Comparação da eficácia da retinografia colorida e da angiografia fluorescente no diagnóstico da retinopatia diabética / Comparing efficacy of fundus photography and fluorescein angiography in the diagnosis of diabetic retinopathy

RESUMO Objetivo: Avaliar a efetividade da retinografia colorida e a da angiografia fluorescente no diagnóstico e no rastreio da retinopatia diabética. Métodos: Estudo retrospectivo, com base na análise de resultados de ambos os exames de 398 pacientes diabéticos. Resultados: Os resultados da angiografia coincidiram com os da retinografia em 77,4% dos casos, e não houve diferença significativa no estadiamento e na identificação da retinopatia pelos dois métodos. Conclusão: Não houve diferença significativa em relação à capacidade diagnóstica da doença pelos métodos descritos, demonstrando não existir benefício em indicar a angiografia como avaliação inicial do paciente diabético.

ABSTRACT Objective: To assess effectiveness of fundus photography and fluorescein angiography in diagnosis and screening of diabetic retinopathy. Methods: A retrospective study of 398 diabetic patients, based on analysis of results of both tests. Results: Results of fluorescein angiography and fundus photography coincided in 77.4% of cases, and there was no significant difference in staging and identification of retinopathy by both methods. Conclusion: There was no significant difference between both methods regarding the capacity to diagnose the disease, showing no benefit in indicating fluorescein angiography as initial assessment of diabetic patients.

Rubeosis faciei diabeticorum is not associated with oxidative stress and skin autofluorescence

Abstract Background Rubeosis faciei diabeticorum is a persistent facial erythema in patients with diabetes mellitus. The actual pathogenesis has not been studied. However, it is speculated to be a cutaneous diabetic microangiopathy. Objective Examine the correlation between the severity of facial erythema and the possible causes of microvascular diabetic complications, namely oxidative stress, hyperglycemia, and cutaneous accumulation of advanced glycation end-products . Methods Patients diagnosed with Type 2 diabetes mellitus (n = 32) were enrolled in the study. The facial erythema index was measured using the Mexameter MX18; cutaneous accumulation of advanced glycation end-products was estimated by measuring skin auto fluorescence with the AGE Reader (DiagnOptics Technologies B.V. - Groningen, Netherlands). Glycated haemoglobin, total antioxidant status, and malondialdehyde were measured in blood by TBARS assay. The correlation between the selected variables was assessed by Spearman's rank test; p ≤ 0.05 was considered statistically significant. Results There was a statistically significant correlation between total antioxidant status and the facial erythema index (ρ = 0.398, p = 0.024). Malondialdehyde, skin autofluorescence, glycated haemoglobin, body mass index, duration of diabetes, and age did not demonstrate statistically significant correlation with the facial erythema index. Study limitations This is an observational study. Elevation of total antioxidant status could have been caused by several factors that might have also influenced the development of rubeosis faciei, including hyperbilirubinemia and hyperuricemia. Conclusions The results contradicted expectations. Total antioxidant status correlated positively with facial erythema index; however, there was no correlation with oxidative stress and skin autofluorescence. Further investigations should be conducted to reveal the cause of total antioxidant status elevation in patients with rubeosis faciei.

Modelos constitutivos hiperelásticos del tejido arterial y su valoración para considerar el descontrol metabólico / Hyperelastic constitutive models of arterial tissue and its assessment to consider metabolic uncontrol

Introducción: Las arterias elásticas se caracterizan por un comportamiento hiperelástico anisotrópico, no lineal y cuasi -incompresible, el cual depende de la contribución y distribución de los principales constituyentes. Su evaluación a través de modelos constitutivos junto con enfoques numéricos apropiados puede contribuir potencialmente al estudio de enfermedades como la aterosclerosis, así como al modelado de las intervenciones quirúrgicas o traumas por accidente. Objetivo: Valorar los modelos constitutivos que caracterizan el comportamiento biomecánico de la pared arterial para la identificación del potencial adecuado que permita la correlación de parámetros bioquímicos y mecánicos, en condiciones de daño. Métodos: Se realizó una revisión bibliográfica entre los años 2010-2016 en las bases de datos: Medline, Cochrane Library, Lilacs, así como en el meta-buscador Google. Se consultaron estudios de cohorte, prospectivos, retrospectivos, clínicos, epidemiológicos, revisiones bibliográficas y ensayos clínicos. Resultados: El modelo constitutivo anisotrópico de dos familias de fibras resulta apropiado para obtener nuevas relaciones constitutivas, que aporten más información sobre las propiedades mecánicas de las arterias bajo la influencia del descontrol metabólico generado por la acción de la diabetes mellitus, en los estadios tempranos de la aterosclerosis. Conclusiones: Los cambios en la estructura, composición y propiedades mecánicas que sufre la pared arterial, debido al descontrol metabólico, permite aseverar que la formulación de un modelo adecuado para representar esta realidad es una etapa crucial en la obtención de nuevas relaciones constitutivas, que contribuyan a una solución satisfactoria en el diagnóstico clínico no invasivo de las enfermedades vasculares(AU)

