Contraception in women with diabetes: adequacy of medical files registration and prescription - a cross-section study.

OBJECTIVE: To describe the adequacy of diabetes mellitus (DM) patient's files registry regarding contraception method (CM), factors associated with lack of registry, and if prescription is in accordance with World Health Organization (WHO) eligibility criteria. RESEARCH DESIGN AND METHODS: This cross-sectional study was developed in two phases: (1) electronic medical records of women with DM who attended the outpatient clinic of a university hospital were reviewed to identify women in reproductive age and to look for CM registration and (2) interviews regarding contraception use, comorbidities and chronic DM complications. RESULTS: Among 1069 files analyzed, 313 women with DM in childbearing age were identified. Out of those, 55.3% had a CM registered. Age >40 years, non-white skin color, and ≤11 years of education were associated with no registration. Of the 270 women interviewed, 201 (74.4%) were using CM. Out of the 69 patients not on CM, 51 fertile patients were at risk of an unplanned pregnancy (18.8% of the sample). The most frequently used method was oral hormonal (combined: 34.3%; progestin-only: 17.9%), and 67 (33.3%) were using an inadequate method (WHO eligibility category 3/4). CONCLUSION: One third of women with DM are in childbearing age. Older age, non-white skin color, and lower education level were associated with lack of CM registration. One-third of respondents were using CM inappropriate for their clinical condition and one-fifth were at risk for an unplanned pregnancy. So, improvements in family planning for women with DM should be instituted.

Glycated Hemoglobin and Blood Pressure Levels in Adults With Type 2 Diabetes: How Many Patients Are on Target?

OBJECTIVES: Achieving glycated hemoglobin (A1C) and blood pressure targets is an important strategy for preventing chronic vascular complications in diabetes. Our aim in this study was to determine the proportion of type 2 diabetes patients who meet the recommended A1C and arterial blood pressure targets and to identify the determinants of failure to do so. METHODS: A cross-sectional study was conducted in an outpatient endocrine clinic at a university hospital. The A1C goal was 7% in general and 8% for patients with advanced chronic complications. Regarding blood pressure, the overall expected target was 140/90 mmHg. RESULTS: A total of 602 type 2 diabetes patients were analyzed: 62% were female, 14% self-reported as black, mean age was 63±11 years, mean diabetes duration was 17±9 years and median A1C was 8.0% (interquartile range, 7.0% to 9.5%). Macrovascular disease was present in 33% of the patients, diabetic retinopathy in 47%, peripheral neuropathy in 43% and diabetic kidney disease in 56%. Regarding metabolic control, 403 (67%) patients were not at the adjusted target A1C level, and being female, black, young and an insulin user were the main determinants of poor glycemic control. Regarding blood pressure, 348 (58%) patients were not at the recommended targets, and a more advanced age was the main associated factor. CONCLUSIONS: Because more than half of type 2 diabetes outpatients do not meet the recommended A1C and blood pressure target values, there is a major call to overcome the therapeutic inertia and target treatment of patients on an individual basis.

Association between left ventricular mass, androgens, adiposity and insulin resistance in girls with precocious pubarche: a case-control study.

