Medical education on hospital hyperglycemia improving knowledge and outcomes

ABSTRACT Objective: To evaluate the effects of medical education on hospital hyperglycemia on physician's technical knowledge and the quality of medical prescriptions, patient care, and clinical outcomes. Subjects and methods: The intervention included online classes and practical consultations provided by an endocrinologist to medical preceptors and residents of the Department of Internal Medicine. A pretest and a post-test (0 to 10 points) were applied before and after the intervention and patients medical records were reviewed before and after the intervention. The outcomes were improvement in medical knowledge, in the quality of prescriptions for patients in the clinical area, and clinical outcomes. Results: The global mean of correct answers improved with the intervention [before: 6.9 points (±1.7) versus after the intervention: 8.8 points (±1.5) (p < 0.001)]. The number of patients who did not have at least one blood glucose assessment during the entire hospitalization for acute illness decreased from 12.6% before to 2.6% (p < 0.001) after the intervention. There was also a significant reduction in hospital hypoglycemia rates (p < 0.026). The use of sliding-scale insulin as the main treatment was quite low before and after the intervention (2.2% and 0%). After 6 months, medical knowledge did not show significant reduction. Conclusion: Medical education on hospital hyperglycemia can improve medical knowledge and clinical outcomes for patients. The improvement in medical knowledge was maintained after 6 months.

Efficacy of empagliflozin for weight and glycemic control of a patient with Prader-Willi syndrome, systemic lymphedema and extreme obesity: a case report.

A patient with Prader-Willi syndrome (PWS), extreme obesity and hyperglycemia had her body weight increased considerably for 6 months, even with exercise and diet programs. Treatment with metformin and empagliflozin (12.5 mg/day) induced a weight loss of 14 kg (-10.3%) for 6 months and the reduction of glycated hemoglobin A1c.

Psychiatric illness, emotional distress, glycemic control and chronic complications in type 1 diabetes subjects

ABSTRACT Objectives: To assess the prevalence of psychiatric disorders in patients with type 1 diabetes mellitus (T1D) and to compare patients with and without psychiatric disorder. Materials and methods: We made a cross-sectional study including patients with T1D assisted in the outpatient clinics of the Brazilian National Health System. To assess depression and anxiety, we used the PHQ-9 questionnaire and the DSM-5th edition criteria, respectively. B-PAID evaluated the level of emotional distress associated with diabetes; EAT-26, eating disorders; SCI-R, adherence to the proposed clinical treatment. Results: We analyzed 166 patients aged 33 (22-45.2) years, 53.6% female. The prevalence of depression and anxiety was 20.5% and 40.4%, respectively. HbA1c was worse in the depressed (9.0% vs. 8.4%, p = 0.008), in the anxious ones (9.0% vs. 8.3%, p = 0.012) and in the patients with high levels of B-PAID (8.8 % vs. 8.3 %, p = 0.009). There was no difference in the prevalence of complications related to diabetes. Conclusions: The prevalence of psychiatric disorders and emotional distress related to diabetes was high in our population of T1D patients, and depression and high levels of B-PAID were associated with the worse glycemic control.

Psychiatric illness, emotional distress, glycemic control and chronic complications in type 1 diabetes subjects.

OBJECTIVE: To assess the prevalence of psychiatric disorders in patients with type 1 diabetes mellitus (T1D) and to compare patients with and without psychiatric disorder. METHODS: We made a cross-sectional study including patients with T1D assisted in the outpatient clinics of the Brazilian National Health System. To assess depression and anxiety, we used the PHQ-9 questionnaire and the DSM-5th edition criteria, respectively. B-PAID evaluated the level of emotional distress associated with diabetes; EAT-26, eating disorders; SCI-R, adherence to the proposed clinical treatment. RESULTS: We analyzed 166 patients aged 33 (22-45.2) years, 53.6% female. The prevalence of depression and anxiety was 20.5% and 40.4%, respectively. HbA1c was worse in the depressed (9.0% vs. 8.4%, p = 0.008), in the anxious ones (9.0% vs. 8.3%, p = 0.012) and in the patients with high levels of B-PAID (8.8 % vs. 8.3 %, p = 0.009). There was no difference in the prevalence of complications related to diabetes. CONCLUSION: The prevalence of psychiatric disorders and emotional distress related to diabetes was high in our population of T1D patients, and depression and high levels of B-PAID were associated with the worse glycemic control.

