Assessment of microvascular endothelial function in type 1 diabetes using laser speckle contrast imaging.

OBJECTIVE: To test whether laser speckle contrast imaging (LSCI) coupled with physiological post-occlusive reactive hyperemia (PORH) and pharmacological iontophoresis of acetylcholine (ACh) as local vasodilator stimuli could distinguish between cutaneous microvascular responses of Type 1 Diabetes (T1DM)'s patients with endothelial dysfunction and that of healthy controls. METHODS: Patients with T1DM aged ≥12years completed a clinical-epidemiological questionnaire. Data detailing patients' such as daily insulin dose, duration of diabetes, and use of pharmaceuticals such as antihypertensive drugs and statins that could interfere with endothelial function were obtained. Vascular reactivity was assessed in the forearm by LSCI and PORH at baseline and during iontophoresis of ACh using increasing anodic currents of 30, 60, 90, 120, 150 and 180µA in 10second intervals. RESULTS: This study included 50 patients with T1DM and 30 control subjects. The mean resting flux did not differ between patients and control subjects. T1DM patients exhibited endothelial dysfunction upon challenge with physiological or pharmacological stimuli. The microvascular response to both ACh and PORH (i.e., maximum response at peak and amplitude) were significantly reduced in patients with diabetes compared with control subjects (p<0.001). CONCLUSION: We demonstrated that endothelium-dependent skin microvascular vasodilator responses are significantly impaired in patients with T1DM compared to healthy subjects investigated using LSCI coupled with ACh iontophoresis and PORH. Additionally, we find that LSCI is a promising methodology for studying physiological vascular reactivity in T1DM.

Assessment of arterial stiffness in type 1 diabetes using digital pulse contour analysis: Is it a reliable method?

AIMS: The aim of this study was to assess the arterial stiffness in patients with type 1 diabetes compared with a control group and determine the associated potential risk factors for its occurrence. METHODS: Fifty-seven subjects with type 1 diabetes and fifty-three healthy controls were submitted to clinical and laboratory evaluation. The peripheral waveform pressure was analyzed to assess arterial stiffness according to the reflection and stiffness index. RESULTS: Arterial stiffness did not differ between the controls and patients with type 1 diabetes. Pulse pressure showed no difference among both groups. In the group of patients with type 1 diabetes, the stiffness index was correlated with diabetes duration (r = 0.59, p < 0.001), body mass index (r = 0.27, p = 0.03), diastolic blood pressure (r = 0.33, p = 0.001), triglycerides (r = 0.35, p = 0.007), and age (r = 0.46, p < 0.001). The reflection index was correlated with the systolic blood pressure (r = 0.29, p = 0.02), diastolic blood pressure (r = 0.30, p = 0.02), and cardiac frequency (r = 0.48, p < 0.001). In the stepwise multivariate analysis, disease duration, diastolic blood pressure, and HDL cholesterol were the most important independent variables associated with arterial stiffness in patients with type 1 diabetes. CONCLUSIONS: We concluded that in the studied population, arterial stiffness showed no difference between patients with diabetes and controls; thus, the use of this method should not be indicated for routine clinical practice in type 1 diabetes.

Economic status and clinical care in young type 1 diabetes patients: a nationwide multicenter study in Brazil.

The aim of this study is to evaluate the influence of economic status on clinical care provided to Brazilian youths with type 1 diabetes in daily practice, according to the American Diabetes Association's guidelines. This was a cross-sectional, multicenter study conducted between 2008 and 2010 in 28 public clinics in Brazil. Data were obtained from 1,692 patients (55.3 % female, 56.4 % Caucasian), with a mean age of 13 years (range, 1-18), a mean age at diagnosis of 7.1 ± 4 years and diabetes duration of 5 ± 3.7 years. Overall, 75 % of the patients were of a low or very low economic status. HbA1c goals were reached by 23.2 %, LDL cholesterol by 57.9 %, systolic blood pressure by 83.9 % and diastolic blood pressure by 73.9 % of the patients. In total, 20.2 % of the patients were overweight and 9.2 % were obese. Patients from very low economic status were less likely to attend tertiary care level when compared with those from low, medium and high economic status, 64.2 % versus 75.5 % versus 78.3 % and 74.0 %; p < 0.001, respectively. The rate of annual screening for retinopathy, nephropathy and for foot alterations was 66.2, 69.7 and 62.7 %, respectively. Insulin dose, age, very low economic status, daily frequency of self-blood glucose monitoring and female gender were independently associated with poor glycemic control. Screening for diabetic complications and attaining glucose, lipid and blood pressure goals present a challenge for young Brazilian type 1 diabetes patients. The low economic status of the majority of our patients may represent a barrier to reaching these goals.

Assessment of psychosocial variables by parents of youth with type 1 diabetes mellitus.