Introduction: The elastic arteries are characterized by a hyper-elastic, anisotropic, non-linear and quasi-incomprehensible behaviour, which depends on the contribution and distribution of the main constituents. Its evaluation through constitutive models together with appropriate numerical approaches can potentially contribute to the study of pathologies such as atherosclerosis, as well as to the modelling of surgical interventions or traumas by accident. Objective: To assess the constitutive models that characterize the biomechanical behavior of the arterial wall for the identification of the adequate potential that allows the correlation of biochemical and mechanical parameters in damage conditions. Methods: A bibliographic review was conducted from 2010 to 2016 in databases such as: Medline, Cochrane Library, Lilacs, as well as in the metasearch engine Google. There were consulted cohort, prospective, retrospective, clinical, epidemiological studies, bibliographic reviews and clinical trials. Results: The constitutive anisotropic model of two families of fibers is appropriate to obtain new constitutive relations, which provide of more information about the mechanical properties of the arteries under the influence of the metabolic decontrol generated by the action of diabetes mellitus, in the early stages of atherosclerosis. Conclusions: The changes in the structure, composition and mechanical properties of the arterial wall as a consequence of the metabolic decontrol allows to assert that the formulation of a suitable model to represent this reality is a crucial stage in obtaining new constitutive relations that contribute to a satisfactory solution in the non-invasive clinical diagnosis of vascular diseases(AU)

Caracterización de pacientes con pie diabético del Hospital General Docente Dr Agostinho Neto, Guantánamo / Characterization of patients with diabetic foot of the Hospital General Docente Dr Agostinho Neto, Guantánamo

Introducción: el pie diabético es un problema de salud, sin embargo, en el Servicio de Angiología y Cirugía Vascular del Hospital General Docente Dr Agostinho Neto se desconocen las características de los pacientes con esta afección. Objetivo: para profundizar en las posibles causas se realizó esta investigación con el objetivo de caracterizar a los pacientes con diagnóstico de pie diabético atendidos en este servicio durante el 2016. Método: se realizó un estudio de tipo observacional, descriptivo, y transversal en el total de pacientes atendidos con esta enfermedad (n=205). Resultados: el pie diabético fue más frecuente en mujeres, entre los 61 y 70 años de edad, con diabetes tipo 2 y más de 16 años de evolución de la enfermedad. Fue más común la forma clínica neuroinfecciosa y fue elevado el porcentaje de pacientes amputados, sobre todo las amputaciones menores. Fallecieron dos pacientes. Conclusiones: se concluyó que dicho padecimiento fue más frecuente en mujeres con edad entre 61 y 70 años, la forma clínica neuroinfecciosa la más común y que se realizaran amputaciones menores. La letalidad en los pacientes con pie diabético fue baja(AU)

Diabetes e lesão cardiovascular - uma consequência inexorável / Diabetes and cardiovascular injury ­ an inexorable consequence

A doença cardiovascular do paciente com diabetes possui múltiplos mecanismos. As manifestações clínicas são variadas, sendo particularmente prevalentes a doença macro e microvascular, a insuficiência cardíaca e a insuficiência renal crônica. Os mecanismos manifestam-se de maneira gradual e diversificada, dependendo do grau de controle glicêmico e de outros fatores de risco associados. A disfunção autonômica, alterações metabólicas glicêmicas e lipídicas, ativação do sistema renina angiotensina aldosterona, disfunção endotelial, comprometimento energético, hipertensão arterial, obesidade e aumento da atividade inflamatória e pró-trombótica têm sido descritos e parecem relacionados ao fenótipo clínico da doença. Uma vez que complicações como doença coronariana, insuficiência cardíaca e renal sejam diagnosticadas, o prognóstico da doença torna-se mais crítico, apesar do notável avanço terapêutico.

The cardiovascular disease in diabetics has multiple mechanisms. The clinical manifestations are diverse, with macro and microvascular disease, heart failure and chronic kidney failure being particularly prevalent. The mechanisms appear gradually and are diverse in form, depending on the degree of glycemic control and other associated risk factors. Autonomic dysfunction, glucose and lipid metabolic abnormalities, renin angiotensin system activation, endothelial dysfunction, energetic impairment, arterial hypertension, obesity and increased inflammatory and prothrombotic activity have been described and appear to be related to the clinical phenotype of the disease. When complications such as coronary heart disease, heart failure or kidney failure are diagnosed, the prognosis of the disease becomes more critical, in spite of notable therapeutic advances.