Clinical characteristics of women with gestational diabetes - comparison of two cohorts enrolled 20 years apart in southern Brazil.

CONTEXT AND OBJECTIVE:: The prevalence and characteristics of gestational diabetes mellitus (GDM) have changed over time, reflecting the nutritional transition and changes in diagnostic criteria. We aimed to evaluate characteristics of women with GDM over a 20-year interval. DESIGN AND SETTING:: Comparison of two pregnancy cohorts enrolled in different periods, in university hospitals in Porto Alegre, Brazil: 1991 to 1993 (n = 216); and 2009 to 2013 (n = 375). METHODS:: We applied two diagnostic criteria to the cohorts: International Association of Diabetes and Pregnancy Study Groups (IADPSG)/World Health Organization (WHO); and National Institute for Health and Care Excellence (NICE). We compared maternal-fetal characteristics and outcomes between the cohorts and within each cohort. RESULTS:: The women in the 2010s cohort were older (31 ± 7 versus 30 ± 6 years), more frequently obese (29.4% versus 15.2%), with more hypertensive disorders (14.1% versus 5.6%) and at increased risk of cesarean section (adjusted relative risk 1.8; 95% confidence interval: 1.4 - 2.3), compared with those in the 1990s cohort. Neonatal outcomes such as birth weight category and hypoglycemia were similar. In the 1990s cohort, women only fulfilling IADPSG/WHO or only fulfilling NICE criteria had similar characteristics and outcomes; in the 2010s cohort, women only diagnosed through IADPSG/WHO were more frequently obese than those diagnosed only through NICE (33 ± 8 kg/m2 versus 28 ± 6 kg/m2; P < 0.001). CONCLUSION:: The epidemic of obesity seems to have modified the profile of women with GDM. Despite similar neonatal outcomes, there were differences in the intensity of treatment over time. The IADPSG/WHO criteria seemed to identify a profile more associated with obesity.

Clinical characteristics of women with gestational diabetes - comparison of two cohorts enrolled 20 years apart in southern Brazil / Caraterísticas clínicas de mulheres com diabetes gestacional - uma comparação de duas coortes arroladas em intervalo de 20 anos no sul do Brasil

ABSTRACT CONTEXT AND OBJECTIVE: The prevalence and characteristics of gestational diabetes mellitus (GDM) have changed over time, reflecting the nutritional transition and changes in diagnostic criteria. We aimed to evaluate characteristics of women with GDM over a 20-year interval. DESIGN AND SETTING: Comparison of two pregnancy cohorts enrolled in different periods, in university hospitals in Porto Alegre, Brazil: 1991 to 1993 (n = 216); and 2009 to 2013 (n = 375). METHODS: We applied two diagnostic criteria to the cohorts: International Association of Diabetes and Pregnancy Study Groups (IADPSG)/World Health Organization (WHO); and National Institute for Health and Care Excellence (NICE). We compared maternal-fetal characteristics and outcomes between the cohorts and within each cohort. RESULTS: The women in the 2010s cohort were older (31 ± 7 versus 30 ± 6 years), more frequently obese (29.4% versus 15.2%), with more hypertensive disorders (14.1% versus 5.6%) and at increased risk of cesarean section (adjusted relative risk 1.8; 95% confidence interval: 1.4 - 2.3), compared with those in the 1990s cohort. Neonatal outcomes such as birth weight category and hypoglycemia were similar. In the 1990s cohort, women only fulfilling IADPSG/WHO or only fulfilling NICE criteria had similar characteristics and outcomes; in the 2010s cohort, women only diagnosed through IADPSG/WHO were more frequently obese than those diagnosed only through NICE (33 ± 8 kg/m2 versus 28 ± 6 kg/m2; P < 0.001). CONCLUSION: The epidemic of obesity seems to have modified the profile of women with GDM. Despite similar neonatal outcomes, there were differences in the intensity of treatment over time. The IADPSG/WHO criteria seemed to identify a profile more associated with obesity.

