Fructosamine and glycated hemoglobin as biomarkers of glycemic control in people with type 2 diabetes mellitus and cancer (GlicoOnco study)

Abstract Introduction Glycemic control is important to avoid diabetes complications in individuals with cancer. There is no evidence for HbA1c and fructosamine as reliable biomarkers in these conditions. There are particularities in caring for patients with diabetes and cancer that can alter these biomarkers. Objective The aim of this study was to evaluate HbA1c and fructosamine as glycemic biomarkers in people with type 2 diabetes and cancer, undergoing clinical or surgical oncological treatment. Methods The authors conducted a single-center, retrospective analysis with people who have cancer and diabetes. Comparison of glycemic biomarkers (HbA1c, fructosamine, and Self-Monitoring of Blood Glucose [SMBG]) was performed including evaluation in individuals undergoing chemotherapy, using glucocorticoids, with anemia, hypoproteinemia or with reduced estimated Glomerular Filtration Rate (eGFR). Results There was a strong positive correlation between fructosamine and HbA1c (n = 318, r= 0.66, p < 0.001) in people with diabetes and cancer even in those under chemotherapy (n = 101, r= 0.61, p < 0.001) or using glucocorticoids (n = 96, r= 0.67, p<0.001). There was a strong correlation between HbA1c and fructosamine in subjects with anemia (n = 111, r= 0.66, p < 0.001), hypoproteinemia (n = 54, r= 0.67, p < 0.001), or with eGFR ≥ 60 mL/min/1.73 m2 (n = 189, r= 0.70, p < 0.001), and moderate correlation with hypoalbuminemia (n = 21, r= 0.54, p = 0.001) and with reduced eGFR (n = 67, r= 0.57, p < 0.001). The correlations between fructosamine and HbA1c with SMBG were moderate (n = 164, r= 0.49, p < 0.001; n = 111, r= 0.55, p < 0.001, respectively), strong in subjects undergoing chemotherapy, with hypoalbuminemia or hypoproteinemia, and at least moderate, if eGFR < 60 mL/min/1.73 m2 or with anemia. Conclusions Fructosamine and HbA1c can be used as glycemic biomarkers in people with diabetes and cancer, even in those with anemia, hypoproteinemia, or undergoing chemotherapy.

Epidemiology and risk factors of hypoglycemia in subjects with type 1 diabetes in Brazil: a cross-sectional, multicenter study

ABSTRACT Objective: The aim of this study was to investigate the factors associated with hypoglycemia and severe hypoglycemia (SH) in individuals with type 1 diabetes mellitus (T1D) in Brazil. Materials and methods: This multicenter, cross-sectional study was conducted between August 2011 and August 2014 across 10 Brazilian cities. The data were obtained from 1,760 individuals with T1D. Sociodemographic and clinical characteristics related to hypoglycemic events in the previous 4 weeks were evaluated. Results: Of 1,760 individuals evaluated, 1,319 (74.9%) reported at least one episode of hypoglycemia in the previous 4 weeks. The main factors associated with hypoglycemia were lower hemoglobin A1c (HbA1c) level, better adherence to self-monitoring of blood glucose (SMBG), and higher education level. Episodes of SH were reported by 251 (19%) individuals who, compared with subjects with nonsevere hypoglycemia, received lower doses of prandial insulin and higher doses of basal insulin, in addition to reporting less frequent use of long-acting basal insulin analogs. The percentage of SH episodes was evenly distributed across all ranges of HbA1c levels, and there were no correlations between the mean number of nonsevere or severe hypoglycemic events and HbA1c values. Higher alcohol consumption and more frequent hospitalizations were independently associated with SH. Conclusion: Although individuals presenting with hypoglycemia had lower HbA1c values than those not presenting hypoglycemia, there were no correlations between the number of nonsevere hypoglycemia or SH and HbA1c values. Also, the frequency of SH was evenly distributed across all ranges of HbA1c values. Better adherence to SMBG and higher education level were associated with hypoglycemia, while alcohol consumption, higher doses of basal insulin, and more frequent hospitalizations in the previous year were associated with SH.

