Type 1 Diabetes Brazilian patients exhibit reduced frequency of recent thymic emigrants in regulatory CD4+CD25+Foxp3+T cells.

To control immune responses, regulatory CD4+CD25+Foxp3+ T cells (Treg) maintain their wide and diverse repertoire through continuous arrival of recent thymic emigrants (RTE). However, during puberty, the activity of RTE starts to decline as a natural process of thymic involution, introducing consequences, not completely described, to the repertoire. Type 1 diabetes (T1D) patients show quantitative and qualitative impairments on the Treg cells. Our aim was to evaluate peripheral Treg and RTE cell frequencies, in T1D patients from two distinct age groups (young and adults) and verify if HLA phenotypes are concomitant associated. To this, blood samples from Brazilian twenty established T1D patients (12 young and 8 adults) and twenty-one healthy controls (11 young and 10 adults) were analyzed, by flow cytometry, to verify the percentages of CD4, Treg (CD4+CD25+Foxp3+) and the subsets of CD45RA+ (naive) and CD31+(RTE) within then. Furthermore, the HLA typing was also set. We observed that the young established T1D patients feature decreased frequencies in total Treg cells and naive RTE within Treg cells. Significant prevalence of HLA alleles, associated with risk, in T1D patients, was also identified. Performing a multivariate analysis, we confirmed that the cellular changes described offers significant variables that distinct T1D patients from the controls. Our data collectively highlight relevant aspects about homeostasis imbalances in the Treg cells of T1D patients, especially in young, and disease prognosis; that might contribute for future therapeutic strategies involving Treg cells manipulation.

Flash glucose monitoring system in patients with type 1 diabetes in healthcare center in Brazil: real world data from a short-term prospective study

ABSTRACT Objectives: To evaluate the alternate use of flash glucose monitoring (FGM) with self-monitoring blood glucose (SMBG), in patients with type 1 diabetes (T1D). Materials and methods: Two weeks of open FGM (P2), both preceded (P1) and followed by 2 weeks (P3) of SMBG with a blinded FGM system. Mean absolute relative difference (MARD) was calculated by (-FGMi − SMBGi-) / SMBGi, where it was a paired data sample. Results: In total, 34 patients were evaluated. Time in range (TIR) did not change between P1 and P2. In 12 patients (35.3%), TIR increased from 40% at P1 to 52% at P2 (p = 0.002) and in 22 (64.7%), TIR decreased or did not change. FGM use resulted in decreased % time spent in hypoglycemia (<70 mg/dL) (6.5% vs. 5.0%; p = 0.005), increased % time spent in hyperglycemia (>180 mg/dL) (44.5% to 51%; p = 0.046) with no significant change in % TIR. The proportion of patients who reached sensor-estimated glycated hemoglobin (eA1c) < 7% decreased from 23.5% at P1 to 12.9% at P2, p = 0.028. For the whole sample, the MARD between the two methods was 15.5% (95% CI 14.5-16.6%). For normal glucose range, hyperglycemic levels and hypoglycemic levels MARD were 16.0% (95% CI 15.0-17.0%), 13.3% (95% CI 11.5-15.2%) and 23.4% [95% CI 20.5-26.3%)], respectively. Conclusion: FGM after usual SMBG decreased the % time spent in hypoglycemia concomitant with an undesired increase in % time spent in hyperglycemia. Lower accuracy of FGM regarding hypoglycemia levels could result in overcorrection of hypoglycemia.

Flash glucose monitoring system in patients with type 1 diabetes in healthcare center in Brazil: real world data from a short-term prospective study.

