Predicted annual costs for inpatients with diabetes and foot ulcers in a developing country-a simulation of the current situation in Brazil.

AIMS: The objective of this cost-of-illness analysis was to quantify the annual costs associated with hospital admission for people with diabetes and foot ulcers in Brazil. METHODS: A hypothetical cohort was simulated using a decision tree model. Prevalence and incidence rates and clinical outcomes were estimated from published studies and applied to the general Brazilian population over 30 years. Costs were quoted in Brazilian real (BRL) and converted to US dollars ($US) at the 2008 currency exchange rate ($US1 = BRL 1.64). In the sensitivity analysis, we reduced and increased rates to assess the robustness of the cost estimates. RESULTS: In this hypothetical cohort there are 6.48 million (95% confidence interval 4.47-7.12) Brazilians citizens with Type 2 diabetes. Each year, approximately 323,000 (89,500-484,500) of these people develop foot ulcers and almost 97,200 (17,900-169,600) require hospital admission as a result. Each year, almost 46,300 (8500-80,900) limb amputations and 12,400 (2300-21,700) deaths occur as a result of diabetic foot disease in Brazil. The annual cost associated with these hospital admissions is estimated to be almost $US264m ($US51m-461m). The estimated cost for patients with amputation is nearly $US128m ($US24.5m-222.3m). CONCLUSIONS: Our model shows that the social and economic impact of diabetic foot disease in Brazil is high. Government decision makers should reflect on the current situation and provide organized foot care throughout the whole country.

Metabolic effects of dietary sucrose and fructose in type II diabetic subjects.

OBJECTIVE: To investigate the metabolic effects of dietary fructose and sucrose in type II diabetic patients. RESEARCH DESIGN AND METHODS: Sixteen well-controlled type II diabetic subjects were fed three isocaloric diets for 28 days each. The three diets provided 50-55, 15, and 30-35% of total energy from carbohydrate, protein, and fat, respectively. In one diet, 20% of total calories were derived from fructose; in another, 19% of total calories were derived from sucrose; and in the control diet, only 5% of daily calories were derived from sugars, all other carbohydrates being supplied as polysaccharides. RESULTS: No significant differences were observed between either the fructose or the sucrose diet and the control polysaccharide diet in any of the measures of glycemic control, serum lipid levels, or insulin and C-peptide secretion. CONCLUSIONS: Our data suggest that in the short and middle terms, high fructose and sucrose diets do not adversely affect glycemia, lipemia, or insulin and C-peptide secretion in well-controlled type II diabetic subjects.

Cortisol and adrenocorticotropin response to desmopressin in women with Cushing's disease compared with depressive illness.

The pituitary-adrenal responsiveness to desmopressin of women with depressive illness was compared with that of patients with Cushing's disease, who are known to be highly responsive, and to that of normal controls, who are known to be poorly responsive to the peptide. Although 100% of the patients in the group with Cushing's disease met the response criterion with cortisol increases of 632 +/- 80 nmol/L above baseline (mean +/- SE), the prevalence of responders was 36% in the depressive group and 10% in normal controls, with cortisol changes from baseline of 154 +/- 28 and 79 +/- 15 nmol/L, respectively. All response parameters were significantly higher in the patients with Cushing's disease and did not differ between depressive patients and normal controls, who exhibited the same general pattern of cortisol and ACTH responses. It is concluded that the desmopressin test can be used in the differentiation between depression and Cushing's disease, and that the hypothalamic-pituitary-adrenal regulation is distinct in these two conditions.

The ROC curve in the evaluation of fasting capillary blood glucose as a screening test for diabetes and IGT.

OBJECTIVE: To assess the performance of different cutoff points of fasting capillary glycemia (FCG) in the diagnosis of diabetes and impaired glucose tolerance (IGT) using the receiver operating characteristics (ROC) curve approach. RESEARCH DESIGN AND METHODS: This study included a sample of 4,019 subjects without a previous history of diabetes who were recruited for a confirmatory 2-h post-glucose challenge capillary glycemia from a larger sample of 21,847 individuals screened with FCG. The sensitivity and the specificity of FCG as a screening test were analyzed in the cutoff range 3.9-8.9 mmol/l, and the corresponding ROC curves were plotted to assess the performance of the test. RESULTS: The screening test performance was better for diabetes than for IGT in the full range of cutoff points studied. Sensitivities ranged between 37.9 and 97.1% for diabetes and 1.8 and 94.4% for IGT; the areas under the ROC curves were 0.91 +/- 0.01 and 0.75 +/- 0.01, respectively. The cutoffs showing the best equilibrium between sensitivity and specificity approached 5.6 and 5.0 mmol/l for diabetes and IGT, respectively. Factors such as age, color, and family history of diabetes can affect the screening test performance. CONCLUSIONS: ROC curves can provide useful information toward improving the usefulness of FCG as a screening test for abnormalities of glucose tolerance.

