Control glicémico perioperatorio / Perioperatory glycemic control

Diabetes is the most common endocrinopathy, in 2014, 8.6% of the population suffered from diabetes, and it was responsible for at least 3.7 million deaths per year. It is estimated that by that by 2050 more than 30% of the population will have this disease. In cardiovascular surgery, it is described that 5.2% of patients are undiagnosed diabetics and this rises to 10% -28% in non-cardiac surgeries. The adverse results are markedly high in those patients with poor glycemic control including an increase of more than 50% in mortality, as well as an increase in respiratory infections, surgical site infection, urinary infection, heart attack and acute kidney injury among others. During the preoperative period of patients with diabetes, it is important to review glycemic control and its current treatment, in addition to providing the patient instructions on how to adjust medications. Intraoperatively, any condition that leads to an uncontrolled increase in surgical stress must be controlled, since this in turn generates hyperglycemia. Knowledge of insulins, their pharmacology and schedules is essential to maintain blood glucose intraoperatively in normal ranges. Different practical algorithms are proposed for the correct and safe management of hyperglycemia in the perioperative period. All care should be continued in the postoperative period defining the continuity of the insulin therapies established and the postoperative care of the patient.

La diabetes es la endocrinopatía más común, en 2014, el 8,6% de la población padecía diabetes siendo responsable de 3,7 millones de muertes por año. Se estima que para el 2050 más del 30% de la población tendrá diabetes. En cirugía cardiovascular el 5,2% de los pacientes son diabéticos no diagnosticados, cifra que aumenta hasta 10%-28% en cirugías no cardíacas. Los resultados adversos son marcadamente elevados en aquellos pacientes con mal control incluyendo un aumento del 50% en la mortalidad, así mismo, incremento de infecciones respiratorias, infección del sitio quirúrgico, infección urinaria, infarto agudo de miocardio y lesión renal aguda, entre otros. Durante el preoperatorio de pacientes con diabetes, es importante revisar el control glucémico y su tratamiento, además de proporcionar al paciente instrucciones por escrito sobre cómo ajustarlo. En el intraoperatorio se debe controlar cualquier condición que lleve a un aumento del estrés quirúrgico pues este a su vez genera hiperglucemia. Es fundamental el conocimiento de las insulinas, su farmacología y esquemas para mantener glucemias en el intraoperatorio en rangos normales. Se proponen diferentes algoritmos prácticos para el correcto y seguro manejo de la hiperglucemia en el perioperatorio. La atención debe continuarse en el posoperatorio definiendo continuidad de terapias insulínicas instauradas y el adecuado cuidado del paciente.

Impact of an inpatient multidisciplinary glucose control management program

ABSTRACT Objective: Glycemic control has been increasingly recognized as a critical element in inpatient care, but optimal management of blood glucose in the hospital setting remains challenging. The aims of this study were to describe and evaluate the impact of the implementation of an inpatient multidisciplinary glucose control management program on glucose control in hospitalized patients. Materials and methods: Retrospective analysis of medical records and glucose monitoring data obtained by point- of-care testing (POCT) in hospitalized patients before (May 2014) and after (June 2015 and May 2017) the implementation of the program. Results: We analyzed 6888, 7290, and 7669 POCTs from 389, 545, and 475 patients in May 2014, June 2015, and May 2017, respectively. Hyperglycemia (≥ 180 mg/ dL) occurred in 23.5%, 19.6%, and 19.3% POCTs in May 2014, June 2015, and May/2017, respectively (p < 0.001), while severe hyperglycemia (≥ 300 mg/dL) was observed in 2.5%, 2.2%, and 1.8% of them, respectively (p = 0.003). Hyperglycemia (≥ 180 mg/dL) reduced significantly from May 2014 to June 2015 (16.3%, p < 0.001) and from May 2014 to May 2017 (178%, p < 0.001). No significant changes occurred in hypoglycemic parameters. Conclusions: The implementation of an inpatient multidisciplinary glucose control management program led to significant reductions in hyperglycemic events. The key elements for this achievement were the development of institutional inpatient glycemic control protocols, establishment of a multidisciplinary team, and continuing educational programs for hospital personnel. Altogether, these actions resulted in improvements in care processes, patient safety, and clinical outcomes of hospitalized patients.

Indicators for best practices in glycemic control in the intensive care unit / Indicativos para mejores prácticas en el control glicémico en una unidad de terapia intensiva / Indicativos para melhores práticas no controle glicêmico em unidade de terapia intensiva

Abstract Objective: To understand the perception of the nursing team' regarding the management of the intensive glycemic control protocol in order to obtain better practices in glycemic control in the Intensive Care Unit of a University Hospital. Method: A qualitative, convergent care study carried out in an Intensive Care Unit of a university hospital. The data were collected through interviews and workshops and analyzed through thematic analysis. Thirty nursing professionals participated in the study. Results: The importance of the glycemic control protocol which standardizes and guides care was reported by the participants, however they indicated that the used protocol is confusing, difficult to understand and does not include some important guidelines. Restructuring was recommended by adding aspects such as: the desired glycemic value, spaces between glycaemia recording, diet and others; as well as training for its application. Conclusion: The participants recognized the weaknesses of the protocol, and reaffirmed the potentialities of this instrument and defended permanent education as a fundamental factor for the best practices in intensive care.