RESUMO CONTEXTO E OBJETIVO: Prevalência e características do diabetes mellitus gestacional (DMG) modificaram-se com o tempo, refletindo transição nutricional e diferentes critérios diagnósticos. Nosso objetivo foi avaliar características de gestações com DMG em intervalo de 20 anos. TIPO DE ESTUDO E LOCAL: Comparação de duas coortes gestacionais arroladas em diferentes períodos, em hospitais universitários de Porto Alegre, Brasil: 1991 a 1993 (n = 216) e 2009 a 2013 (n = 375). MÉTODOS: Aplicamos dois critérios diagnósticos às coortes: International Association of Diabetes and Pregnancy Study Groups (IADPSG)/Organização Mundial de Saúde (OMS); e National Institute for Health and Care Excellence (NICE). Comparamos características e desfechos materno-fetais entre as coortes e dentro de cada uma. RESULTADOS: Na coorte dos anos 2010, as mulheres eram mais velhas (31 ± 7 versus 30 ± 6 anos), obesas (29,4% versus 15,2%), apresentaram mais distúrbios hipertensivos (14,1% versus 5,6%) e risco aumentado de cesariana (risco relativo ajustado 1,8; intervalo de confiança de 95% 1,4 - 2,3), comparadas às da coorte de 1990. Desfechos neonatais, como categoria do peso ao nascer e hipoglicemia, foram semelhantes. Na coorte de 1990, essas características e desfechos foram semelhantes nas mulheres que preenchiam apenas um dos critérios; na de 2010, mulheres diagnosticadas apenas pelo IADPSG/OMS eram mais obesas (33 ± 8 kg/m2 versus 28 ± 6 kg/m2, P < 0,001) do que as diagnosticadas apenas pelo NICE. CONCLUSÃO: A epidemia de obesidade parece ter modificado o perfil de mulheres com DMG. Embora desfechos neonatais sejam semelhantes, houve diferenças na intensidade de tratamento ao longo do tempo. O critério da IADPSG/OMS parece identificar um perfil mais associado à obesidade.

Vitamin D Deficiency Increases the Risk of Adverse Neonatal Outcomes in Gestational Diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) and vitamin D deficiency have been associated with increased risk of adverse perinatal outcomes but the consequences of both conditions simultaneously present in pregnancy have not yet been evaluated. Our objective was to study the influence of vitamin D deficiency in neonatal outcomes of pregnancies with GDM. METHODS: 184 pregnant women with GDM referred to specialized prenatal monitoring were included in this cohort and had blood sampled for 25-hydroxyvitamin D measurement. Vitamin D was measured by chemiluminescence and deficiency was defined as < 20 ng/mL. Participants were followed until puerperium and adverse neonatal outcomes were evaluated. RESULTS: Newborns of women with vitamin D deficiency had higher incidences of hospitalization in intensive care units (ICU) (32 vs 19%, P = 0.048), of hypoglycemia (any, 17.3 vs 7.1%, P = 0.039requiring ICU, 15.3 vs 3.6%, P = 0.008), and were more frequently small for gestational age (SGA) (17.3 vs 5.9%, P = 0.017). After adjustment, relative risk (RR) for hypoglycemia requiring ICU was 3.63 (95%CI 1.09-12.11) and for SGA was 4.32 (95%CI 1.75-10.66). The incidence of prematurity, jaundice and shoulder dystocia was no statistically different between groups. CONCLUSIONS: In this cohort of pregnant women with GDM, vitamin D deficiency was associated with a major increase in the incidence of adverse neonatal outcomes such as SGA newborns and neonatal hypoglycemia.

Birth weight classification in gestational diabetes: is there an ideal chart?