The desmopressin stimulation test in the differential diagnosis of Cushing's syndrome.

OBJECTIVE: We assessed the ability of desmopressin to stimulate the pituitary-adrenal axis in patients with Cushing's syndrome. DESIGN AND SUBJECTS: The cortisol response to 5 ot 10 micrograms of intravenous desmopressin was evaluated in 31 patients with Cushing's syndrome of several aetiologies and in 15 normal subjects. RESULTS: Cortisol responses were observed in 15 out of 16 patients with pituitary dependence and in two patients with adrenal nodular hyperplasia, the increase above baseline ranging from 61 to 379% in the responders. Eight patients with adrenal tumours and one with the ectopic ACTH syndrome did not respond to desmopressin, having shown changes in their cortisol levels from -5 to 42% above baseline. Responses occurred in two out of the 15 normal individuals, whose cortisol increased 58 and 69% above baseline, respectively. Stimulation tests with standard agents as lysine vasopressin or ovine corticotrophin-releasing hormone were performed in the same patients and there was a high degree of concordance. No serious adverse reactions were observed in the tests with desmopressin. CONCLUSIONS: Desmopressin was able to stimulate the pituitary-adrenal axis in patients with Cushing's disease and, like corticotrophin releasing hormone, it may prove useful in the differential diagnosis of Cushing's syndrome.

Multicenter study of the prevalence of diabetes mellitus and impaired glucose tolerance in the urban Brazilian population aged 30-69 yr. The Brazilian Cooperative Group on the Study of Diabetes Prevalence.

OBJECTIVE: To assess the prevalence of diabetes and IGT in the urban adult Brazilian population. RESEARCH DESIGN AND METHODS: We used a two-stage, multicenter, cross-sectional survey in a random sample of 21,847 individuals aged 30-69 yr from nine large cities. Subjects were first screened by FCG. All positive screenees (FCG > or = 5.6 mM/L) and every sixth consecutive negative screenee were administered a 75 g OGTT and classified as diabetic, IGT, or normal (nondiabetic) according to WHO recommendations. OGTT findings from the negative screenees were extrapolated to all negative screenees after adjustments for potential biases. RESULTS: The overall rates were 7.6 and 7.8% for diabetes and IGT, respectively. Men (7.5%) and women (7.6%) had similar rates of diabetes. Similar rates resulted with whites (7.8%) and nonwhites (7.3%). Diabetes prevalence increased from 2.7% in the 30-39-yr age-group to 17.4% in the 60-69-yr age-group. Diabetes was more prevalent among less educated people, but this difference disappeared after adjusting for age. Family history of diabetes was associated with a twofold increase in diabetes prevalence (12.5 vs. 5.8%); the same increase occurred with obesity (11.6 vs. 5.2%). Undiagnosed diabetes accounted for 46% of the total prevalence. Among previously diagnosed cases, 22.3% were not under treatment, 7.9% were on insulin, 40.7% were on oral agents, and 29.1% were on dietary treatment only. Self-reported diabetes prevalence was 0.1, 3.2, and 11.6% in the age groups < 30, 30-69, and > 70 yr, respectively. CONCLUSIONS: The prevalence of diabetes in Brazil is comparable with that of more developed countries, where it is considered a major health problem.

Acute effect of the somatostatin analogue SMS-201995 on plasma glucose and triglycerides in insulin-dependent diabetic patients.

1. The effect of the long-acting somatostatin analogue SMS-201995 on diabetes control was assessed in 6 insulin-dependent diabetic patients (3 men and 3 women aged 19-38 years). 2. Plasma glucose and triglyceride profiles were obtained on 4 consecutive days, from 8:00 a.m. to 2:00 p.m. On the first 2 days the patients received their usual dose of insulin and ate at 8:00 a.m. and at noon. On the third and fourth days they received 1/3 of their usual insulin dose together with 100 micrograms SMS-201995 injected subcutaneously. 3. Postprandial glucose and triglyceride increases were blunted during the 360 min of observation on both days after SMS-201995 administration. The areas under the glucose-time plots fell from 23.72 +/- 12.29 (mean +/- SD) to 7.98 +/- 14.26 (P < 0.05) and the areas under the triglyceride-time plots from 10.51 +/- 9.01 to -3.15 +/- 4.30 g.min.dl-1 (P < 0.01). 4. No adverse reactions were observed after SMS-201995 administration for 2 days. 5. We conclude that administration of the somatostatin analogue SMS-201995 may be beneficial for insulin-dependent diabetic patients.

