[Is silent hypoglycemia part of ideal glycemic control in DM1 patients? - hypoglycemic state by CGMS vs. glycemic average]. / A hipoglicemia silenciosa é parte do controle glicêmico ideal em pacientes com DM1? - tempo de hipoglicemia pelo CGMS versus média glicêmica.

BACKGROUND: To evaluate the impact of silent hypoglycemic state in glycemic control in type 1 diabetic patients (DM1) by CGMS. METHODS: 87 DM1 patients (45%M/55%F) submitted to a 72 h CGMS profile were classified in 4 groups. It was analyzed: unrecognized hypoglycemia (<70 mg/dL); duration time of silent hypoglycemia in which patients were classified into G1 (<5%), G2 (5-10%), G3 (10-20%) and G4 (>20%) of hypoglycemic state by CGMS; A1c and mean capillary glucose (MCG) in each group. RESULTS: The silent hypoglycemia was detected in 64.5% of patients and nighttime episodes of hypoglycemia lasted longer (min) than daytime episodes in all groups (p<0.001). It was verified 41.4% of patients under than 5% of time in hypoglycemic state, 21.8% between 5-10%, 23% between 10-20% and 13.8% with more than 20% of CGMS in silent hypoglycemia. This data showed significant decreased in MCG when the duration time of silent hypoglycemia was longer (p=0.006). CONCLUSION: The silent hypoglycemia is common in DM1 patients and most frequently in night time period. To take an average glycemia of 120-160 mg/dL in these patients, it was necessary a 10-20% of CGMS period in silent hypoglycemia in these patients.

A hipoglicemia silenciosa é parte do controle glicêmico ideal em pacientes com DM1?: tempo de hipoglicemia pelo CGMS versus média glicêmica / Is silent hypoglycemia part of ideal glycemic control in DM1 patients?: hypoglycemic state by CGMS vs. glycemic average

OBJETIVO: Avaliar o impacto do tempo de hipoglicemia silenciosa no controle glicêmico de pacientes diabéticos tipo 1 (DM1) sob monitorização contínua de glicose (CGMS). MÉTODOS: Oitenta e sete pacientes DM1 (45 por centoM/55 por centoF), divididos em quatro grupos, submetidos à CGMS 72 horas. Foram analisados: hipoglicemia silenciosa (HS) (< 70 mg/dL); tempo de hipoglicemia pelo CGMS, sendo os pacientes classificados em G1 (< 5 por cento), G2 (5-10 por cento), G3 (10 por cento a 20 por cento) e G4 (> 20 por cento); níveis de A1c e médias glicêmicas. RESULTADOS: A HS foi detectada em 64,5 por cento dos casos, sendo mais duradoura (mín.) durante a noite versus o dia (p < 0,001). Quanto ao tempo de HS, 41,4 por cento dos pacientes ficaram < 5 por cento, 21,8 por cento entre 5 por cento a 10 por cento, 23 por cento entre 10 por cento a 20 por cento e 13,8 por cento com > 20 por cento do CGMS 72 horas. Verificou-se menor média glicêmica quanto maior o tempo de hipoglicemia (p = 0,006). CONCLUSÃO: A hipoglicemia silenciosa é freqüente em pacientes com DM1, no período noturno. Observou-se tempo de 10 por cento a 20 por cento de hipoglicemia silenciosa para a média glicêmica entre 120 a 160 mg/dL.

BACKGROUND: To evaluate the impact of silent hypoglycemic state in glycemic control in type 1 diabetic patients (DM1) by CGMS. METHODS: 87 DM1 patients (45 percentM/55 percentF) submitted to a 72h CGMS profile were classified in 4 groups. It was analyzed: unrecognized hypoglycemia (<70mg/dL); duration time of silent hypoglycemia in which patients were classified into G1 (<5 percent), G2 (5-10 percent), G3 (10-20 percent) and G4 (>20 percent) of hypoglycemic state by CGMS; A1c and mean capillary glucose (MCG) in each group. RESULTS: The silent hypoglycemia was detected in 64.5 percent of patients and nighttime episodes of hypoglycemia lasted longer (min) than daytime episodes in all groups (p<0.001). It was verified 41.4 percent of patients under than 5 percent of time in hypoglycemic state, 21.8 percent between 5-10 percent, 23 percent between 10-20 percent and 13.8 percent with more than 20 percent of CGMS in silent hypoglycemia. This data showed significant decreased in MCG when the duration time of silent hypoglycemia was longer (p=0.006). CONCLUSION: The silent hypoglycemia is common in DM1 patients and most frequently in night time period. To take an average glycemia of 120-160mg/dL in these patients, it was necessary a 10-20 percent of CGMS period in silent hypoglycemia in these patients.

[Continuous glucose monitoring system (CGMS) in type 1 diabetic patients during 4 (96h) or 5 (120h) days: there is advantage?]. / Uso da monitorização contínua de glicose (CGMS) por quatro (96 horas) ou cinco (120 horas) dias em pacientes com DM1: existe vantagem?

