Adverse pregnancy outcomes in women with diabetes

Pregnancy affects both the maternal and fetal metabolism and even in nondiabetic women exerts a diabetogenic effect. Among pregnant women, 2 to 17.8% develop gestational diabetes. Pregnancy can also occur in women with preexisting diabetes, that can predispose the fetus to many alterations in organogenesis, growth restriction and the mother to some diabetes-related complications like retinopathy and nephropathy or accelerate the course of these complications if they are already present. Women with gestational diabetes generally start their treatment with diet and lifestyle modification; when these changes fail in keeping an optimal glycemic control, then insulin therapy must be considered. Women with type 2 diabetes in use of oral hypoglycemic agents are advised to change to insulin therapy. Those with preexisting type 1 diabetes must start an intensive glycemic control, preferably before conception. All these procedures are performed aiming to keep glycemic levels normal or near-normal as possible to avoid the occurrence of adverse perinatal outcomes to the mother and to the fetus. the aim of this review is to reinforce the need to improve the knowledge on reproductive health of women with diabetes during gestation and to understand what are the reasons for them failing to attend for prepregnancy care programs, and to understand the underlying mechanisms of adverse fetal and maternal outcomes, which in turn may lead to strategies for its prevention.Baurus Diabet Assoc, Dept Internal Med, BR-17012433 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Gynecol & Obstet, São Paulo, BrazilState Univ Hosp Rio de Janeiro, Diabet Unit, Dept Internal Med, Rio de Janeiro, BrazilUniversidade Federal de São Paulo, Dept Gynecol & Obstet, São Paulo, BrazilWeb of Scienc

Repeatability of the evaluation of systemic microvascular endothelial function using laser doppler perfusion monitoring: clinical and statistical implications

OBJECTIVE: An awareness of the repeatability of biological measures is required to properly design and calculate sample sizes for longitudinal interventional studies. We investigated the day-to-day repeatability of measures of systemic microvascular reactivity using laser Doppler perfusion monitoring. METHODS: We performed laser Doppler perfusion monitoring in combination with skin iontophoresis using acetylcholine and sodium nitroprusside as well as post-occlusive reactive and thermal hyperemia twice within two weeks. The repeatability was assessed by calculating the within-subject standard deviations, limits of agreement, typical errors and intra-class correlation coefficients between days 1 and 2. The ratio of the within-subject standard deviation to the mean values obtained on days 1 and 2 (within-subject standard deviation/GM) was used to determine the condition with the best repeatability. RESULTS: Twenty-four healthy subjects, aged 24.6 + 3.8 years, were recruited. The area under the curve of the vasodilatory response to post-occlusive reactivity showed marked variability (within-subject standard deviation/GM = 0.83), while the area under the curve for acetylcholine exhibited less variability (within-subject standard deviation/ GM = 0.52) and was comparable to the responses to sodium nitroprusside and thermal treatment (within-subject standard deviations/GM of 0.67 and 0.56, respectively). The area under the blood flow/time curve for vasodilation during acetylcholine administration required the smallest sample sizes, the area under the blood flow/time curve during post-occlusive reactivity required the largest sample sizes, and the area under the blood flow/time curves of vasodilation induced by sodium nitroprusside and thermal treatment required intermediate sizes. CONCLUSIONS: In view of the importance of random error related to the day-to-day repeatability of laser Doppler perfusion monitoring, we propose an original and robust statistical methodology for use in designing prospective clinical studies

Algorithm for the treatment of type 2 diabetes: a position statement of Brazilian Diabetes Society

The Brazilian Diabetes Society is starting an innovative project of quantitative assessment of medical arguments of and implementing a new way of elaborating SBD Position Statements. The final aim of this particular project is to propose a new Brazilian algorithm for the treatment of type 2 diabetes, based on the opinions of endocrinologists surveyed from a poll conducted on the Brazilian Diabetes Society website regarding the latest algorithm proposed by American Diabetes Association /European Association for the Study of Diabetes, published in January 2009

Profile of Self-Care Capacity and Alcohol Use in Elderly Brazilians during the COVID-19 Outbreak: An Online Study