Factores psicosocio-inmunogenéticos en pacientes diabéticos con complicaciones vasculares / Psychological, social and immunogenetic factors observed in diabetic patients with vascular complications

El desarrollo de la medicina, la ciencia y los medios científicos técnicos, permiten explicar de manera didáctica e integral con un enfoque dialéctico-materialista los fenómenos complejos y sus interrelaciones entre sistemas, en diferentes entidades clínicas como la diabetes mellitus, objeto del presente trabajo. Describir la interacción entre factores psicosocio-inmuno-genéticos en pacientes diabéticos con complicaciones vasculares, fue el objetivo de nuestro trabajo. Se trabajó con las bases de datos PubMed, MedLine, SciELO, Ebsco y artículos científicos publicados en revistas cubanas entre 2011-2015. Se revisaron trabajos en español, inglés y francés. Se analizó la interrelación dialéctica e indisoluble de la función integradora del sistema inmune con los sistemas nervioso y endocrino, la que descansa en las relaciones entre los fenómenos psíquicos y orgánicos, y esto solo puede comprenderse completamente cuando se tiene en cuenta la interacción del hombre con el medio social en que se desenvuelve, así como la relación de este con la naturaleza, que es en definitiva el centro de su actividad creadora y transformadora y sobre todo el análisis de las implicaciones prácticas que conlleva para el campo de la clínica y la ciencia. Podemos concluir que el conocimiento de las interacciones entre factores psicosocio-inmuno-genéticos en pacientes diabéticos tipo 2 con complicaciones vasculares, es imprescindible para comprender la dinámica de los fenómenos bioquímicos, así como entre los tres sistemas integradores: neurológico, endocrino e inmune que tienen lugar en estos pacientes, lo que posibilita el tratamiento más adecuado y eficaz y la prevención de la enfermedad hereditaria en familias portadoras(AU)

The development of medicine, science and technical scientific devices allow explaining didactically and comprehensively, with a dialectical-materialist approach, complex phenomena and their interrelationships in different clinical conditions such as diabetes mellitus The objectives of this paper were to describe the interaction among psychological, social, and immunogenetic factors in diabetic patients with vascular complications and to address how these factors are associated with immunosupression state of type 2 diabetic patients. For this purpose, worked with PubMed, MedLine, SciELO, EBSCO databases and scientific articles published in 2011-2015 journals were consulted. A number of papers in Spanish, English and French languages were reviewed. The dialectic and permanent interrelation of the integrative function of the immune system with the nervous and endocrine systems, which is based on the relationship between psychic and phenomena, was analyzed. All this can only be fully understood when one takes into account man's interaction with the social environment as well as his relationship with nature, which is ultimately the core of their creative and transforming activity and particularly, the analysis of the practical implications for the clinical and scientific fields. The knowledge of the interactions among systems is imperative to understand homeostasis and dynamics of biochemical phenomena that occur in humans, both in the relationship between the biological and the psychic areas, and in the biological and the socio environmental areas, thus allowing scientific advances in this field for the development of more effective therapeutic and prevention methods(AU)

Resultados y reacciones adversas en pacientes tratados con Heberprot-P® en la comunidad / Results and adverse reactions observed in patients treated with Heberprot-P in the community setting

Introducción: La diabetes mellitus es considerada una epidemia en estos momentos a nivel mundial. Al aumentar la prevalencia de esta enfermedad aumenta la de pie diabético con sus respectivas lesiones. Objetivos: Determinar los resultados y reacciones adversas en pacientes tratados Heberprot-P® en la comunidad. Método: Estudio prospectivo en 17 pacientes con distintas lesiones de pie diabético atendidos en un área de salud entre enero de 2012 y abril de 2013. A todos se les aplicó, de forma ambulatoria, Heberprot-P® (factor de crecimiento epidérmico recombinante humano) hasta la granulación total de las lesiones. Resultados: El 52,94 por ciento de los pacientes tenían pie diabético grado 4 según la clasificación de Wagner. El 100 por ciento de los enfermos mostraron resultados satisfactorios. Las reacciones adversas se presentaron en seis ocasiones y en tres pacientes. Conclusiones: Se alcanzaron buenos resultados con el uso del Heberprot-P® considerados por las pocas reacciones adversas y la ausencia de amputación sobre todo en los pacientes diabéticos con úlceras del pie grado 4 de Wagner. El Heberprot-P® constituye un medicamento a tener en cuenta en la curación de las úlceras del pie diabético con la ventaja de que puede utilizarse de forma ambulatoria(AU)

Introduction: Diabetes mellitus is currently considered as an epidemic worldwide. With the rise of the prevalence of this disease, that of the diabetic foot with its different lesions increases too. Objectives: To determine the results and the adverse reactions in patients treated with Heberprot-P® in the community setting. Method: Prospective study of 17 patients with various diabetic foot lesions, who were seen in a health area from January 2012 to April 2013. They all received an outpatient treatment with Heberprot-P® (human recombinant epidermal growth factor) until complete granulation of lesions. Results: In the group, 52.94 percent of patients had grade 4 diabetic feet according to Wagner´s classification scale. All the treated patients showed satisfactory results and adverse reactions occurred six times in three patients. Conclusions: Good results are achieved with the use of Heberprot-P® due to few adverse reactions and absence of amputation, mainly in diabetics with grade 4-foot ulcers in Wagner´s classification scale. This is a drug to be taken into consideration for curing diabetic foot ulcers since it can also be used in outpatient treatment(AU)

Risk Factors for the Rupture of Bifurcation Intracranial Aneurysms Using CT Angiography

