Unsatisfactory glycemic control in type 2 Diabetes mellitus patients: predictive factors and negative clinical outcomes with the use of antidiabetic drugs

ABSTRACT Many factors can interfere with glycemic control in patients with type 2 diabetes mellitus and this patient group has an increased risk of experiencing drug-related negative outcomes (DNO). The aim of this study was to identify the predictive factors of unsatisfactory glycemic control and DNO in this group of patients. A cross-sectional study was conducted collecting data from prescriptions and interviews with 100 patients of the Endocrinology Clinic of the Hospital Complex of Sorocaba, São Paulo, Brazil. Variables associated with unsatisfactory glycemic control were determined and the DNO associated with antidiabetic drugs identified. Age (<65 years) (OR=4.09), family history of diabetes (OR=3.24), use of combined therapy to treat diabetes (2-4 antidiabetic drugs) (OR=5.13) and presence of DNO (OR=5.92) were found to be predictive factors for poor patient glycemic control. DNO were observed in 49% of the patients and were caused predominantly by ineffectiveness in patients with poor glycemic control (p<0.05). There was no significant difference between groups (satisfactory and unsatisfactory glycemic control) for DNO caused by safety issues (p>0.05). Characterization of the profile of patients with uncontrolled diabetes and of aspects associated with drug treatment can contribute to the planning of interventions to improve patient care

Risk Factors for Foot Amputation in Patients Hospitalized for Diabetic Foot Infection.

The aim of this study was to identify and quantify risk factors for amputation in diabetic patients hospitalized for foot infections. This cross-sectional study comprised 100 patients with diabetic infectious complications in the lower limbs. The variables investigated were related to diabetes, infection, and treatment compliance. Multiple Cox regression analysis was performed to identify the variables independently associated with the outcome of amputation. The most prevalent chronic complications were neuropathy and hypertension. Most patients presented with a neuroischemic foot (86%). The Morisky test showed that 72% were not compliant with diabetes treatment. Regarding patient outcome, 61% progressed to amputation, 14% to debridement, and 9% to revascularization. The results showed a 42% higher risk for progression to amputation in patients with previous use of antimicrobials. Also, the amputation risk was 26% higher for those less compliant with diabetes treatment. An increase of one point in the Wagner ulcer classification criteria corresponded to a 65% increase in the risk of amputation. Undergoing conservative, nonsurgical procedures prior to admission provided a 63% reduction in the risk of amputation. Knowledge of these factors is critical to enable multidisciplinary teams to develop treatment plans for these patients so as to prevent the need for amputation.

Baseline characteristics and risk factors for ulcer, amputation and severe neuropathy in diabetic foot at risk: the BRAZUPA study.

BACKGROUND: Studies on diabetic foot and its complications involving a significant and representative sample of patients in South American countries are scarce. The main objective of this study was to acquire clinical and epidemiological data on a large cohort of diabetic patients from 19 centers from Brazil and focus on factors that could be associated with the risk of ulcer and amputation. METHODS: This study presents cross sectional, baseline results of the BRAZUPA Study. A total of 1455 patients were included. Parameters recorded included age, gender, ethnicity, diabetes and comorbidity-related records, previous ulcer or amputation, clinical symptomatic score, foot classification and microvascular complications. RESULTS: Patients with ulcer had longer disease duration (17.2 ± 9.9 vs. 13.2 ± 9.4 years; p < 0.001), and poorer glycemic control (HbA1c 9.23 ± 2.03 vs. 8.35 ± 1.99; p < 0.001). Independent risk factors for ulcer were male gender (OR 1.71; 95 % CI 1.2-3.7), smoking (OR 1.78; 95 % CI 1.09-2.89), neuroischemic foot (OR 20.34; 95 % CI 9.31-44.38), region of origin (higher risk for those from developed regions, OR 2.39; 95 % CI 1.47-3.87), presence of retinopathy (OR 1.68; 95 % CI 1.08-2.62) and absence of vibratory sensation (OR 7.95; 95 % CI 4.65-13.59). Risk factors for amputation were male gender (OR 2.12; 95 % CI 1.2-3.73), type 2 diabetes (OR 3.33; 95 % CI 1.01-11.1), foot at risk classification (higher risk for ischemic foot, OR 19.63; 95 % CI 3.43-112.5), hypertension (lower risk, OR 0.3; 95 % CI 0.14-0.63), region of origin (South/Southeast, OR 2.2; 95 % CI 1.1-4.42), previous history of ulcer (OR 9.66; 95 % CI 4.67-19.98) and altered vibratory sensation (OR 3.46; 95 % CI 1.64-7.33). There was no association between either outcome and ethnicity. CONCLUSIONS: Ulcer and amputation rates were high. Age at presentation was low and patients with ulcer presented a higher prevalence of neuropathy compared to ischemic foot at risk. Ischemic disease was more associated with amputations. Ethnical differences were not of great importance in a miscegenated population.