Objective: To evaluate the alternate use of flash glucose monitoring (FGM) with self-monitoring blood glucose (SMBG), in patients with type 1 diabetes (T1D). Materials and methods: Two weeks of open FGM (P2), both preceded (P1) and followed by 2 weeks (P3) of SMBG with a blinded FGM system. Mean absolute relative difference (MARD) was calculated by (|FGMi - SMBGi|) / SMBGi, where it was a paired data sample. Results: In total, 34 patients were evaluated. Time in range (TIR) did not change between P1 and P2. In 12 patients (35.3%), TIR increased from 40% at P1 to 52% at P2 (p = 0.002) and in 22 (64.7%), TIR decreased or did not change. FGM use resulted in decreased % time spent in hypoglycemia (<70 mg/dL) (6.5% vs. 5.0%; p = 0.005), increased % time spent in hyperglycemia (>180 mg/dL) (44.5% to 51%; p = 0.046) with no significant change in % TIR. The proportion of patients who reached sensor-estimated glycated hemoglobin (eA1c) < 7% decreased from 23.5% at P1 to 12.9% at P2, p = 0.028. For the whole sample, the MARD between the two methods was 15.5% (95% CI 14.5-16.6%). For normal glucose range, hyperglycemic levels and hypoglycemic levels MARD were 16.0% (95% CI 15.0-17.0%), 13.3% (95% CI 11.5-15.2%) and 23.4% [95% CI 20.5-26.3%)], respectively. Conclusion: FGM after usual SMBG decreased the % time spent in hypoglycemia concomitant with an undesired increase in % time spent in hyperglycemia. Lower accuracy of FGM regarding hypoglycemia levels could result in overcorrection of hypoglycemia.

Risk factors associated with nonalcoholic fatty liver disease evaluated by elastography in patients with type 2 diabetes

ABSTRACT Objective: There is controversy about the indication for nonalcoholic fatty liver disease (NAFLD) screening in patients with type 2 diabetes mellitus (T2D). The present study aims to contribute to NAFLD surveillance in patients with T2D, assessing the association of clinical and biological variables with hepatic stiffness and steatosis. Subjects and methods: A cross-sectional design was used, with data collection from electronic medical records, including adults with T2D who underwent transient elastography (TE) between June 2018 and December 2019. Liver stiffness and steatosis were evaluated using TE and controlled attenuation parameter (CAP), respectively, with cutoff points > 8 kpa for increased stiffness and > 275 dBm for steatosis. The relationship between clinical variables and elastography results were evaluated by bivariate correlation and multivariate analysis, using SPSS 27. Seventy-nine patients (n = 79) met the inclusion and exclusion criteria. Results: Advanced fibrosis and hepatic steatosis were detected in 17,7% and in 21,5% of the patients, respectively. There was a direct and significant correlation between CAP and BMI, waist circumference, HbA1c, triglycerides levels, and insulin doses and an inverse correlation with HDL. The waist circumference, low levels of HDL cholesterol and the insulin dose maintained a significant association with CAP values in multivariate analysis. Elastography values showed an inverse correlation with HDL and a direct correlation with BMI and insulin dose. The association was only maintained for the insulin dose in multivariate analysis. Conclusion: Our results suggest that clinical factors such as insulin dose, waist circumference, and HDL cholesterol levels could identify T2D patients more likely to present NAFLD.

Risk factors associated with nonalcoholic fatty liver disease evaluated by elastography in patients with type 2 diabetes.

Objective: There is controversy about the indication for nonalcoholic fatty liver disease (NAFLD) screening in patients with type 2 diabetes mellitus (T2D). The present study aims to contribute to NAFLD surveillance in patients with T2D, assessing the association of clinical and biological variables with hepatic stiffness and steatosis. Subjects and methods: A cross-sectional design was used, with data collection from electronic medical records, including adults with T2D who underwent transient elastography (TE) between June 2018 and December 2019. Liver stiffness and steatosis were evaluated using TE and controlled attenuation parameter (CAP), respectively, with cutoff points > 8 kpa for increased stiffness and > 275 dBm for steatosis. The relationship between clinical variables and elastography results were evaluated by bivariate correlation and multivariate analysis, using SPSS 27. Seventy-nine patients (n = 79) met the inclusion and exclusion criteria. Results: Advanced fibrosis and hepatic steatosis were detected in 17,7% and in 21,5% of the patients, respectively. There was a direct and significant correlation between CAP and BMI, waist circumference, HbA1c, triglycerides levels, and insulin doses and an inverse correlation with HDL. The waist circumference, low levels of HDL cholesterol and the insulin dose maintained a significant association with CAP values in multivariate analysis. Elastography values showed an inverse correlation with HDL and a direct correlation with BMI and insulin dose. The association was only maintained for the insulin dose in multivariate analysis. Conclusion: Our results suggest that clinical factors such as insulin dose, waist circumference, and HDL cholesterol levels could identify T2D patients more likely to present NAFLD.