InsulinAPP application protocol for the inpatient management of type 2 diabetes on a hospitalist-managed ward: a retrospective study

ABSTRACT Objective: We assessed metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of our hospital. Subjects and methods: We performed a retrospective study of patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. InsulinAPP recommends NPH and regular insulins three times a day, in bolus-correction or basal-bolus schemes. Parameters that included BG within range of 70-180 mg/dL, insulin treatment regimen and frequency of hypoglycemia were evaluated. Results: A total of 147 T2D individuals (23% medicine and 77% surgery) were included (mean age 62.3 ± 12.7 years, HbA1c: 8.3 ± 3.0%). The initial insulin regimen was 50% bolus-correction, 47% basal-bolus and 3% with sliding scale insulin. During hospitalization, 71% patients required a bolus-basal regimen. In the first 10 days of the protocol, 71% BG measurements were between 70-180 mg/dL and 26% patients experienced one or more episodes of hypoglycemia < 70 mg/dL, and 5% with BG < 54 mg/dL. Conclusion: The results of this retrospective study indicate the InsulinAPP application using human insulin formulations was effective and safe for the management of hyperglycemia on a hospitalist-managed ward, with more than 70% BG measurements within the therapeutic range and a low rate of hypoglycemia.

Effects of glucocorticoids on interstitial glucose concentrations in individuals with hematologic cancer and without known diagnosis of diabetes: a pilot study

ABSTRACT Objective To analyze interstitial glucose behavior during glucocorticoid use in non-diabetic patients receiving chemotherapy for hematologic malignancies. Methods Prospective pilot study carried out to assess interstitial glucose levels in 15 non-diabetic individuals with hematologic malignancies who received glucocorticoids in combination with chemotherapy. The FreeStyle Libre flash monitoring system (Abbott Diabetes Care) was used for up to 14 days to measure interstitial glucose. Results Median age and body mass index were 53 (42-61) years and 25 (23-28) kg/m2 respectively. Interstitial glucose levels >180mg/dL lasting at least one hour were detected in 60% of participants. Interstitial glucose profile parameters (median and peak interstitial glucose levels and percentage of time during which interstitial glucose levels were >180mg/dL) were significantly (p<0.01) higher during glucocorticoid use (115mg/dL, 218mg/dL and 10% respectively) than after glucocorticoid discontinuation (97mg/dL, 137mg/dL and 0% respectively). Mean interstitial glucose levels increased in the afternoon and at night during glucocorticoid use. Conclusion This pilot study was the first to evaluate interstitial glucose levels in non-diabetic individuals using glucocorticoids in treatment of hematologic cancer. Glucocorticoid use during chemotherapy significantly increases interstitial glucose levels in these patients.

Management of diabetes mellitus in individuals with chronic kidney disease: therapeutic perspectives and glycemic control

The purpose of this study was to evaluate the therapeutic options for diabetes treatment and their potential side effects, in addition to analyzing the risks and benefits of tight glycemic control in patients with diabetic kidney disease. For this review, a search was performed using several pre-defined keyword combinations and their equivalents: “diabetes kidney disease” and “renal failure” in combination with “diabetes treatment” and “oral antidiabetic drugs” or “oral hypoglycemic agents.” The search was performed in PubMed, Endocrine Abstracts and the Cochrane Library from January 1980 up to January 2015. Diabetes treatment in patients with diabetic kidney disease is challenging, in part because of progression of renal failure-related changes in insulin signaling, glucose transport and metabolism, favoring both hyperglycemic peaks and hypoglycemia. Additionally, the decline in renal function impairs the clearance and metabolism of antidiabetic agents and insulin, frequently requiring reassessment of prescriptions. The management of hyperglycemia in patients with diabetic kidney disease is even more difficult, requiring adjustment of antidiabetic agents and insulin doses. The health team responsible for the follow-up of these patients should be vigilant and prepared to make such changes; however, unfortunately, there are few guidelines addressing the nuances of the management of this specific population.

Crianças e adolescentes que convivem com diabetes e doença celíaca / Niños y adolescentes viviendo con la diabetes y la enfermedad celíaca / Children and adolescents living with diabetes and celiac disease

RESUMO Objetivo Compreender a experiência de crianças e adolescentes que convivem com diabetes mellitus tipo 1 e doença celíaca. Método Estudo qualitativo, exploratório e descritivo. A coleta de dados ocorreu entre janeiro e setembro de 2012, com 3 crianças e 2 adolescentes, em um ambulatório de diabetes do Hospital das Clinicas da FMUSP ou na residência dos participantes na cidade de São Paulo, por meio de entrevistas semiestruturadas. Utilizou-se a Análise de Conteúdo como método de tratamento dos dados. Resultados A dieta aparece como foco da experiência dos participantes, porém com diferentes significados. As crianças têm dificuldade em seguir a dieta, enquanto os adolescentes referem que os aspectos sociais e afetivos são os mais afetados. Conclusão Reforça-se a importância do enfermeiro buscar estratégias em parceria com as crianças, os adolescentes e suas famílias a fim de minimizar as dificuldades encontradas principalmente no manejo da dieta imposta por ambas as doenças.