OBJECTIVE: Precocious pubarche (PP) has been linked to higher prevalence of metabolic disturbances and polycystic ovary syndrome (PCOS). The aim of the study was to assess echocardiographic parameters in PP girls and to analyse their relationship with androgens and insulin resistance (IR). DESIGN: Case-control study. PATIENTS: Thirty-five PP girls and 35 healthy age-matched controls. MEASUREMENTS: Clinical, hormonal and metabolic profiles, echocardiography, body composition and oral glucose tolerance test. RESULTS: Chronological age (10·04 ± 2·6 years in PP vs 10·13 ± 2·56 years in controls, P = 0·227), and pubertal stage at the time of the study were similar between the groups. PP girls had higher free androgen index (FAI) [1·39 (0·48-3·64) vs 1·06 (0·39-1·7), P = 0·005] and QUICKI (0·58 ± 0·08 vs 0·63 ± 0·12, P = 0·021). However, HOMA-IR was not significantly different between the groups [2·79 (1·84-4·05) vs 2·15 (1·09-3·23), P = 0·085]. After adjusting for total body fat, left ventricular mass (LVM) was higher in the PP group (97·31 ± 33·37 vs 81·25 ± 19·06 g, P = 0·017) as well as A' wave (5·66 ± 1·34 vs 5·09 ± 0·98 cm/s, P = 0·025), a measurement of diastolic function. FAI and total body fat were independent predictors of higher LVM and together with HOMA-IR contributed 72% of LVM variability in the PP group. CONCLUSION: In this study with PP girls, greater LVM, associated with higher androgen levels, IR and total body fat, occurred early in pubertal development.

Adipose tissue dysfunction, adipokines, and low-grade chronic inflammation in polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS), a complex condition that affects women of reproductive age, is characterized by ovulatory dysfunction and androgen excess. Women with PCOS present higher prevalence of obesity, central adiposity, and dyslipidemia, and face increased risk of type 2 diabetes. PCOS is closely linked to functional derangements in adipose tissue. Adipocytes seem to be prone to hypertrophy when exposed to androgen excess, as experienced by women with PCOS, and both adipose tissue hypertrophy and hyperandrogenism are related to insulin resistance. Hypertrophic adipocytes are more susceptible to inflammation, apoptosis, fibrosis, and release of free fatty acids. Disturbed secretion of adipokines may also impact the pathophysiology of PCOS through their influence on metabolism and on sex steroid secretion. Chronic low-grade inflammation in PCOS is also related to hyperandrogenism and to the hypertrophy of adipocytes, causing compression phenomena in the stromal vessels, leading to adipose tissue hypoperfusion and altered secretion of cytokines. Lifestyle changes are the first-line intervention for reducing metabolic risks in PCOS and the addition of an insulin-sensitizing drug might be required. Nevertheless, there is not sufficient evidence in favor of any specific pharmacologic therapies to directly oppose inflammation. Further studies are warranted to identify an adipokine that could serve as an indirect marker of adipocyte production in PCOS, representing a reliable sign of metabolic alteration in this syndrome.

Vitamin D deficiency in girls from South Brazil: a cross-sectional study on prevalence and association with vitamin D receptor gene variants.

BACKGROUND: Vitamin D deficiency has been associated with a multitude of disorders including diabetes, defective insulin secretion as well as rickets and poor bone health. Vitamin D is also a concern during childhood and adolescence and has been reported in girls from South Brazil. We determined the prevalence of vitamin D deficiency in girls from South Brazil and investigated whether the genotypic distribution of the BsmI, ApaI and TaqI polymorphisms of the VDR gene and their haplotypes were associated with vitamin D levels. METHODS: Cross-sectional study including 234 apparently healthy girls aged 7 to 18 years. Height and weight were measured for calculation of body mass index (BMI) percentiles for age. Plasma levels of 25-hydroxyvitamin D [25(OH)D] were assessed. Participants were genotyped for ApaI (rs7975232), TaqI (rs731236), and BsmI (rs1544410) SNPs. RESULTS: The median and interquartile range (25-75%) of BMI percentile was 62.0 (33.3 - 84.9). The frequency of overweight/obesity was 24.9%. Circulating levels of 25(OH)D (≥ 30 ng/mL) were adequate in 9.4%; insufficient in 54.3% (20-29 ng/mL); and deficient in 36.3% (< 20 ng/mL). Genotype frequencies were GG = 47.0%, GA = 41.5%, and AA = 11.5% for BsmI; GG = 16.7%, GT = 52.6%, and TT = 30.8% for ApaI; TT = 46.2%, TC = 44.9% and CC = 9.0% for TaqI. Genotypes with no gene variance (ancestral wild genotype) of BsmI (GG vs. GA + AA, two-tailed Student's t-test p < 0.001), ApaI (GG vs. GT + TT, two-tailed Student's t-test p = 0.031) and TaqI (TT vs. TC + CC, two-tailed Student's t-test p = 0.005) SNPs and the GGT haplotype (two-tailed Student's t-test p = 0.036) were significantly associated with lower 25(OH)D levels. CONCLUSIONS: 25-hydroxyvitamin D deficiency and insufficiency were highly prevalent in this sample. The BsmI, ApaI and TaqI wild variants of the VDR gene, as well as the GGT haplotype, were associated with lower vitamin D levels, suggesting that VDR gene polymorphisms could be linked to higher susceptibility to vitamin D deficiency in a sub-population of children and adolescents.