Introduction: Gestational diabetes mellitus (GDM) is associated to increased rates of large for gestational age (LGA) newborns and macrosomia. Several charts are used to classify birth weight. Is there an ideal chart to classify newborns of GDM mothers? Methods: We evaluated adequacy of birth weight of 332 neonates born to GDM mothers at Hospital de Clínicas de Porto Alegre, Brazil. Newborns were classified according to gestational age as small (SGA), adequate, or large (LGA) based on four charts: Alexander, Pedreira, INTERGROWTH 21st Project, and SINASC-2012. The latter was built using data from a large national registry of 2012, the Born Alive National Surveillance System (Sistema de Informações de Nascidos Vivos ­ SINASC), which included 2,905.789 birth certificates. Frequencies of SGA and LGA and Kappa agreement were calculated. Results: In non-gender adjusted curves, SGA rates (95% confidence interval) varied from 8% (5-11) to 9% (6-13); LGA rates, from 11% (8-15) to 17% (13-21). For males, SGA rates varied from 3% (1-6%) to 6% (3-11%), and LGA rates, from 18% (13-24%) to 31% (24-38%); for females, SGA rates were from 3% (1-7%) to 10% (6-16%) and LGA rates, from 11% (6-16%) to 19% (13-26%). Kappa results were: ALEXANDER vs. SINASC-2012: 0.80 (0.73-0.88); INTERGROWTH 21st vs. SINASC-2012 (adjusted by sex): 0.62 (0.53-0.71); INTERGROWTH 21st vs. PEDREIRA: 0.71 (0.62-0.79); SINASC-2012 (by sex) vs. PEDREIRA: 0.86 (0.79-0.93). Conclusions: Misclassification has to be taken into account when evaluating newborns of GDM mothers, as LGA rates can almost double depending on the chart used to classify birth weight (AU)

HbA1c Test as a Tool in the Diagnosis of Gestational Diabetes Mellitus.

AIMS: Gestational diabetes mellitus (GDM) is a prevalent and potentially serious condition which may put both mothers and neonates at risk. The current recommendation for diagnosis is the oral glucose tolerance test (OGTT). This study aimed to determine the usefulness of HbA1c test as a diagnostic tool for GDM as compared to the traditional criteria based on the OGTT. METHODS: This was a diagnostic test accuracy study. We performed OGTT and HbA1c test in women attending prenatal visits at a tertiary hospital. GDM was defined according to WHO1999 or ADA/WHO 2013 criteria. ROC curve was used to evaluate the diagnostic performance of HbA1c. Sensitivity, specificity and likelihood ratios for different HbA1c cut-off points were calculated. RESULTS: Of the 262 women in the third trimester of gestation enrolled in the study, 86 (33%) were diagnosed with GDM. Only five of these women presented HbA1c ≥48 mmol/mol (6.5%). This cut-off point presented 100% specificity but very low sensitivity (7%). Based on ROC curve, and considering OGTT as the reference criterion, HbA1c ≥40 mmol/mol (5.8%) showed adequate specificity in diagnosing GDM (94.9%) but low sensitivity (26.4%). Unlike, HbA1c values of 31 mmol/mol (5.0%) presented adequate sensitivity (89.7%) but low specificity (32.6%) to detect GDM. For women with HbA1c ≥40 mmol/mol (5.8%), the positive and negative likelihood ratios were 5.14 (95%CI 2.49-10.63) and 0.78 (0.68-0.88), respectively. The post-test probability of GDM was about 40%, representing a 4.0-fold increase in the mean pre-test probability. This cut-off point could eliminate the need for the unpleasant and laborious OGTT tests in almost one third of cases, as 38% of patients with GDM may be diagnosable by HbA1c test alone. CONCLUSIONS: Our results show that combined HbA1c and OGTT measurements may be useful in diagnosing GDM.

Maternal-fetal impact of vitamin D deficiency: a critical review.