BACKGROUND: To evaluate the accuracy, complications and impact in glycemic control in type 1 diabetic patients (DM1) submitted to 4 or 5 days of CGMS. METHODS: We studied 36 DM1 patients (44.5%M/55.5%F), in three groups without no difference about age, DM duration and A1c levels (p < 0.05), submitted to 72h (G1), 96h (G2) and 120h (G3) CGMS profile. It were analyzed: capillary glycemia (CG) and mean CGMS sensors glycemic value; correlation coefficient, median absolute percent difference (MAD%), number of sensor reading, complications (trauma, local infection, disconnection, dropped), postprandial hyperglycemia, unrecognized hypoglycemia (< 70 mg/dl). A1c levels were measured at the start (1 month before) and after 3 and 12 months in each group. RESULTS: No technical difference were observed into 3 groups: correlation coefficient > 0.79 and MAD < 28% in 95% (p < 0.01). The use of CGMS sensor more than 72h was not related to signal error, trauma, local infection or disconnection. The mean capillary glucose values showed no difference by glucose CGMS sensor (p = 0.01) in all groups. The nighttime episodes of hypoglycemia lasted longer (min) than daytime episodes in all groups (p = 0.05). The postprandial hyperglycemia was statistically identified in groups 1 and 3. This data showed significant decreased A1c level three months after the CGMS in G1 (72h) and G3 (120h) (p < 0.001 and p = 0.002, respectively), which sustained after 1 year (p < 0.001 e p = 0.047, respectively). CONCLUSIONS: The CGMS showed to be a very safety method, with high accuracy/technical efficacy in patients undergoing 96 h and 120 h of CGMS. We do not observed advantages in the use of CGMS during 96 h or 120 h against 72 h in decrease A1c levels after 3 and 12 months. It is possible the use of CGMS > 72h, with no technical damage. However, we do not observed significant clinical benefits of this conduct in DM1 patients.

Uso da monitorização contínua de glicose (CGMS) por quatro (96 horas) ou cinco (120 horas) dias em pacientes com DM1: existe vantagem? / Continuous glucose monitoring system (CGMS) in type 1 diabetic patients during 4 (96h) or 5 (120h) days: there is advantage?

OBJETIVO: Avaliar a acurácia, as complicações e o impacto no controle glicêmico de pacientes com diabetes melito tipo 1 (DM1) submetidos ao uso da monitorização contínua de glicose (CGMS) por quatro e cinco dias. MÉTODOS: Estudamos 36 pacientes DM1 (44,5 por centoM/55,5 por centoF), divididos em três grupos, com idade, tempo de DM e A1c semelhantes (p < 0,05), submetidos ao CGMS por 72 h (G1), 96 h (G2) e 120 h (G3). Foram analisados: GC média e pelo sensor, número de leituras, coeficiente de correlação, mediana da diferença absoluta (MAD por cento); complicações (trauma, infecção, desconexão, abandono); hiperglicemia pós-prandial (HPP) e hipoglicemia assintomática (< 70 mg/dl). Os níveis de A1c após três meses e um ano foram determinados nos três grupos. RESULTADOS: Não houve diferença técnica entre os grupos: coeficiente de correlação > 0,79 e MAD por cento < 28 por cento (p < 0,01) em 95 por cento. O uso do sensor por > 72 h não se associou com erro de sinal, desconexão, trauma, alarmes ou infecção local (p < 0,01). Verificou-se alta correlação entre GC média e pelo sensor, nos três grupos (p = 0,01). A hipoglicemia silenciosa foi mais duradoura (min.) à noite versus dia (p = 0,05), em todos os grupos. A HPP foi estatisticamente mais detectada nos grupos 1 e 3. Observou-se redução significante da A1c três meses após a CGMS no G1 (72 h) e G3 (120 h) (p < 0,001 e p = 0,002, respectivamente), que se manteve após um ano (p < 0,001 e p = 0,047, respectivamente). CONCLUSÃO: Evidenciamos alta acurácia/eficácia técnica com baixo índice de complicações em pacientes submetidos ao CGMS por 96 h ou 120 h. Não verificamos benefícios em relação à CGMS por 72 h quanto à redução da A1c em curto (três meses) e médio (um ano) prazo. O sensor CGMS pode ser utilizado por > 72 h, sem prejuízo técnico, mas sem grandes benefícios do ponto de vista clínico, para pacientes com DM1.

BACKGROUND: To evaluate the accuracy, complications and impact in glycemic control in type 1 diabetic patients (DM1) submitted to 4 or 5 days of CGMS. METHODS: We studied 36 DM1 patients (44.5 percentM/55.5 percentF), in three groups without no difference about age, DM duration and A1c levels (p < 0.05), submitted to 72h (G1), 96h (G2) and 120h (G3) CGMS profile. It were analyzed: capillary glycemia (CG) and mean CGMS sensor’s glycemic value; correlation coefficient, median absolute percent difference (MAD percent), number of sensor reading, complications (trauma, local infection, disconnection, dropped), postprandial hyperglycemia, unrecognized hypoglycemia (< 70 mg/dl). A1c levels were measured at the start (1 month before) and after 3 and 12 months in each group. RESULTS: No technical difference were observed into 3 groups: correlation coefficient > 0.79 and MAD < 28 percent in 95 percent (p < 0.01). The use of CGMS sensor more than 72h was not related to signal error, trauma, local infection or disconnection. The mean capillary glucose values showed no difference by glucose CGMS sensor (p = 0.01) in all groups. The nighttime episodes of hypoglycemia lasted longer (min) than daytime episodes in all groups (p = 0.05). The postprandial hyperglycemia was statistically identified in groups 1 and 3. This data showed significant decreased A1c level three months after the CGMS in G1 (72h) and G3 (120h) (p < 0.001 and p = 0.002, respectively), which sustained after 1 year (p < 0.001 e p = 0.047, respectively). CONCLUSIONS: The CGMS showed to be a very safety method, with high accuracy/technical efficacy in patients undergoing 96 h and 120 h of CGMS. We do not observed advantages in the use of CGMS during 96 h or 120 h against 72 h in decrease A1c levels after 3 and 12 months. It is possible the use of CGMS > 72h, with no technical damage. However, we do not observed significant clinical benefits of this conduct in DM1 patients.

[Switching of NPH insulin to glargine therapy in a cohort of diabetic patients: observational study]. / Substituição da insulina NPH por insulina glargina em uma coorte de pacientes diabéticos: estudo observacional.