Estudo do encurtamento global do átrio esquerdo em fetos de mães diabéticas / Study of global left atrial shortening in fetuses of diabetic mothers

OBJETIVO: Testar a hipótese de que a fração de encurtamento atrial esquerda seja menor nos fetos de mães diabéticas do que em fetos de mães sem doenças sistêmicas. MÉTODOS: Foram examinados, por ecocardiografia, 42 fetos de mães com diabetes prévio ou gestacional e 39 fetos normais de mães sem doença sistêmica (controles), com idades gestacionais a partir da 25ª semana até o termo. A fração de encurtamento atrial esquerda foi obtida pelo quociente diâmetro máximo do átrio esquerdo (AE) - diâmetro mínimo AE/diâmetro máximo AE. Os dados foram comparados pelo teste t de Student, com um alfa crítico de 0,05. RESULTADOS: Os filhos de mães diabéticas apresentaram fração de encurtamento atrial esquerda média de 0,39 ± 0,15 e os fetos do grupo controle de 0,51 ± 0,11. Esta diferença foi significativa, com p < 0,001. CONCLUSÃO: A dinâmica atrial esquerda, com diminuição do seu encurtamento global, está acentuada nos filhos de mães diabéticas. Especulamos que este parâmetro possa ser útil na avaliação da função diastólica ventricular esquerda fetal.

Mobility of the Septum primum does not depend on the foramen ovale diameter in normal fetuses.

OBJECTIVE: To test the hypothesis that a correlation exists between the maximum foramen ovale diastolic diameter and the excursion index (EI) of the septum primum in normal fetuses. METHODS: One hundred and two normal fetuses with gestational ages ranging from 20 to 40 weeks were submitted to echocardiography. The foramen ovale diameter and the "maximal excursion" of the septum primum were measured in a 4-chamber view. The data were analyzed by Pearson's correlation coefficient. RESULTS: The mean foramen ovale (FO) diameter was 5.06 +/- 1.29 mm; the maximal excursion of the septum primum was 5.42 +/- 1.41 mm; the left atrium diameter 11.47 +/- 2.76 mm; the septum primum "excursion index" was 0.48 +/- 0.09. Mean FO/EI ratio was 11.35 +/- 3.94 mm. No FO/EI correlation (r = -0.03) existed, and a weak foramen ovale/left atrium correlation (r = 0.31) was observed, as well as a weak foramen ovale/excursion of septum primum correlation (r = 0.21). CONCLUSION: Septum primum mobility does not depend on the foramen ovale diameter in normal fetuses, suggesting that the modifications of its diastolic displacement is not influenced by the size of the interatrial opening.

