Intermittently Scanned Continuous Glucose Monitoring Performance in Patients With Liver Cirrhosis.

AIM: To evaluate the use of intermittently scanned continuous glucose monitoring (isCGM) in patients with liver cirrhosis (LC). METHODS: Observational study including 30 outpatients with LC (Child-Pugh B/C): 10 without diabetes (DM) (G1), 10 with newly diagnosed DM by oral glucose tolerance test (G2), and 10 with a previous DM diagnosis (G3). isCGM (FreeStyle Libre Pro) was used for 56 days (four sensors/patient). Blood tests were performed at baseline and after 28 and 56 days. RESULTS: No differences were found in the baseline characteristics, except for higher age in G3. There were significant differences between G1, G2 and G3 in glucose management indicator (GMI) (5.28 ± 0.17, 6.03 ± 0.59, 6.86 ± 1.08%, P < .001), HbA1c (4.82 ± 0.39, 5.34 ± 1.26, 6.97 ± 1.47%, P < .001), average glucose (82.79 ± 7.06, 113.39 ± 24.32, 149.14 ± 45.31mg/dL, P < .001), time in range (TIR) (70.89 ± 9.76, 80.2 ± 13.55, 57.96 ± 17.96%, P = .006), and glucose variability (26.1 ± 5.0, 28.21 ± 5.39, 35.31 ± 6.85%, P = .004). There was discordance between GMI and HbA1c when all groups were considered together, with a mean difference of 0.35% (95% SD 0.17, 0.63). In G1, the mean difference was 0.46% (95% SD 0.19, 0.73) and in G2 0.69% (95% SD 0.45, 1.33). GMI and HbA1c were concordant in G3, with a mean difference of -0.10 % (95% SD [-0.59, 0.38]). CONCLUSION: Disagreements were found between the GMI and HbA1c levels in patients with LC. isCGM was able to detect abnormalities in glycemic control that would not be detected by monitoring with HbA1c, suggesting that isCGM can be useful in assessing glycemic control in patients with LC.

Flash glucose monitoring system in special situations

ABSTRACT The management of diabetes mellitus (DM) requires maintaining glycemic control, and patients must keep their blood glucose levels close to the normal range to reduce the risk of microvascular complications and cardiovascular events. While glycated hemoglobin (A1C) is currently the primary measure for glucose management and a key marker for long-term complications, it does not provide information on acute glycemic excursions and overall glycemic variability. These limitations may even be higher in some special situations, thereby compromising A1C accuracy, especially when wider glycemic variability is expected and/or when the glycemic goal is more stringent. To attain adequate glycemic control, continuous glucose monitoring (CGM) is more useful than self-monitoring of blood glucose (SMBG), as it is more convenient and provides a greater amount of data. Flash Glucose Monitoring (isCGM /FGM) is a widely accepted option of CGM for measuring interstitial glucose levels in individuals with DM. However, its application under special conditions, such as pregnancy, patients on hemodialysis, patients with cirrhosis, during hospitalization in the intensive care unit and during physical exercise has not yet been fully validated. This review addresses some of these specific situations in which hypoglycemia should be avoided, or in pregnancy, where strict glycemic control is essential, and the application of isCGM/FGM could alleviate the shortcomings associated with poor glucose control or high glycemic variability, thereby contributing to high-quality care.

Flash glucose monitoring system in special situations.

The management of diabetes mellitus (DM) requires maintaining glycemic control, and patients must keep their blood glucose levels close to the normal range to reduce the risk of microvascular complications and cardiovascular events. While glycated hemoglobin (A1C) is currently the primary measure for glucose management and a key marker for long-term complications, it does not provide information on acute glycemic excursions and overall glycemic variability. These limitations may even be higher in some special situations, thereby compromising A1C accuracy, especially when wider glycemic variability is expected and/or when the glycemic goal is more stringent. To attain adequate glycemic control, continuous glucose monitoring (CGM) is more useful than self-monitoring of blood glucose (SMBG), as it is more convenient and provides a greater amount of data. Flash Glucose Monitoring (isCGM /FGM) is a widely accepted option of CGM for measuring interstitial glucose levels in individuals with DM. However, its application under special conditions, such as pregnancy, patients on hemodialysis, patients with cirrhosis, during hospitalization in the intensive care unit and during physical exercise has not yet been fully validated. This review addresses some of these specific situations in which hypoglycemia should be avoided, or in pregnancy, where strict glycemic control is essential, and the application of isCGM/FGM could alleviate the shortcomings associated with poor glucose control or high glycemic variability, thereby contributing to high-quality care.

Contemporary (2019) prevalence of cardiovascular disease in adults with type 2 diabetes in Brazil: the cross-sectional CAPTURE study.