This study examined the impact of insulin glargine introduction in basal-bolus therapy in type 1 and type 2 diabetic patients with inadequate metabolic control (A1c > 6.9%) using previous NPH insulin regime. In this uncontrolled, retrospective study, 49 patients (28F/21M), average age 24.7 +/- 16.5, mean duration of DM 13.2 +/- 10.1 yrs., 93.1% DM1 patients, received insulin glargine plus mealtime rapid-acting insulin (lispro or aspart) followed by 90-day treatment. We analyzed mean total insulin dose, incidence of hypoglycemic events, convulsive crisis, hyperglycemic complications and A1c levels before and after three months of introduction of glargine therapy. A1c values were determined using the HPLC instrument, with a normal range of 4.3% to 6.9%. After switching to insulin glargine therapy, mean A1c dropped from 10.2 +/- 2.0 to 9.1 +/- 1.8%, with significant impact (p= 0.019). We observed a significant reduction of 0.11 U/kg/day in total insulin dose, dropped from 0.75 U/kg of NPH to 0.64 U/kg of glargine, with significant correlation (p< 0.05). The introduction of glargine therapy was coincident with a decrease of hypoglycemic crisis (p= 0.02), convulsive events due to hypoglycemia (severe hypoglycemic crisis) (p= 0.023) and ketosis (p= 0.001) switching MDI-treated patients with improvement of metabolic control (reduction of A1c levels). This therapy improved quality of life in these patients due to a significant reduction of hypoglycemic (including severe) events, ketosis episodes and total daily insulin dose, with important impact on health public services.

[Endogenous persistent hypoglicemia of adult: case report]. / Hipoglicemia hiperinsulinêmica persistente endógena no adulto: relato de caso.

Persistent Hyperinsulinemic Endogenous hypoglycemia in adults is, in most cases, due to Insulinoma. Nesidioblastosis, a peculiar functional hyperinsulinemia from hypertrophic beta cells, has been described mainly in newborns. This article describes a 34-year-old patient who presented hyperinsulinemic endogenous hypoglycemia clinical and laboratorial situation (Fasting glycemia: 54 mg/dl / Reference Interval (RI): 60-99 mg/dl; Serum insulin: 70.9 mcU/ml / RI: < 29.1 mcU/ml; e C peptide: 7.1 ng/ml / RI: 1.1-5.0 ng/ml). It was suspected Insulinoma. Because of the lack of typical images in radiologic exams (ultrasonography and computerized tomography) it had been decided to do laparotomy, but it was not found any macroscopic pancreatic tumor. Histological and histochemistry examination of a distal pancreatic segment showed alteration suitable to nesidioblastosis. The patient presented clinical stability during the next two months, however, after that, there was a recurrence of a hypoglycemia crisis, refractory to Octreotide administration. It was done "octreoscan", which showed expanded nesidioblastosis, being done extensive partial pancreatectomy. Octreotide was used again, with a good control of the hypoglycemia crisis. As it is an uncommon diagnosis in an adult, the objective of this article is to describe the diagnostic and therapeutic aspects in cases of hyperinsulinemic endogenous hypoglicemia.

Substituição da insulina NPH por insulina glargina em uma coorte de pacientes diabéticos: estudo observacional / Switching of NPH insulin to glargine therapy in a cohort of poorly controlled diabetic patients: observational study

Este estudo avaliou o impacto da introdução da insulina glargina na terapia basal/bólus em pacientes com diabetes mellitus do tipo 1 (DM1) e do tipo 2 (DM2), com controle inadequado (A1c > 6,9 por cento) em uso prévio de insulina basal NPH. Foi realizado um estudo retrospectivo, não-controlado, com 49 pacientes (28F/21M), idade média 24,7 ± 16,5 anos, tempo de diabetes de 13,2 ± 10,1, sendo 93,1 por cento dos pacientes com DM1, que receberam insulina glargina combinada com insulina ultra-rápida (aspart/lispro) pré-refeições, durante 90 dias de seguimento. Foram analisados dose total de insulina, incidência de hipoglicemias, crises convulsivas, complicações hiperglicêmicas (cetoacidose) e níveis de A1c antes e após três meses do uso da insulina glargina. Os valores de A1c foram determinados pelo método HPLC, com valores de referência de 4,3 por cento a 6,9 por cento. Após 3 meses da modificação do esquema basal para insulina glargina, observou-se redução significativa dos níveis de A1c (10,2 ± 2,0 vs. 9,1 ± 1,8 por cento; p= 0,019). Além disso, verificou-se redução de 0,11 U/kg/dia na dose total de insulina utilizada (NPH: 0,75 U/kg para 0,64 U/kg de insulina glargina; p< 0,05). O uso da insulina glargina associou-se com redução das crises hipoglicêmicas (p= 0,02), crises convulsivas por hipoglicemia grave (p= 0,023) e nenhum caso de cetoacidose (p= 0,001). Este estudo corrobora a eficácia da introdução da insulina glargina em pacientes diabéticos mal controlados, em uso prévio de insulina NPH, com redução importante dos níveis de A1c. Estima-se uma melhora da qualidade de vida desses pacientes, marcada pela redução de eventos hipoglicêmicos (inclusive os graves), episódios de cetoacidose e utilização de menor dose diária de insulina, com provável impacto em políticas de saúde pública.

