Impact of environmental changes on Dermatology.

Urbanization, pollution and the modification of natural landscapes are characteristics of modern society, where the change in human relations with the environment and the impact on biodiversity are environmental determinants that affect the health-disease relationship. The skin is an organ that has a strong interface with the environment and, therefore, the prevalence patterns of dermatoses may reflect these environmental changes. In this article, aspects related to deforestation, fires, urbanization, large-scale agriculture, extensive livestock farming, pollution and climatic changes are discussed regarding their influence on the epidemiology of skin diseases. It is important that dermatologists be aware of their social responsibility in order to promote sustainable practices in their community, in addition to identifying the impacts of environmental imbalances on different dermatoses, which is essential for the prevention and treatment of these diseases.

Association between a soy-based infant diet and the onset of puberty: A systematic review and meta-analysis.

The objective of this systematic review was to evaluate the association between a soy-based infant diet and the onset of puberty. We included studies in which children were fed a soy-based diet, and we compared them with those who were not. The primary outcomes were the onset of puberty in girls (thelarche, pubarche, and menarche age), boys (pubarche, voice change, testicular and penis enlargement age), and both (risk of delayed and precocious puberty [PP]). Search strategies were performed in PubMed, Embase, LILACS, and CENTRAL databases. Two reviewers selected eligible studies, assessed the risk of bias, and extracted data from the included studies. The odds ratio (OR) and mean difference (MD) were calculated with a 95% confidence interval (CI) as a measure of the association between soy consumption and outcomes. We used a random-effects model to pool results across studies and the Grading of Recommendations Assessment, Development, and Evaluation to evaluate the certainty of evidence. We included eight studies in which 598 children consumed a soy-based diet but 2957 did not. The primary outcomes that could be plotted in the meta-analysis were the risk of PP and age at menarche. There was no statistical difference between groups for PP (OR: 0.51, 95% CI: 0.09 to 2.94, 3 studies, 206 participants, low certainty of evidence). No between-group difference was observed in menarche age (MD 0.14 years, 95% CI -0.16 to 0.45, 3 studies, 605 children, low certainty of evidence). One study presented this outcome in terms of median and interquartile range, and although the onset of menarche was marginally increased in girls who received a soy-based diet, the reported age was within the normal age range for menarche. We did not find any association between a soy-based infant diet and the onset of puberty in boys or girls. Trial Registration: PROSPERO registration: CRD42018088902.

Relationship Between Lipodystrophy, Body Composition, Metabolic Profile, and Serum Levels of Adipocytokines.

Background: Despite the benefits in improving the clinical state of people living with HIV/aids (PLWHA), some side effects associated with the use of antiretroviral therapy (ART) are reported. Redistribution of body fat has been associated with treatment and is characterized by morphological changes, also known as lipodystrophy. The complications of metabolic and morphological changes in these individuals seem to increase the risk of cardiovascular disease. Adipocytokines are proteins that have essential functions in biological processes, in which the levels of these proteins are related to the pathogenesis of metabolic syndrome (MS) and cardiovascular disease. Recent studies have shown that such levels are generally modified in PLWHA, regardless of whether the treatment is established or not. An application of methods for body fat estimation in patients with fat redistribution, as in the case of aids, especially those that quantify body fat by segments, appears to clarify these alterations and plays an important role in the development of multiprofessional treatment. Objectives: This investigation was carried out to compare and correlate body composition, biochemical metabolic parameters, and levels of adipocytokines and cytokines of PLWHA, with and without lipodystrophy, with individuals with negative HIV serology and stratified by sex. Material and Methods: This is a cross-sectional study in which body composition, metabolic and anthropometric changes, and levels of adipocytokines of 110 individuals were assessed. These individuals were paired in sex, age, and body mass index (BMI) and subdivided into three groups: PLWHA with and without a clinical diagnosis of lipodystrophy associated with HIV, and a group control. Results: Collinearity was identified both in the general sample and for genders of the waist-to-height ratio (WHtR) with all anthropometric parameters, except for muscle mass. The results show strong association between IFN-γ and TNF-α both in the general sample and for genders and moderate correlation between leptin and fasting glucose for women; worsening of the triglyceride profile in both women with lipodystrophy compared with the control group and men without lipodystrophy compared with the control group; higher serum TNF-α values among men without lipodystrophy compared to those with HIV-associated lipodystrophy (HALS). Conclusions: The results of this study underline that, considering the manifestations of the syndrome, these patients have a high-risk endocrine metabolic profile for cardiovascular events.

Acute bullous hemorrhagic prurigo: a diagnostic challenge.

Insect bites and bite wounds are quite common and most often have mild repercussions in humans. Statistics on the incidence of accidents caused by insects are not available, and the skin reactions after the bites are not always known. The authors present two cases of patients with hemorrhagic blisters on their hands after tabanidae bites and discuss the factors that cause the problem and the importance of the differential diagnosis of blisters with hemorrhagic content on human skin.