Background: Preventive and positive online coping strategies are essential for harm reduction associated with alcohol abuse among older adults in pandemic and social isolation scenarios. The objectives were to examine the relationship between alcohol use/abuse and physical capacity/self-care to perform the physical activities of daily living or impairment of the functional capacity of the elderly in the COVID-19 pandemic. Methods: An online cross-sectional survey was carried out. One hundred and one elderly people in the city of São Paulo, Brazil, participated in a community program. Results: Most participants (52.5%) showed excellent self-care skills. Approximately 12% of participants reported problems related to alcohol use/abuse. There was no association between self-care ability and abuse and probable alcohol dependence. Conclusions: Although most participants have excellent self-care and functional capacity and have not evidenced alcohol use/abuse, health professionals need to systematically provide information to prevent alcohol abuse, especially in scenarios of great emotional distress, such as in a pandemic. In addition, the online meetings held by the UAPI program were shown to be opportunities for social interaction and were essential to minimize the negative effects of the possible presence of alcohol use/abuse and the deteriorating performance of physical activities of daily living during a pandemic outbreak for the elderly

Estimating cardiovascular risk in patients with type 2 diabetes: a national multicenter study in Brazil

According to Brazilian National Data Survey diabetes is the fifth cause for hospitalization and is one of the ten major causes of mortality in this country.Aimsto stratify the estimated cardiovascular risk (eCVR) in a population of type 2 diabetics (T2DM) according to the Framingham prediction equations as well as to determine the association between eCVR with metabolic and clinical control of the disease.MethodsFrom 2000 to 2001 a cross-sectional multicenter study was conducted in 13 public out-patients diabetes/endocrinology clinics from 8 Brazilian cities. the 10-year risk of developing coronary heart disease (CHD) was estimated by the prediction equations described by Wilson et al (Circulation 1998). LDL equations were preferably used; when patients missed LDL data we used total cholesterol equations instead.ResultsData from 1382 patients (59.0% female) were analyzed. Median and inter-quartile range (IQ) of age and duration of diabetes were 57.4 (51-65) and 8.8 (3-13) years, respectively without differences according to the gender. Forty-two percent of these patients were overweight and 35.4% were obese (the prevalence of higher BMI and obesity in this T2DM group was significantly higher in women than in men; p 20%) in 738 (53.4%), intermediate in 202 (14.6%) and low in 442 (32%) patients. Men [25.1(15.4-37.3)] showed a higher eCVR than women [18.8 (12.4-27.9) p < 0.001]. the most common risk factor was high LDL-cholesterol (80.8%), most frequently found in women than in men (p = 0.01). the median of risk factors present was three (2-4) without gender differences. Overall we observed that 60 (4.3%) of our patients had none, 154(11.1%) one, 310 (22.4%) two, 385 (27.9%) three, 300 (21.7%) four, 149 (10.5%) five and six, (2%) six risk factors. A higher eCVR was noted in overweight or obese patients (p = 0.01 for both groups). No association was found between eCVR with age or a specific type of diabetes treatment. A correlation was found between eCVR and duration of diabetes (p < 0.001), BMI (p < 0.001), creatinine (p < 0.001) and triglycerides levels (p < 0.001) but it was not found with HbA1c, fasting blood glucose and postprandial glucose. A higher eCVR was observed in patients with retinopathy (p < 0.001) and a tendency in patients with microalbuminuria (p = 0.06). Conclusion: our study showed that in this group of Brazilian T2DM the eCVR was correlated with the lipid profile and it was higher in patients with microvascular chronic complications. No correlation was found with glycemic control parameters. These data could explain the failure of intensive glycemic control programs aiming to reduce cardiovascular events observed in some studies.Univ Estado Rio de Janeiro, Diabet Unit, Rio de Janeiro, BrazilUniv São Paulo Scholl Med, Hosp Clin, Lab Clin & Expt Gatroenterol LIM07, São Paulo, BrazilUniv Fed Maranhao, Div Endocrinol, Sao Luis, BrazilUniv Estadual Campinas, Div Endocrinol, Campinas, BrazilCtr Estudos Diabet & Endocrinol Estado Bahia CEDE, Salvador, BA, BrazilUniv Fed Parana, Div Endocrinol, BR-80060000 Curitiba, Parana, BrazilHosp Agamenon Magalhaes, Div Endocrinol, Recife, PE, BrazilPosto Assistencia Med Jaguribe, Joao Pessoa, Paraiba, BrazilSanta Casa Porto Alegre, Div Endocrinol, Porto Alegre, RS, BrazilInst Assistencia & Previdencia Servidor Estado Ba, Div Endocrinol, Salvador, BA, BrazilSanta Casa Belo Horizonte, Diabet Unit, Belo Horizonte, MG, BrazilHosp Geral Goiania, Div Endocrinol, Goiania, Go, BrazilSecretaria Municipal Saude Brasilia, Brasilia, DF, BrazilUniversidade Federal de São Paulo, Div Endocrinol, São Paulo, BrazilUniversidade Federal de São Paulo, Div Endocrinol, São Paulo, BrazilWeb of Scienc