RESUMEN Objective Comprender la experiencia de los niños y adolescentes que viven con diabetes tipo 1 y la enfermedad celíaca. Método Estudio cualitativo exploratorio y descriptivo, se incluyeron 3 niños y 2 adolescentes; los datos fueron colectados de enero a septiembre de 2012, en la clínica de diabetes del Hospital de Clínicas de la Facultad de Medicina de la Universidad de São Paulo o en la residencia de los participantes en São Paulo, a través de entrevistas semi-estructuradas. Para el tratamiento de los datos se utilizó la técnica de Análisis de Contenido. Resultados La dieta es el foco de la experiencia de los participantes, pero con diferentes significados. Los niños tienen dificultad para seguir la dieta, mientras que los adolescentes reportan que los aspectos sociales y afectivos son los más afectados. Conclusión Los resultados refuerzan la importancia de la enfermera buscar estrategias en colaboración con los niños, adolescentes y sus familias para minimizar dificultades encontradas principalmente en la gestión de la dieta impuesta por ambas enfermedades.

ABSTRACT Objective To understand the experience of children and adolescents living with type 1 diabetes and celiac disease. Method This is a qualitative exploratory-descriptive study. The participants were 3 children and 2 adolescents. The data were collected by means of semi-structured interviews between January and September 2012 at the participant's residence or at the diabetic outpatient clinic of the Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo in São Paulo, Brazil. The content analysis technique was used to process the data. Results The key aspect of the illness experience of the patients was their diet, but with different meanings. The children had difficulty following the diet, while the adolescents reported that they had greater difficulty coping with the social and affective aspects of their diet. Conclusion The results reinforce the importance of nurses who seek strategies, together with the patients and their families, that help minimize the difficulties of these patients, especially with regard to managing the diet imposed by both diseases.

Improvement in medication adherence and self-management of diabetes with a clinical pharmacy program: a randomized controlled trial in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital

OBJECTIVE: To evaluate the impact of a clinical pharmacy program on health outcomes in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital in Brazil. METHOD: A randomized controlled trial with a 6-month follow-up period was performed in 70 adults, aged 45 years or older, with type 2 diabetes who were taking insulin and who had an HbA1c level ≥8%. Patients in the control group (CG) (n = 36) received standard care, patients in the intervention group (IG) (n = 34) received an individualized pharmacotherapeutic care plan and diabetes education. The primary outcome measure was change in HbA1c. Secondary outcomes included diabetes and medication knowledge, adherence to medication, insulin injection and home blood glucose monitoring techniques and diabetes-related quality of life. Outcomes were evaluated at baseline and 6 months using questionnaires. RESULTS: Diabetes knowledge, medication knowledge, adherence to medication and correct insulin injection and home blood glucose monitoring techniques significantly improved in the intervention group but remained unchanged in the control group. At the end of the study, mean HbA1c values in the control group remained unchanged but were significantly reduced in the intervention group. Diabetes-related quality of life significantly improved in the intervention group but worsened significantly in the control group. CONCLUSION: The program improved health outcomes and resulted in better glycemic control in patients with type 2 diabetes undergoing insulin therapy. .

Celiac crisis in an adult type 1 diabetes mellitus patient: a rare manifestation of celiac disease / Crise celíaca em paciente adulto com diabetes melito tipo 1: uma manifestação rara da doença celíaca

Celiac crisis, an acute severe onset of celiac disease, is a rare and life-threatening manifestation. We report a 30-year-old woman with type 1 diabetes mellitus who arrived at our service with one-month history of severe acute watery diarrhea associated with nausea, vomiting, abdominal pain, and weight loss of 9 kg. The diagnostic hypothesis of celiac crisis was reached based on profuse diarrhea leading to dehydration, severe metabolic and electrolyte abnormalities, and subsequent improvement after introduction of a gluten-free diet.