Resumen Objetivo: Conocer la percepción del equipo de enfermería sobre el manejo del protocolo de control glicémico intensivo, con el objetivo de obtener mejores prácticas en el control glicémico en la Unidad de Terapia Intensiva de un Hospital Universitario. Método: Estudio cualitativo y convergente asistencial realizado en una Unidad de Terapia Intensiva de un hospital universitario. Los datos fueron obtenidos através de entrevistas y talleres y analizados através del análisis temático. Participaron del estudio 30 profesionales de enfermería. Resultados: Relatan la importancia del protocolo de control glicémico que estandariza y guía la asistencia. Sin embargo, refieren que el protocolo utilizado es confuso, difícil de entender y no contempla algunas orientaciones importantes. Recomiendan su reestructuración agregando aspectos como: valor de glicemía pretendido, espaciamiento entre glicemías, dieta y otros, y la capacitación para su ejecución. Conclusión: Reconocen las fragilidades del protocolo utilizado, reafirman las potencialidades de este instrumento y defienden la educación permanente como factor fundamental para mejores prácticas en terapia intensiva.

Resumo Objetivo: Conhecer a percepção da equipe de enfermagem quanto ao manejo do protocolo de controle glicêmico intensivo, com vistas a obter melhores práticas no controle glicêmico na Unidade de Terapia Intensiva de um Hospital Universitário. Método: Estudo qualitativo, convergente assistencial, realizado em Unidade de Terapia Intensiva de um hospital universitário. Os dados foram coletados através de entrevistas e oficinas e analisados por meio da análise temática. Participaram do estudo 30 profissionais de enfermagem. Resultados: Relatam a importância do protocolo de controle glicêmico, que padroniza e guia a assistência, entretanto referem que o protocolo utilizado é confuso, difícil de entender não contemplando algumas orientações importantes. Recomendam sua reestruturação acrescentando aspectos como: valor de glicemia pretendido, espaçamento entre glicemias, dieta e outros; bem como capacitação para sua execução. Conclusão: Reconhecem as fragilidades do protocolo utilizado, reafirmam as potencialidades desse instrumento e defendem a educação permanente como fator fundamental para as melhores práticas em terapia intensiva.

The effect of two different glycemic management protocols on postoperative cognitive dysfunction in coronary artery bypass surgery / Efeito de dois protocolos de controle glicêmico diferentes sobre a disfunção cognitiva após cirurgia de revascularização do miocárdio

Abstract Introduction: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. Methods: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the "Tight Control" group (GI), the glycemia was maintained between 80 and 120 mg dL-1 while in the "Liberal" group (GII), it ranged between 80-180 mg dL-1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. Results: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p = 0.047). Conclusion: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment.

Resumo Introdução: A disfunção cognitiva pós-operatória (DCPO) é um resultado adverso cirúrgico que é mais comum após cirurgias cardíacas abertas. O objetivo deste estudo foi investigar o papel dos níveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declínio cognitivo precoce e tardio. Métodos: Foram randomizados em dois grupos 40 pacientes acima de 50 anos e submetidos à cirurgia coronariana eletiva. No grupo "controle rigoroso" (GI), a glicemia foi mantida entre 80-120 mg.dL-1; enquanto no grupo "liberal" (GII), variou entre 80-180 mg.dL-1. A bateria de testes neuropsicológicos foi feita três vezes: fase basal, antes da cirurgia e na primeira e 12ª semana de acompanhamento no pós-operatório. DCPO foi definida como uma queda de um desvio padrão da fase basal em dois ou mais testes. Resultados: Na primeira semana de pós-operatório, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidência de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliação tardia revelou que a disfunção cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI (p = 0,047). Conclusão: Sugerimos que o controle glicêmico rigoroso no perioperatório de cirurgia coronariana pode desempenhar um papel na prevenção da deterioração cognitiva persistente.

