Diminuição de internação hospitalar por complicações agudas em pacientes diabeticos tipo 1 apos a implantação de um programa estruturado de atendimento e distribuição de fitas para automonitorização

Orientador: Marcos Antonio TambasciaDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: O objetivo deste estudo foi avaliar se a implementação de um serviço estruturado de atendimento a crianças e adolescentes com Diabetes Mellitus do tipo 1 (DM tipo 1), associada a um programa de distribuição de fitas reagentes para sangue e urina, diminui o número de internações agudas (hipoglicemia, hiperglicemia e cetoacidose diabética) dessa população. Foram estudados 358 pacientes atendidos no Ambulatório de Diabetes Pediatria, do Hospital das Clínicas da UNICAMP, no período de 1989 a 2000. Os resultados mostraram que após o início do grupo estruturado: 1 - houve diminuição da taxa anual de internações desses pacientes, de 0,57 para 0,31 e 0,37, no primeiro (1990) e no segundo anos (1991), respectivamente; 2 - houve uma diminuição da taxa anual de internações, para valores entre 0,09 a 0,07 internações por paciente, após o início da distribuição de tiras diagnósticas, nos últimos cinco anos do grupo; 3 - embora a introdução das tiras diagnósticas tenha causado uma redução da taxa anual de internações estatisticamente significativa, não houve relação entre tal redução e o número ou o tipo de tira (sangue ou urina) distribuídos. As conclusões deste estudo confirmam a hipótese de que o atendimento de crianças e adolescentes diabéticos num serviço estruturado de médicos e enfermeiras, aliado à distribuição de fitas reagentes para urina e sangue, é capaz de diminuir os índices de internação por complicações agudas do diabetes. Neste estudo constatamos que, embora a distribuição de fitas diagnósticas diminuísse nitidamente a taxa de internação por complicações agudas, nem o número de fitas distribuídas, tampouco o seu tipo (glicosúria/cetonúria ou glicemia) teve relação com essa diminuição. É nossa opinião que esse modelo pode ser reproduzido em outros hospitais, mesmo de menor complexidade, com grande melhora na qualidade do atendimento às crianças e adolescentes com DM tipo 1 e diminuição dos custos hospitalares para a rede públicaAbstract: In this retrospective study we tried to evaluate the introduction of a structured team and the distribution of reagent strips for blood and urine determinations in a group of children and adolescents with type 1 Diabetes. A total number of 358 patients were followed during the period of 1989-2000, from the outpatient clinic at the University of Campinas (Unicamp) Medical School Hospital - São Paulo - Brazil, and the purpose was to analyse the hospitalization rate for acute complications of diabetes: hypoglycemia, hyperglycemia and ketoacidosis. The results showed: 1 - A decrease in the hospitalization rate, after the beginning of the study, from 0.57 per patients/year to 0.31 in the first year and 0.37 in the second year, which dropped around 0.09 to 0.07 hospitalization per patient/year, after the distribution of reagent strips for blood glucose and urine glycosuria/ketonuria determinations. 2 - Despite the fact that after the beginning of the distribution of the strips there was a great decline in the hospitalization rate, no statistical difference was found between the dispensation of any of the types of strips nor their total number versus the hospitalization rate. We concluded that a structured group of doctors and nurses along with the distribution of reagents strips for blood glucose and urine glucose and ketones can help diminish the hospitalization rates for acute complication of diabetes in a type 1 population. Therefore it is our opinion that efforts should be made to implement this model, which is suitable even to medium size hospitals in the developing countriesMestradoClinica MedicaMestre em Clinica Medic

Short-acting insulin analogues versus regular human insulin on postprandial glucose and hypoglycemia in type 1 diabetes mellitus : a systematic review and meta-analysis

Introduction: Strict glucose control using multiple doses of insulin is the standard treatment for type 1 diabetes mellitus (T1DM), but increased risk of hypoglycemia is a frequent drawback. Regular insulin in multiple doses is important for achieving strict glycemic control for T1DM, but short-acting insulin analogues may be better in reducing hypoglycemia and postprandial glucose levels. Objective: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose in patients with T1DM. Methods: Searches were run on the electronic databases MEDLINE, Cochrane-CENTRAL, EMBASE, ClinicalTrials.gov, LILACS, and DARE for RCTs published until August 2017. To be included in the study, the RCTs had to cover a minimum period of 4 weeks and had to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose levels in patients with T1DM. Two independent reviewers extracted the data and assessed the quality of the selected studies. The primary outcomes analyzed were hypoglycemia (total episodes, nocturnal hypoglycemia, and severe hypoglycemia) and postprandial glucose (at all times, after breakfast, after lunch, and after dinner). Glycated hemoglobin (HbA1c) levels and quality of life were considered secondary outcomes. The risk of bias of each RCT was assessed using the Cochrane Collaboration Risk of Bias table, while the quality of evidence for each outcome was assessed using the GRADEpro software. The pooled mean difference in the number of hypoglycemic episodes and postprandial glucose between short-acting insulin analogues vs. regular human insulin was calculated using the random-effects model. Results: Of the 2897 articles retrieved, 22 (6235 patients) were included. Short-acting insulin analogues were associated with a decrease in total hypoglycemic episodes (risk rate 0.93, 95% CI 0.87–0.99; 6235 patients; I2 = 81%), nocturnal hypoglycemia (risk rate 0.55, 95% CI 0.40–0.76, 1995 patients, I2 = 84%), and severe hypoglycemia (risk rate 0.68, 95% CI 0.60–0.77; 5945 patients, I2 = 0%); and with lower postprandial glucose levels (mean difference/MD − 19.44 mg/dL; 95% CI − 21.49 to − 17.39; 5031 patients, I2 = 69%) and lower HbA1c (MD − 0,13%; IC 95% − 0.16 to − 0.10; 5204 patients; I2 = 73%) levels. Conclusions: Short-acting insulin analogues are superior to regular human insulin in T1DM patients for the following outcomes: total hypoglycemic episodes, nocturnal hypoglycemia, severe hypoglycemia, postprandial glucose, and HbA1c

