Comparison between continuous subcutaneous insulin infusion and multiple daily injection regimens in adolescent with type 1 diabetes from a public health care system approach to severe hypoglycemia

OBJECTIVE: We compared the incidence of severe hypoglycemia episodes with therapy with multiple doses of insulin (MDI) and after changing to pump (CSII). PATIENTS AND METHODS: 7 T1DM patients with 14 years median and median duration of diabetes of 8 years. We analyzed insulin requirement (U/kg/day), BMI (Kg/m²), HbA1c (normal range: 3.5-6.7%) one year before and one year after changing therapy. The severe hypoglycemia episodes decreased from 1.3 to 0 episodes/patient/year; p = 0.00). The insulin requirement decreased from 1.33 ± 0.26 U/Kg/day to 0.87 ± 0.17 U/kg/day; p = 0.04 and HbA1c decreased from 8.7 ± 0.7% to 7.8 ± 0.9%; p = 0.05. CONCLUSION: CSII is efficient in decreasing severe hypoglycemia in a subgroup of T1DM using MDI also in Public Health Care System (PHCS) conditions. However, these finding should be reproduced by other Diabetes Care centers and cost studies are necessary to confirm the viability and possibility of this therapy, when necessary, to T1DM patients, which correspond to the majority of these individuals in our country, seeing in the PHCS.OBJETIVO: Avaliação comparativa da freqüência de hipoglicemia severa após mudança da terapia com múltiplas doses de insulina (MDI) para bomba de insulina subcutânea (BIISC). PACIENTES E MÉTODOS: Sete pacientes DM1, idade Mi = 14 anos e tempo médio de diabetes de 8 anos, comparados de acordo com a incidência de hipoglicemia, a dose total de insulina (U/Kg/d), IMC (Kg/m²) e HbA1c (vn: 3,5-6,7%) 1 ano antes e 1 ano após a transferência de terapêutica. Houve redução significativa dos episódios de hipoglicemia severa (1,3 episódio/paciente/ano para zero episódio/paciente/ano; p = 0,04), na dose total diária de insulina (1,33 ± 0,26 U/Kg/dia para 0,87 ± 0,17 U/kg/dia; p = 0,04) e na HbA1c (8,7 ± 0,7% para 7,8 ± 0,9%; p = 0,05 com BIISC). Concluímos que a BIISC é eficaz e segura na redução de hipoglicemia severa em um subgrupo de pacientes DM1 com MDI. Entretanto, os resultados obtidos precisam ser reproduzidos em centros semelhantes e estudos de custo são necessários para que a sua viabilidade seja confirmada e aplicada nos sistemas públicos de saúde, que correspondem à maioria no nosso país.UNIFESP-EPM Centro de DiabetesUNIFESP, EPM, Centro de DiabetesSciEL

Type 2 diabetes in children and adolescents: literature review

OBJECTIVE: the objective of this manuscript was to perform a critical review of epidemiology, pathophysiology, diagnosis e treatment of T2DM in youth. SOURCES OF DATA: this review is based on the relevant literature published. The sources available for the authors were integrated with sources identified through Medline database. The key words used for searching were Type 2 Diabetes in the Youth in the last ten years. SUMMARY OF THE FINDINGS: the pathophysiology (altered beta-cell function and insulin resistance) of T2DM in youth is similar to adult's pathophysiology. Familiar Type 2 diabetes history, presence of obesity, acanthosis nigricans, high fasting plasma C-peptide levels and absence of islet-cell auto-antibodies are important clues to diagnostic the T2DM in youth. Five to 25% of these patients can present ketosis at diagnosis. Insulin therapy can be discontinued during the evolution. Compliance to diet and an exercise program essential aspects of the treatment of adolescents. CONCLUSION: as obesity in the young is currently increasing in several developed or developing countries, T2DM in the youth can be consider an emergent problem also in our population.OBJETIVO: análise crítica dos estudos sobre a epidemiologia, fisiopatologia, diagnóstico e tratamento do DM2 no jovem. MÉTODOS: revisão da literatura nos últimos 10 anos, através de pesquisa no banco de dados Medline, utilizando os termos diabetes do tipo 2 no jovem. RESULTADOS: a fisiopatologia do DM2 no jovem é semelhante à do adulto, e compreende tanto a resistência à ação da insulina como uma alteração na função da célula beta-pancreática. O antecedente familiar para DM2, a presença de obesidade, a acanthosis nigricans, o peptídeo C de jejum superior a 0,6 ng/ml, a ausência de auto-anticorpos antiilhotas pancreáticas, em combinações variáveis, são pontos importantes para o diagnóstico desse tipo de DM. Cinco a 25% dos jovens com esse tipo de DM podem apresentar cetoacidose no diagnóstico. Nesses pacientes, o tratamento inicial com insulina é possível de ser descontinuado durante a evolução. A aderência à dieta e ao exercício físico são os elementos mais importantes do tratamento destes adolescentes. CONCLUSÃO: como a obesidade nos jovens tem aumentado, tanto em países industrializados como nos países em industrialização, o DM2 no jovem pode ser considerado um problema emergente também na nossa população.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Centro de DiabetesUNIFESP, EPM, Centro de DiabetesSciEL