Research into the extra-skeletal functions of vitamin D has been expanding in recent years. During pregnancy, maternal vitamin D status may be of concern because of the key role of this vitamin in fetal skeletal development and due to the association between hypovitaminosis D and adverse maternal-fetal outcomes. Therefore, the objective of this manuscript was to review the maternal-fetal impact of gestational vitamin D deficiency and the benefits of vitamin D supplementation during pregnancy. A literature search was performed in PubMed and Embase employing the following keywords: vitamin D deficiency, pregnancy, 25-hydroxyvitamin D, and hypovitaminosis D. All relevant articles in English language published since 1980 were analysed by the two authors. Neonatal complications derived from vitamin D deficiency include low birth weight, growth restriction, and respiratory tract infection. In the mother, vitamin D deficiency has been associated with altered glucose homeostasis and increased incidence of gestational diabetes mellitus, pre-eclampsia, and bacterial vaginosis. However, the current state of the evidence is controversial for some other endpoints and the actual benefit of vitamin D supplementation in pregnancy remains unclear. Additional longitudinal studies may clarify the actual impact of vitamin D deficiency during pregnancy, and randomised trials are required to define the benefits of vitamin D supplementation in reducing the incidence of adverse outcomes in the mother and infant.

Síndrome de Guillain-Barré: relato de caso da neuropatia sensitivo-motora axonal aguda em criança / Guillain-Barré syndrome: case report of a child with acute axonal sensorimotor neuropathy

A forma sensitivo-motora axonal aguda da Síndrome de Guillain-Barré (SBG) é uma apresentação rara, a qual pode apresentar um comprometimento neurológico mais grave. O diagnóstico desta morbidade é realizado através da avaliação clínica associada à eletroneuromiografia. Neste artigo, reportamos o caso de um paciente de 13 anos, submetido a medidas de suporte isoladamente, com evolução neurológica favorável. Em crianças e adolescentes, a melhor abordagem terapêutica para esta condição ainda carece de evidência científica (AU)

The acute axonal sensorimotor form of Guillain-Barre Syndrome (GBS) is a rare presentation which may have a more severe neurological impairment. The diagnosis of this condition is made by clinical evaluation associated with electroneuromyography. In this paper we report the case of a 13-year-old patient who underwent supportive measures alone, with a favorable neurological outcome. In children and adolescents, the best therapeutic approach for this condition still lacks scientific evidence (AU)

Postpartum glucose tolerance status 6 to 12 weeks after gestational diabetes mellitus: a Brazilian cohort.

OBJECTIVES: The aims of this study were to estimate the local rate of postpartum diabetes screening after gestational diabetes mellitus (GDM) pregnancies, and to identify clinical variables associated with retesting rates and with the persistence of decreased glucose tolerance. SUBJECTS AND METHODS: Prospective cohort of GDM women with prenatal delivery at a specialized center, from November 2009 to May 2012. All women were advised to schedule a 6 weeks postpartum 75-g oral glucose tolerance test (OGTT). RESULTS: Of the 209 women included, 108 (51.7%) returned to be tested with fasting plasma glucose (n=14), OGTT (n=93) or random glucose (n=1). Return was associated with lower parity rate (2 vs. 3, p<0.001) and higher pregnancy 2-h OGTT (165 vs. 155 mg/dL, p=0.034), but not with socio-demographic characteristics. Four women (3.7%) had diabetes, 22 (20.4%) had impaired fasting glucose or impaired glucose tolerance. Persistent hyperglycemia was associated with a positive family history of diabetes (relative risk-RR 2.41, p=0.050), diagnostic 2-h OGTT in pregnancy (RR 1.01, p=0.045), insulin use during pregnancy (RR 2.37, p=0.014), and cesarean section (RR 2.61, p=0.015). CONCLUSIONS: Even though postpartum abnormalities were frequent in GDM, rates of postpartum diabetes screening were undesirably low. As no specific clinical profile defines who will adhere to postpartum testing, it is essential to encourage all women to reevaluate their glucose status, particularly those with a family history of diabetes and more severe hyperglycemia.

