o instrumento Clinical Interview Schedule - Revised (CIS-R). Para a classificação dos estágios de glicemia, foi utilizado o teste de tolerância a glicose, hemoglobina glicada (HbA1c), relato pessoal de diabetes e uso de medicamentos. A glicemia foi categorizada como: normal, hiperglicemia intermediária, classificação nova de diabetes, e diabetes prévio. Controle glicêmico foi avaliado pela HbA1c. RESULTADOS: TMCs foram mais prevalentes nos pacientes com diabetes prévio. Após ajustes, as associações foram consideravelmente enfraquecidas, permanecendo significativas somente para aqueles com escore do CIS-R ≥ 12 (razão de prevalência, RP: 1,15; intervalo de confiança de 95%, IC: 1,03-1,29). Hiperglicemia intermediária não teve associação com CMDs. Para aqueles com diabetes prévio e classificação nova de diabetes, para cada aumento de 1% na HbA1c, a prevalência de transtorno depressivo foi, respectivamente, 12% e 23% maior (RP: 1,12; IC: 1,00-1,26 e RP: 1,23; IC: 1,04-1,44). CONCLUSÃO: Aqueles com diabetes prévio tiveram escore do CIS-R mais elevado. Entre todos com diabetes, o controle glicêmico pior foi relacionado ao transtorno depressivo. Não foi observada relação entre hiperglicemia intermediária e TMCs, sugerindo que a relação causal relacionada aos TMCs, se presente, deve agir de forma mais próxima ao início de diabetes.

Diarrea crónica en el diabético: Una revisión de la literatura / Chronic diarrhea in the diabetic: A review of the literature

Desde hace más de 70 años se conoce la asociación de diarrea con diabetes mellitus. En pacientes diabéticos su prevalencia es de alrededor del 20%. Sus manifestaciones clínicas son diversas, y representa un reto diagnóstico y terapéutico. Existen ciertos diagnósticos de mayor prevalencia en pacientes diabéticos que en la población general. Las distintas etiologías relacionadas pueden ser diagnosticadas adecuadamente a través de la historia clínica y pruebas diagnósticas complementarias. Los medicamentos utilizados por el paciente diabético para el manejo de su enfermedad, frecuentemente causan diarrea crónica, por lo que se debe profundizar en los antecedentes farmacológicos al momento de estudiar la diarrea. Los pacientes diabéticos pueden presentar otras condiciones patológicas asociadas, como enfermedad celíaca o colitis microscópica, cuya molestia única es la diarrea. La función del páncreas exocrino puede estar disminuida en el paciente diabético, frecuentemente llevando a insuficiencia pancreática exocrina. Factores dietarios, como los edulcorantes libres de azúcar y otros agentes, pueden causar diarrea en el paciente diabético. La presencia de condiciones como la neuropatía autonómica y neuropatía periférica secundarias a la diabetes mellitus, pueden explicar desordenes como la disfunción anorrectal y la incontinencia fecal. Finalmente, la enteropatía diabética per se o con sobrecrecimiento bacteriano asociado, puede causar diarrea. Lograr un control glicémico adecuado constituye el pilar del tratamiento de la diarrea en el diabético, después de esto existen medidas adicionales que se aplican según el contexto especifico del paciente. En el presente artículo se revisan las causas de mayor incidencia diarrea en el paciente diabético y los mecanismos fisiopatológicos implicados

The association of diarrhea with diabetes mellitus has been known for more than 70 years. In diabetic patients its prevalence is around 20%.Its clinical manifestations are diverse, and represents a diagnostic and therapeutic challenge.There are certain diagnoses of higher prevalence in diabetic patients than in the general population.The different related etiologies can be adequately diagnosed through the clinical history and complementary diagnostic tests.The medications used by the diabetic patient to manage their disease often cause chronic diarrhea, so the pharmacological background should be studied at the time of the study of diarrhea.Diabetic patients can present other associated pathological conditions, such as celiac disease or microscopic colitis, which only discomfort is diarrhea.Exocrine pancreatic function may be decreased in the diabetic patient, frequently leading to exocrine pancreatic insufficiency. Dietary factors, such as sugar-free sweeteners and other agents, can cause diarrhea in the diabetic patient.The presence of conditions such as autonomic neuropathy and peripheral neuropathy secondary to diabetes mellitus may explain disorders such as anorectal dysfunction and faecal incontinence. Finally, diabetic enteropathy alone or with associated bacterial overgrowth can cause diarrhea.Achieving adequate glycemic control is the pillar of the treatment of diarrhea in the diabetic, after which there are additional measures that are applied according to the specific context of the patient.This article reviews the causes of higher diarrhea incidence in the diabetic patient and the pathophysiological mechanisms involved