PURPOSE: To investigate the clinical and morphological characteristics in relation to risk of bifurcation intracranial aneurysm rupture. MATERIALS AND METHODS: Data from 202 consecutive patients with 219 bifurcation aneurysms (129 ruptured and 90 unruptured) managed at the authors' facility between August 2011 and July 2014 were retrospectively reviewed. Based on their clinical records and CT angiographic findings, the ability of risk factors to predict aneurysm rupture was assessed using statistical methods. RESULTS: Age, hypertension, diabetes mellitus, and cerebral atherosclerosis were negatively correlated with aneurysm rupture. Aneurysms located in the middle cerebral artery, daughter artery ratio, lateral angle ratio (LA ratio), and neck width were negatively correlated with rupture. Aneurysms located in the anterior communicating artery, irregularity, with daughter sac, depth, width, maximum size, aspect ratio (AR), depth-to-width ratio, and bottleneck factor were significantly and positively correlated with rupture. Binary logistic regression model revealed that irregular shape [odds ratio (OR) 6.598] and AR (OR 3.507) strongly increased the risk of bifurcation aneurysm rupture, while age (OR 0.434), cerebral atherosclerosis (OR 0.125), neck width (OR 0.771), and LA ratio (OR 0.267) were negatively correlated with rupture (p<0.05). Receiver operating characteristic analysis revealed the threshold values of AR and LA ratio to be 1.18 and 1.50, respectively. CONCLUSION: Age (≥60 yr), cerebral atherosclerosis, and aneurysms with a larger neck width and larger LA ratio are protective factors against bifurcation aneurysm rupture. An aneurysm with an irregular shape and an increased AR reflect the greater likelihood of a rupture.

Efecto de cohorte al nacer sobre la prevalencia de factores de riesgo asociados a enfermedad coronaria en un país latinoamericano / Birth cohort effect on prevalence of cardiovascular risk factors in coronary artery disease. Experience in a Latin-american country

Antecedentes: La prevalencia de los factores de riesgo tradicionales asociados a enfermedad coronaria ha cambiado con el tiempo. En la actualidad se ha aumentado la frecuencia de dislipidemia, hipertensión y diabetes mellitus, pero disminuido la de tabaquismo. El efecto de cohorte al nacer en sujetos con enfermedad coronaria como aproximación de la verdadera prevalencia en el tiempo no se ha estudiado en Latinoamérica. Objetivo: Determinar la tendencia temporal de la prevalencia de factores de riesgo tradicionales para enfermedad coronaria por efecto de cohorte al nacer en una población de alto riesgo. Métodos: En pacientes con enfermedad coronaria se estimó la prevalencia de: diabetes mellitus, tabaquismo, hipertensión y dislipidemia. Se define como la presencia del efecto de cohorte al nacer la metodología estadística, epidemiológica y sociológica que pretende identificar la influencia del entorno en el transcurso de la vida de acuerdo con la década de nacimiento. Se realizaron análisis ajustados por género. Resultados: Se incluyen 3,056 sujetos. De ellos, el 72% son varones, la mediana de edad fue de 61 años (rango intercuartílico = 53-69). Para toda la población de estudio, la prevalencia de hipertensión fue del 62.3%, diabetes mellitus del 48.8%, tabaquismo activo del 18.8% y dislipidemia del 48.8%. Para diabetes mellitus y dislipidemia se observó un incremento de la prevalencia en cada cohorte según la década de nacimiento, mientras que para la hipertensión se vio una disminución en las mismas décadas de nacimiento. Conclusiones: La prevalencia de los factores de riesgo tradicionales ha cambiado con el tiempo y se evidencia la presencia del efecto del momento al nacer, influido posiblemente por las condiciones sociales del entorno en cada década de la vida.

Background: The prevalence of major risk factors associated to coronary artery disease has changed over time. Today, the frequency of dyslipidemia, hypertension and diabetes mellitus has increased, while smoking has decreased. The birth cohort effect for coronary artery disease in subjects as an approximation of the true prevalence over time has not been studied in Latin-America. Objective: To determine the trends in the prevalence of major risk factors for coronary artery disease by birth cohort effect in a high risk population. Methods: We estimate the prevalence of diabetes mellitus, smoking, hypertension and dyslipidemia from a prospective institutional registry (DREST registry) of patients who underwent percutaneous coronary intervention for acute coronary event. Birth cohort effect was defined as a statistical, epidemiological and sociological methodology to identify the influence of the environment in the lifetime from birth by each decade. Univariate and multivariate analyses were performed adjusted by gender. Results: Out of 3,056 subjects who were enrolled, 72% were male, with a median age of 61 years (interquartile range = 53-69). Hypertension prevalence was 62.3%, for diabetes mellitus it was 48.8%, for smoking it was 18.8% and for dyslipidemia it was 48.8%. We observed an increase in prevalence for diabetes mellitus and dyslipidemia in each cohort according to birth decade, while there was a reduction in prevalence for hypertension in the same decades. Conclusions: The prevalence of major cardiovascular risk factors has changed in time and the presence of time at birth effect is evident, possibly influenced by the environment's social conditions in each decade of life.