Análogos de insulina no tratamento do diabetes gestacional

Pregnancy affects both maternal and fetal metabolism, and even in non-diabetic women, it exerts a diabetogenic effect. Among pregnant women, 2% to 14% develop gestational diabetes. Pregnancy can also occur in women with preexisting diabetes, which may predispose the fetus to many alterations in organogenesis, restrict growth, and the mother, to some diabetes-related complications, such as retinopathy and nephropathy, or to acceleration of the course of these complications, if they are already present. Women with gestational diabetes generally start their treatment with diet and lifestyle changes; when these changes are not enough for optimal glycemic control, insulin therapy must then be considered. Women with type 2 diabetes using oral hypoglycemic agents are advised to change to insulin therapy. Those with preexisting type 1 diabetes should start intensive glycemic control. As basal insulin analogues have frequently been used off-label in pregnant women, there is a need to evaluate their safety and efficacy. The aim of this review is to report the use of both short- and long-acting insulin analogues during pregnancy and to enable clinicians, obstetricians, and endocrinologists to choose the best insulin treatment for their patients

Prevalence and progression of chronic kidney disease among patients with type 2 diabetes:Insights from the DISCOVER study

We report the prevalence and change in severity of chronic kidney disease (CKD) in DISCOVER, a global, 3-year, prospective, observational study of patients with type 2 diabetes (T2D) initiating second-line glucose-lowering therapy. CKD stages were defined according to estimated glomerular filtration rate (eGFR). Overall, 7843 patients from 35 countries had a baseline serum creatinine measurement. Of these (56.7% male; mean age: 58.1 years; mean eGFR: 87.5 mL/min/1.73 m2), baseline prevalence estimates for stage 0-1, 2, 3 and 4-5 CKD were 51.4%, 37.7%, 9.4% and 1.4%, respectively. A total of 5819 patients (74.2%) also had at least one follow-up serum creatinine measurement (median time between measurements: 2.9 years, interquartile range: 1.9-3.0 years). Mean eGFR decreased slightly to 85.7 mL/min/1.73 m2 over follow-up. CKD progression (increase of ≥1 stage) occurred in 15.7% of patients, and regression (decrease of ≥1 stage) in 12.0%. In summary, a substantial proportion of patients with T2D developed CKD or had CKD progression after the initiation of second-line therapy. Renal function should be regularly monitored in these patients, to ensure early CKD diagnosis and treatment

Progression to microalbuminuria in patients with type 1 diabetes: a seven-year prospective study

<p>Abstract</p> <p>Background</p> <p>The presence of microalbuminuria can be associated with overt nephropathy and cardiovascular disease in patients with type 1 diabetes (T1D). We aimed to determine the incidence and evaluate the baseline predictors for the development of microalbuminuria in patients with T1D.</p> <p>Methods</p> <p>This study is a longitudinal cohort study of 122 normoalbuminuric patients with T1D who were receiving routine clinical care at baseline. A detailed medical history was taken, and a physical examination was performed at baseline. All of the patients were regularly examined for diabetes-associated complications. An analysis of predictors was performed using the Cox regression.</p> <p>Results</p> <p>Over 6.81 (3.59-9.75) years of follow-up, 50 (41%) of the patients developed microalbuminuria. The incidence density was 6.79/100 people per year (95% CI 5.04-8.95), and the microalbuminuria developed after 5.9 (2.44-7.76) and 11 (5-15) years of follow-up and diabetes duration, respectively. After an individual Cox regression, the baseline variables associated with the development of microalbuminuria were age, age at diagnosis, duration of diabetes, systolic and diastolic blood pressure, fasting glycemia, body mass index (BMI), total cholesterol and triglycerides levels, cholesterol/HDL ratio and a family history of type 2 diabetes.After a multivariate Cox regression, the only independent factors associated with the development of microalbuminuria were BMI [HR 1.12 (1.03-1.21)] and cholesterol/HDL ratio [HR 1.32 (1.05-1.67)].</p> <p>Conclusions</p> <p>A higher BMI and cholesterol/HDL ratio increased the risk of developing microalbuminuria in young patients with T1D after a short follow-up. Both risk factors are modifiable and should be identified early and followed closely.</p

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