A crise celíaca é uma manifestação rara e grave da doença celíaca. Relatamos um caso de uma paciente de 30 anos de idade, com antecedente de diabetes melito tipo 1 e história de um mês de diarreia aquosa aguda, associada a náuseas, vômitos, dor abdominal e perda de peso de 9 kg. A hipótese diagnóstica de crise celíaca foi realizada, baseada no quadro de diarreia profusa, desidratação e distúrbios hidroeletrolíticos e ácido-básicos que melhorou após a introdução de dieta enteral sem glúten.

Incidental mild hyperglycemia in children: two MODY 2 families identified in Brazilian subjects / Hiperglicemia incidental em crianças: duas famílias com MODY 2 identificadas em brasileiros

Maturity-onset diabetes of the young (MODY) is characterized by an autosomal dominant mode of inheritance, early onset of hyperglycemia, and defects of insulin secretion. MODY subtypes described present genetic, metabolic, and clinical differences. MODY 2 is characterized by mild asymptomatic fasting hyperglycemia, and rarely requires pharmacological treatment. Hence, precise diagnosis of MODY is important for determining management and prognosis. We report two heterozygous GCK mutations identified during the investigation of short stature. Case 1: a prepubertal 14-year-old boy was evaluated for constitutional delay of growth and puberty. During follow-up, he showed abnormal fasting glucose (113 mg/dL), increased level of HbA1c (6.6%), and negative β-cell antibodies. His father and two siblings also had slightly elevated blood glucose levels. The mother had normal glycemia. A GCK heterozygous missense mutation, p.Arg191Trp, was identified in the proband. Eighteen family members were screened for this mutation, and 11 had the mutation in heterozygous state. Case 2: a 4-year-old boy investigated for short stature revealed no other laboratorial alterations than elevated glycemia (118 mg/dL); β-cell antibodies were negative. His father, a paternal aunt, and the paternal grandmother also had slightly elevated glycemia, whereas his mother had normal glycemia. A GCK heterozygous missense mutation, p.Glu221Lys, was identified in the index patient and in four family members. All affected patients had mild elevated glycemia. Individuals with normal glycemia did not harbor mutations. GCK mutation screening should be considered in patients with chronic mild early-onset hyperglycemia, family history of impaired glycemia, and negative β-cell antibodies. Arq Bras Endocrinol Metab. 2012;56(8):519-24.

O diabetes do tipo MODY (maturity-onset diabetes of the young) caracteriza-se por herança autossômica dominante, início precoce da hiperglicemia e defeitos na secreção de insulina. Os subtipos de MODY apresentam diferenças genéticas, metabólicas e clínicas. O MODY 2 é caracterizado por hiperglicemia leve assintomática e raramente requer tratamento farmacológico. O diagnóstico preciso de MODY é importante para se determinar o tratamento e o prognóstico. Relatamos duas mutações no gene GCK em heterozigose identificadas durante investigação de baixa estatura. Caso 1: paciente do sexo masculino, com 14 anos, pré-púbere, avaliado por atraso constitucional do crescimento e da puberdade. Durante o acompanhamento, apresentou glicemia de jejum alterada (113 mg/dL), aumento de HbA1c (6,6%) e anticorpos anticélulas β negativos. Seu pai e dois irmãos também apresentavam glicemia levemente elevada. A mãe tinha glicemia normal. Foi identificada no gene GCK uma mutação missense em heterozigose, p.Arg191Trp. Dezoito membros da família foram rastreados e 11 apresentavam essa mutação. Caso 2: paciente do sexo masculino, com 4 anos, em avaliação por baixa estatura. Não apresentou alterações laboratoriais, exceto por glicemia elevada (118 mg/dL). Anticorpos anticélulas β foram negativos. Seu pai, uma tia paterna e a avó paterna também apresentavam glicemia discretamente elevada, e a mãe, glicemia normal. A mutação missense em heterozigose, p.Glu221Lys, foi identificada no paciente-índice e em 4 membros da família. Todos os pacientes afetados apresentavam hiperglicemia leve. Essas mutações não foram identificadas nos indivíduos com glicemia normal. O rastreamento de mutações no gene GCK deve ser considerado em pacientes com hiperglicemia crônica leve e de início precoce, história familiar de glicemia elevada e anticorpos anticélulas β negativos. Arq Bras Endocrinol Metab. 2012;56(8):519-24.