Fatores de risco e complicações em hipertensos/diabéticos de uma regional sanitária do nordeste brasileiro / Risk factors and complications in patients with hypertension/diabetes in a regional health district of northeast Brazil / Factores de riesgo y complicaciones en hipertensos/diabéticos de una región sanitaria del noreste brasileño

Objetivou-se com este estudo identificar os fatores de risco e a complicações associadas em usuários com hipertensão/diabetes, cadastrados no HIPERDIA da Secretaria Executiva Regional VI em Fortaleza, CE. O estudo documental analítico abordou 2.691 pessoas. Do total, 73,6% eram mulheres; 44,6% tinham 60-79 anos, com média de 60,8 anos; 87,4% eram brancos, amarelos ou pardos; 63,7% tinham até oito anos de estudo; 79,7% não eram fumantes; 56,6% sedentários; 59,6% apresentavam sobrepeso/obesidade; 48,4% possuíam antecedente familiar de doença cardiovascular. Verificou-se associação entre sedentarismo e sobrepeso/obesidade com diabéticos e diabéticos hipertensos; antecedente familiar de doença cardiovascular com os hipertensos e diabéticos hipertensos; acidente vascular encefálico, doença arterial coronariana e insuficiência renal crônica com hipertensos e diabéticos hipertensos; infarto e acidente vascular encefálico com diabéticos. O antecedente familiar cardiovascular associou-se com doença arterial coronariana e infarto. Evidenciou-se a presença relevante de fatores de risco e complicações, destacando a necessidade da educação em saúde com os usuários.

The objective of this study was to identify the risk factors and associated complications present in clients with hypertension/diabetes, enrolled in the HIPERDIA of the Executive Regional Health Department VI in Fortaleza, CE. This analytical documental study included 2,691 people. Of this total, 73.6% were women; 44.6% were between 60-79 years of age (mean age of 60.8 years); 87.4% were Caucasian, Asian or Pardo; 63.7% had eight or fewer years of education; 79.7% were non-smokers; 56.6% were considered sedentary; 59.6% were overweight/obese; and 48.4% had a family history of cardiovascular disease. An association was observed between having a sedentary lifestyle and being overweight/obese among patients with diabetes, and those with both diabetes and hypertension; family history of cardiovascular disease in patients with hypertension and those with both diabetes and hypertension; stroke, coronary artery disease and chronic renal failure in patients with hypertension and those with both diabetes and hypertension; and infarction and stroke in patients with diabetes. A family history of cardiovascular disease was associated with coronary artery disease and infarction. A relevant presence of risk factors and complications was found, highlighting the need for health education among clients.

Se objetivó identificar factores de riesgo y complicaciones asociadas en pacientes con hipertensión/diabetes, registrados en el HIPERDIA de la Secretaría Ejecutiva Regional IV de Fortaleza-CE. Estudio documental analítico que abordó 2.691 personas; 73,6% de sexo femenino, 44,6% con 60-79 años, promedio de 60,8 años; 87,4% blancos, amarillos o trigueños, 63,7% con hasta ocho años de escolarización; 79,7% no fumadores, 56,6% sedentarios, 59,6% con sobrepeso/obesidad, 48,4% con antecedentes cardiovasculares familiares. Se verificó asociación entre sedentarismo y sobrepeso/obesidad con los diabéticos y diabéticos hipertensos; antecedentes cardiovasculares familiares con los hipertensos y diabéticos hipertensos; accidente cerebro-vascular, enfermedad coronaria e insuficiencia renal crónica con hipertensos y diabéticos hipertensos; infarto y accidente cerebro-vascular con diabéticos. Antecedentes cardiovasculares familiares se asociaron con enfermedad coronaria e infarto. Se evidenció presencia relevante de factores de riesgo y complicaciones, destacándose la necesidad de educación sanitaria a los pacientes.

Dor torácica no infarto agudo do miocárdio entre pacientes diabéticos e não diabéticos / Chest pain in acute myocardial infarction among diabetic and non-diabetic patients / Dolor torácico en el infarto agudo de miocardio entre pacientes diabéticos y no diabéticos

Considerando-se que pacientes diabéticos acometidos de Infarto Agudo do Miocárdio (IAM) podem, ou não, apresentar dor torácica, objetivou-se neste estudo comparar a presença e intensidade de dor torácica no IAM entre pacientes diabéticos e não diabéticos. Realizou-se um estudo transversal, que incluiu pacientes com IAM, idade ≥18 anos, ambos os sexos. Utilizou-se uma escala numérica verbal para avaliar a presença e a intensidade da dor.Foram incluídos 88 pacientes no estudo, dentre os quais 77 (87,5%) não diabéticos e 11 (12,5%) diabéticos. A dor esteve presente em 11 (100%) dos diabéticos e 76 (98,7%) dos não diabéticos. A intensidade da dor nos diabéticos foi de 8,91 versus 8,23 nos não diabéticos. O estudo mostrou semelhança na presença e intensidade da dor torácica entre pacientes diabéticos e não diabéticos acometidos de IAM.