Brazilian Consensus on second-generation antipsychotics and metabolic disorders

Objetivo: Discutir os aspectos atuais do tratamento com os antipsicóticos, levando-se em consideração o perfil de efeitos metabólicos, tais como ganho de peso, diabetes, dislipidemias e síndrome metabólica. Tais fatores aumentam o risco de doença cardiovascular, que é a principal causa de morte nos portadores de esquizofrenia. Método: Foi realizada uma reunião de consenso com psiquiatras especialistas em esquizofrenia e endocrinologistas, os quais, com base nas evidências provenientes de ampla revisão da literatura, elaboraram um documento com recomendações que auxiliam a prática clínica. Resultados e conclusões: A avaliação periódica dos efeitos adversos metabólicos em pacientes que fazem uso de antipsicóticos é fundamental para a prática clínica, especialmente nos caso de antipsicóticos de segunda geração. O equilíbrio entre eficácia e tolerabilidade deve ser cuidadosamente considerado em todas as etapas do tratamento.Objective: To discuss current aspects of use of antipsychotics considering their metabolic side effects profile, which includes weight gain, dyslipidemias, diabetes and metabolic syndrome. Such metabolic effects increase the risk of mortality by cardiovascular disease, which is the leading cause of death among schizophrenic patients. Method: A consensus meeting was held, with participation of endocrinologists and psychiatrists specialists in schizophrenia and, based on a literature review, an article was elaborated emphasizing practical and helpful recommendations to clinicians. Results and conclusions: Monitoring metabolic side effects is essential to patients taking antipsychotics, particularly in the case of second generation antipsychotics. Efficacy and tolerability should be carefully balanced in all phases of treatment

Short-acting insulin analogues versus regular human insulin on postprandial glucose and hypoglycemia in type 1 diabetes mellitus : a systematic review and meta-analysis

Introduction: Strict glucose control using multiple doses of insulin is the standard treatment for type 1 diabetes mellitus (T1DM), but increased risk of hypoglycemia is a frequent drawback. Regular insulin in multiple doses is important for achieving strict glycemic control for T1DM, but short-acting insulin analogues may be better in reducing hypoglycemia and postprandial glucose levels. Objective: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose in patients with T1DM. Methods: Searches were run on the electronic databases MEDLINE, Cochrane-CENTRAL, EMBASE, ClinicalTrials.gov, LILACS, and DARE for RCTs published until August 2017. To be included in the study, the RCTs had to cover a minimum period of 4 weeks and had to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose levels in patients with T1DM. Two independent reviewers extracted the data and assessed the quality of the selected studies. The primary outcomes analyzed were hypoglycemia (total episodes, nocturnal hypoglycemia, and severe hypoglycemia) and postprandial glucose (at all times, after breakfast, after lunch, and after dinner). Glycated hemoglobin (HbA1c) levels and quality of life were considered secondary outcomes. The risk of bias of each RCT was assessed using the Cochrane Collaboration Risk of Bias table, while the quality of evidence for each outcome was assessed using the GRADEpro software. The pooled mean difference in the number of hypoglycemic episodes and postprandial glucose between short-acting insulin analogues vs. regular human insulin was calculated using the random-effects model. Results: Of the 2897 articles retrieved, 22 (6235 patients) were included. Short-acting insulin analogues were associated with a decrease in total hypoglycemic episodes (risk rate 0.93, 95% CI 0.87–0.99; 6235 patients; I2 = 81%), nocturnal hypoglycemia (risk rate 0.55, 95% CI 0.40–0.76, 1995 patients, I2 = 84%), and severe hypoglycemia (risk rate 0.68, 95% CI 0.60–0.77; 5945 patients, I2 = 0%); and with lower postprandial glucose levels (mean difference/MD − 19.44 mg/dL; 95% CI − 21.49 to − 17.39; 5031 patients, I2 = 69%) and lower HbA1c (MD − 0,13%; IC 95% − 0.16 to − 0.10; 5204 patients; I2 = 73%) levels. Conclusions: Short-acting insulin analogues are superior to regular human insulin in T1DM patients for the following outcomes: total hypoglycemic episodes, nocturnal hypoglycemia, severe hypoglycemia, postprandial glucose, and HbA1c