The lifestyle of Brazilian medical students: What changed and how it protected their emotional wellbeing during the COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: Adopting healthy lifestyle pillars promotes longer lives free from major chronic diseases. The COVID-19 pandemic imposed behavioural changes and psychological burdens. The aim of this study was to assess changes in medical students' six lifestyle pillars that were imposed by the COVID-19 pandemic. METHOD: This cross-sectional study included 548 Brazilian medical students' digitally collected demographic data and lifestyle characteristics from before and during the pandemic. RESULTS: The pandemic had a neutral impact on sleep quality and a predominantly negative impact on interpersonal relationships, exercise and eating. Approximately 67.5% students decreased their tobacco and alcohol use. Spirituality was maintained at 66%. Those who reported having emotional wellbeing (27.9%) during the pandemic fulfilled a higher number of pre-pandemic lifestyle pillars (median [IQR]) when compared with those who reported an absence of wellbeing (4 [3-4] pillars, compared with 3 [2-4], P = 0.006). DISCUSSION: The results reinforce the importance of adhering to as many lifestyle pillars as possible to preserve emotional wellbeing during periods of stress such as those experienced during the pandemic.

Telemonitoring type 1 diabetes patients during the COVID-19 pandemic in Brazil: was it useful?

ABSTRACT Objectives: To evaluate the performance of telemonitoring in detecting clinical and psychological needs and adherence to the protective measures imposed by the COVID-19 pandemic in addition to providing remote assistance for patients with type 1 diabetes (T1D) in a public university center in Brazil. Subjects and methods: Telemonitoring protocol included phone calls and e-mails. Patients were asked to rate COVID-19-like symptoms, psychological symptoms, epidemiological issues, and adherence to diabetes management (insulin, exercise, and diet) using a 0-to-10 scale. An e-mail address and phone number were offered for further contact if needed. Clinical, demographic, and laboratorial data from the consultations before the pandemic were collected from medical records. Results: Among 321 patients with a previously scheduled consultation over the first 15 weeks of social distancing, 237 (73.8%) could be successfully contacted. Of these, 207 (87.3%) were exclusively evaluated by telemonitoring (190 only by phone or text message and 17 who were also reached by email), and 30 (12.7%) patients attended the consultation for medical reasons detected during the telephone screening. Overall, 44 (18.5%) patients reported COVID-19-like symptoms. One (2.3%) patient was hospitalized and subsequently died. Psychological symptoms were reported by 137 (60.4%) patients and 30 (12.7%) required remote psychological assistance. Appropriate social distancing was performed by 203 (87.9%) patients, and 221 (97.8%) referred use of masks. Conclusions: Telemonitoring T1D patients during the pandemic helped reduce the need for in-person consultations, detect clinical and psychological needs, and offer support to patients in addition to monitoring suspected COVID-19 cases and the adherence to protective measures.

Telemonitoring type 1 diabetes patients during the COVID-19 pandemic in Brazil: was it useful?