Considering that diabetic patients suffering from Acute Myocardial Infarction (AMI) may or may not have chest pain, this study aimed to compare the presence and intensity of chest pain in AMI between diabetic and non-diabetic patients. We conducted a cross-sectional study that included patients with AMI, aged ≥ 18 years, both sexes. We used a verbal numeric scale for assessing the presence and intensity of pain. The study included 88 patients, of whom 77 (87.5%) non-diabetic patients and 11 (12.5%) diabetics. The pain was present in 11 (100%) of diabetics and in 76 (98.7%) of non-diabetics. The intensity of pain in diabetics was 8.91 versus 8.23 in non-diabetic patients. The study showed similarity in the presence and intensity of chest pain between diabetic and non diabetic patients suffering from AMI.

Teniendo en cuenta que los pacientes diabéticos acometidos de Infarto Agudo del Miocardio (IAM) pueden o no presentar dolor torácico. Este estudio objetivó comparar la presencia e intensidad de dolor torácico en el IAM entre pacientes diabéticos y no-diabéticos. Realizó-se un estudio transversal, que incluyó a pacientes con IAM, ambos sexos, edad ≥18 años. La presencia y la intensidad del dolor fueron evaluadas a través de la escala numérica verbal. Se incluyeron 88 pacientes, de los cuales 77 (87,5%) no-diabéticos y 11 (12,5%) diabéticos. El dolor estuvo presente en 11 (100%) de los diabéticos y en 76 (98,7%) de los no-diabéticos. La intensidad del dolor en los diabéticos fue de 8,91 versus 8,23 en no-diabéticos. El estudio mostró igualdades en la presencia e intensidad del dolor torácico entre pacientes diabéticos y no-diabéticos acometidos de IAM.

Feridas em pacientes diabéticos / Wounds in diabetic patients

No Brasil, a prevalência do diabetes na população brasileira acima de 40 anos de idade é de 10%, com estimativa de mais de 3,6 milhões de usuários do sistema público. Entre as complicaçõessérias e onerosas que afetam os pacientes diabéticos, aquelas que ocorrem nos membros inferiores (MMII) representam a maior parte delas (40 a 70%). A microangiopatia atinge os pequenos vasos responsáveis pela irrigação nervosa, os chamados vasa nervorum e é. a desencadeadora daneuropatia periférica, retinopatia e nefropatia diabética. O processo neuropático, pelo fato de favorecer deformidades ósseas no pé, acarreta aumento das pressões plantares. A associação da insensibilidade do pé e do aumento destas pressões resulta em ulceração. Desde 1988, com o desenvolvimento do Pressure Specified Sensory Device™ - PSSD, um só equipamento é capaz de quantificar o limiar de pressão aplicada sobre a pele, necessário para que o paciente sinta o estímulo de um ponto estático e um ponto dinâmico assim como os testes com dois pontos. Consegue-se melhor avaliação do déficit sensitivo nos pés e melhor planejamento de medidas terapêuticas. O tratamento da ferida diabética envolve o controle da isquemia, se necessário e de desbridamento cirúrgico. O sistema a vácuo auxilia na redução do edema, na melhora do aporte sanguíneo ao leitoe na formação do tecido de granulação, acelerando o preparo do leito e tornando mais precoce a indicação do tratamento cirúrgico definitivo, através em geral com uso de enxertos de pele...

Diabetes, in Brasil, affects 10% of the population over 40 years of age Amongthe serious complications, those on the lower extremities are the majority (40 to 70%). Microangiopathy affects the small vessels the blood supply of nerves, the vasa nervorum and causes the peripheral neuropathy, retinopathy and nephropathy. Neuropathic process enhances osseous deformities on the the foot, which increase plantar pressures in an insensitive foot,ending in ulcerations. Since 1988 the development of the Pressure Specified Sensory Device™ - PSSD turn out to be a single device able to quantify thresholds of pressure, necessary forthe patient to feel one or two points tested, statically and in movement. We can now better access the sensitive deficit on the diabetic patients and plan appropriate prevention measures.Treatment of the diabetic wound involves ischemia control, if necessary and surgical debridement in order to remove necrotic tissues. The new developed vacuum system helps the reduction of edema, enhance blood perfusion to the wound and granulation tissue growth providing faster bed preparation and earlier surgical repair usually with skin grafts...

Klebsiella pneumoniae Orbital Cellulitis with Extensive Vascular Occlusions in a Patient with Type 2 Diabetes

A 39-year-old woman visited the emergency room complaining of right eye pain and swelling over the preceding three days. The ophthalmologist's examination revealed orbital cellulitis and diabetic retinopathy in the right eye, although the patient had no prior diagnosis of diabetes. It was therefore suspected that she had diabetes and orbital cellulitis, and she was started on multiple antibiotic therapies initially. She then underwent computed tomography scans of the orbit and neck and magnetic resonance imaging of the brain. These studies showed an aggravated orbital cellulitis with abscess formation, associated with venous thrombophlebitis, thrombosis of the internal carotid artery, and mucosal thickening of maxillary sinus with multiple paranasal abscesses. Three days later, initial blood culture grew Klebsiella pneumoniae. She recovered after incision and drainage and antibiotic therapy for 37 days.