Comparison of pre-dinner regular versus pre-lunch NPH as a third insulin application in adolescents with type 1 diabetes from a Public Health Service

The majority of the type 1 Diabetes (DM1) patients are seen in Public Health Services. The management of these children, by several reasons, did not meet most of the standards for good diabetes control. In the present study we compare 2 different insulin treatment strategies in 53 uncontrolled DM1 adolescents despite a twice-a-day insulin regimen. A regimen: NPH + R before breakfast, R insulin before dinner and bedtime NPH. B regimen: NPH + R before breakfast and lunch and bedtime NPH. This was a 12-month open-label, randomized, clinical trial conducted in a Public Hospital. BMI (A: 23.4±3.5Kg/m² x B: 23.5±0.8Kg/m²), average daily insulin dose (A: 1.04±0.28U/Kg/d x B: 1.08±0.22U/Kg/d) as well as the overall frequency of severe hypoglycemia (A: 9.4% x B: 7.5%) were similar in both groups during the study. However, HbA1c values at the end of the study were significantly lower in the B (9%) as compared to the A regimen (7,5%; p= 0.05). In conclusion, we have shown that breakfast and lunchtime NPH + R insulin plus bedtime NPH insulin is superior to pre-dinner R insulin plus breakfast and bedtime NPH insulin for overall glycemic control with similar weight status and comparable frequency of hypoglycemia. Thus, three times a day NPH insulin application is a feasible option for public service patients.A maioria dos pacientes com diabetes do tipo 1 (DM1) são acompanhados em serviços de Saúde Pública. O controle glicêmico nas crianças, por várias razões, não atinge as metas desejadas. Neste estudo, comparamos 2 estratégias de otimização da administração de insulina em 53 adolescentes DM1 com controle glicêmico inadequado no esquema convencional (insulina NPH 2 vezes ao dia). Regime A: NPH + Regular (R) antes do café, insulina R antes do jantar e NPH ao deitar. Regime B: NPH + R antes do café e almoço e NPH ao deitar. O estudo clínico de coorte, longitudinal, aberto, randomizado com 12 meses de duração foi realizado em um hospital público. O IMC (A: 23,4±3,5Kg/m² x B: 23,5±0,8Kg/m²), a dose diária média de insulina (A: 1,04±0,28U/Kg/d x B: 1,08±0,22U/ Kg/d), assim como a freqüência de hipoglicemia severa (A: 9,4% x B: 7,5%), foi semelhante nos 2 grupos durante o estudo. Entretanto, a HbA1c ao final do estudo foi significativamente menor no regime B (9%) comparado ao regime A (7,5%; p= 0,05). Em conclusão, mostramos que a introdução da insulina NPH + R no almoço associada ao tradicional esquema de insulina NPH + R como desjejum pela manhã e NPH ao deitar é superior ao esquema de insulina R pré-jantar associada à insulina NPH + R pela manhã e NPH ao deitar para o controle glicêmico, não havendo diferenças com relação à variação de peso e freqüência de hipoglicemia entre os 2 esquemas. Deste modo, a utilização de 3 doses de insulina NPH por dia pode ser considerada uma opção eficaz e factível de ser utilizada em pacientes com DM1 assistidos em um Serviço Público de Saúde.Universidade Federal de São Paulo (UNIFESP) Departamento de Medicina Centro de DiabetesUNIFESP, Depto. de Medicina Centro de DiabetesSciEL

Modal Logics of Reactive Frames

A reactive graph generalizes the concept of a graph by making it dynamic, in the sense that the arrows coming out from a point depend on how we got there. This idea was fi rst applied to Kripke semantics of modal logic in [2]. In this paper we strengthen that unimodal language by adding a second operator. One op- erator corresponds to the dynamics relation and the other one relates paths with the same endpoint. We explore the expressivity of this interpretation by axiomatizing some natural subclasses of reactive frames. The main objective of this paper is to present a methodology to study reactive logics using the existent classic techniques

The impact of knowledge about diabetes, resilience and depression on glycemic control: a cross-sectional study among adolescents and young adults with type 1 diabetes