This study examined the impact of insulin glargine introduction in basal-bolus therapy in type 1 and type 2 diabetic patients with inadequate metabolic control (A1c > 6.9 percent) using previous NPH insulin regime. In this uncontrolled, retrospective study, 49 patients (28F/21M), average age 24.7 ± 16.5, mean duration of DM 13.2 ± 10.1 yrs., 93.1 percent DM1 patients, received insulin glargine plus mealtime rapid-acting insulin (lispro or aspart) followed by 90-day treatment. We analyzed mean total insulin dose, incidence of hypoglycemic events, convulsive crisis, hyperglycemic complications and A1c levels before and after three months of introduction of glargine therapy. A1c values were determined using the HPLC instrument, with a normal range of 4.3 percent to 6.9 percent. After switching to insulin glargine therapy, mean A1c dropped from 10.2 ± 2.0 to 9.1 ± 1.8 percent, with significant impact (p= 0.019). We observed a significant reduction of 0.11U/kg/day in total insulin dose, dropped from 0.75U/kg of NPH to 0.64U/kg of glargine, with significant correlation (p< 0.05). The introduction of glargine therapy was coincident with a decrease of hypoglycemic crisis (p= 0.02), convulsive events due to hypoglycemia (severe hypoglycemic crisis) (p= 0.023) and ketosis (p= 0.001) switching MDI-treated patients with improvement of metabolic control (reduction of A1c levels). This therapy improved quality of life in these patients due to a significant reduction of hypoglycemic (including severe) events, ketosis episodes and total daily insulin dose, with important impact on health public services.

Hipoglicemia hiperinsulinêmica persistente endógena no adulto: relato de caso / Endogenous persistent hypoglicemia of adult: case report

A hipoglicemia hiperinsulinêmica persistente endógena em adultos é, na maioria dos casos, causada por insulinoma. A Nesidioblastose, uma hiperinsulinemia funcional rara por hiperplasia das células beta do pâncreas, tem sido descrita principalmente em neonatos. Apresentamos o caso de uma paciente de 34 anos com quadro clínico-laboratorial compatível com hipoglicemia hiperinsulinêmica endógena (Glicemia jejum: 54 mg/dl / Valor de referência (VR): 60­99 mg/dl; Insulina sérica: 70,9 mcU/ml / VR: < 29,1 mcU/ml; e Peptídeo C: 7,1 ng/ml / VR: 1,1­5,0 ng/ml - simultâneos à glicemia). Foi aventada a hipótese de insulinoma. Em função da ausência de imagem característica aos exames radiológicos (ultra-som e tomografia de abdome), optou-se pela laparotomia exploradora, onde também não foi evidenciado tumor pancreático macroscopicamente. Os exames histopatológico e imuno-histoquímico evidenciaram hiperplasia de células beta, de segmento distal do pâncreas, compatível com nesidioblastose. A paciente evoluiu com estabilidade clínica por cerca de dois meses, quando se verificou recidiva das crises hipoglicêmicas, refratárias ao uso de Octreotide. Optou-se pela realização de "octreosan", que indicou nesidioblastose difusa, sendo procedida pancreatectomia parcial extensa. Seguiu-se o uso contínuo de Octreotide, com controle eficaz das crises hipoglicêmicas. Uma vez que esse é um diagnóstico raro no adulto, objetiva-se, nesse artigo, divulgar o manejo diagnóstico-terapêutico em casos de hipoglicemia hiperinsulinêmica endógena.

Persistent Hyperinsulinemic Endogenous hypoglycemia in adults is, in most cases, due to Insulinoma. Nesidioblastosis, a peculiar functional hyperinsulinemia from hypertrophic beta cells, has been described mainly in newborns. This article describes a 34-year-old patient who presented hyperinsulinemic endogenous hypoglycemia clinical and laboratorial situation (Fasting glycemia: 54 mg/dl / Reference Interval (RI): 60­99 mg/dl; Serum insulin: 70.9 mcU/ml / RI: < 29.1 mcU/ml; e C peptide: 7.1 ng/ml / RI: 1.1­5.0 ng/ml). It was suspected Insulinoma. Because of the lack of typical images in radiologic exams (ultrasonography and computerized tomography) it had been decided to do laparotomy, but it was not found any macroscopic pancreatic tumor. Histological and histochemistry examination of a distal pancreatic segment showed alteration suitable to nesidioblastosis. The patient presented clinical stability during the next two months, however, after that, there was a recurrence of a hypoglycemia crisis, refractory to Octreotide administration. It was done "octreoscan", which showed expanded nesidioblastosis, being done extensive partial pancreatectomy. Octreotide was used again, with a good control of the hypoglycemia crisis. As it is an uncommon diagnosis in an adult, the objective of this article is to describe the diagnostic and therapeutic aspects in cases of hyperinsulinemic endogenous hypoglicemia.

Efficacy of continuous glucose monitoring system (CGMS) to detect postprandial hyperglycemia and unrecognized hypoglycemia in type 1 diabetic patients.

BACKGROUND: To evaluate the efficacy of continuous glucose monitoring system (CGMS) to detect postprandial hyperglycemia and unrecognized hypoglycemia in type 1 diabetes mellitus (DM1) patients. METHODS: We studied 46 patients (43.4%M/56.6%F), average age of 25.9+/-12.8 years, submitted to 72 h CGMS. It were analyzed: capillary glycemia (CG) and CGMS sensor's value, glycemic excursions, postprandial hyperglycemia, asymptomatic hypoglycemia and therapeutic management after CGMS. Correlation coefficient during hypo and hyperglycemia and sensitivity/specificity were determined. RESULTS: The mean capillary glucose values were 191.8+/-46.2mg/dl versus 190.9+/-42.1mg/dl by CGMS sensor, with no statistical difference by T-test (T=-0.6; p=0.79). The CGMS was significantly more efficient in detection of glycemic excursion than CG (p=0.001). The postprandial hyperglycemia was identified in 76.9% of diabetic patients and asymptomatic hypoglycemia was detected in 58.2% of these patients. The correlation coefficient presented no significance (p=0.16) during hypoglycemia versus during hyperglycemia (p=0.002). The CGMS sensor presented low sensitivity (79.1%) to detect hypoglycemia versus hyperglycemia (96.8%). CONCLUSIONS: The CGMS showed to be a good method to identify postprandial hyperglycemia, to improve therapeutics management and confirmed the low sensitivity of CGMS to detect unrecognized hypoglycemia in DM1 patients.