Alfabetización en salud y control de la diabetes en pacientes de un hospital universitario de Argentina / Health literacy and diabetes control in patients attending a university outpatient clinic in Argentina

La alfabetización en salud (AS) es una medida de la capacidad de los pacientes de leer, comprender y tomar decisiones en base a instrucciones médicas. La inadecuada AS se asocia con peor estado de salud en pacientes con enfermedades crónicas. Es escasa la información sobre el nivel de alfabetización en pacientes diabéticos en Argentina. Se realizó este estudio con el objeto de estimar la relación de inadecuada AS y el control de la diabetes, evaluada a través del valor de la hemoglobina A1c en diabéticos tratados con insulina que concurren a un hospital universitario de Argentina. La AS se evaluó con el Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA) y se evaluó el control de la glucemia por el último valor de hemoglobina A1c. Participaron 156 pacientes seleccionados en forma aleatoria, 58% mujeres. El puntaje promedio de SALHSA fue 35 (rango: 11-50). Se encontró inadecuada AS en 94 pacientes (60.3%). La HbA1c promedio en los pacientes con inadecuada AS fue 8.15% vs 7.15% entre los que tenían adecuada AS (p = 0.0001). La regresión lineal múltiple mostró que la inadecuada AS se asocia en forma significativa con el mal control de la glucemia (β = -0.05 IC 95% -0.07; -0.02, p < 0.001). En conclusión, sería necesario implementar medidas para garantizar la educación de los pacientes con limitada AS.

Health literacy (HL) is a measure of a patient ability to read, understand and to take decisions on medical instructions. Patients with inadequate HL have poorer health outcomes than those with adequate HL. There is little information on HL levels in diabetic patients in Argentina. The aim of this study was to explore the association between HL and glycemic control in diabetic patients from a university hospital in Argentina. HL was assessed with the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), glycemic control through glycosylated hemoglobin A1c (HbA1c); 156 patients (58% women) took part in the study. Average SAHLSA score was 35 (range: 11-50). Patients with inadequate values of HL had HbA1c of 8.15% vs. 7.15% among those with adequate HL (p = 0.0001). The multiple linear regression shows that inadequate HL was significantly associated with poorer glycemic control (β = -0.05 IC 95% -0.07; -0.02, p < 0.001). Efforts should focus on developing interventions to improve glycemic control among patients with inadequate HL.

Hyperglycemia in critical patients: Determinants of insulin dose choice / Pacientes críticos com hiperglicemia: determinantes da escolha da dose de insulina

Summary Objective: To identify factors that can determine the choice of intermittent subcutaneous regular insulin dose in critically ill patients with hyperglycemia. Method: Cross-sectional study in a general adult ICU with 26 beds, data collected between September and October 2014. The variables analyzed were: sex, age, previous diagnosis of diabetes mellitus, use of corticosteroids, use of lactulose, sepsis, fasting, enteral nutrition, use of dextrose 5% in water, NPH insulin prescription and blood glucose level. Patients with one or more episodes of hyperglycemia (blood glucose greater than 180 mg/dL) were included as a convenience sample, not consecutively. Those with continuous insulin prescription were excluded from analysis. Results: We included 64 records of hyperglycemia observed in 22 patients who had at least one episode of hyperglycemia. The median administered subcutaneous regular human insulin was 6 IU and among the factors evaluated only blood glucose levels were associated with the choice of insulin dose administered. Conclusion: Clinical characteristics such as diet, medications and diagnosis of diabetes mellitus are clearly ignored in the decision-making regarding insulin dose to be administered for glucose control in critically ill patients with hyperglycemia.

Resumo Objetivo: Identificar os fatores associados à escolha da dose de insulina regular subcutânea intermitente em pacientes críticos com hiperglicemia. Método: Estudo transversal em uma UTI geral adulta com 26 leitos. Pacientes com um ou mais episódios de hiperglicemia (glicemia capilar superior a 180 mg/dL) foram incluídos por conveniência, de forma não consecutiva. Aqueles com prescrição de insulina contínua foram excluídos da análise. As variáveis analisadas foram: sexo, idade, diagnóstico prévio de diabetes melito, uso de corticosteroide, uso de lactulose, presença de sepse, jejum, dieta enteral, uso de soro glicosado contínuo, prescrição de insulina NPH e valor da glicemia capilar. Resultados: Foram incluídos 64 registros de hiperglicemia verificados em 22 pacientes que apresentaram pelo menos um episódio de hiperglicemia. O valor mediano administrado de insulina regular humana subcutânea foi de 6,0 UI e, entre os fatores analisados, o único associado à dose de insulina administrada visando à normalização dos níveis glicêmicos foi o valor da glicemia capilar. Conclusão: Evidencia-se a inobservância de características clínicas dos pacientes, como dieta, uso de medicamentos e diagnóstico prévio de diabetes melito, para a tomada de decisão quanto à dose de insulina a ser administrada visando ao controle glicêmico em pacientes críticos com hiperglicemia.

