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.

Determinants of intensive insulin therapeutic regimens in patients with type 1 diabetes: data from a nationwide multicenter survey in Brazil.

BACKGROUND: To evaluate the determinants of intensive insulin regimens (ITs) in patients with type 1 diabetes (T1D). METHODS: This multicenter study was conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. Data were obtained from 3,591 patients (56.0% female, 57.1% Caucasian). Insulin regimens were classified as follows: group 1, conventional therapy (CT) (intermediate human insulin, one to two injections daily); group 2 (three or more insulin injections of intermediate plus regular human insulin); group 3 (three or more insulin injections of intermediate human insulin plus short-acting insulin analogues); group 4, basal-bolus (one or two insulin injections of long-acting plus short-acting insulin analogues or regular insulin); and group 5, basal-bolus with continuous subcutaneous insulin infusion (CSII). Groups 2 to 5 were considered IT groups. RESULTS: We obtained complete data from 2,961 patients. Combined intermediate plus regular human insulin was the most used therapeutic regimen. CSII was used by 37 (1.2%) patients and IT by 2,669 (90.2%) patients. More patients on IT performed self-monitoring of blood glucose and were treated at the tertiary care level compared to CT patients (p < 0.001). The majority of patients from all groups had HbA1c levels above the target. Overweight or obesity was not associated with insulin regimen. Logistic regression analysis showed that economic status, age, ethnicity, and level of care were associated with IT (p < 0.001). CONCLUSIONS: Given the prevalence of intensive treatment for T1D in Brazil, more effective therapeutic strategies are needed for long term-health benefits.

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.

Regional differences in clinical care among patients with type 1 diabetes in Brazil: Brazilian Type 1 Diabetes Study Group.

BACKGROUND: To determine the characteristics of clinical care offered to type 1 diabetic patients across the four distinct regions of Brazil, with geographic and contrasting socioeconomic differences. Glycemic control, prevalence of cardiovascular risk factors, screening for chronic complications and the frequency that the recommended treatment goals were met using the American Diabetes Association guidelines were evaluated. METHODS: This was a cross-sectional, multicenter study conducted from December 2008 to December 2010 in 28 secondary and tertiary care public clinics in 20 Brazilian cities in north/northeast, mid-west, southeast and south regions. The data were obtained from 3,591 patients (56.0% females and 57.1% Caucasians) aged 21.2 ± 11.7 years with a disease duration of 9.6 ± 8.1 years (<1 to 50 years). RESULTS: Overall, 18.4% patients had HbA1c levels <7.0%, and 47.5% patients had HbA1c levels ≥ 9%. HbA1c levels were associated with lower economic status, female gender, age and the daily frequency of self-blood glucose monitoring (SBGM) but not with insulin regimen and geographic region. Hypertension was more frequent in the mid-west (32%) and north/northeast (25%) than in the southeast (19%) and south (17%) regions (p<0.001). More patients from the southeast region achieved LDL cholesterol goals and were treated with statins (p<0.001). Fewer patients from the north/northeast and mid-west regions were screened for retinopathy and nephropathy, compared with patients from the south and southeast. Patients from the south/southeast regions had more intensive insulin regimens than patients from the north/northeast and mid-west regions (p<0.001). The most common insulin therapy combination was intermediate-acting with regular human insulin, mainly in the north/northeast region (p<0.001). The combination of insulin glargine with lispro and glulisine was more frequently used in the mid-west region (p<0.001). Patients from the north/northeast region were younger, non-Caucasian, from lower economic status, used less continuous subcutaneous insulin infusion, performed less SBGM and were less overweight/obese (p<0.001). CONCLUSIONS: A majority of patients, mainly in the north/northeast and mid-west regions, did not meet metabolic control goals and were not screened for diabetes-related chronic complications. These results should guide governmental health policy decisions, specific to each geographic region, to improve diabetes care and decrease the negative impact diabetes has on the public health system.

Pré-diabetes / Pre diabetes

O pré-diabetes é uma condição clínica caracterizada por alteração na glicemia de jejum e/ou na tolerância a glicose. Indivíduos com intolerância à glicose são considerados de alto risco para o desenvolvimento do diabetes e têm 34% mais chance de desenvolver doença cardiovascular que indivíduos sadios. Portanto, a identificação de pré-diabéticos é de fundamental importância e a intervenção terapêutica precoce pode reverter esta condição ao estado de tolerância normal à glicose, prevenindo ou retardando a evolução para o diabetes. Modificação do estilo de vida, buscando hábitos alimentares saudáveis, perda ponderal e incorporação de atividade física devem ser sempre estimulados. O uso de drogas anti-hiperglicemiantes pode ser considerado nos indivíduos que não conseguem obter êxito com as medidas não farmacológicas instituídas.