A mobilidade do Septum primum não depende do diâmetro do forame oval em fetos normais / Mobility of the Septum primum does not depend on the foramen ovale diameter in normal fetuses

OBJETIVO: Testar a hipótese de que existe correlação entre o diâmetro máximo diastólico do forame oval e o índice de excursão do septum primum em fetos normais. MÉTODOS: Foram examinados, por ecocardiografia, 102 fetos normais de gestantes com idades gestacionais entre 20 e 40 semanas. O diâmetro do forame oval e a excursão máxima do septum primum foram medidos num corte de 4 câmaras. Na análise dos dados utilizou-se o coeficiente de correlação de Pearson. RESULTADOS: A média do forame oval foi de 5,06 ± 1,29 mm; a da excursão máxima do septum primum de 5,42 ± 1,41 mm; a do átrio esquerdo 11,47 ± 2,76 mm e a do índice de excursão 0,48 ± 0,09. A relação média FO/IE foi de 11,35 ± 3,94 mm. Não houve correlação FO/IE (r = -0,03) e observou-se correlação fraca do forame oval com o átrio esquerdo (r = 0,031) e com a excursão do septum primum (r = 0,21). CONCLUSAO: A mobilidade do septum primum não depende do diâmetro do forame oval em fetos normais, sugerindo que as modificações da sua excursão diastólica não decorram do grau de abertura interatrial.

Ductus venosus flow and myocardial hypertrophy in fetuses of diabetic mothers.

OBJECTIVE: To test the hypothesis that the pulsatility index of ductus venosus (PIDV) is greater in the fetuses of diabetic mothers (FDM) with myocardial hypertrophy (MH) than in the FDM with no MH and in the control fetuses of nondiabetic mothers (FNDM). Comparing the results with mitral and tricuspid diastolic peak flows. METHODS: The cross-sectional study included fetuses with gestational ages ranging from 20 weeks to term, divided into the following 3 groups: 56 FDM with MH (group I), 36 FDM with no MH (group II), and 53 FNDM (group III, control). The Doppler echocardiogram assessed the PIDV through the ratio (systolic velocity - presystolic velocity)/mean velocity. The mitral and tricuspid E and A waves were also assessed. RESULTS: The mean PIDV in groups I, II, and III were 1.13 +/- 0.64, 0.84 +/- 0.38, and 0.61 +/- 0.17, respectively. Using ANOVA and the Tukey test, a statistically significant difference was found in the 3 groups (P = 0.015 between groups I and II; P < 0.001 between groups I and III; and P = 0.017 between groups II and III). The mean mitral E wave was significantly greater in group I (0.39 +/- 0.12 m/s) than in groups II (0.32 +/- 0.08 m/s) (P = 0.024) and III (0.32 +/- 0.08 m/s) (P = 0.023). The mean tricuspid E wave was also greater in group I (0.43 +/- 0.1 m/s) than in group III (0.35 +/- 0.10 m/s) (P = 0.031). CONCLUSION: The PIDV is significantly greater in FDM with MH than in FDM with no MH and in FNDM. Because the PIDV may represent modifications in ventricular compliance, this index may be a more sensitive parameter for assessing fetal diastolic function.

Fluxo no ducto venoso e hipertrofia miocárdica em fetos de mães diabéticas / Ductus venosus flow and myocardial hypertrophy in fetuses of diabetic mothers

OBJETIVO: Testar a hipótese de que o índice de pulsatilidade do ducto venoso (IPDV) é maior nos fetos de mães diabéticas (FMD) com hipertrofia miocárdica (HM) do que em FMD sem HM e em fetos controles de mães não diabéticas (FMND) comparando os resultados com os picos de velocidade dos fluxos diastólicos nas valvas mitral e tricúspide. MÉTODOS: Estudo transversal incluindo fetos com idade gestacional entre 20 semanas até o termo, divididos em 3 grupos: 56 FMD com HM (grupo I), 36 FMD sem HM (grupo II) e 53 FMND (grupo III, controle). O Doppler-ecocardiograma avaliou o IPDV através da razão (velocidade sistólica - velocidade pré-sistólica)/velocidade média. As ondas E e A dos fluxos mitral e tricúspide foram também avaliadas. RESULTADOS: A média do IPDV no grupo I foi de 1,13 ± 0,64, no grupo II, de 0,84 ± 0,38 e no grupo III de 0,61±0,17. Aplicando-se a ANOVA e o teste de Tukey, houve diferença estatisticamente significativa entre os 3 grupos (p= 0,015 entre os grupos I e II, p < 0,001 entre os grupos I e III e p = 0,017 entre os grupos II e III). A média da onda E mitral foi significativamente maior no grupo I (0,39 ± 0,12 m/s) do que nos grupos II (0,32 ± 0,08 m/s) (p=0,024) e III (0,32 ± 0,08 m/s) (p=0,023). A média da onda E tricúspide foi também maior no grupo I (0,43 ± 0,1 m/s) do que no grupo III (0,35 ± 0,10 m/s) (p= 0,031). CONCLUSAO: O IPDV é significativamente maior em FMD com HM do que em FMD sem HM e do que em FMND. Como o IPDV pode representar modificações na complacência ventricular, este índice pode ser um parâmetro mais sensível para a avaliação da função diastólica fetal.