Influence of the informal primary caretaker on glycemic control among prepubertal pediatric patients with type 1 diabetes mellitus / Influência do cuidador familiar principal sobre o controle glicêmico entre pacientes pediátricos pré-púberes com diabetes mellitus tipo 1

Abstract Objectives: In prepubertal type 1 diabetic patients (DM1), the availability of an informal primary caregiver (ICP) is critical to making management decisions; in this study, the ICP-related risk factors associated with glycemic control were identified. Patients, materials, and methods: A comparative cross-sectional study was performed. Fifty-five patients with DM1 under the age of 11 years were included. The patient-related factors associated with glycemic control evaluated were physical activity, DM1 time of evolution, and adherence to medical indications. The ICP-related factors evaluated were education, employment aspects, depressive traits (Beck questionnaire), family functionality (family APGAR), support of another person in patient care, stress (Perceived Stress Scale), and socioeconomic status (Bronfman questionnaire). Multivariate logistic and linear regression analyses were performed. Results: The patients' median age was 8 years; 29 patients had good glycemic control, and 26 were uncontrolled. The main risk factor associated with glycemic dyscontrol was stress in the ICP (OR 24.8; 95% CI 4.06-151.9, p = 0.001). While, according to the linear regression analysis it was found that lower level of education (β 0.991, 95% CI 0.238-1.743, p = 0.011) and stress (β 1.918, 95% CI 1.10-2.736, p = 0.001) in the ICP, as well as family dysfunction (β 1.256, 95% CI 0.336-2.177, p = 0.008) were associated with higher levels of glycated hemoglobin. Conclusions: Level of education and stress in the ICP, as well as family dysfunction, are factors that influence the lack of controlled blood glucose levels among prepubertal DM1 patients.

Resumo Objetivos: Em pacientes pré-púberes com diabetes tipo 1 (DM1), a disponibilidade de um cuidador familiar principal (CFP) é fundamental para tomar decisões de administração; neste estudo, foram identificados os fatores de risco relacionados a CFPs associados ao controle glicêmico. Pacientes, materiais e métodos: Foi feito um estudo transversal comparativo. Foram incluídos 55 pacientes com DM1 menores de 11 anos. Os fatores relacionados aos pacientes associados ao controle glicêmico avaliados foram atividade física, tempo de evolução da DM1 e adesão às indicações médicas. Os fatores relacionados a CFPs avaliados foram escolaridade, aspectos profissionais, traços de depressão (questionário de Beck), funcionalidade familiar (Apgar familiar), ajuda de outra pessoa no cuidado do paciente, estresse (Escala de Estresse Percebido) e situação socioeconômica (questionário de Bronfman). Foram feitas análises de regressão logística multivariada e de regressão linear. Resultados: A idade média dos pacientes era de oito anos; 29 pacientes apresentavam bom controle glicêmico e 26 não tinham controle. O principal fator de risco associado ao descontrole glicêmico foi o estresse no CFP (RC 24,8; IC de 95% 4,06-151,9, p = 0,001). Ao passo que, de acordo com a análise de regressão linear, constatamos que: o menor nível de escolaridade (0,991, IC de 95% 0,238-1,743, p = 0,011) e estresse (1,918, IC de 95% 1,10-2,736, p = 0,001) do CFP, bem como a disfunção familiar (1,256, IC de 95% 0,336-2,177, p = 0,008), foram associados a níveis maiores de hemoglobina glicosilada. Conclusões: O nível de escolaridade e o estresse do CFP e a disfunção familiar são fatores que influenciam a falta de níveis glicêmicos controlados entre pacientes pré-púberes com DM1.

Vitamin C decreases the obesogenic and hyperglycemic effect of invert sugar in prediabetic rats / Vitamina C reduz o efeito obesogênico e hiperglicemiante do açúcar invertido em ratos pré-diabéticos

ABSTRACT Objective: To evaluate whether vitamin C can help to prevent obesity and hyperglycemia in Wistar rats treated with excess invert sugar to induce prediabetes. Methods: One hundred-day-old Male Wistar rats with a mean weight of 336.58±23.43g were randomly assigned to the following groups: (1) control, receiving water (C); (2) invert sugar control, receiving a 32% watery solution of invert sugar; (3) vitamin C control, receiving a watery solution of vitamin C (60mg/L), and (4) vitamin C plus invert sugar, receiving a watery solution of vitamin C and invert sugar. All animals had access to chow and water ad libitum and were treated for 17 weeks. Prediabetes was assessed according to two criteria: obesity (based on body mass indexand peritoneal fat content) and impaired glucose tolerance (assessed by the intraperitoneal glucose tolerance test and expressed as area under the curve) . Results: Group invert sugar control gained significantly more weight (p=0.035) and visceral fat (p<0.001) than groups vitamin C control and vitamin C plus invert sugar. Consequently, groups vitamin C control and vitamin C plus invert sugar had gained as little body mass index as group C by the end of the experiment. Vitamin C decreased the fasting glycemia of both groups supplemented with vitamin C and normalized the glucose tolerance of group vitamin C plus invert sugar, whose area under the curve matched that of group C. Conclusion: Vitamin C has anti-obesogenic and glycemia-lowering effects in Wistar rats, which might be promising to prediabetics. Future studies are needed to understand the anti-obesogenic and anti-hyperglycemic mechanisms of vitamin C in prediabetes.