Anorectal dysfunctions in diabetic autonomic neuropathy and microangiopathy

Disturbed motility may explain gastrointestinal symptoms of patients with diabetic neuropathy. This study investigates the anorectal dysfunctions in diabetic autonomic neuropathy [DAN] and microangiopathy. The study includes 47 diabetic patients [group 1: 30 non-complicated; group 2: 17 complicated by DAN and microangiopathy] and 10 healthy non-diabetic volunteers as control subjects. Following medical history, clinical examination and laboratory investigations, the included patients were subjected to sigmoidoscopy with mucosal biopsy and anorectal manometry. The lower gastrointestinal symptoms [e.g., constipation, diarrhoea or faecal incontinence] were reported more in group 2 [complicated diabetic patients] than in group 1 [non-complicated diabetic patients] [p=0.003]. Group 2 patients had significantly higher fasting blood glucose, serum uric acid, serum creatinine and triglycerides than group 1 patients [p=0.001, 0.03, 0.04,<0.001, respectively]. Overall, diabetic patients had lower resting anal pressure [p=0.004], squeeze pressure [p=0.007], and higher thresholds of minimal rectal sensation and sense of desire for defaecation [all p<0.001] when compared to control subjects. Group 2 patients had lower resting anal pressure [p<0.001], squeeze pressure [p=0.02], and higher thresholds of minimal rectal sensation [p<0.001], sense of desire for defaecation [p=0.009] and maximum tolerable volume [p=0.002] than group 1 patients. Group 2b [patients with DAN and microaniopathy] had significantly lower resting anal pressure than group 2a [patients with DAN] [p=0.001]. Anorectal dysfunctions occur in diabetic patients particularly when complicated by autonomic neuropathy and microangiopathy

Epistemologia sobre amputações e desbridamentos de membros inferiores realizados no Hospital Universitário de Maringá / Epistemology of lower limb amputations and debridements at Hospital Universitário de Maringá

CONTEXTO: Não há estatísticas precisas sobre o número de amputações realizadas anualmente, mas é conhecido o comprometimento da qualidade de vida desses indivíduos e a necessidade de uma equipe multiprofissional para sua reabilitação. OBJETIVO: Analisar todas as amputações de membros inferiores realizadas pelo Serviço de Angiologia e Cirurgia Vascular do Hospital Universitário Regional de Maringá entre 2000 e 2006. MÉTODOS: Estudo descritivo e retrospectivo a partir dos prontuários de pacientes submetidos a amputação ou desbridamento cirúrgico de membros inferiores por trauma ou doença vascular. RESULTADOS: Ocorreram 116 procedimentos, sendo 84,5 por cento amputações e 15 por cento desbridamentos cirúrgicos, em 111 pacientes, sendo 78 homens e 33 mulheres, cuja média das idades foi de 63,4 anos (4 a 100 anos), sendo os principais fatores etiológicos: doenças vasculares (92,8 por cento) e trauma (7,2 por cento). As comorbidades e fatores de risco mais prevalentes foram: hipertensão arterial sistêmica (66 por cento), diabetes melito (60 por cento), tabaco (28 por cento) e arritmia cardíaca (0,9 por cento). Quanto à escolaridade, se observou que 52,2 por cento dos pacientes cursaram apenas o ensino fundamental, 6,5 por cento fizeram o ensino médio, completo ou incompleto, e 41,3 por cento eram analfabetos. A percentagem de pacientes submetidos à amputação primária foi de 94,9 por cento, e secundárias, 5,1 por cento. No entanto, houve diminuição progressiva do coeficiente desses procedimentos a cada ano. CONCLUSÕES: Este trabalho permite inferir que a incidência de amputação de membros inferiores foi maior no sexo masculino e teve como principal causa a doença aterosclerótica, mas apresentou uma redução progressiva.

BACKGROUND: There are no precise data on the number of amputations performed every year. However, the decrease in quality of life of patients submitted to amputation is well-known, as is the need to involve a multidisciplinary team in the rehabilitation of these individuals. OBJECTIVE: To analyze all lower limb amputations performed by the Angiology and Vascular Surgery at Hospital Universitário Regional de Maringá, from 2000 to 2006. METHODS: A descriptive and retrospective study was performed to review medical records of patients submitted to amputation or surgical debridement of lower limbs to treat vascular diseases or trauma. RESULTS: A total of 116 procedures were carried out (84.5 percent amputations and 15 percent debridements) in 111 patients; 78 were males and 33 were females, with a mean age of 63.4 years (4-100 years). The main etiological factors were vascular diseases (92.8 percent) and trauma (7.2 percent). The most prevalent comorbidities and risk factors were hypertension (66 percent), diabetes mellitus (60 percent), tobacco (28 percent) and cardiac arrhythmia (0.9 percent). As to schooling, 52.2 percent of the patients had complete elementary school, 6.5 percent had complete or incomplete high school, and 41.3 percent were illiterate. Primary amputation was performed in 94.9 percent of patients, and secondary amputation in 5.1 percent. However, there was a progressive reduction in amputation rate at each year. CONCLUSIONS: Incidence of lower limb amputation was greater in males, had atherosclerotic disease as its main cause, but had progressive reduction.