Wake-up stroke: Clinical characteristics, sedentary lifestyle, and daytime sleepiness / Wake-up stroke: achados clínicos, sedentarismo e sonolência diurna

Summary Objective: Wake-up stroke (WUS) is defined when the exact time of the beginning of the symptoms cannot be determined, for the deficits are perceived upon awakening. Sleep alterations are important risk factors for stroke and cardiovascular diseases. This study evaluates the characteristics of patients with and without WUS, the presence of daytime sleepiness, and associated risk factors. Method: Patients with ischemic stroke were investigated about the presence of WUS. Clinical and demographic characteristics were evaluated. Stroke severity was studied by the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (MRS), and daytime sleepiness severity was studied by the Epworth Sleepiness Scale (ESS). Results: Seventy patients (57.1% men) aged from 32 to 80 years (58.5±13.3) were studied. WUS was observed in 24.3%. Arterial hypertension (67.1%), type 2 diabetes (27.1%), and hyperlipidemia (22.8%) were frequent. Type 2 diabetes and sedentary lifestyle were more common in patients with WUS (p<0.05). Overall, mild, moderate or very few symptoms of stroke (NIHSS<5) were predominant (62.3%). Among all cases, 20% had excessive daytime sleepiness (ESS>10). No differences were found between patients with and without WUS as regards stroke severity or excessive daytime sleepiness. Patients with excessive daytime sleepiness were younger and had more sedentary lifestyle (p<0.05). Individuals with previous history of heavy drinking had more daytime sleepiness (p=0.03). Conclusion: Wake-up stroke occurs in approximately 25% of stroke cases. In this study, patients with WUS had more diabetes and sedentary lifestyle. Daytime sleepiness is frequent and is associated with sedentary lifestyle and heavy drinking.

Resumo Objetivo: wake-up stroke (WUS) define o acidente vascular cerebral (AVC) que ocorre sem horário preciso de início, pois os sintomas manifestam-se ao despertar. Alterações do sono associam-se a maior risco de AVC e doenças cardíacas. Este estudo avalia as características dos pacientes com e sem WUS, a presença de sonolência diurna e os fatores de risco associados. Método: pacientes com AVC isquêmico foram identificados quanto à presença de WUS. Foram avaliadas as características clínico-demográficas, a gravidade do AVC pela National Institutes of Health Stroke Scale (NIHSS) e pela Modified Rankin Scale (MRS) e o grau de sonolência pela Epworth Sleepiness Scale (ESS). Resultados: setenta pacientes (57,1% homens) com idade entre 32 e 80 anos (58,5±13,3) foram estudados. Wake-up stroke foi observado em 24,3% dos casos. Hipertensão arterial sistêmica (67,1%), diabetes (27,1%) e distúrbio do metabolismo lipídico (22,8%) foram frequentes. Diabetes e hábitos sedentários foram mais comuns nos casos com WUS (p<0,05). Na amostra total, 62,3% dos casos apresentavam AVC leve, moderado ou com poucos sintomas (NIHSS<5). Sonolência excessiva diurna (SED) (ESS>10) foi identificada em 20% dos pacientes. Não houve diferença entre os grupos com e sem WUS quanto à gravidade do AVC e o grau de sonolência. Pacientes com SED eram mais jovens e mais sedentários (p<0,05). Os indivíduos com etilismo tinham maior grau de sonolência (p=0,03). Conclusão: wake-up stroke manifesta-se em 25% dos casos de AVC isquêmico. Neste estudo, os pacientes com WUS apresentaram mais diabetes e sedentarismo. Sonolência diurna é frequente e associa-se a hábitos sedentários e etilismo.