OBJECTIVE: To evaluate the performance of telemonitoring in detecting clinical and psychological needs and adherence to the protective measures imposed by the COVID-19 pandemic in addition to providing remote assistance for patients with type 1 diabetes (T1D) in a public university center in Brazil. METHODS: Telemonitoring protocol included phone calls and e-mails. Patients were asked to rate COVID-19-like symptoms, psychological symptoms, epidemiological issues, and adherence to diabetes management (insulin, exercise, and diet) using a 0-to-10 scale. An e-mail address and phone number were offered for further contact if needed. Clinical, demographic, and laboratorial data from the consultations before the pandemic were collected from medical records. RESULTS: Among 321 patients with a previously scheduled consultation over the first 15 weeks of social distancing, 237 (73.8%) could be successfully contacted. Of these, 207 (87.3%) were exclusively evaluated by telemonitoring (190 only by phone or text message and 17 who were also reached by email), and 30 (12.7%) patients attended the consultation for medical reasons detected during the telephone screening. Overall, 44 (18.5%) patients reported COVID-19-like symptoms. One (2.3%) patient was hospitalized and subsequently died. Psychological symptoms were reported by 137 (60.4%) patients and 30 (12.7%) required remote psychological assistance. Appropriate social distancing was performed by 203 (87.9%) patients, and 221 (97.8%) referred use of masks. CONCLUSION: Telemonitoring T1D patients during the pandemic helped reduce the need for in-person consultations, detect clinical and psychological needs, and offer support to patients in addition to monitoring suspected COVID-19 cases and the adherence to protective measures.

Cytokine Levels in Neural Pain in Leprosy.

Pain is a frequent symptom in leprosy patients. It may be predominantly nociceptive, as in neuritis, or neuropathic, due to injury or nerve dysfunction. The differential diagnosis of these two forms of pain is a challenge in clinical practice, especially because it is quite common for a patient to suffer from both types of pain. A better understanding of cytokine profile may serve as a tool in assessing patients and also help to comprehend pathophysiology of leprosy pain. Patients with leprosy and neural pain (n = 22), neuropathic pain (n = 18), neuritis (nociceptive pain) (n = 4), or no pain (n = 17), further to those with diabetic neuropathy and neuropathic pain (n = 17) were recruited at Souza Araujo Out-Patient Unit (Fiocruz, Rio de Janeiro, RJ, Brazil). Serum levels of IL1ß, IL-6, IL-10, IL-17, TNF, CCL-2/MCP-1, IFN-γ, CXCL-10/IP-10, and TGF-ß were evaluated in the different Groups. Impairment in thermal or pain sensitivity was the most frequent clinical finding (95.5%) in leprosy neuropathy patients with and without pain, but less frequent in Diabetic Group (88.2%). Previous reactional episodes have occurred in patients in the leprosy and Pain Group (p = 0.027) more often. Analysis of cytokine levels have demonstrated that the concentrations of IL-1ß, TNF, TGF-ß, and IL-17 in serum samples of patients having leprosy neuropathy in combination with neuropathic or nociceptive pain were higher when compared to the samples of leprosy neuropathy patients without pain. In addition, these cytokine levels were significantly augmented in leprosy patients with neuropathic pain in relation to those with neuropathic pain due to diabetes. IL-1ß levels are an independent variable associated with both types of pain in patients with leprosy neuropathy. IL-6 concentration was increased in both groups with pain. Moreover, CCL-2/MCP-1 and CXCL-10/IP-10 levels were higher in patients with diabetic neuropathy over those with leprosy neuropathy. In brief, IL-1ß is an independent variable related to neuropathic and nociceptive pain in patients with leprosy, and could be an important biomarker for patient follow-up. IL-6 was higher in both groups with pain (leprosy and diabetic patients), and could be a therapeutic target in pain control.

Combination of basal insulin and GLP-1 receptor agonist: is this the end of basal insulin alone in the treatment of type 2 diabetes?

Glycemic control has been considered a major therapeutic goal within the scope of diabetes management, as supported by robust observational and experimental evidence. However, the coexistence of micro and macrovascular disease is associated with the highest cardiovascular risks which highlights the importance that pharmacological treatment of type 2 diabetes mellitus provides not only glycemic control, but also cardiovascular safety. Basal insulin is a highly effective treatment in reducing fasting blood glucose, but it is associated with considerable risk of hypoglycemia and weight gain. Glucagon like peptide 1 receptor agonists (GLP-1 RAs) are also effective in terms of glycemic control and associated with weight loss and low risk of hypoglycemia. The potential benefits of combining GLP-1RAs with basal insulin are contemplated in the current position statement of several different position statement and guidelines. This article reviews the efficacy and safety of different strategies to initiate and intensify basal insulin, with focus on new fixed ratio combinations of basal insulin with GLP-1 RAs available for use in a single injection pen (insulin degludec/liraglutide and insulin glargine/lixisenatide).