Impacto do sistema de monitorização contínua da glicose em pacientes diabéticos / Metabolic / glycemic control accuracy, effect and complications of the continuous glucose monitoring system in diabetic patients

OBJETIVO: Avaliar a acurácia da CGMS em pacientes diabéticos, bem como seu impacto no controle glicêmico/metabólico e possíveis complicações do método. MÉTODOS: Foram estudados 53 pacientes (47,2 por centoM/52,8 por centoF), idade: 29,74±16,38 anos, predomínio de DM1 (86,8 por cento), submetidos à monitorização contínua da glicose (CGM) (Medtronic; Northridge, CA) por 72 h. Foram analisados: glicemia capilar (GC) média e pelo sensor CGMS, coeficiente de correlação, excursões glicêmicas (CGMS versus GC), hiperglicemia pós-prandial (HPP) e hipoglicemia assintomática; complicações e conduta após a CGM. Os níveis de A1c foram medidos antes (um mês) e três meses após a CGM. RESULTADOS: A GC média durante a CGM foi 191,3±45,6 mg/dl versus 192,5±43,9 mg/dl detectada pelo sensor, com correlação altamente significativa (p=0,001). O coeficiente de correlação foi de 0,87±0,16 (VR>0,79). O CGMS detectou mais excursões glicêmicas em relação à GC (p=0,001). HPP foi evidenciada em 77,3 por cento dos casos e a hipoglicemia noturna assintomática em 54 por cento. Observou-se redução significante da A1c três meses após a CGM (p=0,001). Não houve complicações durante a CGM em 89,8 por cento dos exames. CONCLUSÃO: A CGMS mostrou-se método seguro, com baixo índice de complicações e alta acurácia nos valores glicêmicos em relação à glicemia capilar. Verificou-se alta eficácia da CGMS na detecção de excursões glicêmicas, hipoglicemia noturna assintomática e HPP, com importante impacto na redução da A1c após três meses nesse grupo de pacientes.

OBJECTIVE: To evaluate the accuracy, safety and complications of the continuous glucose monitoring system (CGMS) in diabetic patients (DM). The impact of this system on metabolic/glycemic control is still under discussion. METHODS: The 53 patients studied (47.2 percent male / 52.8 percent female), average age: 29.74±16.38 years, DM1 prevalence (86.8 percent) were submitted to 72h CGMS (Medtronic; Northridge, CA). Capillary glycemia (CG) and mean CGMS sensor's glycaemic value; correlation coefficient, glycemic excursions (CGMS vs. CG), postprandial hyperglycemia, unrecognized hypoglycemia, complications and therapeutic management after CGMS were analyzed. A1c levels were measured at baseline (1 month before) and after 3 months of the study. RESULTS: The mean capillary glucose values were 191.3±45.6 vs. 192.5±43.9mg/dl by CGMS sensor, with significant correlation (p=0.001). The correlation coefficient was 0.87± 0.16 (VR>0.79). The CGMS was significantly more efficient in the detection of glycemic excursion related to capillary glycemia (p=0.001). Postprandial hyperglycemia was identified in 77.3 percent of diabetic patients and nocturnal unrecognized hypoglycemia was detected in 54 percent. Data showed a significantly decreased A1c level, three months after the CGMS (p=0.001). No complications were registered in 89.8 percent of patients. CONCLUSION: The CGMS was confirmed to be a very safe method, with high accuracy in glycemic values and to have a low complication rate. It is a good method to identify glucose excursion, postprandial hyperglycemia and asymptomatic hypoglycemia, with a significant impact on the A1c levels of diabetic patients.

[Metabolic/glycemic control accuracy, effect and complications of the continuous glucose monitoring system in diabetic patients]. / Impacto do sistema de monitorização contínua da glicose em pacientes diabéticos.

OBJECTIVE: To evaluate the accuracy, safety and complications of the continuous glucose monitoring system (CGMS) in diabetic patients (DM). The impact of this system on metabolic/glycemic control is still under discussion. METHODS: The 53 patients studied (47.2% male / 52.8% female), average age: 29.74+/-16.38 years, DM1 prevalence (86.8%) were submitted to 72h CGMS (Medtronic; Northridge, CA). Capillary glycemia (CG) and mean CGMS sensor's glycaemic value; correlation coefficient, glycemic excursions (CGMS vs. CG), postprandial hyperglycemia, unrecognized hypoglycemia, complications and therapeutic management after CGMS were analyzed. A1c levels were measured at baseline (1 month before) and after 3 months of the study. RESULTS: The mean capillary glucose values were 191.3+/-45.6 vs. 192.5+/-43.9 mg/dl by CGMS sensor, with significant correlation (p=0.001). The correlation coefficient was 0.87+/-0.16 (VR>0.79). The CGMS was significantly more efficient in the detection of glycemic excursion related to capillary glycemia (p=0.001). Postprandial hyperglycemia was identified in 77.3% of diabetic patients and nocturnal unrecognized hypoglycemia was detected in 54%. Data showed a significantly decreased A1c level, three months after the CGMS (p=0.001). No complications were registered in 89.8% of patients. CONCLUSION: The CGMS was confirmed to be a very safe method, with high accuracy in glycemic values and to have a low complication rate. It is a good method to identify glucose excursion, postprandial hyperglycemia and asymptomatic hypoglycemia, with a significant impact on the A1c levels of diabetic patients.

[Accuracy, effect on insulin therapy and glycemic control and complications of the continuous glucose monitoring system in type 1 diabetic patients]. / Acurácia, efeitos na terapia insulínica e controle glicêmico e complicações do sistema de monitorização contínua da glicose em pacientes com diabetes mellitus tipo 1.