BACKGROUND: Type 2 diabetes (T2D) is a known risk factor for cardiovascular disease (CVD), and CVD is a major cause of mortality in patients with T2D. The CAPTURE study investigated the contemporary (2019) prevalence of established CVD in adults with T2D around the world. We report the findings from Brazil. METHODS: The multinational, non-interventional, cross-sectional CAPTURE study was conducted across 13 countries from five continents. The current manuscript explores data for the CAPTURE study sample in Brazil. Standardized demographic and clinical data were collected from adults with T2D aged ≥ 18 years attending a single routine healthcare visit in primary or specialized care between December 2018 and September 2019. Data were analyzed descriptively. RESULTS: Data from 912 adults with T2D were collected in the CAPTURE study in Brazil, with 822 patients from primary care and 90 patients from specialized care. Median (interquartile range [IQR]) patient characteristics were as follows: age 64 years (57; 71), diabetes duration 11 years (6; 19), glycated hemoglobin 7.7% (6.7; 9.1), and body mass index 29.5 kg/m2 (26.4; 33.5); 59% were female. The CVD prevalence and atherosclerotic CVD prevalence in the Brazil sample were 43.9% (95% confidence interval [CI] 40.9; 46.8) and 37.6% (95% CI 34.7; 40.5), respectively. The majority of patients with CVD had atherosclerotic CVD (85.8%). For the specific CVD subtypes, coronary heart disease prevalence was 27.9% (95% CI 25.2; 30.5), heart failure was 12.4% (95% CI 10.4; 14.4), cerebrovascular disease was 8.7% (95% CI 6.8; 10.5), and carotid artery disease was 3.4% (95% CI 2.3; 4.5). Glucagon-like peptide-1 receptor agonists and/or sodium-glucose co-transporter-2 inhibitors with proven cardiovascular benefit were prescribed to 15.5% of patients with CVD, compared with 18.4% of patients without CVD. CONCLUSIONS: CAPTURE was the first multinational, standardized study to provide contemporary data on CVD prevalence in adults with T2D in Brazil, and it demonstrated that almost one in two adults with T2D had established CVD. Except for carotid artery disease, the prevalence of all CVD subtypes in adults with T2D in Brazil appeared higher than the global CAPTURE prevalence. Trial registration NCT03786406, NCT03811288.

Time in range: a new parameter to evaluate blood glucose control in patients with diabetes.

The International Consensus in Time in Range (TIR) was recently released and defined the concept of the time spent in the target range between 70 and 180 mg/dL while reducing time in hypoglycemia, for patients using Continuous Glucose Monitoring (CGM). TIR was validated as an outcome measures for clinical Trials complementing other components of glycemic control like Blood glucose and HbA1c. The challenge is to implement this practice more widely in countries with a limited health public and private budget as it occurs in Brazil. Could CGM be used intermittently? Could self-monitoring blood glucose obtained at different times of the day, with the amount of data high enough be used? More studies should be done, especially cost-effective studies to help understand the possibility of having sensors and include TIR evaluation in clinical practice nationwide.

Real-world flash glucose monitoring in Brazil: can sensors make a difference in diabetes management in developing countries?

BACKGROUND: New technologies are changing diabetes treatment and contributing better outcomes in developed countries. To our knowledge, no previous studies have investigated the comparative effect of sensor-based monitoring on glycemic markers in developing countries like Brazil. The present study aims to evaluate the use of intermittent Continuous Glucose Measurements (iCGM) in a developing country, Brazil, regarding (i) frequency of glucose scans, (ii) its association with glycemic markers and (iii) comparison with these findings to those observed in global population data. METHODS: Glucose results were de-identified and uploaded to a dedicated database when Freestyle Libre™ readers were connected to an internet-ready computer. Data between September 2014 and Dec 2018, comprising 688,640 readers and 7,329,052 sensors worldwide, were analysed (including 17,691 readers and 147,166 sensors from Brazil). Scan rate per reader was determined and each reader was sorted into 20 equally-sized rank ordered groups, categorised by scan frequency. Glucose parameters were calculated for each group, including estimated A1c, time above, below and within range identified as 70-180 mg/dL. RESULTS: In Brazil, reader users performed an average of 14 scans per day, while around the world, reader users performed an average of 12 scans per day (p < 0.01). In Brazil dataset, those in the lowest and in the highest groups scanned on average 3.6 and 43.1 times per day had an estimated A1c of 7.56% (59 mmol/mol) and 6.71% (50 mmol/mol), respectively (p < 0.01). Worldwide, the lowest group and the highest groups scanned 3.4 times/day and 37.8 times/day and had an eA1c of 8.14% (65 mmol/mol) and 6.70% (50 mmol/mol), respectively (p < 0.01). For the scan groups in both populations, the time spent above 180 mg/dL decreased as the scan frequency increased. In both Brazil and around the world, as scan frequency increased, time in range (TIR) increased. In Brazil, TIR increased from 14.15 to 16.62 h/day (p < 0.01). Worldwide, TIR increased from 12.06 to 16.97 h/day (p < 0.01). CONCLUSIONS: We conclude that Brazilian users have a high frequency of scans, more frequent than global data. Similarly to the world findings, increased scan frequency is associated with better glycemic control.