The impact of ethnicity, educational and economic status on the prescription of insulin therapeutic regimens and on glycemic control in patients with type 1 diabetes. A nationwide study in Brazil.

AIMS: Establish the relationship between demographic, educational and economic status on insulin therapeutic regimens (ITRs) and on glycemic control in patients with type 1 diabetes. METHODS: This was a cross-sectional, multicenter study with 1760 patients conducted between August 2011 and August 2014 in 10 Brazilian cities. RESULTS: Patients were stratified according to ITRs as follows: only NPH insulin (group 1, n=80(4.5%)); only long-acting insulin analogs (group 2, n=6(0.3%)); continuous subcutaneous insulin infusion (CSII) (group 3, n=62(3.5%)); NPH plus regular insulin (group 4, n=710(40.3%)); NPH plus ultra-rapid insulin analogs (group 5, n=259(14.8%)); long-acting insulin analogs plus regular insulin (group 6, n=25(4.4%)) and long-acting plus ultra-rapid insulin analogs (group 7, n=618 (35.1%)). As group A (provided free of charge by the government) we considered groups 1 and 4, and as group B (obtained through lawsuit or out-of-pocket) groups 2, 3 and 7. Multivariate logistic analysis showed that independent variables related to group B were older age, more years of school attendance, higher economic status and ethnicity (Caucasians). The independent variables related to better glycemic control were older age, higher adherence to diet, higher frequency of self-monitoring of blood glucose, more years of school attendance and belonging to group B. CONCLUSIONS: In Brazilian National Health Care System, prescriptions of insulin analogs or CSII are more frequent in Caucasian patients with type 1 diabetes, with higher economic status and more years ofschool attendance. Among these variables years of school attendance was the only one associated with better glycemic control.

Double-diabetes in a real-world sample of 2711 individuals: associated with insulin treatment or part of the heterogeneity of type 1 diabetes?

BACKGROUND: Double diabetes (DD) describes both individuals with obesity upon diagnosis of type 1 diabetes and those who have gained weight during follow-up, although cardiovascular risk factors (CVRF) are not well understood in this group. We aim to evaluate the frequency of DD in a real-world type 1 diabetes sample and the interaction of insulin treatment with CVRF. METHODS: Multicentre cross-sectional study of 2711 individuals with clinical diagnosis of type 1 diabetes from secondary diabetes centres in 20 Brazilian cities. RESULTS: Patients with diabetes duration <5 and ≥5 years had similar frequency of overweight (20.4 vs. 25 %) and obesity, (9.8 vs. 6.1 %), p 0.28 for trend. Insulin dose (U/kg/day) was lower in obese individuals compared to normal BMI, with mean (95 % CI) 0.72 (0.62-0.83) vs. 0.88 (0.84-0.92) U/kg/day for diabetes duration <5 years and 0.84 (0.77-0.92) vs. 0.99 (0.97-1.01) U/kg/day for duration ≥5 years. Obese individuals had lower HDL (47.5 vs. 54.4 mg/dL) and higher non-HDL-cholesterol (134.5 vs. 115.2 mg/dL) than lean ones only among those with more than 5 years of diabetes. CONCLUSIONS: Lower insulin doses in obese individuals point to a role of clinical heterogeneity in insulin deficiency rather than normal progression of type 1 diabetes. Early obesity in type 1 diabetes is associated to lower HDL-cholesterol and higher number of CVRF. These data suggest a broad landscape of pathophysiological phenomena in double diabetes, rather than simple progression of a homogeneous clinical entity.

Health-related quality of life in patients with type 1 diabetes mellitus in the different geographical regions of Brazil: data from the Brazilian Type 1 Diabetes Study Group.

