Cardiovascular Risk Prediction by the American Diabetes Association Risk-Assessment Tool and Novel and Traditional Cardiovascular Risk Factors in Young Adults With Type 1 Diabetes.

INTRODUCTION: Cardiovascular disease is an important cause of morbidity and mortality in individuals with type 1 diabetes (T1D). The American Diabetes Association (ADA) has the ADA risk-assessment tool for cardiovascular risk (CVR) prediction in individuals with T1D. This study aims to evaluate the prevalence of novel and traditional cardiovascular risk factors (CVRF) and the CVR by the ADA risk-assessment tool: 10-year risk for diabetes complications in young adults with T1D. METHODS: Cross-sectional observational study of T1D individuals aged 18-40 years and T1D duration ≥1 year. The ADA risk-assessment tool was applied to predict CVR. RESULTS: 75 individuals, 61.3% male, with a median age of 30 (26.0-36.0) and 13.0 (6.0-20.0) years of T1D duration. Hypertension was found in 16% of individuals and dyslipidemia in 75.0%. 21.3% were active smokers, 30.7% sedentary, and 42.7% were at least overweight. Most individuals had a 10-year risk <1% for all complications except myocardial infarction (MI). In individuals who were outside the honeymoon period (T1D duration ≥ 5 years), most had a 10-year risk <1% for all complications except MI and amputation. Non-traditional CVRF homocysteine, apolipoprotein B, apolipoprotein B/apolipoprotein A1 ratio, magnesium, and vitamin D correlated with the ADA risk-assessment tool. 10-year risk for MI ≥1% was significantly more frequent in men. CONCLUSION: To our knowledge, this is the first study to apply the ADA risk-assessment tool: 10-year risk for diabetes complications in T1D. Young adults with T1D have a worrying prevalence of CVRF and show suboptimal control. Most individuals with T1D duration ≥1 year have an estimated 10-year risk <1% for all complications, except for MI.

Association Between Serum Magnesium and Glycemic Control, Lipid Profile and Diabetic Retinopathy in Type 1 Diabetes.

INTRODUCTION: Many studies have shown an association between decreased serum magnesium (Mg) levels and poor glycemic control and dyslipidemia in individuals with type 1 diabetes (T1D). Few studies evaluated the association between magnesium (Mg) levels and diabetic retinopathy (DR) in individuals with type 1 diabetes (T1D). METHODS: Retrospective study of adults with T1D, with an ophthalmological evaluation and a serum Mg level determination. According to Mg levels, the individuals were stratified into two groups: normal Mg levels (1.81-2.60 mg/dL) and low Mg levels (≤1.80 mg/dL). Exclusion criteria were individuals on diuretics or proton-pump inhibitors, malabsorption or diarrhea, oral magnesium supplementation in the recent past, pregnancy, or sepsis. RESULTS: 105 individuals, with median Mg levels of 1.96 (interquartile range 0.23) mg/dL. Hypomagnesemia (≤1.80 mg/dL) was detected in 20.0% individuals and 26.7% had DR. Individuals with hypomagnesemia had higher HbA1c (p = 0.014) and triglycerides (p = 0.024). Mg levels were negatively correlated with systolic blood pressure (r = -0.200, p = 0.041), HbA1c (r = -0.281, p = 0.004) and body mass index (BMI) (r = -0.197, p = 0.041). There was no significant difference between Mg levels or prevalence of hypomagnesemia in individuals with or without DR. Also, there was no significant difference between Mg levels and the severity of DR. CONCLUSION: Hypomagnesemia is a common problem in adults with T1D, and it was correlated with poor glycemic control, although we did not find a significant association between Mg levels and prevalence or severity of DR.

Incidence of diabetes in children and adolescents in Dhaka, Bangladesh.

OBJECTIVES: Bangladesh has limited information regarding incidence of type 1 diabetes (T1D) and type 2 diabetes (T2D) in young people. The objective of this study was to measure minimum incidence of T1D and T2D, and record other types of new-onset diabetes in children and adolescents <20 years (y), in Dhaka District, Bangladesh, from 2011-2018. METHODS: Retrospective study using clinical records from Diabetic Association of Bangladesh clinics. Cases were classified by clinical evaluation. RESULTS: 725 cases were diagnosed. 482 (66.5%) had T1D, 205 (28.3%) T2D, 14 (1.9%) fibrocalculous pancreatic diabetes, and 24 (3.3%) other types. Male:female ratios for T1D/T2D were 1:1.6 (p<0.0001) (T1D) and 1:1.4 (p<0.01) respectively. T1D cases by age-group were 7.3% (0-4 y), 19.9% (5-9 y), 43.6% (10-14 y) and 29.3% (15-19 y). Mean ± SD ages of onset were 12.3 ± 4.2 y (T1D) and 13.1 ± 2.4 y (T2D). Annual T1D mean incidences/100,000 were 1.22 [95%CI: 0.85-1.58] (<15 y) and 1.25 [0.94-1.57] (<20 y), and for T2D 0.52 [0.33-0.73] (<20 y). T1D incidence <15 y was 1.04 [0.69-1.39] in 2011 and 1.42 [1.04-1.80] in 2018 (p=0.08). T2D incidence rose from 0.22 [0.80-0.36] (2011) to 0.57 [0.36-0.77] (2018), an annualized increase of 12% [8-22%] (p=0.001). Ascertainment was estimated as 95%. CONCLUSIONS: T1D was most common, but T2D, FCPD and other forms also occur. T2D incidence increased during the study period.

Lipid Profile in Relation to Glycemic Control in Type 1 Diabetes Children and Adolescents in Bangladesh.