RESUMO Objetivo: Avaliar o efeito da vitamina C na prevenção da obesidade e da hiperglicemia, em ratos Wistar tratados com sobrecarga de açúcar invertido, para induzir o estágio de pré-diabetes. Métodos: Ratos Wistar machos (100 dias de vida e peso médio de 336,58±23,43g) foram distribuídos aleatoriamente nos grupos: (1) controle água; (2) controle açúcar invertido, recebendo 32% de açúcar invertido diluído em água; (3) controle vitamina C, recebendo vitamina C (60mg/L) diluído em água e, (4) açúcar invertido+vitamina C, tratados com vitamina C e açúcar invertido diluídos em água. Todos os animais receberam ração e água ad libitum, sendo tratados por 17 semanas. O estágio de pré-diabetes foi avaliado considerando-se obesidade (índice de massa corporal e quantidade de gordura peritoneal) e tolerância à glicose diminuída (Teste de Tolerância à Glicose Intraperitoneal, expresso pela área sob a curva) . Resultados: Os grupos vitamina C e açúcar invertido + vitamina C apresentaram redução significativa do peso (p=0,035) e da gordura visceral (p<0,001) em relação ao grupo açúcar invertido. Consequentemente, verificou-se uma diminuição do índice de massa corporal dos grupos vitamina C e açúcar invertido+vitamina C, assemelhando-se ao do grupo C no final do experimento. A vitamina C reduziu a glicemia de jejum dos animais de ambos os grupos suplementados com Vitamina C e normalizou a tolerância à glicose do grupo açúcar invertido+vitamina C, igualando-se a área sob a curva a do grupo C. Conclusão: A suplementação de vitamina C teve efeito anti-obesogênico e hipoglicemiante, mostrando-se promissora no pré-diabetes. Estudos futuros são necessários para entender os mecanismos anti-obesogênicos e anti-hiperglicemiantes da vitamina C no pré-diabetes.

Influence of glycemic control on the levels of subgingival periodontal pathogens in patients with generalized chronic periodontitis and type 2 diabetes

Abstract Objective This study evaluated the influence of glycemic control on the levels and frequency of subgingival periodontal pathogens in patients with type 2 diabetes mellitus (DM) and generalized chronic periodontitis (ChP). Material and Methods Fifty-six patients with generalized ChP and type 2 DM were assigned according to the levels of glycated hemoglobin (HbA1c) into one of the following groups: HbA1c<8% (n=28) or HbA1c≥8% (n=28). Three subgingival biofilm samples from sites with probing depth (PD)<5 mm and three samples from sites with PD≥5 mm were analyzed by quantitative Polymerase Chain Reaction (PCR) for the presence and levels of Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Eubacterium nodatum, Parvimona micra, Fusobacterium nucleatum ssp. and Prevotella intermedia. Results The mean counts of F. nucleatum ssp. were statistically significantly higher in the sites with PD≥5 mm of the HbA1c≥8% group (p<0.05). Frequencies of detection of T. forsythia, E. nodatum, P. micra and F. nucleatum ssp. were all higher in the sites with PD≥5 mm of the patients with HbA1c≥8%, compared with those of patients with HbA1c<8% (p<0.05). Frequency of detection of P. intermedia was higher in the sites with PD<5 mm of the patients with HbA1c≥8% than those of the patients with HbA1c<8% (p<0.05). Conclusions Poor glycemic control, as indicated by HbA1c≥8%, is associated with increased levels and frequencies of periodontal pathogens in the subgingival biofilm of subjects with type 2 DM and ChP.

Medium-term glycemic control in diabetics before coronary bypass surgery

The aim of this study was to determine the association between preoperative medium-term (60-90 days) glycemic control, as reflected by glycosylated hemoglobin levels (HbA1c), and the incidence of major complications (mediastinitis, perioperative infarction, heart failure, stroke and kidney failure dialysis) and mortality in diabetic patients undergoing elective coronary artery by-pass graft surgery (CABG). This study suggests that aggressive glycemic control three months before surgery, achieving HbA1c ≤ 7% improvement results with less postoperative morbidity and mortality.

El propósito de este estudio fue determinar la asociación entre el control glucémico a mediano plazo, 2-3 meses previos a la cirugía cardiaca, evaluado mediante el dosaje de hemoglobina glicosilada (HbA1c), y la incidencia de muerte y complicaciones mayores (mediastinitis, infarto perioperatorio, insuficiencia cardíaca, accidente cerebrovascular e insuficiencia renal dialítica) en pacientes diabéticos tipo 2. Este estudio sugiere que el control glucémico 3 meses antes de la cirugía en pacientes con diabetes mellitus tipo 2, logrando HbA1c ≤ 7%, mejora los resultados en el posoperatorio observándose menor morbilidad y mortalidad.