BACKGROUND: In type 1 diabetes mellitus (T1DM) management, enhancing health-related quality of life (HRQoL) is as important as good metabolic control and prevention of secondary complications. This study aims to evaluate possible regional differences in HRQoL, demographic features and clinical characteristics of patients with T1DM in Brazil, a country of continental proportions, as well as investigate which variables could influence the HRQoL of these individuals and contribute to these regional disparities. METHODS: This was a retrospective, cross-sectional, multicenter study performed by the Brazilian Type 1 Diabetes Study Group (BrazDiab1SG), by analyzing EuroQol scores from 3005 participants with T1DM, in 28 public clinics, among all geographical regions of Brazil. Data on demography, economic status, chronic complications, glycemic control and lipid profile were also collected. RESULTS: We have found that the North-Northeast region presents a higher index in the assessment of the overall health status (EQ-VAS) compared to the Southeast (74.6 ± 30 and 70.4 ± 19, respectively; p < 0.05). In addition, North-Northeast presented a lower frequency of self-reported anxiety-depression compared to all regions of the country (North-Northeast: 1.53 ± 0.6; Southeast: 1.65 ± 0.7; South: 1.72 ± 0.7; Midwest: 1.67 ± 0.7; p < 0.05). These findings could not be entirely explained by the HbA1c levels or the other variables examined. CONCLUSIONS: Our study points to the existence of additional factors not yet evaluated that could be determinant in the HRQoL of people with T1DM and contribute to these regional disparities.

Determinants of intensive insulin therapeutic regimens in patients with type 1 diabetes: data from a nationwide multicenter survey in Brazil.

BACKGROUND: To evaluate the determinants of intensive insulin regimens (ITs) in patients with type 1 diabetes (T1D). METHODS: This multicenter study was conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. Data were obtained from 3,591 patients (56.0% female, 57.1% Caucasian). Insulin regimens were classified as follows: group 1, conventional therapy (CT) (intermediate human insulin, one to two injections daily); group 2 (three or more insulin injections of intermediate plus regular human insulin); group 3 (three or more insulin injections of intermediate human insulin plus short-acting insulin analogues); group 4, basal-bolus (one or two insulin injections of long-acting plus short-acting insulin analogues or regular insulin); and group 5, basal-bolus with continuous subcutaneous insulin infusion (CSII). Groups 2 to 5 were considered IT groups. RESULTS: We obtained complete data from 2,961 patients. Combined intermediate plus regular human insulin was the most used therapeutic regimen. CSII was used by 37 (1.2%) patients and IT by 2,669 (90.2%) patients. More patients on IT performed self-monitoring of blood glucose and were treated at the tertiary care level compared to CT patients (p < 0.001). The majority of patients from all groups had HbA1c levels above the target. Overweight or obesity was not associated with insulin regimen. Logistic regression analysis showed that economic status, age, ethnicity, and level of care were associated with IT (p < 0.001). CONCLUSIONS: Given the prevalence of intensive treatment for T1D in Brazil, more effective therapeutic strategies are needed for long term-health benefits.

Relationship between adherence to diet, glycemic control and cardiovascular risk factors in patients with type 1 diabetes: a nationwide survey in Brazil.

BACKGROUND: To determine the relationship between adherence to the diet reported by patients with type 1 diabetes under routine clinical care in Brazil, and demographic, socioeconomic status, glycemic control and cardiovascular risk factors. METHODS: This was a cross-sectional, multicenter study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. The data was obtained from 3,180 patients, aged 22 ± 11.8 years (56.3% females, 57.4% Caucasians and 43.6% non-Caucasians). The mean time since diabetes diagnosis was 11.7 ± 8.1 years. RESULTS: Overall, 1,722 (54.2%) of the patients reported to be adherent to the diet without difference in gender, duration of diabetes and socioeconomic status. Patients who reported adherence to the diet had lower BMI, HbA1c, triglycerides, LDL-cholesterol, non HDL-cholesterol and diastolic blood pressure and had more HbA1c at goal, performed more frequently self-monitoring of blood glucose (p < 0.001), and reported less difficulties to follow specific schedules of diet plans (p < 0.001). Less patients who reported to be adherent were obese or overweight (p = 0.005). The quantity of food and time schedule of the meals were the most frequent complaints. Logistic regression analysis showed that ethnicity, (Caucasians, (OR 1.26 [1.09-1.47]), number of medical clinical visits in the last year (OR 1.10 [1.06-1.15]), carbohydrate counting, (OR 2.22 [1.49-3.30]) and diets recommended by diabetes societies', (OR 1.57 [1.02-2.41]) were related to greater patients' adherence (p < 0.05) and age, [adolescents (OR 0.60 [0.50-0.72]), high BMI (OR 0.58 [0.94-0.98]) and smoking (OR 0.58 [0.41-0.84]) with poor patients' adherence (p < 0.01). CONCLUSIONS: Our results suggest that it is necessary to rethink medical nutrition therapy in order to help patients to overcome barriers that impair an optimized adherence to the diet.