Effectiveness of non-pharmacological strategies in the management of type 2 diabetes in primary care: a protocol for a systematic review and network meta-analysis.

INTRODUCTION: Despite the increasing number of drugs and various guidelines on the management of type 2 diabetes mellitus (T2DM), several patients continue with the disease uncontrolled. There are several non-pharmacological treatments available for managing T2DM, but various of them have never been compared directly to determine the best strategies. OBJECTIVE: This study will evaluate the comparative effects of non-pharmacological strategies in the management of T2DM in primary care or community settings. METHODS AND ANALYSIS: We will perform a systematic review and network meta-analysis (NMA), and will include randomised controlled trials if one of the following interventions were applied in adult patients with T2DM: nutritional therapy, physical activity, psychological interventions, social interventions, multidisciplinary lifestyle interventions, diabetes self-management education and support (DSMES), technology-enabled DSMES, interventions delivered only either by pharmacists or by nurses, self-blood glucose monitoring in non-insulin-treated T2DM, health coaching, benchmarking and usual care. The primary outcome will be glycaemic control (glycated haemoglobin (HbA1c) (%)), and the secondary outcomes will be weight loss, quality of life, patient satisfaction, frequency of cardiovascular events and deaths, number of patients in each group with HbA1c <7, adverse events and medication adherence. We have developed search strategies for Embase, Medline, Latin American and Caribbean Health Sciences Literature, Cochrane Central Register of Controlled Trials, Trip database, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature Australasian Medical Index and Chinese Biomedical Literature Database. Four reviewers will assess the studies for their eligibility and their risk of bias in pairs and independently. An NMA will be performed using a Bayesian hierarchical model, and the treatment hierarchy will be obtained using the surface under the cumulative ranking curve. To determine our confidence in an overall treatment ranking from the NMA, we will follow the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: As no primary data collection will be undertaken, no formal ethical assessment is required. We plan to present the results of this systematic review in a peer-reviewed scientific journal, conferences and the popular press. PROSPERO REGISTRATION NUMBER: CRD42019127856.

Effectiveness of strategies for nutritional therapy for patients with type 2 diabetes and/or hypertension in primary care: protocol of a systematic review of randomised controlled trials.

INTRODUCTION: Despite the increasing number of drugs available and various guidelines on the management of type 2 diabetes mellitus (T2DM) and hypertension, an expressive number of patients continue with these diseases uncontrolled. Nutrition therapy (NT) plays a fundamental role in the prevention and management of these comorbidities, as well as in the prevention of complications related to them. The objective of this review is to evaluate the effectiveness of NT strategies in the management of patients with T2DM and/or hypertension in primary care. The selected strategies did not substitute pharmaceutical treatment but instead focused on preventing a sedentary lifestyle and stimulating healthy nutrition. METHODS AND ANALYSIS: We will perform a systematic review according to Cochrane methodology of randomised controlled trials, wherein patients with T2DM and/or hypertension were allocated into one of the two groups: NT strategy, which may be of dietary quality or energy restriction, and conventional treatment. The primary outcomes will be glycaemic and blood pressure (BP) control, measured by final glycosylated hemoglobin (HbA1c) (%) and BP (mm Hg), respectively. Four general and adaptive search strategies have been created for the Embase, Medline, Latin American and Caribbean Health Sciences Literature (LILACS) and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases. Two reviewers will independently select eligible studies, assess the risk of bias and extract data from the included studies. Similar outcomes measured in at least two trials will be plotted in the meta-analysis using Review Manager V.5.3. The quality of evidence of the effect estimate of the intervention will be generated according to the Grading of Recommendations Assessment, Development, and Evaluation Working Group. ETHICS AND DISSEMINATION: As no primary data collection will be undertaken, formal ethical assessment is not required. We plan to present the results of this systematic review in a peer-reviewed scientific journal, conferences and the popular press. PROSPERO REGISTRATION NUMBER: Our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 20 December 2018 (Registration number CRD42018118117).

Diabetes mellitus and the skin.

Several dermatoses are routinely associated with diabetes mellitus, especially in patients with chronic disease. This relationship can be easily proven in some skin disorders, but it is not so clear in others. Dermatoses such necrobiosis lipoidica, granuloma annulare, acanthosis nigricans and others are discussed in this text, with an emphasis on proven link with the diabetes or not, disease identification and treatment strategy used to control those dermatoses and diabetes.

Higher Carotid Intima-Media Thickness in Subclinical Hypothyroidism Associated with the Metabolic Syndrome.