Testosterona falsamente elevada em uma paciente diabética tipo 1 com acne e insuficiência renal crônica em diálise / Falsely elevated testosterone in a type 1 diabetes patients with acne and chronic renal failure on dyalisis

Descrevemos uma paciente com diabetes tipo 1 com acne e insuficiência renal crônica, em diálise, que apresentou uma dosagem de testosterona total e livre elevada (612 ng/dL, normal < 90 ng/dL e 255 pMol/L, normal: 20-45 pMol/L, respectivamente). Na avaliação clínica, além da acne facial não havia qualquer outro sinal de hiperandrogenismo. Após ter esse resultado confirmado, ela foi submetida à avaliação morfológica de adrenal e ovários (tomografia computadorizada de adrenal e ultrassom pélvico), cujos resultados foram normais. Na ausência de quadro clínico de virilização, foram consideradas outras possibilidades que pudessem explicar a elevação da testosterona, entre as quais a presença de comorbidades (diabetes e insuficiência renal crônica) e falha do método de dosagem. Uma nova determinação da testosterona total, por meio da cromatografia líquida de alta performance como método preparativo e espectrometria de massa em tandem, resultou normal (21 ng/dL), compatível com uma concentração de testosterona total falsamente elevada pela presença de interferentes com o método de dosagem.

The purpose of this report is to present the case of a patient with type 1 diabetes with acne and chronic renal failure on dialysis admitted to the hospital with high total total and free testosterone (612 ng/dL, normal < 90 ng/dL; 255 pMol/L, normal: 20-45 pMol/L). On clinical evalua­tion, she presented facial acne, and no other signs of hyperandrogenism. As this result was confirmed, she underwent adrenal and ovary morphological assessment (adrenal CT and pelvic ultrasound), which yielded normal results. Due to divergence between clinical and laboratory findings, we considered other possibilities that could explain the elevation of testosterone, including the presence of comorbidities (diabetes and chronic renal failure) and failure of the testosterone assay. Testosterone levels were determined again by high performance liquid chromatography, as a preparative method, and tandem mass spectrometry, yielding normal results (21 ng/dL), which were compatible with a falsely elevated total testosterone level caused by the presence of factors that intereferred with the assay.

Fatores preditivos da marcha em pacientes diabéticos neuropático e não neuropáticos / Predictive factors of gait in neuropathic and non-neurophatic diabetic patients

OBJETIVO: Analisar a amplitude de movimento do tornozelo e as forças de reação vertical do solo envolvidas na marcha de pacientes portadores de diabetes com e sem neuropatia periférica. CASUÍSTICA E MÉTODO: 36 indivíduos divididos em três grupos: Controle - GC: 10 indivíduos sem diabetes, Diabetes - GD: 10 indivíduos portadores de diabetes sem neuropatia periférica e Neuropatia - GDN: 16 indivíduos portadores de diabetes e neuropatia diabética periférica. Foi realizada análise da marcha - AMTI® OR6/6, e da amplitude de movimento articular tíbio-társica - Sistema Vicom 640® - de todos os participantes. RESULTADOS: O primeiro e segundo pico de força vertical de reação do solo são maiores no grupo Neuropatia e a amplitude de movimento articular do tornozelo é menor nos grupos Diabetes e Neuropatia. CONCLUSÃO: A amplitude de movimento da articulação tíbio-társica está diminuida nos diabetéticos, independente da presença ou ausência de neuropatia periférica, e os diabéticos com neuropatia periférica, apresentaram aumento no primeiro e no segundo pico da força de reação vertical do solo durante a marcha.

OBJECTIVE: The purpose of this study was to analyze the range of movement of the ankle and the vertical ground reaction force involved in gait among diabetic patients with and without peripheral neuropathy. SAMPLE AND METHOD: 36 individuals were divided into three groups: Control group - CG: 10 individuals without diabetes, Diabetic group - DG: 10 individuals with diabetes without peripheral neuropathy and Neuropathy, and Diabetic neuropathic group - DNG: 16 individuals with diabetes and peripheral diabetic neuropathy. Gait - AMTI® OR6/6m and range of tibiotarsal joint movement - System Vicom 640® was carried out in all the participants. RESULTS: The first and second vertical ground reaction force peaks were statistically higher in the neuropathy group, and the range of ankle motion was lower in the Diabetes and Neuropathy groups. CONCLUSION: The range of movement of the tibiotarsal joint is lower in diabetics, regardless of the presence or absence of peripheral neuropathy, and diabetics with peripheral neuropathy show an increase in the first and second vertical ground reaction force peaks during walking.