PURPOSE: To evaluate the impact of type 1 diabetes (T1D) on family functioning and child-rearing practices from parents' point of view, to assess parents' health-related quality of life and to explore the relations between psychosocial variables and diabetes care outcomes in youth with diabetes. METHODS: This research was part of the cross-sectional multicenter Brazilian Type 1 Diabetes Study, conducted between December 2008 and December 2010 in 28 public clinics of 20 cities across four Brazilian geographical regions. Psychosocial questions were addressed to 1,079 parents of patients with T1D through an interview (89.3% mothers, 52.5% Caucasians, 38.6 ± 7.6 years old). Overall, 72.5% of the families were from low or very low socioeconomic levels. Parents were also submitted to health-related quality of life instruments (EQ-5D+EQ-VAS). Clinical data from the last medical appointment were collected by a physician using standardized chart review forms. The demographic, educational and socioeconomic profiles were also obtained and HbA1c levels registered. RESULTS: Discomfort and anxiety/depression were the main complaints in EQ-5D, and were significantly more frequent in mothers (37.3% and 53.4%, respectively) than in fathers (25.7% and 32.7%, respectively). The mother was the only parent involved in diabetes care in 50.5% of the cases. The majority of parents (78.5%) mentioned changes in family functioning after the diagnosis, although they neither treated their diabetic children differently from the others (76.3%), nor set prohibitions (69.1%) due to diabetes. The majority was worried about diabetes complications (96.4%) and felt overwhelmed by diabetes care (62.8%). Parents report of overwhelming was significantly associated with anxiety/depression, as measured by the EQ-5D questionnaire. Less than half of the patients had already slept over, and the permission to do it increased as a function of children's age. Nearly half of the parents (52%) admitted to experiencing difficulties in setting limits for their children/adolescents. HbA1c levels in patients from this group (9.7 ± 2.5%) were significantly higher than those of children/adolescents whose parents reported no difficulties towards limit-setting (8.8 ± 2.1%). Parents whose children/adolescents reported the occurrence of hypoglycemic episodes in the last month complained significantly more about anxiety/depression (55.1%) than parents from patients who did not report it (45.7%). Also a significantly greater proportion of parents whose children/adolescents had been hospitalized due to hyperglycemia reported anxiety /depression (58.7%) than those whose children/adolescents had not been hospitalized (49.8%). CONCLUSIONS: After the diagnosis of T1D, the lifestyle of all family members changes, what interferes with their quality of life. Mothers are still the primary caregivers for children/adolescents with diabetes. Difficulty to set limits for children/adolescents may be a risk for poor metabolic control. The study demonstrates the importance of family context in the adjustment of young patients to T1D. The specific needs of T1D patients and their impact on a family routine must be considered for future improvement on therapy elements and strategies.

Assessment of vascular function in HIV-infected patients.

PURPOSE: The vascular function in HIV-infected persons under HAART and non-HIV-infected persons was investigated. METHOD: 18 HIV-positive patients and 23 HIV-negative subjects (14 younger group and 9 older group) were evaluated for microvascular vasodilatation during postocclusive reactive hyperemia (PORH) and during prolonged local thermal hyperemia; overall microvascular flux increase induced by iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) and large artery stiffness (SI(DVP)). RESULTS: Cutaneous vascular conductance (CVC) responses to ACh were lower in HIV patients compared to both HIV-negative groups (mean [SEM]) (HIV positive: 878.2 [99.5]; older HIV negative: 1129.3 [231.6]; younger HIV negative: 1366.5 [172.6] % baseline). Regarding SNP iontophoresis, HIV-positive and older HIV-negative groups showed lower CVC responses than younger HIV-negative group (HIV positive: 1043.0 [164.6]; older HIV-negative: 980.8 [108.3]; younger HIV-negative: 1757.3 [245.1] % baseline). Vasodilatation induced by thermal hyperemia (HIV positive: 1.63 [0.11]; older HIV negative: 1.48 [0.08]; younger HIV negative: 1.85 [0.27] perfusion units/mm Hg) and PORH (HIV positive: 0.374 [0.025]; older HIV negative: 0.326 [0.025]; younger HIV negative: 0.326 [0.037] PU/mm Hg) were similar between all groups. SIDVP was greater in HIV and older healthy groups than younger healthy group (HIV positive: 9.17 [0.42]; older HIV negative: 8.19 [0.43]; younger HIV negative: 6.42 [0.22] m/s). CONCLUSION: HIV-infected patients under HAART exhibited slight but nonsignificant lower microvascular reactivity to pharmacological stimuli and increased arterial stiffness compared to age-matched HIV-negative subjects. Comparison of both HIV-positive and older HIV-negative groups with younger HIV-negative subjects suggests that age plays a major role in microvascular reactivity regardless the HIV-infection.

The costs of type 2 diabetes mellitus outpatient care in the Brazilian public health system.