[Nationwide multicenter study on the prevalence of overweight and obesity in type 2 diabetes mellitus in the Brazilian population]. / Prevalência de sobrepeso e obesidade em pacientes com diabetes mellitus do tipo 2 no Brasil: estudo multicêntrico nacional.

AIM: To evaluate the prevalence of overweight and obesity in type 2 diabetic (DM2) outpatients from different regions of Brazil. PATIENTS AND METHODS: We studied 2,519 randomly selected patients, from 11 hospitals, 2 endocrine and one general public care clinics from 10 cities. Overweight was defined as body-mass index (BMI) > 25 and obesity as BMI > 30 kg/m2. Glycemic control (GC) was evaluated by GC index (GCI = patient's HbA1 or HbA1c/upper limit of normal for the method x 100). RESULTS: 39% of the population studied was male, the mean age was 58.8 +/- 11.6 y, the duration from clinical diagnosis of DM2 was 9.0 +/- 7.3y, and BMI was 28.3 +/- 5.2 kg/m2. No measurements of BMI were recorded from 265 patients (10.5%). Patients from the Northeast presented lower BMI as compared with those from the Midwest, Southeast and South areas, respectively (26.4 +/- 4.7 vs. 27.9 +/- 4.8 vs. 29.2 +/- 5.1 vs. 29.4 +/- 5.4 kg/m2; p < 0.001). A greater prevalence of obesity was observed in the Southeast and South areas as compared to the Northeast (p < 0.001), as well as in the female group, respectively (69% vs. 31%; p < 0.001). Normal weight patients presented lower GCI. Patients being treated with two or more oral drugs and an association of insulin plus oral drug presented greater BMI values than those being treated with diet, oral hypoglycemic agents and insulin p < 0.001. The BMI of patients treated by a specialist did not differ from those treated by a generalist. CONCLUSIONS: 75% of our sample was out of adequate BMI and 30% was obese. The percentage of patients with overweight and obesity was comparable to those found in similar European studies but still lower than those found in the USA. The prevalence of obesity in diabetic patients was three times higher than in the overall Brazilian population according to data from the Brazilian Institute of Geography and Statistics (IBGE).

Prevalência de sobrepeso e obesidade em pacientes com diabetes mellitus do tipo 2 no Brasil: estudo multicêntrico nacional / Nationwide multicenter study on the prevalence of overweight and obesity in type 2 diabetes mellitus in the Brazilian population

OBJETIVO: Avaliar a prevalência de sobrepeso e obesidade em pacientes ambulatoriais com diabetes mellitus tipo 2 (DM2) em diferentes regiões do Brasil. PACIENTES E MÉTODOS: Avaliamos aleatoriamente 2.519 pacientes em 11 hospitais, 2 ambulatórios especializados e um posto de saúde em 10 cidades brasileiras. Consideramos sobrepeso um índice de massa corporal (IMC) > 25 e obesidade um IMC > 30 kg/m². O controle glicêmico (CG) foi avaliado pelo índice de CG [ICG= HbA1 e ou HbA1c do paciente/limite superior de normalidade do método x 100]. RESULTADOS: Os pacientes tinham idade de 58,8 ± 11,6 anos, tempo de diagnóstico clínico de DM de 9,0 ± 7,3 anos, IMC de 28,3 ± 5,2 kg/m², e 39 por cento eram do sexo masculino. Do total da amostra, 265 pacientes (10,5 por cento) não apresentavam avaliação do IMC. Os pacientes da região Nordeste apresentaram menor IMC em comparação com os das regiões Centro-Oeste, Sudeste e Sul, respectivamente (26,4 ± 4,7 vs. 27,9 ± 4,8 vs. 29,2 ± 5,1 vs. 29,4 ± 5,4 kg/m²; p< 0,001). Houve maior prevalência de obesidade na região Sudeste e Sul em comparação à região Nordeste (p< 0,001) e nos pacientes do sexo feminino, respectivamente (69 vs. 31 por cento; p< 0,001). Os pacientes com peso normal apresentaram menor ICG. Aqueles em tratamento com associação de duas ou mais drogas orais e associação de insulina + droga oral apresentaram maior IMC do que aqueles em tratamento com dieta, hipoglicemiante oral e insulina; p< 0,001. O IMC não diferiu entre os pacientes assistidos ou não por especialistas. CONCLUSÕES: Da população estudada, 75 por cento não estava na faixa de peso ideal, sendo que um terço tinha obesidade. Nossos dados indicam que o sobrepeso e a obesidade já atingem um percentual de pacientes com DM2 no Brasil semelhante ao relatado em estudos europeus, mas ainda menor do que o observado nos EUA. A prevalência de obesidade nos pacientes diabéticos foi três vezes maior do que a observada na população brasileira em geral de acordo com os dados do IBGE.