Background: the purpose of this study is to evaluate the relationship between glycemic control and the factors of knowledge about diabetes, resilience, depression and anxiety among Brazilian adolescents and young adults with type 1 diabetes.Methods: This cross-sectional study included 85 adolescents and young adults with type 1 diabetes, aged between 11-22 years, with an average age of 17.7 +/- 3.72 years. Glycemic control degree was evaluated through HbA1c. To assess psychosocial factors, the following questionnaires were used: resilience (Resilience Scale, RS) and anxiety and depression (Hospital Anxiety and Depression Scale, HADS). the Diabetes Knowledge Assessment Scale (DKNA) was used to assess knowledge about diabetes.Results: Significant correlations were found between HbA1c and resilience, anxiety and depression. Multiple linear regression analysis revealed that the only variable which presented significant association with the value of HbA1c was depression.Conclusions: Depression has a significant association with higher HbA1c levels, as demonstrated in a regression analysis. the results suggest that depression, anxiety and resilience should be considered in the design of a multidisciplinary approach to type 1 diabetes, as these factors were significantly correlated with glycemic control. Glycemic control was not correlated with knowledge of diabetes, suggesting that theoretical or practical understanding of this disease is not by itself significantly associated with appropriate glycemic control (HbA1c <= 7.5%).Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Diabetes Center, Universidade Federal de São PauloUniversidade Federal de São Paulo, Dept Hlth Informat, BR-04023062 São Paulo, BrazilUniversidade Federal de São Paulo, Div Endocrinol, Dept Med, BR-04023062 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Hlth Informat, BR-04023062 São Paulo, BrazilUniversidade Federal de São Paulo, Div Endocrinol, Dept Med, BR-04023062 São Paulo, BrazilWeb of Scienc

Vitamin D e diabetes melito: uma atualização 2013

Vitamin D deficiency and diabetes mellitus are two common conditions and they are widely prevalent across all ages, races, geographical regions, and socioeconomic conditions. Epidemiologic studies have shown association of vitamin D deficiency and increased risk of chronic diseases, such as cancer, cardiovascular disease, type 2 diabetes, and autoimmune diseases, such as multiple sclerosis and type 1 diabetes mellitus. The identification of 1,25(OH)2D receptors and 1-α-hydroxilase expression in pancreatic beta cells, in cells of the immune system, and in various others tissues, besides the bone system support the role of vitamin D in the pathogenesis of type 2 diabetes. Observational studies have revealed an association between 25(OH) D deficiency and the prevalence of type 1 diabetes in children and adolescents. This review will focus on the concept of vitamin D deficiency, its prevalence, and its role in the pathogenesis and risk of diabetes mellitus and cardiovascular diseases.A deficiência de vitamina D e o diabetes melito são enfermidades comuns na população e são altamente prevalentes em todas as raças, idades, regiões geográficas e situação socioeconômica. Estudos epidemiológicos mostram uma associação entre hipovitaminose D com o aumento do risco de doenças crônicas, tais como câncer, doença cardiovascular, diabetes melito do tipo 2 e doenças autoimunes como a esclerose múltipla e o diabetes mellitus do tipo 1. A identificação de receptores da 1,25(OH)2 D e da expressão da 1 α-hidroxilase nas células betapancreáticas, em células do sistema imunológico e em uma variedade de células do organismo além do tecido ósseo, suporta o papel da vitamina D na patogênese do diabetes tipo 2 e do tipo 1. Esta revisão apresenta e discute o conceito de deficiência de vitamina D, sua prevalência e seu papel na patogênese e no risco de desenvolvimento do diabetes melito e doenças cardiovasculares.Universidade Federal de Pernambuco Endocrinology, Diabetes and Bone Diseases Division of Agamenon Magalhães HospitalUniversidade Federal de São Paulo (UNIFESP) Endocrinology Division and Diabetes CenterUFPE Public Health and Epidemiology DivisionUNIFESP, Endocrinology Division and Diabetes CenterSciEL

Psi-calculi: a framework for mobile processes with nominal data and logic

The framework of psi-calculi extends the pi-calculus with nominal datatypes for data structures and for logical assertions and conditions. These can be transmitted between processes and their names can be statically scoped as in the standard pi-calculus. Psi-calculi can capture the same phenomena as other proposed extensions of the pi-calculus such as the applied pi-calculus, the spi-calculus, the fusion calculus, the concurrent constraint pi-calculus, and calculi with polyadic communication channels or pattern matching. Psi-calculi can be even more general, for example by allowing structured channels, higher-order formalisms such as the lambda calculus for data structures, and predicate logic for assertions. We provide ample comparisons to related calculi and discuss a few significant applications. Our labelled operational semantics and definition of bisimulation is straightforward, without a structural congruence. We establish minimal requirements on the nominal data and logic in order to prove general algebraic properties of psi-calculi, all of which have been checked in the interactive theorem prover Isabelle. Expressiveness of psi-calculi significantly exceeds that of other formalisms, while the purity of the semantics is on par with the original pi-calculus.Comment: 44 page

Global view on reactivity: switch graphs and their logics

The notion of reactive graph generalises the one of graph by allowing the base accessibility relation to change when its edges are traversed. Can we represent these more general structures using points and arrows? We prove this can be done by introducing higher order arrows: the switches. The possibility of expressing the dependency of the future states of the accessibility relation on individual transitions by the use of higher-order relations, that is, coding meta-relational concepts by means of relations, strongly suggests the use of modal languages to reason directly about these structures. We introduce a hybrid modal logic for this purpose and prove its completeness