Key Points for Curbing Cardiopulmonary Bypass Inflammation

PURPOSE: Cardiopulmonary bypass (CPB) procedures are thought to activate systemic inflammatory reaction syndrome (SIRS). Strategies to curb systemic inflammation have been previously described. However, none of them is adequate, since "curbing" the extent of the inflammatory response requires a multimodal approach. The aim of the present mini-review is to discuss the main key points about the main principles in cardiopulmonary bypass curbing inflammation. METHODS: No systematic literature search (MEDLINE) and extracted data from the accumulated experience of the authors. The preconceived idea of an association between severe inflammation and coagulation disorders is reviewed. Also, some fundamental concepts, CPB inflammatory biomarkers, the vasoplegic syndrome and the need forindividual CPB protocols for children, diabetes and old patients, are discussed. CONCLUSION: The ways in which surgical technique (atraumatic vein harvest, biocompatibility and shear resistance of the circuit, monitoring, minimizing organ ischemia, minimal cross-clamping trauma, and blood management) are thought to curb SIRS induced by CPB and affect positively the patient outcome.Improved patient outcomes are strongly associated with these modalities of care, more than single or combinatorial drug strategies (aprotinin, tranexamic acid, pentoxifylline) or CPB modalities (minicircuits, heparin-coated circuits, retrograde autologous prime).

Alteraciones hematológicas en la diabetes mellitus / Blood disorders in diabetes mellitus

Although it has been treated in a limited way the relationship between diabetes and hematopoietic system, there is evidence demonstrating thedeleterious effect of hyperglycemia on the three cell lines: red blood cells, white cells and platelets. Different forms of anemia associated with hyperglycemia are analyzed and erythrocyte alterations observed in diabetes. In chronic decompensated patients have been demonstrated alterationsof monocytes, lymphocytes and polymorphonuclear particularly, with decreased chemotaxis, adherence, phagocytosis and opsonization. Hyperglycemia determines a prothrombotic state by platelet hyperreactivity, which is a marker of inflammation...

Macroscopic placental changes associated with fetal and maternal events in diabetes mellitus

OBJECTIVES: The current study sought to identify macroscopic placental changes associated with clinical conditions in women with or without diabetes and their newborns. METHODS: The study population consisted of 62 pregnant women clinically diagnosed with diabetes and 62 healthy women (control group). RESULTS: Among the subjects with diabetes, 43 women (69.3%) were diagnosed with gestational diabetes mellitus, 15 had diabetes mellitus I (24.2%), and four had diabetes mellitus II (6.5%). The mean age of the women studied was 28.5 ± 5.71 years, and the mean gestational age of the diabetic women was 38.51 weeks. Of the 62 placentas from diabetic pregnancies, 49 (79%) maternal surfaces and 59 (95.2%) fetal surfaces showed abnormalities, including calcium and fibrin deposits, placental infarction, hematoma, and fibrosis. A statistical association was found between newborn gender and fetal and maternal placental changes (p = 0.002). The mean weight of the newborns studied was 3,287 ± 563 g for women with diabetes mellitus, 3,205 ± 544 g for those with gestational diabetes mellitus, 3,563 ± 696 g forthose with diabetes mellitus II, and 3,095 ± 451 g forthose with diabetes mellitus I. CONCLUSIONS: Infarction, hematoma, calcification, and fibrin were found on the maternal and fetal placental surfaces in women with diabetes. Women with gestational diabetes and post-term infants had more calcium deposits on the maternal placental surface as compared to those with type I and type II diabetes.

Exercise alleviates hypoalgesia and increases the level of calcitonin gene-related peptide in the dorsal horn of the spinal cord of diabetic rats

OBJECTIVE: The aim of this study was to evaluate the effects of treadmill training on nociceptive sensitivity and immunoreactivity to calcitonin gene-related peptide in the dorsal horn of the spinal cord of diabetic rats. METHODS: Male Wistar rats were divided into three groups: control, diabetic and trained diabetic. Treadmill training was performed for 8 weeks. The blood glucose concentrations and body weight were evaluated 48 h after diabetes induction and every 30 days thereafter. The nociceptive sensitivity was evaluated using the tail-flick apparatus. The animals were then transcardially perfused, and the spinal cords were post-fixed, cryoprotected and sectioned in a cryostat. Immunohistochemistry for calcitonin gene-related peptide analysis was performed on the dorsal horn of the spinal cord. RESULTS: The nociceptive sensitivity analysis revealed that, compared with the control and trained diabetic animals, the latency to tail deflection on the apparatus was longer for the diabetic animals. Optical densitometry demonstrated decreased calcitonin gene-related peptide immunoreactivity in the dorsal horn of the spinal cord in diabetic animals, which was reversed by treadmill training. CONCLUSION: We concluded that treadmill training can alleviate nociceptive hypoalgesia and reverse decreased calcitonin gene-related peptide immunoreactivity in the dorsal horn of the spinal cord of diabetic animals without pharmacological treatment.