Postpartum glucose tolerance status 6 to 12 weeks after gestational diabetes mellitus: a Brazilian cohort / Reavaliação do estado glicêmico 6 a 12 semanas após o diabetes melito gestacional: uma coorte brasileira

Objectives: The aims of this study were to estimate the local rate of postpartum diabetes screening after gestational diabetes mellitus (GDM) pregnancies, and to identify clinical variables associated with retesting rates and with the persistence of decreased glucose tolerance. Subjects and methods: Prospective cohort of GDM women with prenatal delivery at a specialized center, from November 2009 to May 2012. All women were advised to schedule a 6 weeks postpartum 75-g oral glucose tolerance test (OGTT). Results: Of the 209 women included, 108 (51.7%) returned to be tested with fasting plasma glucose (n = 14), OGTT (n = 93) or random glucose (n = 1). Return was associated with lower parity rate (2 vs. 3, p < 0.001) and higher pregnancy 2-h OGTT (165 vs. 155 mg/dL, p = 0.034), but not with socio-demographic characteristics. Four women (3.7%) had diabetes, 22 (20.4%) had impaired fasting glucose or impaired glucose tolerance. Persistent hyperglycemia was associated with a positive family history of diabetes (relative risk - RR 2.41, p = 0.050), diagnostic 2-h OGTT in pregnancy (RR 1.01, p = 0.045), insulin use during pregnancy (RR 2.37, p = 0.014), and cesarean section (RR 2.61, p = 0.015). Conclusions: Even though postpartum abnormalities were frequent in GDM, rates of postpartum diabetes screening were undesirably low. As no specific clinical profile defines who will adhere to postpartum testing, it is essential to encourage all women to reevaluate their glucose status, particularly those with a family history of diabetes and more severe hyperglycemia. Arq Bras Endocrinol Metab. 2014;58(2):197-204 .

Objetivos: Os objetivos foram estimar a taxa de reavaliação de diabetes pós-parto em mulheres com diabetes melito gestacional (DMG) e identificar fatores associados ao retorno e à persistência das alterações glicêmicas. Sujeitos e métodos: Coorte prospectiva de mulheres com DMG atendidas em ambulatório de pré-natal especializado, de novembro de 2009 a maio de 2012. Todas foram orientadas a agendar o teste oral de tolerância à glicose (TOTG) a partir da sexta semana pós-parto. Resultados: Das 209 mulheres arroladas na gestação, 108 (51,7%) foram avaliadas após o parto: 14 com glicemia de jejum, 93 com o TOTG e uma com glicemia ao acaso. O retorno para reavaliação foi associado com menor paridade (2 vs. 3, p < 0,001) e com glicemia de 2-h mais elevada no TOTG diagnóstico (165 vs. 155 mg/dL, p = 0,034). Diabetes foi diagnosticado em quatro mulheres (3,7%) e pré-diabetes em 22 (20,4%). Análise multivariada evidenciou que a história familiar de diabetes (risco relativo – RR 2,41, p = 0,050), a glicemia de 2 horas no TOTG da gestação (RR 1,01, p = 0,045), o uso de insulina na gestação (RR 2,37, p = 0,014) e a taxa de cesariana (RR 2,61, p = 0,015) foram os fatores associados à persistência da hiperglicemia. Conclusões: O retorno para reavaliação foi baixo, embora as alterações glicêmicas tenham sido frequentes. Como não houve fatores que indiquem quais mulheres retornarão, estratégias para aumentar a adesão são necessárias, especialmente quando há história familiar ou o DMG foi mais grave. Arq Bras Endocrinol Metab. 2014;58(2):197-204 .

Comparison between IDMS-traceable Jaffe and enzymatic creatinine assays for estimation of glomerular filtration rate by the CKD-EPI equation in healthy and diabetic subjects.