Prevalence of Type 2 diabetic patients within the targets of care guidelines in daily clinical practice: a multi-center study in Brazil.

Major clinical studies have shown that the targets for blood glucose, lipid profile and blood pressure in type 2 diabetic patients are difficult to maintain in clinical practice. However, there are few data concerning South American populations. Using guidelines represented by the Brazilian Diabetes Society, we evaluated cardiovascular (CV) risk factors, glycemic control and the availability of screening for diabetes complications in 2233 (60% females) outpatients with type 2 diabetes aged 59.2 +/- 11.3 yr and with a known duration of diabetes of 9.2 +/- 7.2 yr, collected from 8 Brazilian cities. The outcome showed that less intensive clinical care available for diabetic patients in Brazil compared to western industrialized countries leads to widespread poor metabolic control and health status. Less than 30% of the patients reached the target for systolic (28.5%, < 130 mmHg) and diastolic (19.3%, < 80 mmHg) blood pressure, BMI (24.6%, < 25 kg/m2), LDL cholesterol (20.6%, < 2.6 mmol/l) and only 46% reached the goal for HbA1c (one % point above the upper limits of normality for the method used). Only 0.2% of patients reached all the targets. A lower number of women reached the targets for HbA1c, LDL and HDL cholesterol than men (p < 0.001). Women were less likely than men to have funduscopy examinations and urine albumin testing (p < 0.001). We conclude that the national goals for glycemic control, blood pressure and lipid levels are rarely achieved in clinical practice, and that the availability for diabetic complication screening is low. The quality of diabetes care, in particular for women, is poor and should be further reviewed in developing countries.

Perfil hormonal de pacientes com esquistossomose mansônica hepatoesplênica e retardo do desenvolvimento somático e sexual, antes e após a esplenectomia / Profile hormonal of patients with hepatosplenic mansoni Schistosomiasis, grouth and sexual development retardation before and after splenic splenectomy

Foram estudados dez pacientes com esquistossomose mansônica hepatoesplênica e retardo de crescimento e desenvolvimento sexual, antes, 30 e 180 dias após esplenectomia, por meio de minuciosa anamnese, exame físico e avaliaçäo laboratorial, radiológica e endócrina. Paralelamente foram avaliados dez indivíduos sem esquistossomose com mesma etária e condiçöes sócio-econômicas que constituiram o grupo controle. Aumento de peso e estatura ao qual correspondeu uma aceleraçäo da maturaçäo esquelética e sinais de desenvolvimento sexual foram evidenciados 180 dias após a cirurgia. Aumento das concentraçöes de LH, FSH e GH observados durante estímulo fisiológico do sono noturno foi também constatado. Concentraçöes de somatomedina-C foram normais em 70% e baixas em 30% dos casos durante toda a duraçäo do estudo. Houve aumento discreto de concentraçöes individuais em 80% dos casos, mas a elevaçäo média näo foi estatisticamente significante nem aos 30 nem aos 180 dias após a esplenectomia. O presente estudo permitiu as seguintes conclusöes: 1. Esplenectomia é acompanhada de ganho de peso, aumento em altura e aceleraçäo da maturaçäo óssea em pacientes com esquistossomose hepatoesplênica e atraso estatural e sexual. 2. Acidose tubular renal pode estar presente em pacientes com esquistossomose mansônica e ser responsável por retardo de crescimento em alguns casos. 3. Hipotiroidismo subclínico revelado por uma resposta exagerada do TSH ao TRH foi eventualmente observada na presente casuística. Estudos subsequentes säo necessários para estabelecer se esta observaçäo representa coincidência ou reflete uma associaçäo. Houve aumento progressivo das concentraçöes de SDHEA caracterizando início do aumento de produçäo doa andrógenos supra renais nestes casos. 5. As concentraçöes de GH em vigília e durante o estímulo fisiológico do sono noturno foram normais, näo sendo evidenciado deficiência de GH nestes casos. 6. Houve aumento significativo nas concentraçöes de LH entre 2 e 6 horas da manhä 30 dias após a cirurgia, caracterizando deflagraçäo da puberdade nestes pacientes um mês após a esplenectomia. 7. Na casuística estudada näo observamos hipossomatomedinismo significante antes da cirurgia em 70% dos pacientes, e näo houve aumento estatisticamente significante entre as médias das concentraçöes de somatomedina-C após a esplenectomia. 8. Os mecanismos que explicariam o desenvolvimento somático e sexual após a esplenectomia ainda permanecem obscuros. A melhora do estado nutrici