INTRODUCTION: Dyslipidemia and hyperglycemia are metabolic abnormalities commonly found in young patients with Type 1 diabetes mellitus (T1DM) and both increase the risk of cardiovascular disease. METHODS: This cross-sectional study was aimed to evaluate the pattern of dyslipidemia and its relationship with other risk factors in children and adolescents with T1DM. A total of 576 T1DM patients aged 10-18 years who attended Changing Diabetes in Children, a pediatric diabetes clinic in Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders over 1 year period from July 2015 to June 2016 were included in this study. RESULTS: The overall frequency of dyslipidemia was 65%. The high triglyceride, high cholesterol, high low-density lipoprotein (LDL) and low high-density lipoprotein were found in 50%, 66%, 75%, and 48%, respectively. Compared to patients without dyslipidemia, patients with dyslipidemia had significantly lower mean body mass index (kg/m2) (18.4 [interquartile range; 16.2-21.4] vs. 19.5 [17.3-21.5] (P = 0.005)); significantly higher median fasting blood sugar (12.7 [9.9-15.2] vs. 10.6 [7.9-12.6] (P < 0.0001)) and higher median glycosylated hemoglobin (9.8 [8.4-11.8] vs. 7.9 [9.3-10.5] (P < 0.0001)). Hypertension was significantly higher in dyslipidemic patients (9.4% vs. 2.5% P < 0.002). CONCLUSION: More than half (65%) of our children and adolescents with T1DM had dyslipidemia, among them high LDL was the most common. These findings emphasize the screening of lipid profile in T1DM children and adolescents.

Takotsubo Cardiomyopathy Associated with Levothyroxine Over-replacement.

Takotsubo cardiomyopathy (TC) is characterised by acute, transient left ventricular apical ballooning precipitated by emotional or physiologically stressful stimuli and has been previously associated with Grave's disease based on a few clinical reports. More recently, the association with exogenous thyrotoxicosis and radioiodine-induced thyroiditis has also been described. Iatrogenic hyperthyroidism on patients on levothyroxine replacement therapy for hypothyroidism has not been reported as a cause of TC. The authors describe two female patients with TC associated with levothyroxine over-replacement. A 74-year-old and a 48-year-old female patient, medicated with levothyroxine (respectively, 2.27 µg/kg and 1.85 µg/kg) for autoimmune thyroiditis were admitted to our emergency room with precordial pain. The first had an electrocardiogram with ST-segment elevation in the anterior precordial leads, and the latter had sinus tachycardia with deep T-wave inversion and QT interval prolongation. Further investigation revealed a mild elevation of cardiac biomarker levels and severe apical hypokinesis, but no significant coronary lesions on catheterisation. The suppressed thyroid stimulating hormone (TSH) levels were verified in the cardiac intensive care unit: 0.21 and 0.07 mIU/l (0.35-5.50) respectively. Both patients showed improvement of the apical hypokinesis on the discharge echocardiogram and normalisation of cardiac biomarker levels. Levothyroxine dose was reduced. This case report focuses on the cardiovascular risks of thyrotoxicosis, emphasises the importance of correct dose adjustment on patients under levothyroxine replacement therapy and stresses that TSH should be determined in patients presenting with acute coronary syndrome and typical findings of TC.

[Continuous subcutaneous insulin infusion]. / Terapêutica de Infusão Subcutânea Contínua de Insulina.

BACKGROUND: Continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) represent two strategies of intensive insulin therapy, obtaining a strict metabolic control. The importance of such rigorous metabolic control in reducing the frequency and severity of diabetes long-term complications was highlighted by the Diabetes Control and Complication Trial (DCCT). AIM: To review the experience in the use of ISCI at Hospital São João, comparing it with the therapeutic modality of MID, regarding metabolic control, weight and body mass index (BMI), microalbuminuria, frequency of adverse events, lipid profile and quality of life. METHODS: This retrospective, observational study included 25 type 1 diabetic patients followed-up on Endocrinology outpatient at Hospital São João, receiving CSII for more than 3 months after they were treated with MDI also for a period exceeding 3 months. For both periods of treatment, clinical data were obtained on the quality of glycaemic control (assessed by the levels of glycated hemoglobin--A1c), lipid profile, weight and body mass index (BMI) and microalbuminuria. To evaluate the impact on quality of life we used the ADDQoL questionnaire. A questionnaire was also used to determine the frequency of adverse events (severe hypoglycemia and ketoacidosis). RESULTS: The sample of 25 subjects with mean age of 33.35 ± 9.59 years, with a duration of disease, on average, of 17.1 ± 8.15 years and receiving ISCI for an average of 2.48 ± 1 08 years, obtained a decrease of 1.1% (p = 0.001) on the median value of A1c between 3 and 6 months of treatment when compared to MDI, reduction sustained throughout the analyzed period. The variation of the daily insulin requirements after pump placement was 12.75 units of insulin (p = 0.015), equivalent to a decrease of 0.20 units/kg (p = 0.023). The median of the distribution of BMI decreased 0.48 kg/m2 (p = 0.507) during CSII. The parameters of lipid profile and microalbuminuria showed no trend upward or downward after institution of CSII. The score obtained in the ADDQoL questionnaire was greater with CSII, the difference between the medians of the score distribution, before and after pump placement, was 0.056 (p = 0.92). There was a subjective perception of reduced frequency of adverse events with ISCI. CONCLUSION: The introduction of CSII allowed optimization of metabolic control, reduction of the daily insulin requirements and achievement of a higher level of satisfaction with no change in lipid profile, no weight gain and without increasing the frequency of adverse events.