OBJECTIVES: The aim of this paper was to compare the agreement between creatinine measured by Jaffe and enzymatic methods and their putative influence on eGFR as calculated by the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation in healthy and diabetic individuals. DESIGN AND METHODS: Cross-sectional study conducted in 123 adult southern Brazilians with GFR>60 mL/min/1.73 m² (53 patients with type 2 diabetes, 70 healthy volunteers). Mean age was 49±16 years (range of 19-86). Most were female (55%) and white (83%). Creatinine was measured by a traceable Jaffe method (Modular P, Roche Diagnostic) and by an enzymatic method (CREA plus, Roche/Hitachi 917). GFR was measured by the 5¹Cr-EDTA single-injection method. RESULTS: Serum creatinine measured by the Jaffe and enzymatic methods was similar in healthy subjects (0.79±0.16 vs. 0.79±0.15 mg/dL, respectively, P=0.76), and diabetic patients (0.96±0.22 vs. 0.92±0.29 mg/dL, respectively, P=0.17). However, the correlation between the two methods was higher in the healthy group (r=0.90 vs. 0.76, P<0.001). The difference between Jaffe creatinine and enzymatic creatinine was <10% in 63% of cases in the healthy group and 40% of cases in the diabetes group (P=0.018). In the subset of patients with diabetes, eGFR based on enzymatic assay results showed better agreement with measured GFR than did eGFR based on Jaffe results. CONCLUSION: Jaffe and enzymatic creatinine methods show adequate agreement in healthy subjects, but in the presence of diabetes, the enzymatic method performed slightly better.

Influence of age at diagnosis and duration of diabetes on the positivity of glutamic acid decarboxylase antibody in South-Brazilian type 1 diabetes mellitus.

AIM: To evaluate the influence of age of onset and duration of diabetes on the positivity of glutamic acid decarboxylase antibody (GADA) in South-Brazilian type 1 diabetes mellitus (DM) patients. METHODS: GADA was evaluated in 92 patients with type 1 diabetes, in 147 gestational DM patients, and in 59 subjects with normal glucose tolerance. RESULTS: Type 1 patients with positive GADA (N = 44, 48%) were older at the onset of diabetes (22 ± 9 versus 18 ± 10 y, P = 0.043) and had a shorter DM duration (12 ± 8 versus 19 ± 9 y, P < 0.001), as compared with negative GADA patients. A logistic regression with antibody positivity as the dependent variable and diabetes duration as the independent variable, showed that the shorter diabetes duration was related to the presence of the antibody with an odds ratio (OR) = 5.6; (CI 95% = 2.1-14.6); P < 0.001. Another model, with age at diagnosis as the independent variable, did not show any association with antibody positivity. However, analysing only men, a shorter DM duration (OR = 6.5; CI = 1.7-24.0; P = 0.006), and also a higher age at diagnosis (OR = 5.5; CI = 1.5-21.0; P = 0.01) were significantly related to the antibody positivity. The performance of GADA was similar in up to 15 y of duration of DM (P = 0.78), but significantly diminished with higher duration (P = 0.001). CONCLUSION: GADA testing is a helpful tool in the diagnosis of type 1 DM starting in young adults and older individuals. Even though the positivity rate declines along the course of disease, it still provides useful information up to 15 y after the diabetes diagnosis.

Reference values for glomerular filtration rate in healthy Brazilian adults.

BACKGROUND: Glomerular filtration rate (GFR) is the best index of renal function, but age, gender and ethnicity can putatively affect its values. The aim of this study was to establish reference values for GFR in healthy Brazilian subjects while taking these factors into account. METHODS: In this cross-sectional study, GFR was measured by the 51Cr-EDTA single-injection method. GFR reference values were developed according to CLSI Guidelines for Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory (CLSI C28 protocol). RESULTS: The age range of the 285 healthy individuals was 19 to 70 years, 57% were females, and GFR was 106 ± 18 mL/min/1.73 m(2). There was no difference between male and female GFRs (108 ± 18 vs. 104 ± 18 mL/min/1.73 m(2) respectively, P = 0.134), and reference values were therefore developed from the pooled sample. GFR values were lower in subjects aged ≥45 years as compared with those younger than 45 years (98 ± 15 vs.112 ± 18 mL/min/1.73 m(2), P < 0.001). Based on mean ± 2 SD, GFR reference values were 76 to 148 mL/min/1.73 m(2) for subjects younger than 45 years and 68 to 128 mL/min/1.73 m(2) for individuals older than 45 years, irrespective of gender. CONCLUSION: The age-adjusted reference intervals reported may be reliably adopted to evaluate kidney function, since they are based on recommended standards.