A randomized controlled trial to compare the effects of sulphonylurea gliclazide MR (modified release) and the DPP-4 inhibitor vildagliptin on glycemic variability and control measured by continuous glucose monitoring (CGM) in Brazilian women with type 2 diabetes.

AIMS: This study aims to evaluate whether there is a difference between the effects of vildagliptin and gliclazide MR (modified release) on glycemic variability (GV) in women with type 2 diabetes (T2DM) as evaluated by continuous glucose monitoring (CGM). METHODS: An open-label, randomized study was conducted in T2DM women on steady-dose metformin monotherapy which were treated with 50 mg vildagliptin twice daily or 60-120 mg of gliclazide MR once daily. CGM and GV indices calculation were performed at baseline and after 24 weeks. RESULTS: In total, 42 patients (age: 61.9 ±â€¯5.9 years, baseline glycated hemoglobin (HbA1c): 7.3 ±â€¯0.56) were selected and 37 completed the 24-week protocol. Vildagliptin and gliclazide MR reduced GV, as measured by the mean amplitude of glycemic excursions (MAGE, p = 0.007 and 0.034, respectively). The difference between the groups did not reach statistical significance. Vildagliptin also significantly decreased the standard deviation of the mean glucose (SD) and the mean of the daily differences (MODD) (p = 0.007 and 0.030). CONCLUSIONS: Vildagliptin and gliclazide MR similarly reduced the MAGE in women with T2DM after 24 weeks of treatment. Further studies are required to attest differences between vildagliptin and gliclazide MR regarding glycemic variability.

The impact of type 2 diabetes on bone metabolism.

Diabetes complications and osteoporotic fractures are two of the most important causes of morbidity and mortality in older patients and share many features including genetic susceptibility, molecular mechanisms, and environmental factors. Type 2 diabetes mellitus (T2DM) compromises bone microarchitecture by inducing abnormal bone cell function and matrix structure, with increased osteoblast apoptosis, diminished osteoblast differentiation, and enhanced osteoclast-mediated bone resorption. The linkage between these two chronic diseases creates a possibility that certain antidiabetic therapies may affect bone quality. Both glycemic and bone homeostasis are under control of common regulatory factors. These factors include insulin, accumulation of advanced glycation end products, peroxisome proliferator-activated receptor gamma, gastrointestinal hormones (such as the glucose-dependent insulinotropic peptide and the glucagon-like peptides 1 and 2), and bone-derived hormone osteocalcin. This background allows individual pharmacological targets for antidiabetic therapies to affect the bone quality due to their indirect effects on bone cell differentiation and bone remodeling process. Moreover, it's important to consider the fragility fractures as another diabetes complication and discuss more deeply about the requirement for adequate screening and preventive measures. This review aims to briefly explore the impact of T2DM on bone metabolic and mechanical proprieties and fracture risk.

Vildagliptin has the same safety profile as a sulfonylurea on bone metabolism and bone mineral density in post-menopausal women with type 2 diabetes: a randomized controlled trial.

BACKGROUND: Several antidiabetic therapies affect bone metabolism. Sulfonylureas have the lowest impact on bone among oral antidiabetics. The objective of this study is to compare the effects of vildagliptin and gliclazide modified release (MR) on bone turnover markers (BTMs) and bone mineral density (BMD) in postmenopausal women with uncontrolled type 2 diabetes (T2D). METHODS: Forty-two postmenopausal women with uncontrolled T2D were randomly allocated into vildagliptin or gliclazide MR (control) groups. The primary endpoint was the change in the BTMs in months 6 and 12 compared with the baseline. The secondary endpoint was the variation in the BMD, which was assessed via dual-energy X-ray absorptiometry at the lumbar spine, femoral neck and total hip at baseline and month 12. RESULTS: After a 12-month treatment, the BTM serum carboxy-terminal telopeptide of type 1 collagen increased 0.001 ± 0.153 ng/mL in the vildagliptin group versus 0.008 ± 0.060 ng/mL in the gliclazide MR group (p = 0.858). The serum osteocalcin, serum amino-terminal propeptide of procollagen type I and urinary amino-terminal telopeptide of type 1 collagen remained stable in both groups, and there was no statistically significant difference between the effect of vildagliptin and gliclazide MR on these variables. The lumbar spine BMD did not change in the vildagliptin or gliclazide MR groups after a 12-month treatment (0.000 ± 0.025 g/cm2 versus -0.008 ± 0.036, respectively, p = 0.434). Furthermore, there was a similar lack of change in the femoral neck and total hip BMD values in both treatments. CONCLUSIONS: Bone turnover markers and BMD remained unchanged after a 12-month treatment in both groups, which suggests that vildagliptin has the same safety profile as gliclazide MR on bone metabolism. Trial Registration ClinicalTrials.gov number NCT01679899.