To evaluate the efficacy, safety and complications of continuous glucose monitoring system (CGMS) in type 1 diabetic patients (DM1), we retrospectively studied 30 patients (25.8 +/- 12.2 years) submitted to 72 hs CGMS (Medtronic; Northridge, CA) and analyzed: mean self monitoring blood glucose (SMBG) and mean CGMS sensors glycemic value; correlation coefficient (%), median absolute percent difference (MAD%), number of sensor reading, glycemic excursions (CGMS vs. SMBG), complications (trauma, local infection, disconnection) and therapeutic management after CGMS. A1c levels were measured 1 month before and 3 months after the study. Mean capillary glucose values were 186.5 +/- 43.3 mg/dl vs. 179.7 +/- 48.1 mg/dl by CGMS sensor, with significant correlation (p = 0.001). An average of 772.4 +/- 254.1 (VR > 680) glucose measurements was recorded for each patient, with 68.7 +/- 19.8 hs of exam. Correlation coefficient was 0.86 +/- 0.21 (VR > 0.79). Median absolute percent difference between sensor and glucometer values was 13.9 +/- 4.7% (VR < 28%). The CGMS was significant more efficient in detection of glycemic excursion related to capillary glycemia (p = 0.009). This data showed important decreased level of A1c in this population 3 months after the CGMS with statistical significance (p = 0.018). No complications were registered in 96.7% of patients. No trauma, local infection or bleeding were registered. The insulin therapeutic regimen was adjusted in 100% of patients. The CGMS showed to be a very safety method, well tolerated, with high accuracy in glycemic values and low complications rate. This method has to be more stimulated by physicians and patients.

Efficacy of continuous glucose monitoring system to detect unrecognized hypoglycemia in children and adolescents with type 1 diabetes.

This retrospective study assessed 17 DM1 pediatric patients (15.76 +/- 4.5 years) submitted to 72 h continuous glucose monitoring system (CGMS) (Medtronic, CA). The aim of this study was to evaluate the accuracy of CGMS in children and adolescents with type 1 diabetes mellitus (DM1) and the efficacy of this method to detect unrecognized hypoglycemia in this population. It were analyzed capillary glycemia (CG) and CGMS sensors value; glycemic excursions; postprandial hyperglycemia; unrecognized hypoglycemia; complications and therapeutic management after CGMS. A1c levels were measured at the start and after 3 months of the study. Correlation coefficient during hypo, hyper, and normoglycemia and sensitivity/specificity was determined. The mean CG values were 213.8 +/- 63.4 mg/dl vs. 209.7 +/- 52.5 mg/dl by sensor, with statistical significance by Pearson's correlation (p < 0.001). There was no difference between CGMS and CG value in order to detect glycemic excursions (p = 0.32). The postprandial hyperglycemia and unrecognized hypoglycemia was detected in 66.7% and 56.2% of this patients, respectively. The correlation coefficient during hypoglycemia presented no statistical significance by Pearson's correlation (p = 0.29) vs. during hyperglycemia (p = 0.001). The CGMS sensor presented low sensitivity (63.3%) to detect hypoglycemia. This data showed important decreased level of A1c in this population 3 months after CGMS with statistical significance (p = 0.03). The CGMS showed to be a very safe method, well tolerated, with high accuracy in glycemic values and low complications rate. This results suggest that CGMS is a good method to identify postprandial hyperglycemia, to improve metabolic changes in therapeutics with significant impact in A1c of diabetic pediatric patients. This data confirmed the low sensitivity of CGMS to detect unrecognized hypoglycemia in pediatric DM1 patients.

[Accuracy, utility and complications of continuous glucose monitoring system (CGMS) in pediatric patients with type 1 diabetes]. / Acurácia, utilidade e complicações da monitorização subcutânea contínua da glicose (CGMS) em pacientes pediátricos com diabetes tipo 1.

OBJECTIVE: To evaluate the accuracy, utility and complications of continuous glucose monitoring system in children and adolescents with type 1 diabetes. METHODS: This retrospective study assessed 16 type 1 diabetic patients (16.12+/-4.41 years) submitted to continuous glucose monitoring system (Medtronic; Northridge, CA) for 72 hours. The following parameters were analyzed: mean capillary glucose level and mean glucose value measured by the continuous glucose monitoring system; glucose excursions (continuous glucose monitoring system vs. capillary glucose measurement), postprandial hyperglycemia (NR < 140 mg/dl), nocturnal hypoglycemia, complications (trauma, local infection, disconnection) and therapeutic management after continuous glucose monitoring. A1c levels were measured at the beginning and after 3 months of the study. RESULTS: The mean capillary glucose values were 214.3+/-66.5 mg/dl vs. 207.6+/-54.6 mg/dl by continuous glucose monitoring system, with a significant correlation (p = 0.001). The correlation coefficient and mean absolute error were 0.86+/-0.21 and 12.6% of the median, respectively. The continuous glucose monitoring system was significantly more efficient in detecting glucose excursion than fingerstick capillary blood sampling (p = 0.04; W = 74), and postprandial hyperglycemia was identified in 60% of type 1 diabetic patients with a median value of 157 mg/dl (< 140 mg/dl). Nocturnal hypoglycemia was detected in 46.7% of these patients. The evaluation of A1c levels in eight (50%) patients before continuous glucose monitoring and after 3 months showed a significantly lower level of A1c in this population (8.18+/-1.5 vs. 7.28+/-1.3; p = 0.034). The therapeutic management of type 1 diabetes was changed in 100% of patients. No complications were detected in 93.7% of patients. CONCLUSIONS: The continuous glucose monitoring system showed to be a very safe, well-tolerated and highly accurate method, with a low complication rate. It is a good method to identify glucose excursion and postprandial hyperglycemia, and to improve metabolic changes in therapeutic strategies, with a significant impact on the A1c levels of pediatric diabetic patients. The efficacy of the continuous glucose monitoring system in detecting hypoglycemia is still unclear in the medical literature.

