Biochemical and clinical markers of endothelial dysfunction do not outweigh traditional risk factors for the presence of diabetic retinopathy in patients with type 1 diabetes.

BACKGROUND: This study aimed to evaluate whether soluble vascular cytoadhesive molecule-1 (sVCAM-1), intracellular cytoadhesive molecule-1 (sICAM-1), and endothelial function as assessed by EndoPat outweighed traditional risk factors for the presence of diabetic retinopathy (DR) in patients with type 1 diabetes (T1D). METHODS: Patients aged ≥ 12 years completed a clinical-epidemiological questionnaire. Fasting venous blood samples were obtained (lipid profile, glycemic control, and C-reactive protein levels). Vascular reactivity was assessed via peripheral arterial tonometry performed by supplying the reactive hyperemia index (RHI) through the EndoPAT device. sVCAM-1 and sICAM-1 levels were measured using multiplex assays. RESULTS: Data were obtained from 187 patients (51.3% female), aged 32 ± 13 years with a disease duration of 14 (6-15) years and mean hemoglobin A1c (HbA1c) of 9.1% ± 2.1%. After adjustments were made, age, HbA1c, arterial blood pressure, and use of drugs that could interfere with endothelial function were found to be associated with DR. No association was noted with sVCAM-1 and sICAM-1 levels and RHI. CONCLUSIONS: In our sample, sVCAM-1, sICAM and EndoPAT did not outweigh the traditional DR risk factors, such as age, high HbA1c, arterial blood pressure, and use of drugs that could interfere with endothelial function and are significantly associated with DR. Further prospective studies should evaluate if markers of endothelial dysfunction could predict diabetes-related micro and macrovascular complications in T1D.

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.

Early aggressive macrovascular disease and type 1 diabetes mellitus without chronic complications: a case report.

BACKGROUND: Type 1 diabetes (T1DM) is considered to be one of the most significant risk factors for the development of coronary artery disease (CAD). However, the specific risk predictor models for T1DM are subject to many limitations. CASE PRESENTATION: We report the case of a 42-year-old Caucasian woman presenting with T1DM for 26 years. During her chronic hyperglycemic evolution (mean of HbA1c > 3 percentage points above the superior limit) without microvascular complications, this patient presented with early and aggressive coronary artery disease, despite the lack of classical risk factors for CAD CONCLUSIONS: The rapidly progressive macrovascular disease observed in this case demonstrates the different degrees of aggressiveness and unpredictable clinical evolution observed in some cases. It also confirms the need for a multi-factorial, early and optimized clinical management regime.

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.