Trichuris trichiura in a post-Colonial Brazilian mummy

Trichuris trichiura is a soil-transmitted helminth which is prevalent in warm, moist, tropical and subtropical regions of the world with poor sanitation. Heavy whipworm can result either in Trichuris dysenteric syndrome - especially in children - or in a chronic colitis. In heavy infections, worms can spread proximally and may cause ileitis. Here we provide first microscopic evidence for a T. trichiura adult worm embedded in the rectum of a post-Colonial Brazilian adult mummy. During Colonial and post-Colonial times, many European chroniclers described a parasitic disease named Maculo whose symptomatology coincides with heavy helminthiasis. Based on our findings and on comparison of ancient textual evidence with modern description of heavy whipworm, we feel confident in considering that the two syndromes are expressions of the same pathological condition.

Antioxidant and anti hyperglycemic role of wine grape powder in rats fed with a high fructose diet

BACKGROUND: Metabolic syndrome is a growing worldwide health problem. We evaluated the effects of wine grape powder (WGP), rich in antioxidants and fiber, in a rat model of metabolic syndrome induced by a high fructose diet. We tested whether WGP supplementation may prevent glucose intolerance and decrease oxidative stress in rats fed with a high fructose diet. METHODS: Male Sprague-Dawley rats weighing 180 g were divided into four groups according to their feeding protocols. Rats were fed with control diet (C), control plus 20 % WGP (C + WGP), 50 % high fructose (HF) or 50 % fructose plus 20 % WGP (HF + WGP) for 16 weeks. Blood glucose, insulin and triglycerides, weight, and arterial blood pressure were measured. Homeostasis model assessment (HOMA) index was calculated using insulin and glucose values. A glucose tolerance test was performed 2 days before the end of the experiment. As an index of oxidative stress, thio-barbituric acid reactive substances (TBARS) level was measured in plasma and kidney, and superoxide dismutase was measured in the kidney. RESULTS: Thiobarbituric acid reactive substances in plasma and renal tissue were significantly higher when compared to the control group. In addition, the area under the curve of the glucose tolerance test was higher in HF fed animals. Furthermore, fasting blood glucose, plasma insulin levels, and the HOMA index, were also increased. WGP supplementation prevented these alterations in rats fed with the HF diet. We did not find any significant difference in body weight or systolic blood pressure in any of the groups. CONCLUSIONS: Our results show that WGP supplementation prevented hyperglycemia, insulin resistance and reduced oxidative stress in rats fed with HF diet. We propose that WGP may be used as a supplement in human food as well.

Glycemic control in cardiac surgery: Rationale and current evidence.

Studies in cardiac surgical patients have shown an association of hyperglycemia with increased incidences of sepsis, mediastinitis, prolonged mechanical ventilation, cardiac arrhythmias and longer intensive care and hospital stay. There is considerable controversy regarding appropriate glycemic management in these patients and in the defi nition of hyperglycemia and hypoglycemia or the blood sugar levels at which therapy should be initiated. There is also dilemma regarding the usage of “tight glycemic control” with studies showing confl icting evidences. Part of the controversy can be explained by the differing designs of these studies and the variable defi nitions of hyperglycemia and hypoglycemia.

Controle glicêmico em pacientes com diabetes mellitus e doença cardiovascular acompanhados em ambulatório de referência / Glycemic control in patients with diabetes mellitus and cardiovascular disease monitored at a reference outpatient clinic

INTRODUÇÃO: O controle da hiperglicemia característica do diabetes mellitus é parte importante do seu tratamento, e se associa, em longo prazo, à redução de complicações crônicas da doença. No entanto, atingir bom controle glicêmico não é tarefa fácil; múltiplas abordagens têm sido buscadas com este intuito. Nosso objetivo foi descrever o controle glicêmico de uma amostra de pacientes atendidos em nível terciário e analisar possíveis preditores de alcance de bom controle glicêmico no seguimento. MÉTODOS: Estudo observacional, coletados dados de pacientes com diabetes tipo 2 em acompanhamento ambulatorial, através de dados do prontuário eletrônico. Coletadas variáveis demográficas, clínicas e laboratoriais (glicemia, hemoglobina glicada (HbA1c), lipídios, creatinina e microalbuminúria). RESULTADOS: Foram incluídos 57 pacientes; 61,4% alcançaram HbA1c ≤8% (grupo Diabetes Mellitus controlado, DMC) e 22 (38,6%) não atingiram este valor (grupo Diabetes Mellitus não controlado, DMNC) em 1 ano. A maioria dos pacientes do grupo DMNC eram homens (p = 0,030); idade, associação com outras comorbidades, escolaridade, tempo de diabetes não foram diferentes entre os grupos. Número de consultas marcadas foi semelhante entre os grupos, mas o de consultas realizadas foi maior no grupo DMNC. O controle glicêmico inicial era pior no grupo DMNC (HbA1c 9,2 ±1,4 vs.11,0 ±1,5%, p < 0,001). Alta ambulatorial foi mais frequente no grupo DMC (p = 0,01). CONCLUSÃO: A intensificação do cuidado ao diabetes por equipe especializada em nível terciário é capaz de trazer melhor controle glicêmico para a maioria destes pacientes, especialmente quando encaminhados ainda com HbA1c não muito elevada