Acurácia, utilidade e complicacões da monitorizacão subcutânea contínua da glicose (CGMS) em pacientes pediátricos com diabetes tipo 1 / Accuracy, utility and complications of continuous glucose monitoring system (CGMS) in pediatric patients with type 1 diabetes

OBJETIVO: Avaliar a acurácia, utilidade e complicacões da monitorizacão subcutânea contínua da glicemia em criancas e adolescentes com diabetes melito tipo 1 (DM1). MÉTODOS: Foram estudados retrospectivamente 16 pacientes (16,12n4,41 anos), submetidos à monitorizacão subcutânea contínua da glicemia (Medtronic; Northridge, CA, EUA) por 72 horas. Foram analisados os valores de glicemia capilar média e pelo sensor monitorizacão subcutânea contínua da glicemia; excursões glicêmicas (monitorizacão subcutânea contínua da glicemia versus. glicemia capilar); hiperglicemia pós-prandial (< 140 mg/dl); hipoglicemia noturna assintomática; complicacões (trauma, infeccão local, desconexão) e conduta terapêutica após a monitorizacão subcutânea contínua da glicemia. Os níveis de A1c foram determinados antes e 3 meses após a monitorizacão subcutânea contínua da glicemia. RESULTADOS: A glicemia capilar média durante a monitorizacão subcutânea contínua da glicemia foi de 214,3n66,5 mg/dl vs. 207,6n54,6 detectada pelo sensor, com correlacão significante (p = 0,001). O coeficiente de correlacão e erro médio absoluto foram de 0,86n0,21 e mediana de 12,6 por cento, respectivamente. A monitorizacão subcutânea contínua da glicemia mostrou-se mais eficaz na deteccão de excursões glicêmicas (p = 0,04; W = 74) em relacão à glicemia capilar em ponta de dedo. A hiperglicemia pós-prandial foi identificada em 60 por cento dos pacientes com DM1, com mediana de 157 mg/dl (< 140 mg/dl). A hipoglicemia noturna assintomática foi detectada em 46,7 por cento dos casos. A avaliacão dos níveis de A1c em oito (50 por cento) pacientes, antes e após 3 meses da monitorizacão subcutânea contínua da glicemia, mostrou reducão significante da A1c (8,18n1,5 vs. 7,28n1,3; p = 0,034) nesse grupo de pacientes. A mudanca de conduta terapêutica foi instituída em 100 por cento das criancas e adolescentes. Não houve complicacões durante o exame em 93,7 por cento dos casos. CONCLUSÕES: A monitorizacão subcutânea contínua da glicemia mostrou-se método seguro, bem tolerado, com alta acurácia nos valores glicêmicos detectados, com baixo índice de complicacões. Esse método mostrou-se eficaz na deteccão de excursões glicêmicas, hiperglicemia pós-prandial, na promocão de mudancas terapêuticas com reducão importante da A1c em criancas e adolescentes diabéticos. A eficácia desse método na identificacão da hipoglicemia assintomática ainda mostra-se indefinida na literatura.

Acurácia, efeitos na terapia insulínica e controle glicêmico e complicações do sistema de monitorização contínua da glicose em pacientes com diabetes mellitus tipo 1 / Accuracy, effect on insulin therapy and glycemic control and complications of the continuous glucose monitoring system in type 1 diabetic patients

Para avaliar a acurácia, segurança e complicações do sistema de monitorização contínua da glicose (CGMS) em pacientes com diabetes mellitus tipo 1 (DM1), estudamos retrospectivamente 30 pacientes (25,8 ± 12,2 anos) sob monitorização contínua da glicose (CGM) (Medtronic; Northridge, CA) por 72hs. Foram analisados: glicemia capilar (GC) média e pelo sensor durante a CGM, coeficiente de correlação ( por cento), mediana da diferença percentual absoluta (MAD por cento), número de leituras, excursões glicêmicas (sensor CGMS vs. GC), presença de complicações (trauma, infecção, desconexão), abandono e conduta após CGMS. Os níveis de A1c foram determinados 1 mês antes e 3 meses após o CGMS. A GC média durante a utilização do CGMS foi de 186,5 ± 43,3mg/dl vs. 179,7 ± 48,1mg/dl detectada pelo sensor, com correlação significativa (p= 0,001). O número de leituras pelo sensor CGMS foi de 772,4 ± 254,1 (VR > 680), com duração média de 68,7 ± 19,8hs de exame. O coeficiente de correlação foi de 0,86 ± 0,21 (VR > 0,79). Quanto à MAD por cento, observou-se valor de 13,9 ± 4,7 por cento (VR < 28 por cento). O CGMS mostrou-se estatisticamente mais eficaz na detecção de excursões glicêmicas em relação à GC (p= 0,009). Observou-se redução significante da A1c três meses após o CGMS nesse grupo de pacientes (p= 0,018). Não houve complicações durante a CGM em 96,7 por cento dos exames. Não houve registro de trauma, infecção local ou sangramento em nenhum caso. A CGM promoveu mudança de conduta terapêutica em 100 por cento dos pacientes. A CGM mostrou-se método seguro, bem tolerado, com alta acurácia nos valores glicêmicos detectados, sendo método de alta eficácia, com baixo índice de complicações e abandono, devendo sua prática ser cada vez mais estimulada em nosso meio.