Is there a role for inherited TRß mutation in human carcinogenesis? [corrected].

Resistance to thyroid hormone (RTH) is a rare autosomal dominant inherited disorder characterized by end-organ reduced sensitivity to thyroid hormone. This syndrome is caused by mutations of the thyroid hormone receptor (TR) ß gene, and its clinical presentation is quite variable. Goiter is reported to be the most common finding. A close association of TRß mutations with human cancers has become apparent, but the role of TRß mutants in the carcinogenesis is still undefined. Moreover, higher TSH levels, described in RTH syndrome, are correlated with increased risk of thyroid malignancy, whereas TSH receptor stimulation is likely to be involved in tumor progression. We report here an illustrative case of a 29 year-old patient with RTH caused by a mutation in exon 9 (A317T) of TRß gene, who presented multicentric papillary thyroid cancer. We review the literature on this uncommon feature, and discuss the potential role of this mutation on human tumorigenesis, as well as the challenges in patient follow-up.

Is there a role for inherited TR βmutation in human carcinogenesis? / Qual o papel da mutação do TR β na carcinogênese da tireoide em humanos?

Resistance to thyroid hormone (RTH) is a rare autosomal dominant inherited disorder characterized by end-organ reduced sensitivity to thyroid hormone. This syndrome is caused by mutations of the thyroid hormone receptor (TR) β gene, and its clinical presentation is quite variable. Goiter is reported to be the most common finding. A close association of TRβ mutations with human cancers has become apparent, but the role of TRβ mutants in the carcinogenesis is still undefined. Moreover, higher TSH levels, described in RTH syndrome, are correlated with increased risk of thyroid malignancy, whereas TSH receptor stimulation is likely to be involved in tumor progression. We report here an illustrative case of a 29 year-old patient with RTH caused by a mutation in exon 9 (A317T) of TRβ gene, who presented multicentric papillary thyroid cancer. We review the literature on this uncommon feature, and discuss the potential role of this mutation on human tumorigenesis, as well as the challenges in patient follow-up.

A síndrome da resistência aos hormônios tireoidianos (RHT) é caracterizada por redução da sensibilidade aos hormônios da tireoide. A apresentação clínica é variável, sendo a presença de bócio a manifestação mais frequentemente descrita. A associação de mutação no receptor β e neoplasias em humanos vem sendo demonstrada recentemente, porém o mecanismo pelo qual a mutação desse receptor está envolvida na carcinogênese não está completamente definido. Além disso, níveis elevados de TSH sérico, descritos na RHT, estão associados a aumento do risco de câncer de tireoide, e o estímulo do TSH está provavelmente envolvido na patogênese desses carcinomas. Este artigo relata o caso de um homem de 29 anos com RHT, com análise molecular demonstrando mutação no éxon 9, códon 317, e carcinoma papilar de tireoide. Revisamos a literatura dos casos relatados os quais descrevem associação entre RHT e câncer de tireoide e discutimos os desafios do tratamento e seguimento desses pacientes.

[Gestational diabetes management: a multidisciplinary treatment algorithm]. / Diabetes gestacional: um algoritmo de tratamento multidisciplinar.

Effective treatment of gestational diabetes is important as an attempt to avoid unfavorable maternal and fetal outcomes. The objective of this paper is to describe the available therapies to optimize gestational diabetes treatment and to suggest a multidisciplinary approach algorithm. Nutrition therapy is the first option for the majority of these pregnancies; light to moderate physical activity is recommended in the absence of obstetrical contraindications. Medical treatment is recommended if glycemic control is not achieved or if excessive fetal growth is detected by ultrasound. Insulin is the standard treatment although oral antidiabetic drugs have recently been considered an effective and safe option. The monitoring of gestational diabetes treatment includes capillary glucose measurements and evaluation of fetal abdominal circumference by ultrasound performed around the 28th gestational week.