BACKGROUND: The subclinical hypothyroidism (SH) and the metabolic syndrome (MS) have been associated with increased risk of atherosclerosis and cardiovascular disease (CVD). The measurement of carotid intima-media thickness (IMT) is capable of detecting early signs of atherosclerotic disease. The goal of the study was to compare the carotid IMT of patients with SH with and without the MS. METHODS: Twenty-nine SH patients were subdivided into two groups: one with MS (SH + MS) and one without MS (SH - MS). The study also assessed a group of euthyroid patients (n = 31), also subdivided into two groups: one with MS (EU + MS) and one without MS (EU - MS). The clinical and laboratory data and the mean and maximum carotid IMT of the groups were compared. RESULTS: Maximum (P = 0.012) and mean (P = 0.025) IMT were higher in the SH + MS group than in the SH-MS group. Maximum IMT was higher in the SH + MS group than in the EU + MS group (P = 0.048). Maximum IMT was positively correlated with fasting glucose (FG; R = 0.621; P < 0.01) and body mass index (R = 0.258; P = 0.041) and negatively correlated with low-density lipoprotein cholesterol (LDL-C) (R = -0.297; P = 0.017). Mean IMT was positively correlated with FG (R = 0.580; P < 0.01), systolic blood pressure (R = 0.292; P = 0.02), and triglycerides (R = 0.250; P = 0.048) and negatively correlated with LDL-C (R = -0.288; P = 0.022). CONCLUSIONS: SH + MS patients have higher IMT than SH - MS or EU + MS patients, suggesting that SH may be one more CVD risk factor in patients with the MS.

Acute bullous hemorrhagic prurigo: a diagnostic challenge

Abstract Insect bites and bite wounds are quite common and most often have mild repercussions in humans. Statistics on the incidence of accidents caused by insects are not available, and the skin reactions after the bites are not always known. The authors present two cases of patients with hemorrhagic blisters on their hands after tabanidae bites and discuss the factors that cause the problem and the importance of the differential diagnosis of blisters with hemorrhagic content on human skin.

Diabetes mellitus and the skin

Abstract: Several dermatoses are routinely associated with diabetes mellitus, especially in patients with chronic disease. This relationship can be easily proven in some skin disorders, but it is not so clear in others. Dermatoses such necrobiosis lipoidica, granuloma annulare, acanthosis nigricans and others are discussed in this text, with an emphasis on proven link with the diabetes or not, disease identification and treatment strategy used to control those dermatoses and diabetes.

Mordeduras de animais (selvagens e domésticos) e humanas / Human and animal bites: an update

As mordeduras humanas e de animais domésticos e selvagens são comuns e representam uma porcentagem importante dos atendimentos médicos de urgência. Além de complicações agudas como sangramento e grandes lacerações, podem ocorrer infecções graves por espécies comuns e incomuns de bactérias. O tratamento envolve duas etapas: as medidas de primeiros socorros e os cuidados tardios para o tratamento das infecções secundárias e reparos de tecidos lesados. Estaatualização discute estes aspectos, levando em consideração que o médico e outros participantes de equipes de saúde devem ter conhecimento destas complicações e das medidas terapêuticas propostas para estes acidentes.

Caso para diagnóstico / Case for diagnosis

Apresenta-se um caso de bullosis diabeticorum, doença rara associada ao diabetes mellitus crônico e complicações como a neuropatia ou nefropatia. As bolhas são tensas e grandes, com pouca inflamação circundante e localização acral, regredindo espontaneamente em cerca de três semanas. O exame histopatológico é inespecífico, e o diagnóstico diferencial deve ser feito com a epidermólise bolhosa, os pênfigos, o penfigóide bolhoso, queimaduras e erisipelas bolhosas.

The bullosis diabeticorum is a rare disease associated with Diabetes mellitus of long duration. The clinical manifestations are large and distended acral blisters. The differential diagnosis must be made with epidermolysis bullosa, pemphigus, bullous pemphigoid, burns, erysipelas, arthropod bites and others. The histopathology exam is not typical. The dermatologist should suspect of the disease in long-term diabetic patients of with blisters in acral locations without marked inflammation.

Diabetes Mellitus Tipo 2 no mundo: atualização do tratamento medicamentoso / Type 2 Diabetes Mellitus in the world: an update of drug treatment