Heterogeneity in the costs of type 1 diabetes in a developing country: what are the determining factors?

BACKGROUND AND AIMS: Regional differences in the clinical care of Type 1 diabetes (T1D) in Brazil have been recently described. This study aimed to estimate the costs of T1D from the public health care system's perspective across the regions of Brazil and to determine the components that influence these costs. METHODS: This was a retrospective, cross-sectional and nationwide multicenter study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. The study included 3,180 T1D subjects receiving healthcare from the National Brazilian Healthcare System (NBHCS) with a follow-up of at least one year. The direct medical costs were derived from the costs of medications, supplies, examinations, visits to the center, medical procedures and hospitalizations that occurred during the previous year. Clinical and demographic factors that determined the differences in the cost across four geographic regions (southeast, south, north/northeast and mid-west) were investigated. RESULTS: The per capita mean annual direct medical costs of T1D in US$ were 1,466.36, 1,252.83, 1,148.09 and 1,396.30 in southeast, south, north/northeast and mid-west regions, respectively. The costs of T1D in the southeast region were higher compared to south (p < 0.001) and north/northeast regions (p = < 0.001), but not to the mid-west (p = 0.146) region. The frequency of self-monitoring of blood glucose (SMBG) was different across the regions as well as the daily number of SMBG, use of insulin pumps or basal or prandial insulin analogs. Age, ethnicity, duration of diabetes, level of care, socioeconomic status and the prevalence of chronic diabetic complications differed among the regions. In a regression model the determinants of the costs were the presence of microvascular diabetes-related complications (p < 0.001), higher economic status (p < 0.001), and being from the southeast region (p < 0.001). CONCLUSIONS: The present data reinforce the regional differences in the costs of T1D and in the socioeconomic profile and health care provided to the patients with T1D in specialized public centers in Brazil. Both factors influenced directly the costs of T1D and should be considered for discussing future health policies.

The cost of type 1 diabetes: a nationwide multicentre study in Brazil.

OBJECTIVE: To determine the direct medical costs of type 1 diabetes mellitus (T1DM) to the National Brazilian Health-Care System (NBHCS) and quantify the contribution of each individual component to the total cost. METHODS: A retrospective, cross-sectional, nationwide multicentre study was conducted between 2008 and 2010 in 28 public clinics in 20 Brazilian cities. The study included 3180 patients with T1DM (mean age 22 years ± 11.8) who were surveyed while receiving health care from the NBHCS. The mean duration of their diabetes was 10.3 years (± 8.0). The costs of tests and medical procedures, insulin pumps, and supplies for administration, and supplies for self-monitoring of blood glucose (SMBG) were obtained from national and local health system sources for 2010-2011. Annual direct medical costs were derived by adding the costs of medications, supplies, tests, medical consultations, procedures and hospitalizations over the year preceding the interview. FINDINGS: The average annual direct medical cost per capita was 1319.15 United States dollars (US$). Treatment-related expenditure - US$ 1216.33 per patient per year - represented 92.20% of total direct medical costs. Insulin administration supplies and SMBG (US$ 696.78 per patient per year) accounted for 52.82% of these total costs. Together, medical procedures and haemodialysis accounted for 5.73% (US$ 75.64 per patient per year) of direct medical costs. Consultations accounted for 1.94% of direct medical costs (US$ 25.62 per patient per year). CONCLUSION: Health technologies accounted for most direct medical costs of T1DM. These data can serve to reassess the distribution of resources for managing T1DM in Brazil's public health-care system.