Diagnóstico precoce do câncer de pulmão: o grande desafio. Variáveis epidemiológicas e clínicas, estadiamento e tratamento / Early diagnosis of lung cancer: the great challenge. Epidemiological variables, clinical variables, staging and treatment

OBJETIVO: Avaliar casos confirmados de câncer de pulmão, revisando suas variáveis epidemiológicas, clínicas, estadiamento e tratamento. MÉTODOS: Foram estudados 263 casos provenientes do Hospital de Clínicas da Universidade Federal do Paraná e do Hospital Erasto Gaertner, instituições responsáveis por parcela significativa do atendimento a pacientes na cidade de Curitiba (PR). Realizou-se um estudo retrospectivo através de preenchimento de questionário e os dados obtidos foram analisados de forma descritiva, utilizando-se o software EPI-INFO. RESULTADOS: Houve predomínio de pacientes do sexo masculino (76 por cento), sendo que a maioria dos pacientes era fumante ou ex-fumante por ocasião do diagnóstico (90 por cento). Não havia referência a doença pulmonar prévia em 87 por cento dos casos. Tosse (142 casos) e dor torácica (92 casos) foram os sintomas iniciais mais freqüentes. O câncer de pulmão tipo não pequenas células foi encontrado em 87 por cento dos pacientes e o tipo histológico mais freqüente foi o carcinoma espinocelular, representando 49 por cento dos casos. O tabagismo foi considerado o fator predisponente mais importante. CONCLUSÃO: As características evolutivas do câncer de pulmão, como a inespecificidade dos sintomas iniciais e o tempo e evolução do tumor, somadas à ausência de programas de rastreamento efetivos, constituem os principais fatores que contribuem para a não detecção da neoplasia pulmonar de forma precoce, o que torna difícil o tratamento e dificulta o aumento da sobrevida.

OBJECTIVE: To evaluate confirmed cases of lung cancer, reviewing epidemiological variables, clinical variables, staging and treatment. METHODS: The cases of 263 patients were studied. All of the patients had been treated at the Universidade Federal do Paraná (Federal University of Paraná) Hospital de Clínicas or at the Hospital Erasto Gaertner, two institutions that, together, serve a significant portion of the patients seeking treatment in the city of Curitiba, located in the state of Paraná. This was a retrospective study, involving the administration of questionnaires. The descriptive analysis of the data obtained was performed using the Epi-Info program. RESULTS: There was a predominance of male patients (76 percent). At the time of diagnosis, the majority of patients (90 percent) were smokers or former smokers. In 87 percent of the cases, there was no history of lung disease. The most common initial symptoms were cough (142 cases) and chest pain (92 cases). Non-small cell lung cancer was found in 87 percent of the patients, and the most common histological type was spinocellular carcinoma, which was found in 49 percent of all of the patients. Smoking was found to be the most significant predisposing factor. CONCLUSION: The characteristics of lung cancer progression, such as the nonspecificity of the initial symptoms, the duration of tumor growth and the course of the tumor, together with the lack of tracking programs, are the principal factors that hinder the early detection of lung cancer, making it difficult to treat lung cancer patients and to increase their survival.

Early diagnosis of lung cancer: the great challenge. Epidemiological variables, clinical variables, staging and treatment.

OBJECTIVE: To evaluate confirmed cases of lung cancer, reviewing epidemiological variables, clinical variables, staging and treatment. METHODS: The cases of 263 patients were studied. All of the patients had been treated at the Universidade Federal do Paraná (Federal University of Paraná) Hospital de Clínicas or at the Hospital Erasto Gaertner, two institutions that, together, serve a significant portion of the patients seeking treatment in the city of Curitiba, located in the state of Paraná. This was a retrospective study, involving the administration of questionnaires. The descriptive analysis of the data obtained was performed using the Epi-Info program. RESULTS: There was a predominance of male patients (76%). At the time of diagnosis, the majority of patients (90%) were smokers or former smokers. In 87% of the cases, there was no history of lung disease. The most common initial symptoms were cough (142 cases) and chest pain (92 cases). Non-small cell lung cancer was found in 87% of the patients, and the most common histological type was spinocellular carcinoma, which was found in 49% of all of the patients. Smoking was found to be the most significant predisposing factor. CONCLUSION: The characteristics of lung cancer progression, such as the nonspecificity of the initial symptoms, the duration of tumor growth and the course of the tumor, together with the lack of tracking programs, are the principal factors that hinder the early detection of lung cancer, making it difficult to treat lung cancer patients and to increase their survival.