Continuous glucose monitoring system: dawn period calibration does not change accuracy of the method / Sistema de monitorização contínua de glicose: calibração da madrugada não interfere na acurácia do método

INTRODUCTION: Continuous glucose monitoring system is a valuable instrument to measure glycemic control, which uses a retrospective calibration based upon 3 to 4 capillary glucose meter values inserted by the patient each day. OBJECTIVE: We evaluated the interference of calibration during the dawn period in the system accuracy. METHODS: The monitoring data were retrospectively divided into two groups: with (Group A) or without (Group B) the dawn period calibration (between 1:00 and 5:00 AM). Accuracy of the method was expressed by relative absolute difference. RESULTS: Thirty-four continuous glucose monitoring data were evaluated comprising a total of 112 nights. A total of 289 paired readings were analyzed - 195 in Group A and 94 in Group B. We did not find a difference in relative absolute difference (RAD%) in any analyzed period of day by adding dawn calibration. CONCLUSIONS: These data suggest that dawn calibration does not alter accuracy of method.

INTRODUÇÃO: O CGMS (sigla do inglês continuous glucose monitoring system) é um instrumento valioso no controle glicêmico e utiliza uma calibração por meio de 3 ou 4 medidas de glicemia capilar inseridas pelo paciente em cada dia do exame. OBJETIVO: Avaliar a interferência da calibração durante a madrugada na acurácia do sistema. MÉTODOS: Os dados das monitorizações foram divididos retrospectivamente em dois grupos: com (Grupo A) ou sem (Grupo B) a calibração da madrugada (entre 1:00 e 5:00 AM). A acurácia do método foi mostrada pela diferença relativa absoluta (DRA por cento). RESULTADOS: Trinta e quarto dados de monitorização foram avaliados em um total de 112 noites. Um total de 289 leituras pareadas foi analisado - 195 no Grupo A e 94 no Grupo B. Não foi encontrada diferença em DRA% em nenhum período do dia quando adicionada a calibração durante a madrugada. CONCLUSÕES: Esses dados sugerem que a calibração da madrugada não altera a acurácia do método.

Curso de imersão em diabetes como técnica educativa para profissionais médicos / Diabetes immersion training as teaching method to medical practitioners

Este estudo avaliou a eficácia do método de ensino teórico e prático sobre diabetes e a atitude de profissionais médicos quanto à realização de controle glicêmico intensivo. Participaram de um curso de imersão em diabetes, com dois dias de duração, 48 médicos-residentes de clínica médica ou endocrinologia. Os participantes receberam treinamento de monitorização de glicemia capilar, técnicas de aplicação de insulina e contagem de carboidratos, sendo orientados a se portarem como diabéticos e a seguir prescrição médica individual. Foram avaliados através de questionários. No questionário de conhecimentos, observou-se um aumento significante de 12 por cento no índice de acertos entre o início e o final do curso (61,2 por cento e 73,2 por cento, respectivamente, com p < 0,0001). Antes do curso, 70,8 por cento dos participantes diziam ter dificuldades na contagem de carboidratos e 89,6 por cento, na automonitorização glicêmica. Após a experiência prática, 82,9 por cento dos participantes encontraram dificuldades na realização de contagem de carboidratos e 80,8 por cento, na automonitorização; 40,4 por cento fizeram uso de todas as medicações prescritas e 36,1 por cento monitorizaram todas as glicemias. Os resultados deste estudo mostram que esse tipo de curso é eficaz para a aquisição de conhecimentos e contribui com a sensibilização do profissional médico quanto às dificuldades cotidianas enfrentadas pelo portador de diabetes melito na aderência às recomendações.