OBJECTIVE: The prevalence of type 2 diabetes has shown a significant increase in parallel with health care costs. The objective of the Brazilian Study on Diabetes Costs (ESCUDI study) was to estimate direct and indirect costs of type 2 diabetes outpatient care in the Brazilian Public Health Care System. METHODS: Data were collected from different levels of health care in eight Brazilian cities in 2007. A total of 1000 outpatients were interviewed and had their medical records data analyzed. Direct medical costs included expenses with medications, diagnostic tests, procedures, blood glucose test strips, and office visits. Nonmedical direct costs included expenses with diet products, transportation, and caregivers. Absenteeism, sick leave, and early retirement were classified as indirect costs. RESULTS: Total annual cost for outpatient care was US$2108 per patient, out of which US$1335 per patient of direct costs (63.3%) and US$773 per patient of indirect costs (36.7%). Costs escalated as duration of diabetes and level of health care increased. Patients with both microvascular and macrovascular complications had higher costs (US$3199 per patient) compared to those with either microvascular (US$2062 per patient) or macrovascular (US$2517 per patient) complications only. The greatest portion of direct costs was attributed to medication (48.2%). CONCLUSIONS: Diabetes treatment leads to elevated costs both to Brazilian Public Health Care System and society. Costs increased along with duration of disease, level of care and presence of chronic complications, which suggested a need to reallocate health resources focusing on primary prevention of diabetes and its complications.

Assessment of efficacy and tolerability of once-daily extended release metformin in patients with type 2 diabetes mellitus.

AIMS: To determine prospectively the efficacy, tolerability and patient satisfaction of an extended release formulation of metformin (metformin XR) in hospital based outpatients with type 2 diabetes mellitus currently treated with standard metformin. METHODS: Patients on immediate release standard metformin either alone or combined with other oral agents were switched to extended release metformin XR 500 mg tablets and titrated to a maximum dose of 2000 mg/day Measurements to include glucose and lipid control, blood pressure, body weight, waist circumference, C-reactive protein, adverse events and patient satisfaction were recorded at baseline, three and six months. RESULTS: Complete data were obtained for 35 of the 61 patients enrolled to the study. At three and six months no changes were reported for any of the cardiovascular risk factors except for lipids where there was a modest rise in plasma triglycerides. These effects were achieved with a reduced dose of metformin XR compared to pre-study dosing with standard metformin (1500 mg +/- 402 vs 1861 +/- 711 p = 0.004). A total of 77% of patients were free of gastrointestinal side effects and 83% of patients stated a preference for metformin XR at the end of the study. Ghost tablets were reported in the faeces by the majority of the patients (54.1%). CONCLUSIONS: Patients switched to extended release metformin XR derived the same clinical and metabolic benefits as for standard metformin but with reduced dosage, fewer gastrointestinal side effects and a greater sense of well being and satisfaction on medication.

Assessment of cognitive status in patients with type 2 diabetes through the Mini-Mental Status Examination: a cross-sectional study.

BACKGROUND: Diabetes is considered an independent risk factor for cognitive impairment and some studies observed through neuropsychological tests that cognitive disfunction affects both elderly and younger patients with diabetes. The aims of this study were to evaluate the cognitive status of outpatients with type 2 diabetes and to evaluate factors associated with impaired function. METHODS: A cross-sectional study was conducted in a group of type 2 diabetic outpatients. They were asked to undergo the Mini-Mental State Examination (MMSE) during routine ambulatory visits between April 2006 and January 2007, with the highest pontuation of the test being 30 points. Patients were classified as having possible dementia according to years of study. Exclusion criteria were blindness, illiteracy, stroke, Alzheimer disease and psychiatric disorder. Results are presented as median (interquartile range) or mean +/- SD. RESULTS: The study group was composed of 346 type 2 diabetic outpatients (216 females), aged 58,6 +/- 12,1 years and with duration of diabetes of 12,3 +/- 9,1 years. Hypertension was present in 77,2%. The total MMSE score achieved was 26 points (16 - 30) and was correlated with years of study (R2 = 0,39, p < 0,001) and 'per capita' income (R2 = 0,22, p < 0,0001) and duration of diabetes (R2 = - 0,13, p = 0,01). Patients who needed help to take their medications obtained worst performance in the MMSE (23,16 +/- 3,55 vs 25,7 +/- 2,84, p < 0,01) and were more likely to present possible dementia (p < 0,01). Forty two subjects (12.1%) had diagnosis of possible dementia and this was also associated with years of study (p = 0,045). No association was observed between possible dementia and total MMSE scores with A1C levels. CONCLUSIONS: We conclude that patients with type 2 diabetes should be regularly evaluated for their cognitive function, because duration of disease could be associated with decline in cognition. The early implementation of mini mental which is a simple method of execution can be done to detect early stages of dementia. This test could be an important tool to access the ability of patient to understand their disease and treatment.