INTRODUCTION: Controlling hyperglycemia in diabetes mellitus is an important part of the treatment and is associated with long-term reduction of chronic complications. However, it is difficult to achieve, and different approaches to glycemic control are being investigated. We aimed to analyze glycemic control in a sample of patients treated at a tertiary hospital, as well as to analyze possible predictors of good glycemic control during follow-up. METHODS: In this observational study, we collected data from the electronic medical records of patients with type 2 diabetes treated at a reference outpatient clinic. We analyzed demographic, clinical and laboratory variables (blood glucose, glycosylated hemoglobin (HbA1c), lipids, creatinine and microalbuminuria). RESULTS: Out of 57 patients, 61.4% had HbA1c levels ≤8% (controlled diabetes mellitus group, CDM), and 38.6% (n = 22) did not reach this value (uncontrolled diabetes mellitus group, UDM) in 1 year. Most patients in the UDM group were men (p = 0.030). Age, association with other comorbidities, educational attainment, and duration of diabetes were not different between groups. The number of scheduled appointments was similar between groups, but the number of attended appointments was higher in the UDM group. Initial glycemic control was worse in the UDM group (HbA1c 9.2 ±1.4 vs. 11.0 ±1.5%, p < 0.001). Outpatient discharge was more frequent in the CDM group (p = 0.01). CONCLUSION: Intensifying diabetes care by a specialized team at tertiary centers can improve metabolic control for the majority of these patients, especially for those with a lower HbA1c at the time of referral

Cytoprotective activity of mulberry leaf extract against oxidative stress-induced cellular injury in rats

Morus alba Linn. [MA], mulberry leaves have been used as a beverage for prevention of various diseases including hyperlipidemia and hyperglycemia. Recently, the antioxidant activities of the MA leaf extract have been reported. The objective of this study was to investigate the effect of the MA leaf extract on free radical-induced cellular injury. In the in vitro models, the extract scavenged stable free radical [1, 1-diphenyl-2-picrylhydrazyl; DPPH] in a concentration-dependent manner with an IC[50] of 20.10 +/- 0.78 micro g/ml. The extract protected the erythrocytes from free radical [2, 2'-azobis [2-amidinopropane] dihydrochloride; AAPH]-induced hemolysis with an IC[50] of 74.22 +/- 9.87 micro g/ml. Additionally, the extract significantly prevented the gastric mucosal injury induced by ischemia-reperfusion [I/R] in rats when given orally at doses of 0.25 and 0.50 g/kg/day for 3 consecutive days [p<0.05; n=7]. However, this effect was not found when the higher doses [1 and 2 g/kg/day] of the extract were tested. In conclusion, these results indicate that the MA leaf extract possesses the cytoprotective activity against free radical-induced cell injury. Therefore, when given at the appropriate dose range, the mulberry leaf may potentially be used as a food supplement in patients with certain diseases in which the oxidative stress-induced cellular injury is pathologically involved

Glycemic control in type 2 diabetes mellitus and its association with duration of diabetes and glycosylated hemoglobin A1

The aim of present study was to evaluate glycemic control in type 2 diabetes mellitus [DM] subjects and its association with the duration of diabetes and glycosylated Hemoglobin A1 [HbA1c]. A descriptive study, comprising of 571 diagnosed cases of type 2 DM were studied at the Diabetic clinic of Isra University/ consultant private clinics over a year period. Diabetic subjects were divided as; controlled diabetics [Group I. HbA1c 7%]. The data was recorded on a proforma. Blood glucose was measured by glucose oxidase method and HbA1c on automated clinical chemistry analyzer. The student`s t-test and chi-square were used for the quantitative and qualitative data respectively. Spearman`s correlations was used for a linear correlation of HbA1c with the duration of DM and random blood sugar [RBS]. The data was analyzed on SPSS version 16.0 for windows. P-value at /= 7% [Group II]. The HbA1c values as high as >/= 13.1% was noted in 73 [12.7%]. A highly significant difference was observed in HbA1c [p=0.0001] between groups. Significant correlation of HbA1c was found with duration of DM [r=0.65, p=0.0001] but not with the RBS [r=0.038, p=0.36] We report poor glycemic control as indicated by glycosylated Hb A in type 2 diabetics. Public campaigns be attempted on regular basis to make diabetics aware of glycemic control

Control de la glucemia en el postoperatorio de cirugía cardíaca: Informe del Consejo de Emergencias de la Sociedad Argentina de Cardiología / Blood glucose control during cardiac surgery: Report of the Emergency Council of the Argentine Society of Cardiology

La hiperglucemia en el postoperatorio de cirugía cardÍaca es un hallazgo frecuente asociado a peor evolución, que afecta tanto a diabéticos como no diabéticos. A pesar de las múltiples publicaciones disponibles, aún no existe un abordaje universalmente aceptado a este problema. En una iniciativa originada en el Consejo de Emergencias de la Sociedad Argentina de Cardiología, se convocó a expertos de nuestro medio con el propósito de debatir cómo debe ser el manejo de la glucemia en el paciente crítico cardiovascular. Este documento refleja lo discutido en este evento académico con la intención de resumir los principales aspectos del control de la glucemia en el postoperatorio de cirugía cardíaca.