This study evaluated the effectiveness of theoretical and practical teaching method in diabetes and doctors' position about feasibility of intensive blood glucose control. Forty-eight internal medicine or endocrinology residents participated in a two-day diabetes immersion course. The participants received training on self-blood glucose monitoring, techniques of insulin administration and carbohydrate counting. They were also instructed to behave as patients with diabetes and to follow individual medical prescription. They were assessed through questionnaires. In knowledge assessment, a significant increase of 12 percent was observed between the beginning and the end of the course (61.2 percent and 73.2 percent, respectively, with p < 0.0001). Before the course, 70.8 percent and 89.6 percent of the participants believed there were complications in performing carbohydrate counting and blood glucose monitoring, respectively. After the experience, 82.9 percent of them had difficulties in carbohydrate counting and 80.8 percent in self-monitoring; 40.4 percent took all medications prescribed and 36.1 percent monitored blood glucose correctly. These results show that the methodology of this course is an effective way to disseminate knowledge and that it contributes to doctors becoming more sensitive to daily problems faced by patients with diabetes melito concerning the acceptance of medical recommendations.

Adipose tissue at the crossroads in the development of the metabolic syndrome, inflammation and atherosclerosis / Tecido adiposo na encruzilhada no desenvolvimento da síndrome metabólica, inflamação e aterosclerose

The authors analyze insulin resistance, the metabolic syndrome and endothelial dysfunction as consequence of a common antecedent, a low grade inflammation, indicating that in obesity there is a chronically activated inflammatory state of the adipose tissue. Furthermore, the inflammatory signaling is discussed according to the adipose tissue depot, visceral or subcutaneous.

Os autores analisam a resistência à insulina, a síndrome metabólica e a disfunção endotelial como consequência de um antecedente comum, a inflamação de baixo nível, o que mostra que a obesidade é um estado inflamatório cronicamente ativado do tecido adiposo. Discute-se, aqui, a sinalização inflamatória de acordo com a localização do tecido adiposo subcutâneo ou visceral.

Hipoglicemia como fator complicador no tratamento do diabetes melito tipo 1: [revisão] / Hypoglycemia as a Limiting Factor in the Management of Type 1 Diabetes: [review]

Os portadores de diabetes melito tipo 1 têm, com freqüência, episódios de hipoglicemia durante a insulinoterapia, que, além do desconforto e de proporcionar situações constrangedoras no dia-a-dia, impedem a obtenção do controle glicêmico ideal. Mais ainda, hipoglicemias induzem deficiente mecanismo de contra-regulação em episódio posterior, com diminuição de liberação de adrenalina e dos sintomas de alarme, estabelecendo a síndrome de hipoglicemia associada à insuficiência autonômica. A ocorrência de hipoglicemias durante algumas atividades de risco, em especial a direção veicular, pode resultar acidentes com o paciente e terceiros, além de lesão de propriedade, motivo pelo qual pessoas com diabetes devem ser orientadas quanto aos cuidados na direção de veículos. Em geral, a recuperação neurológica é total após a correção de coma hipoglicêmico. No entanto, quando esses episódios são repetitivos, especialmente em crianças, podem ter como conseqüência distúrbios cognitivos definitivos. A reversão de quadros de hipoglicemia sem sinal de alerta é difícil, devendo-se evitar meticulosamente sua ocorrência, adequando o tratamento, os alvos glicêmicos, utilizando a monitoração domiciliar e fazendo treinamento para o reconhecimento precoce de hipoglicemias.

Type 1 diabetic patients frequently present hypoglycemic episodes during their insulinotherapy, which, besides the discomfort and constrains does not allow the ideal glycemic control. Further, hypoglycemic events lead to the deficiency of the counter-regulation mechanisms in the subsequent episode, with a decrease in the release of epinephrine and the symptoms of warming, with great risk of severe hypoglycemia. The occurrence of hypoglycemia during some risky activities, specially driving, could result in accidents with the patient and /or third parts including property damage, stressing here the need to advise diabetics against having the necessary caution wheli driving. Generally the connective recovery is total after correcting a hypoglycemic coma. However when these episodes are repetitive, particularly in children, they could result in definitive cognitive disturbances. Hypoglycemic events without a warning signal (hypoglycemic unawareness) are difficult to reverse, thus it is necessary to prevent their occurrence, adjusting the treatment with glycemic targets, using continuous glucose monitoring at home and teaching them how to have an early recognition of hypoglycemia.