Síndrome de Sheehan. Relato de caso e revisão da literatura / Sheehan´s syndrome. Case report and literature review / Agalactia

Justificativa e objetivo: Síndrome de Sheehan (SS) é a necrose da glândula pituitária decorrente de uma complicação hemorrágica pós-parto. Nos países em que a assistência ao parto é precária é importante causa de hipopituitarismo. Logo após o parto a mulher pode cursar com falência da lactação e amenorreia. Ao longo dos anos é frequente ocorrer deficiência de hormônio de crescimento (GH), gonadotropinas (LH e FSH), corticotropina (ACTH) e hormônio estimulante da tireoide (TSH). Ainda é desconhecida para muitos médicos, sendo pouco diagnosticada no mundo. O objetivo deste relato de caso é informar sobre a doença, o que pode contribuir para o diagnóstico de casos semelhantes. Relato de caso: Apresentamos um caso clínico de SS com diagnóstico tardio. Adicionalmente acrescentamos uma breve revisão da literatura. Trata-se de uma paciente do sexo feminino, 60 anos, caucasiana, internada com queixa de oligúria, edema de membros inferiores e de face de longa data. Apresentava antecedentes pessoais de hemorragia após o último parto, agalactia e amenorreia aos 34 anos. Apresentava exames que demonstravam T4 livre baixo, T3 baixo e TSH baixo. Foi pensado em hipotireoidismo central, tendo como causa SS. Conclusão: A SS é uma doença rica em sintomatologia que ocasiona muitos prejuízos na saúde da mulher. Além disso, há grande diversidade de queixas causadas por múltiplas carências hormonais e perda da correlação entre o início dos sintomas e o parto em si. Isso dificulta o diagnóstico. O tratamento garante qualidade de vida, com redução da morbimortalidade...

Linfoma de tireoide: diagnóstico e tratamento / Thyroid lymphoma: diagnostic and treatment

Os linfomas de tireoide são uma forma rara de tumor que acomete, sobretudo, mulheres acima de 40 anos. Apresenta-se com quadro de aumento do volume cervical súbito, associado a sintomas compressivos e o diagnóstico envolve análise citológica e métodos complementares. O tratamento inclui quimioterapia e radioterapia com boa resposta clínica. A seguir, relataremos um caso de linfoma de tireoide e discutiremos o diagnóstico e tratamento.

Altos níveis de HDL colesterol: proteção ou risco cardiovascular: relato de caso / High levels of HDL cholesterol: protection or cardiovascular risk: case report

JUSTIFICATIVA E OBJETIVOS: Níveis de HDL colesterol (HDLc) comumente fazem parte da rotina de exames solicitados para investigação de risco cardiovascular. O conhecimento médico e popular atribui ao HDLc propriedades benéficas, isto é, associado à diminuição de eventos mórbidos, cardiovasculares e isquêmicos. Estudos mostram que nem sempre essa associação é verdadeira e atribui por vezes um aumento no risco cardiovascular associado ao HDLc. O objetivo deste estudo foi refletir sobre essas associações positivas e negativas envolvendo o HDLc. RELATO DO CASO: Paciente com 49 anos compareceu para consulta de prevenção de câncer de próstata e realização de exames de rotina para avaliação cardiovascular e renal. Os exames laboratoriais referentes ao seu perfil lipídico mostravam: HDLc: 132 = mg/dL; LDL colesterol = 33,6 mg/dL; 2ª dosagem = HDLc = 127 mg/dL; LDL colesterol = 52 mg/dL; colesterol total = 196 mg/dL. CONCLUSÃO: Estudos ainda não estabeleceram os benefícios e riscos envolvendo as HDL. É preciso cautela ao avaliar apenas os níveis de HDL e seu prognóstico, portanto faz-se necessário um seguimento mais detalhado do paciente, pois é de rotina para o clínico a abordagem inicial destes pacientes.(AU)

BACKGROUND AND OBJECTIVES: HDL cholesterol levels are commonly included in routine exams for evaluation of cardiovascular risk. The medical and common knowledge attributes beneficial properties for HDL cholesterol, that is, associated with low occurrence of morbid cardiovascular and ischemic events. Currently, studies show that not always this association is true and sometimes attributes an increase in cardiovascular risk associated with HDL cholesterol. The objective of this report was to make a reflection on this positive and negative association involving the HDL cholesterol. CASE REPORT: A forty-nine-year-old patient comes for prostate cancer prevention and realization of routine exams for cardiovascular and kidney evaluation. Laboratory exams concerning his lipid profile showed: HDL cholesterol = 132 mg/dL; LDL cholesterol = 33.6 mg/dL; 2nd dosage: HDL cholesterol = 127 mg/dL; LDL cholesterol = 52 mg/dL; total cholesterol = 196 mg/dL. CONCLUSION: Studies still haven’t established the benefits and risks involving HDL. Caution is necessary when evaluating only the HDL levels and its prognosis and a more detailed follow up is necessary because it’s routine for physicians, an initial approach of these patients.(AU)