Hyperglycemia after cardiac surgery is a common finding associated with the worse outcomes affecting both diabetic and non diabetic patients. Despite the large number of publications available, there is no universally accepted approach to this problem. In an initiative of the Emergency Council of the Argentine Society of Cardiology, local experts gathered to discuss the management of hyperglycemia after adult cardiac surgery. The main objective of the present paper is to summarize the current state of knowledge regarding glycemic control in postoperative cardiac surgery.

Análise comparativa entre aparelhos de pressão arterial (digital e aneróide) e entre glicosímetros de diferentes marcas na detecção de pacientes hipertensos e diabéticos / Comparative analysis of blood pressure devices (aneroid and digital) and between different brands of glucometers in detecting hypertension and diabetes patients

Objetivo: O objetivo do presente estudo foi comparar e testar a confiabilidade e eficiência de dois aferidores de pressão arterial, aneróide (BD®) e digital (G-Tech®) e dois aparelhos medidores de glicemia capilar (Accu-Chek Active® e Optium Xceed®), em uma situação de pré-cirúrgico odontológico. Métodos: A amostra total de 60 pacientes foi avaliada por um único examinador calibrado. As aferições da pressão arterial foram realizadas com ambos os aparelhos (aneróide e digital) com o paciente em repouso e o braço ao nível do coração, e em seguida, as mensurações de testes de glicemia capilar foram realizadas por meio de dois glicosímetros (Accu-Chek Active® e Optium Xceed®). Todos os aparelhos estavam devidamente calibrados e certificados pelo INMETRO. Foram aplicados o teste t de "Student" e a análise do coeficiente de correlação. Resultados: As médias da pressão arterial sistólica (PAS) e pressão arterial diastólica (PAD) para o método auscultatório foram respectivamente, 124,5 mmHg e 80,67 mmHg; e para o oscilométrico, 132,80 mmHg e 82,20 mmHg. Em relação à glicemia capilar, as médias foram de 115,05 mg/dl para o Optium Xceed® e 107,28 mg/dl para Accu-Check Active®. Diferença estatisticamente significante (p menor que 0,001) foi encontrada entre os métodos avaliados. Quanto à análise do coeficiente de correlação, obteve-se correlação normal entre PAS (r=0,6486) e PAD (r=0,6618), e excelente entre os glicosímetros (r=0,9621). Conclusão: A utilização dos dois métodos, auscultatório e oscilométrico, permitiu verificar uma correlação normal entre as aferições obtidas para PAS e para PAD. Houve excelente correlação entre os valores de glicemia capilar, encontrados por meio dos glicosímetros, Accu-Check Active® (Roche) e Optium Xceed® (Abbott).

Objective: The aim of the present study was to compare and test the reliability and efficiency of two blood pressure measurements devices, aneroid (BD®) and digital (G-Tech®), and two glucose measurements devices (Accu-Chek Active® and Optium Xceed®), in the a preoperative dentistry situation. Methods: A sample with 60 patients was evaluated by one calibrated examiner. Blood pressure measurement was performed with both devices (aneroid and digital) with the patient at rest and the arm at the level of the heart, and then, the measurements of capillary blood glucose were performed by two glucometers (Accu-Chek Active® and Optium Xceed®). All equipment was properly calibrated and certified by INMETRO. We applied Student's t test and analysis of the correlation coefficient. Results: The medias of systolic blood pressure (SBP) and diastolic blood pressure (DBP) to the auscultatory method were respectively, 124,50 mmHg and 80,67 mmHg; and to the oscillometric method were 132,80 mmHg and 82,20 mmHg. In relation to capillary glucose, the media were 115,05 mg/dl to Optium Xceed® and 107,28 mg/dl to the Accu-Check Active®. There was a statistically significant difference (p less than 0,001) between the methods evaluated. As for correlation, we obtained normal correlation between SBP (r=0,6486) and DBP (r=0,6618) and between the two glucometers (r=0,9621). Conclusions: The use of two methods, auscultatory and oscillometric, has show a normal correlation between measurements obtained for SBP and DBP. There was excellent correlation between capillary glucose values, found by the glucometer, Accu-Check Active® (Roche) and Optium Xceed® (Abbott).