Prevalence of abnormalities of glucose metabolism in patients with polycystic ovary syndrome

Patients with polycystic ovary syndrome (PCOS) present a higher risk for abnormalities of glucose metabolism (AGM). For to study this in our population, we submitted 85 patients, with body mass index (BMI) of 28.5 ± 6.6 kg/m² and aged 25.5 ± 5.4 years old, to an oral glucose tolerance test (OGTT), and assessed the impact of BMI on the prevalence of impaired glucose tolerance (IGT) and of diabetes mellitus (DM). The states of glucose tolerance were classified considering fasting plasma glucose (FPG) according to the American Diabetes Association (ADA) criterion and plasma glucose at 120 minutes according to the Word Health Organization (WHO) criterion. According to the ADA criteria, 83.5 percent classified as normal and 16.5 percent as with AGM, with 15.3 percent presenting impaired fasting glucose and 1.2 percent DM, while according to the WHO criteria, 68.2 percent were classified as normal and 31.8 percent as with AGM, with 27.0 percent of them presenting IGT and 4.8 percent DM. Seventy-three percent of PCOS patients with IGT by WHO criterion had normal FPG by ADA criterion. The prevalence of AGM for both criteria increased with the body mass index. In conclusion, we found a higher prevalence of AGM in PCOS patients than that found in the general population, being the highest in obese patients. Glycemia at 120 minutes on the OGTT identified more patients with AGM than fasting glycemia. We recommended that the assessment of AGM must be done by the OGTT in all patients with PCOS.

Pacientes com a síndrome dos ovários policísticos (SOP) têm um risco maior para desenvolver anormalidades do metabolismo da glicose (AMG). Para avaliarmos a prevalência dessas anormalidades na nossa população, submetemos 85 pacientes, com índice de massa corporal (IMC) de 28,5 ± 6,6 kg/m² e média etária de 25,5 ± 5,4 anos, a teste de tolerância oral à glicose (TTOG). Os estados de tolerância à glicose foram classificados considerando a glicemia de jejum (GJ; American Diabetes Association - ADA) e glicemia aos 120 minutos (G120; Organização Mundial de Saúde - OMS). De acordo com a ADA, 83,5 por cento das pacientes foram normais e 16,5 por cento com AMG, com 15,3 por cento apresentando glicemia de jejum imprópria e 1,2 por cento diabetes mellitus (DM). De acordo com a OMS, 68,2 por cento foram normais e 31,8 por cento com AMG, com 27,0 por cento apresentando intolerância à glicose (IG) e 4,8 por cento DM. Observamos que 73 por cento das pacientes com IG pelos critérios da OMS apresentavam GJ normal pelos critérios da ADA. A prevalência de AMG para ambos os critérios foi maior entre as pacientes com IMC mais elevado. Conclusão: encontramos maior prevalência de AMG nas pacientes com a SOP do que na população geral, sendo mais elevada entre as pacientes obesas. Além disso, a G120 no TTOG identificou maior número de pacientes com AMG do que a GJ. Assim, recomendamos avaliação de AMG através do TTOG para todas as pacientes portadoras da SOP.

Diabetes mellitus / Diabetes mellitus

Diabetes mellitus é uma síndrome heterogênea decorrente da falta de insulina ou da incapacidade da insulina exercecr adequadamente seus efeitos. Pacientes com diabetes tem hipertriglicemia crônica com distúrbios gerais säo associados a complicaçöes crônicas e falência de vários órgäos. A classificaçäo, o diganóstico e o tratamento do diabetes säo aqui revisados com ênfase nos aspectos atuais.(au)

Gêmeas idênticas discordantes para a doença de cushing: relato de caso / Identical twins discordant for Cushing's disease: case report

A doença de Cushing é rara em crianças e sua ocorrência em gêmeos é ainda mais rara. O presente estudo relata a ocorrência de gêmeas idênticas discordantes quanto à doença de Cushing. Uma das gêmeas, desenvolveu síndrome de Cushing aos 10 anos de idade. Sua investigação demonstrou cortisol urinário elevado, ACTH sérico elevado e testes de supressão com dexametasona compatíveis com doença de Cushing. A RMN mostrou macroadenoma hipofisário que foi operado por via transesfenoidal. O estudo imuno-histoquímico confirmou a presença de células produtoras de ACTH. A paciente entrou em remissão clínica e laboratorial desde a cirurgia. Após o desaparecimento dos estigmas do Cushing, a paciente reiniciou ganho estatural, mas permanece menor que sua irmã gêmea. Esta última permanece saudável 4 anos após o início da doença de sua irmã. Este é o terceiro caso do gênero relatado na literatura. Estes achados sugerem que fatores não genéticos estão envolvidos na gênese da doença de Cushing.