O diabetes mellitus tipo 2 (DM2) está alcançando proporções epidêmicas, e embora as mudanças no estilo de vida possam manter o controle glicêmico, o curso da doença, em longo prazo, requer algum tipo de intervenção farmacológica. É bem conhecido que os indivíduos que se mantêm mal controlados apresentam mais complicações macro e microvasculares e a redução da hemoglobina glicada (HbA1c) diminui significativamente o risco de desenvolvimento de complicações microvasculares em pacientes com DM2. Atualmente há seis classes de antidiabéticos orais: sulfonilureias, meglitinidas, biguanidas, tiazolidinedionas (TZDs), inibidores da alfa-glicosidase e os incretinomiméticos. As sulfonilureias e as meglitinidas estimulam a secreção de insulina; a metformina age principalmente suprimindo a produção hepática de glicose; as tiazolidinedionas melhoram a resistência periférica à insulina e os inibidores da alfa-glicosidase retardam a degredação e a digestão dos carboidratos complexos no intestino. Uma nova opção terapêutica para o DM2 são as drogas incretinomiméticas. Dentre elas temos os análogos de GLP-1 (exenatida e liraglutida) e os inibidores da DPP-IV. Ambos estimulam a secreção de insulina, suprimem a secreção de glucagon e desaceleram o esvaziamento gástrico; a redução de peso é característica dos análogos. O bom controle glicêmico em longo prazo e a prevenção do DM2 requerem uma abordagem agressiva e abrangente. No entanto, uma vez instalada a doença, além das modificações do estilo de vida, o tratamento farmacológico deve ser iniciado e cuidadosamente monitorado, com o uso de drogas que agem nos diversos mecanismos fisiopatológicos conhecidos. Novos estudos serão sempre necessários para se obter mais informações a respeito do diabetes e, assim, aprimorar o desenvolvimento de novas drogas.

The type 2 diabetes has reached epidemic proportions in the worldwide and lifestyle modification provide insufficient glucose control over the long-term course of the disease, the vast majority of patients require some type of pharmacological intervention. Several studies have shown that individuals who remain poorly controlled have more macro and microvascular complications and the decrease in glycated hemoglobin (HbA1c) significantly reduces the risk of developing microvascular complications in type 2 diabetes. At the moment, there are six classes of oral antidiabetics drugs: sulfonylureas, meglitinides, biguanides (metformin), thiazolidinediones (pioglitazone), alpha-glucosidase inhibitors (acarbose) and incretin-mimetics drugs. The sulfonylureas and meglitinide acting insulin secretion; metformin acts primarily by suppressing hepatic glucose production; thiazolidinediones improve insulin resistance; and alpha-glucosidade inhibitors retard the degradation and digestion of complex carbohydrates in the intestine and incretin-mimetics drugs that stimulate insulin secretion, suppress glucagon secretion, slows gastric emptying and weight loss (it is characteristic of the GLP-1 analogues). The good longterm glycemic control and prevention of type 2 diabetes requires an aggressive and comprehensive approach. However, once installed the disease, in addition to lifestyle modifications, pharmacotherapy should be initiated and carefully monitored using drugs that act on different pathophysiologicals mechanisms. New studies are always necessary to obtain more information about diabetes and thus improve the development of new drugs.

Secreção de insulina e sensibilidade à insulina em indivíduos de risco para o Diabetes Mellitus Tipo 2 / Secretion of insulin and insulin sensitivity in individuals at risk for Diabetes Mellitus Type 2

O diabetes mellitus tipo 2 (DMT2) é das principais doenças do século atual, com repercussões importantes à sociedade e ao indivíduo. Para o melhor tratamento e até mesmo a prevenção, faz-se necessário melhor compreensão do DMT2. Embora haja evidência crescente quanto à superposição de um ou mais fatores que causam resistência à insulina, às células f3 com capacidade de compensação geneticamente limitada o(s) fator (es) primário(s) patogenético(s) do DMT2 ainda é (são) controverso(s). O objetivo foi portanto, compreender melhor a patogênese do DMT2 avaliando-se: 1) parentes em primeiro grau de portadores de DMT2 após cerca de 9 anos; 2) indivíduos que progrediram da TGN para TGD ou DMT2. Indivíduos e Métodos: Dos 130 indivíduos que participaram do 10 estudo (há 9 anos) 79 puderam ser reavaliados atualmente. Todos foram submetidos ao teste oral de tolerância à glicose (TOTG), com dosagem da glicose e insulina a cada 30 minutos por 120 minutos após a carga oral de 75 g de glicose. Observou-se que 17 participantes progrediram na tolerância à glicose. Assim, foram estudados os indivíduos progressores (P) versus os não­ progressores (NP) (IA e IB) e os com parentes em primeiro grau de portadores de DMT2 (HF mais) versus não-parentes (HF menos), ambos com TGN (IIA e IIB), numa abordagem transversal e prospectiva, respectivamente. Para cada um dos estudos, os grupos foram comparados quanto: a) às características clínicas e bioquímicas basais; b) parâmetros obtidos durante o TOTG; c) parâmetros obtidos do clamp hiperglicêmico. A glicose foi determinada pelo método da glicose oxidase; a insulina, por radioimunoensaio de fase sólida e 3 pró-insulina, pelo ensaio imuno-enzimático. A análise estatística dos resultados foi realizada pelo teste t de Student e Mann-Whitney para as variáveis paramétricas e não-paramétricas, respectivamente. E análise da variância de medidas repetidas para as variáveis estudadas nos estudos prospectivos (RMANOVA)...