Acute effect of the somatostatin analogue sms-201995 on plasma glucose and triglycerides in insulin-dependent diabetic patients

The effect of the long-acting somatostatin analogue SMS-201995 on diabetes control was assessed in 6 insulin-dependent diabetic patients (3 men and 3 women agged 19-38 years). Plasma glucose and triglyceride profiles were obtained ion 4 consecutive days, from 8:00 a.m. to 2:00 p. m. On the first 2 days the patients received their usual dose of insulin and ate at 8:00 a. m. and noon. On the third and fourth days they received 1/3 of their usual insulin dose together with 100 ug SMS-201995 injected subcutaneously. Postprandial glucose and triglyceride increases were blunted during the 360 min of observation on both day after SMS-201995 administration. The areas under the glucose-time plots fell from 23.72 ñ 12.29 (mean ñ SD) to 7.98 ñ 14.26 (P<0.05) and the areas under the triglyceride-time plots from 10.51 ñ 9.01 to -3.15 ñ 4.30 g. min.dl-1 (P<0.01). No adverse rfeactions were observed after SMS-201995 administration for 2 days. We conclude that administration of the somatostatin analogue SMS-201995 may be beneficial for insulin-dependent diabetic patients

Suppression and stimulation of mineralocorticoid hormones (MCH) in the simple virilizing form of congenital adrenal hyperplasia (CAH) evaluated by the quantitation in adrenal venous blood.

Four untreated female patients with the nonsalt-losing form of congenital virilizing adrenal hyperplasia (21-hydroxylase deficiency) (21-OHD) maintained on a daily sodium intake of 120 m-equiv were studied by bilateral adrenal vein catheterization. Simultaneous right and left adrenal and peripheral blood samples were collected for determination of cortisol (F), progesterone (P), 17-hydroxyprogesterone (17-OHP), aldosterone (Aldo), and deoxycorticosterone (DOC). All patients were studied during sequential ACTH suppression (30 min after intravenous administration of 4 mg of dexamethasone) and stimulation (5 min after intravenous administration of 250 micrograms beta-ACTH [cosyntropin]). Basal peripheral concentrations of Aldo, DOC, P and 17-OHP were increased, whereas F concentrations were in the lower limit of the normal range. Dexamethasone suppressed adrenal secretion in all subjects. Subsequent adrenal stimulation by ACTH increased P, 17-OHP and DOC, whereas F returned to only control levels. DOC responses to ACTH in the adrenal vein effluents correlated significantly with Aldo responses but not with the 17-OHP increments, suggesting that the adrenal responses of Aldo and DOC to ACTH are events that probably occur in the same zone.

The zonal origins of the mineralocorticoid hormones in the 21-hydroxylation deficiency of congenital adrenal hyperplasia.

The 0800 h plasma concentrations of the mineralocorticoid hormones, 18-hydroxydeoxycorticosterone (18-OHDOC), deoxycorticosterone (DOC), corticosterone, 18-hydroxycorticosterone (18-OHB), and aldosterone, in six patients with nonsalt-losing congenital adrenal hyperplasia revealed two groupings of these steroids: in one group, DOC, 18-OHB, and aldosterone were significantly elevated (P less than 0.001) at 51.7 +/- 18.0, 70.8 +/- 14.2, and 22.7 +/- 3.0 ng/dl, respectively; in the other group, corticosterone and 18-OHDOC were normal at 363.6 +/- 76.0 and 7.8 +/- 1.1 ng/dl, respectively. No significant increases in response to upright posture were observed in DOC, 18-OHB, or aldosterone. After a 1-h Cortrosyn stimulation test, the already elevated levels of DOC, 18-OHB, and aldosterone showed slight additional increases, but the normal levels of corticosterone and 18-OHDOC changed little within the normal unstimulated range. In these patients certain mineralocorticoid hormone patterns permit the identification of the zonal origins of steroids. The normal and fixed levels of 18-OHDOC and corticosterone, zona fasciculata steroids, are similar to those of cortisol and imply deficiency of formation and of their precursor, zona fasciculata DOC, a 21-hydroxylated steroid. Both the mineralocorticoid and glucocorticoid pathways distal to 21-hydroxylation are impaired in the zona fasciculata. However, the elevated and partially responsive levels of DOC, 18-OHB, and aldosterone imply that there is greater activation of 21-hydroxylation in the zona glomerulosa than in the zona fasciculata, with its normal fixed steroid levels, and that the elevated level of DOC is primarily from this zone.