Disfunção endotelial no diabetes melito tipo 1: [revisão] / Endothelial dysfunction in type 1 diabetes: [review]

As complicações vasculares são a maior causa de morbimortalidade em pacientes com diabetes. Os mecanismos envolvidos no desenvolvimento das doenças micro e macrovasculares são complexos e parcialmente compreendidos, mas se iniciam invariavelmente por um endotélio que se torna disfuncionado. O óxido nítrico é um importante regulador da função endotelial e o comprometimento da sua atividade é fator determinante para a disfunção endotelial (DE). No diabetes tipo 1, diversos fatores, como a hiperglicemia aguda, mau controle glicêmico crônico, tempo de diagnóstico e presença de neuropatia autonômica ou microalbuminúria estão associados à DE. Tanto o estresse oxidativo, como a ativação da via dos polóis, via da proteína quinase C e formação dos produtos avançados de glicação não-enzimática são potenciais mecanismos patogenéticos da DE. A detecção precoce da disfunção endotelial tem valor prognóstico para o desenvolvimento de complicações vasculares e pode ser importante em estratégias de prevenção primária de eventos cardiovasculares no diabetes tipo 1.

Vascular complications are the main cause of mortality and morbidity in diabetes. Mechanisms involved in the development of micro and macrovascular disease are complex and partially understood, but invariably begin as a dysfunctional endothelium. Nitric oxide is an important regulator of endothelial function and the impairment of its activity is determinant of the endothelial dysfunction. In type 1 diabetes, many factors like acute, chronic and post-prandial hyperglycemia, as well as the duration of diabetes or autonomic neuropathy and microalbuminuria are associated to endothelial dysfunction. Oxidative stress, polyol pathway activation, protein kinase C activation and the presence of advanced glycation end-products are potential mechanisms involved in the development of endothelial dysfunction. Early detection of endothelial dysfunction has prognostic value for the development of vascular complications and may be important in strategies for primary prevention of cardiovascular endpoints in type 1 diabetes.

Prevenção cardiovascular em pacientes com diabetes: revisão baseada em evidências / Cardiovascular prevention in diabetic patients: an evidenced-based review

Diabetes mellitus é uma doença associada com elevada incidência de doença aterotrombótica, especialmente cardíaca. Diversos estudos demonstraram que é possível reduzir a carga de doença nesta população através de estratégias preventivas. Este artigo revisa as evidências sobre a estimativa de risco cardiovascular nessa população e ações de prevenção, levando em consideração as principais recomendações na área. Modificações no estilo de vida, como dieta pobre em carboidratos, redução de peso e prática regular de atividade física, devem ser instituídas. Todo paciente de alto risco ou com evidências de doença cardiovascular deve manter sua glicemia < 100 mg/dl e A1c < 7 por cento. É recomendado uso diário de AAS em doses baixas e estatinas para controle de lípides, tendo como alvo LDL < 100 mg/dl, HDL > 50 mg/dl e triglicerídios < 150 mg/dl. O controle da pressão arterial deve ser buscado com medidas não-farmacológicas e anti-hipertensivos, sendo inibidores do sistema renina-angiotensina indicados na maioria dos casos, especialmente naqueles pacientes com nefropatia, associado a diuréticos tiazídicos na sua maioria para alcançar níveis tensionais-alvo < 130/80 mmHg.

Diabetes mellitus is a condition associated with cardiac complications, especially atherotrombotic disease. Several studies have demonstrated the importance of reducing cardiovascular burden on this population by adopting prevention strategies. This article revised clinical evidences on cardiovascular risk assessment and prevention actions, taking into consideration major recommendations in the field. Life-style changes with low-carbohydrate diet, weight control, and regular physical activity must be implemented. High-risk patients or with established cardiovascular disease ought to have glycemic levels < 100 mg/dL and A1c < 7 percent. It is recommended low dose of aspirin and statin for lipid management, targeting LDL < 100 mg/dL, HDL > 50 mg/dL and tryglicerides < 150 mg/dL. Blood pressure control with non-pharmacological and antihypertensive drugs must be instituted, favoring ACE inhibitors as first option, mainly in patients with renal disease, and combined with tiazides for the majority to achieve target blood pressure of < 130/80 mmHg.

A study on micro-albuminuria--an independent risk factor for vasculopathy in diabetes mellitus.

Diabetes is becoming a serious threat to combat felt among the doctors of the world. India, in partcular is a vulnerable country contributing maximum number of cases to the global diabetic pool. Macro-and microvascular complications are important causes of mortality and morbidity. Micro-albuminuria is a surrogate marker for detetion of vasculopathy for which early detection and aggressive treatment can reduce mortality and morbidity. A small study was conducted to identify the usefulness of this marker in our setting which can be used as a cost-effective tool for detecting the dreadful complication early. This study has demonstrated that in presence of micro-albuminuria the vascular complications of diabetes definitely increase and it is more relevant in cases of type 2 diabetes irrespective of other parameters rendering it to be a independent risk factor. It also indicates that presence of this marker along with vasculopathy is time dependent ie, more the duration of the disease more is the complication.