Efficacy of continuous glucose monitoring system to detect unrecognized hypoglycemia in children and adolescents with type 1 diabetes

Foram estudados retrospectivamente 17 pacientes (15,76 ± 4,5 anos) submetidos a monitorização subcutânea contínua da glicemia (CGMS) (Medtronic; CA) por 72 horas. Buscou-se avaliar a acurácia da CGMS em crianças e adolescentes com diabetes mellitus tipo 1 (DM1) e sua eficácia na detecção de hipoglicemia assintomática nesse grupo de pacientes. Foram analisados os valores de glicemia capilar (GC) e pelo sensor CGMS; excursões glicêmicas; hiperglicemia pós-prandial; hipoglicemia assintomática; complicações e conduta após a CGMS. Os níveis de A1c foram determinados antes e 3 meses após a CGMS. A correlação sensor/glicemia capilar foi avaliada durante normo, hipo e hiperglicemia, bem como a sensibilidade e especificidade. A GC média durante a CGMS foi de 213,8 ± 63,4mg/dl vs. 209,7 ± 52,5mg/dl detectada pelo sensor, com correlação de Pearson significante (p< 0,001). Não houve diferença significante entre a CGMS e GC na detecção de excursões glicêmicas (p= 0,32). A hiperglicemia pós-prandial e hipoglicemia assintomática foram identificadas em 66,7% e 56,2% dos pacientes durante a CGMS, respectivamente. A correlação entre sensor CGMS e GC durante hipoglicemia assintomática mostrou-se não significante (p= 0,32) vs. durante hiperglicemia (p= 0,001). O sensor CGMS apresentou baixa sensibilidade (63,3%) para detecção de hipoglicemia assintomática. Observou-se redução significante da A1c três meses após a CGMS em crianças e adolescentes com DM1 (p= 0,03). A CGMS mostrou-se método seguro, bem tolerado, com alta acurácia nos valores glicêmicos detectados, com baixo índice de complicações. Esses dados comprovam a alta eficácia da CGMS na detecção de hiperglicemia pós-prandial, na redução da A1c e melhora do controle metabólico, com baixas sensibilidade para na identificação de hipoglicemia assintomática em crianças e adolescentes com DM1.

Transplante de pâncreas na síndrome de Mauriac: evolução clínica e laboratorial após um ano de acompanhamento / Pancreas transplantation in Mauriac syndrome: clinical and biochemical parameters after one year follow up

O transplante de pâncreas tem se mostrado método eficaz no tratamento do diabetes mellitus tipo 1 (DM1) em casos selecionados, com redução da necessidade diária de insulina e normalização da glico-hemoglobina (A1c). Não há conhecimento, ainda, sobre o efeito do transplante de pâncreas em pacientes com síndrome de Mauriac (SM). Apresentamos um caso de SM refratário ao tratamento clínico instituído (insulinoterapia intensiva, atividade física programada, acompanhamento psicológico e nutricional), com persistência de níveis de glicemia de jejum e A1c continuamente elevados, dislipidemia e IGF-1 (fator de crescimento insulina símile) reduzido, sendo indicado o transplante pancreático. Após 1 ano do transplante de pâncreas total, o paciente permanecia assintomático, insulino-independente, com glicemia de jejum adequada (<110mg/dl), normalização do perfil lipídico e de IGF-1, com redução importante da A1c (4,6 por cento), melhora da auto-estima e maior qualidade de vida para o paciente. O transplante de pâncreas mostrou-se método eficaz no controle da SM, com reversão importante dos parâmetros clínico-laboratoriais nesse caso. Objetiva-se divulgar o primeiro caso de SM controlado com transplante de pâncreas descrito na literatura médica indexada, como alternativa terapêutica nesse grupo de pacientes.

[Pancreas transplantation in Mauriac Syndrome: clinical and biochemical parameters after one year follow up]. / Transplante de pâncreas na síndrome de Mauriac: evolução clínica e laboratorial após um ano de acompanhamento.

In select cases of type 1 diabetes mellitus (DM1) the pancreas transplantation has been shown to ameliorate the disease, to reduce the need for exogenous insulin and normalize glycosylated hemoglobin (A1c) levels. The efficacy of this therapy in Mauriac Syndrome (SM) is not yet well established. We report a patient with MS treated with intensive insulin therapy, physical activity program, nutritional and psychological assistance, with persistently elevated fast glycemia and A1c levels, inadequate lipid profile and decreased IGF-1 (insulin like growth factor) levels. Due to a poorly metabolic control, pancreas transplantation was indicated. After one year follow up, the patient had no symptoms and showed persistent insulin independence with fast glucose <110 mg/dl, normal lipid profile and IGF-1 levels and significant decrease in A1c (4.6%). The pancreas transplantation improved diabetes control and promoted better quality of life for this patient. Pancreas transplantation proved to be an effective treatment strategy in patients with MS, improving their clinical and biochemical derangements. In this report we present the first case of MS controlled by pancreas transplantation registered in the indexed medical literature, as an alternative therapy in this group of patients.

Glicemia capilar em ponta do dedo versus lóbulo de orelha: estudo comparativo dos valores resultantes e preferências dos pacientes / Fingerstick capillary glycemia versus ear lobe measurement: comparative analysis of results and patient preferences

Para avaliar a eficácia da glicemia capilar (GC) em lóbulo de orelha e a preferência desse método em relação à "ponta de dedo", estudamos 40 pacientes (13M/27F; 41,6 ± 13,5 anos) com diabetes tipo 2 (DM2). A monitorização foi realizada com glicosímetro digital e lancetador Accu-Chek Softclix® Pro, com grau 2 (médio) de penetração na falange distal do 3° dedo da mão direita e porção inferior do lóbulo da orelha direita, simultaneamente e em jejum durante 27 dias. Quanto à GC, não houve diferença significante entre o exame de ponta de dedo e lóbulo de orelha (p = 0,008). Quanto à dor, 72,5 por cento dos pacientes não apresentou desconforto ao exame em lóbulo da orelha, enquanto 15 por cento relatava tal fato ao exame de ponta de dedo. Houve correlação significante entre exame em lóbulo de orelha e baixo índice de dor (p< 0,001). Quanto ao local de preferência, 82,5 por cento preferiu a GC em lóbulo de orelha. A monitorização glicêmica em lóbulo de orelha foi tão eficaz quanto em ponta dedo, com menor sensação de dor e maior índice de preferência, mostrando-se um método seguro, confortável e com ótima aceitação dos pacientes.