Prevalence, awareness, and treatment of hypertension in patients with type 1 diabetes: a nationwide multicenter study in Brazil.

Objective. This study evaluated the prevalence, awareness, and type of treatment for hypertension in Brazil in patients with type 1 diabetes (T1D). Methods. This was a cross-sectional, multicenter study that was conducted from December 2008 to December 2010 in 28 public clinics located in 20 Brazilian cities. Results. A total of 3,591 patients were studied, 56% female, average age 21.2 ± 11.7 years, with a median duration of diabetes 9.6 ± 8.1 years. Blood pressure levels were available for a total of 3,323 patients and 689 (19.2%) patients were hypertensive. Hypertensive patients were older, exhibited longer duration of diabetes, and had higher body mass index (BMI), total cholesterol, triglycerides, and LDL-C values (P < 0.001, for all comparisons), but only 370 (53.7%) received treatment. Patient awareness of hypertension was documented in 453 (65.5%) patients. However, only 76 (22.9%) of the treated patients attained the target systolic (sBP) and diastolic blood pressures (dBP). Conclusions. Our results demonstrate that a large number of T1D patients with hypertension do not receive appropriate treatment; few of the treated T1D patients achieved the target sBP and dBP values. Greater attention should be paid to blood pressure evaluation, hypertension diagnosis, and treatment of T1D patients in Brazil.

Impact of diabetes on cardiovascular disease: an update.

Cardiovascular diseases are the most prevalent cause of morbidity and mortality among patients with type 1 or type 2 diabetes. The proposed mechanisms that can link accelerated atherosclerosis and increased cardiovascular risk in this population are poorly understood. It has been suggested that an association between hyperglycemia and intracellular metabolic changes can result in oxidative stress, low-grade inflammation, and endothelial dysfunction. Recently, epigenetic factors by different types of reactions are known to be responsible for the interaction between genes and environment and for this reason can also account for the association between diabetes and cardiovascular disease. The impact of clinical factors that may coexist with diabetes such as obesity, dyslipidemia, and hypertension are also discussed. Furthermore, evidence that justify screening for subclinical atherosclerosis in asymptomatic patients is controversial and is also matter of this review. The purpose of this paper is to describe the association between poor glycemic control, oxidative stress, markers of insulin resistance, and of low-grade inflammation that have been suggested as putative factors linking diabetes and cardiovascular disease.

Economic status and clinical care in young type 1 diabetes patients: a nationwide multicenter study in Brazil.

The aim of this study is to evaluate the influence of economic status on clinical care provided to Brazilian youths with type 1 diabetes in daily practice, according to the American Diabetes Association's guidelines. This was a cross-sectional, multicenter study conducted between 2008 and 2010 in 28 public clinics in Brazil. Data were obtained from 1,692 patients (55.3 % female, 56.4 % Caucasian), with a mean age of 13 years (range, 1-18), a mean age at diagnosis of 7.1 ± 4 years and diabetes duration of 5 ± 3.7 years. Overall, 75 % of the patients were of a low or very low economic status. HbA1c goals were reached by 23.2 %, LDL cholesterol by 57.9 %, systolic blood pressure by 83.9 % and diastolic blood pressure by 73.9 % of the patients. In total, 20.2 % of the patients were overweight and 9.2 % were obese. Patients from very low economic status were less likely to attend tertiary care level when compared with those from low, medium and high economic status, 64.2 % versus 75.5 % versus 78.3 % and 74.0 %; p < 0.001, respectively. The rate of annual screening for retinopathy, nephropathy and for foot alterations was 66.2, 69.7 and 62.7 %, respectively. Insulin dose, age, very low economic status, daily frequency of self-blood glucose monitoring and female gender were independently associated with poor glycemic control. Screening for diabetic complications and attaining glucose, lipid and blood pressure goals present a challenge for young Brazilian type 1 diabetes patients. The low economic status of the majority of our patients may represent a barrier to reaching these goals.