Sexual dysfunction and sperms abnormalities in individuals suffering from diabetes mellitus

This paper aims to put light on sexual dysfunction [disorder] and sperms abnormalities in individuals suffering from diabetes mellitus and also to reveal the relationship of sexual dysfunction with diabetes mellitus, both type-1 and type-2, in diabetic patients. This paper also describes and enlightens the complications developed in such individuals who are first diabetic and then become vulnerable to sexual dysfunction

Modelo de sistema basado en conocimiento para apoyo en la investigación y p'roceso clínico de la diabetes / Knowledge-based system model to support diabetes research and clinical process

Due to the great amount of information generated and supported by the explosive evolution of computer science systems since the end of the last century, the expansion and transference of scientific knowledge has caused a rapid transformation of scientific discoveries in products and applications that have positive effects in the life quality of societies. Today, a great amount of data in medicine is obtained by the application of biotechnological methods that constantly evolve. Thus, scientific research related to diabetes keeps improving. In this context, productivity and competitiveness must be sustained on knowledge which facilitates and encourages organizational innovation capacity. For this reason, knowledge based systems emerge as a useful tool to help organizations solve difficult assignments or improve their processes. In this work, derivate from known diabetes group of symptoms and interactions that diabetes research maintains with the biotechnological processes, the authors carried out a brief analysis of the knowledge involved as well as the role that knowledge-based systems have played, and keep playing in support of them. Additionally, with the systemic perspective obtained by the authors regarding aspects like knowledge, practices and resources needed in clinical and laboratory practices, they propose a systemic model that can support diabetes research and clinical process.

Debido a la gran cantidad de información generada y apoyada por la evolución explosiva de sistemas de la ciencia computacional, desde finales del siglo pasado, la expansión y transferencia de conocimiento científico ha provocado una rápida transformación de los descubrimientos científicos en productos y aplicaciones que afectan positivamente la calidad de vida de las sociedades. Actualmente, una gran cantidad de datos en medicina se obtiene por la aplicación de métodos biotecnológicos que constantemente evolucionan. De igual manera, la investigación científica sobre diabetes mantiene una mejora constante. En este contexto, tanto la productividad como la competitividad se deben apoyar con conocimiento que facilite y promueva la capacidad de innovación organizacional. Por esta razón, los sistemas basados en conocimiento emergen como una herramienta útil para coadyuvar con las organizaciones en la solución de situaciones difíciles o en la mejora de sus procesos. En este trabajo, derivado del conocido grupo de síntomas y de las interacciones que la investigación en diabetes mantiene con los procesos biotecnológicos, los autores realizan un breve análisis del conocimiento implicado y del rol que los sistemas basados en el conocimiento han desempeñado, -y continúan desempeñando, en apoyo a tales procesos. Adicionalmente, con la perspectiva sistémica obtenida por los autores respecto al conocimiento y recursos necesarios en prácticas clínicas y de laboratorio, proponen un modelo sistémico capaz de apoyar la investigación y el proceso clínico de la diabetes.

Asociación de la neuropatía autonómica cardiovascular y el intervalo QT prolongado con la morbimortalidad cardiovascular en pacientes con diabetes mellitus tipo 2 / Association of cardiovascular autonomic neuropathy and prolonged QT interval with cardiovascular morbidity and mortality in patients with type 2 diabetes mellitus

Con el objetivo de evaluar la relación entre la neuropatía autonómica cardiovascular (NACV) y el intervalo QT corregido (QTc) con la morbimortalidad cardiovascular en pacientes con diabetes mellitus tipo 2, se realizó el seguimiento a 5 años de 67 pacientes que acudieron a consulta externa del Servicio de Endocrinología. Se presentaron eventos cardiovasculares en 16 pacientes; el 82 por ciento completó el seguimiento y se encontró que el intervalo QTc prolongado fue la única variable que se asoció de forma significativa a morbimortalidad cardiovascular en el análisis de regresión logística múltiple (RR: 13,56; IC 95 por ciento: 2,01-91,36) (p=0,0074).

In order to evaluate the relationship between cardiovascular autonomic neuropathy and corrected QT interval (QTc) with cardiovascular morbidity and mortality in patients with type 2 diabetes mellitus, we followed up for 5 years 67 patients attending the outpatient Endocrinology Service. 82 percent completed follow-up and cardiovascular events occurred in 16 patients. We found that long QTc interval was the only variable significantly associated with cardiovascular morbidity and mortality in the multiple logistic regression analysis (RR: 13.56, 95 percent CI: 2.01-91.36) (p = 0.0074).