Study of global left atrial shortening in fetuses of diabetic mothers.

OBJECTIVE: To test the hypothesis that left atrial shortening fraction is lower in fetuses of diabetic mothers than in fetuses of mothers with no systemic disease. METHODS: Forty-two fetuses of mothers with previous diabetes or gestational diabetes and 39 healthy fetuses of mothers with no systemic disease (controls) underwent echocardiographic examination. Their gestational ages ranged from 25 weeks to term. The left atrial shortening fraction was obtained with the following formula: (left atrial maximum diameter - left atrial minimum diameter)/left atrial maximum diameter. Data were compared using the Student t test, with an alpha level of 0.05. RESULTS: Mean left atrial shortening fractions in fetuses of diabetic mothers and in those in the control group were 0.39 +/- 0.15 and 0.51 +/- 0.11, respectively. This difference was significant with P < 0.001. CONCLUSION: Left atrial dynamics, with a reduction in global left atrial shortening, is increased in fetuses of diabetic mothers. We speculate that this parameter may be useful in assessing fetal left ventricular diastolic function.

Pulsatilidade venosa pulmonar em fetos de mäes diabéticas: estudo Doppler-ecocardiográfico pré-natal / Pulmonary vein pulsatility in fetuses of diabetic mothers: prenatal Doppler echocardiographic study

OBJECTIVE: To verify the hypothesis that the pulmonary vein pulsatility index is higher in fetuses of diabetic mothers than it is in normal fetuses of nondiabetic mothers. METHODS: Twenty-four fetuses of mothers with either gestational or previous diabetes (cases), and 25 normal fetuses of mothers without systemic disease (control) were examined. Fetuses were examined through prenatal Doppler and color flow mapping. The pulmonary vein pulsatility index was obtained by placing the pulsed Doppler sample volume over the right superior pulmonary vein and applying the formula (systolic velocity - presystolic velocity)/mean velocity. RESULTS: The mean gestational age of the study fetuses was 30.3±2.7 weeks, and gestational age of the controls was 29±3.3 weeks, with no significant difference in gestational age between groups (p=0.14). Fetuses of diabetic mothers had a mean pulmonary vein pulsatility index of 1.6±1, and those of the control group had an index of 0.86±0.27. CONCLUSION: Fetuses of diabetic mothers had pulmonary vein pulsatility indexes (parameter easily obtained through Doppler echocardiography that may be related to fetal diastolic function) higher than those in fetuses of mothers with normal glycemia

Dynamics of the pulmonary venous flow in the fetus and its association with vascular diameter.

BACKGROUND: The usual positioning of the Doppler sample volume to assess fetal pulmonary vein flow is in the distal portion of the vein, where the vessel diameter is maximal. This study was performed to test the association of the pulmonary vein pulsatility index (PVPI) with the vessel diameter. METHODS AND RESULTS: Twenty-three normal fetuses (mean gestational age, 28.6+/-5.3 weeks) were studied by Doppler echocardiography. Pulmonary right upper vein flow was assessed adjacent to the venoatrial junction ("distal" position) and in the middle of the vein ("proximal" position). The vessel diameter was measured by 2D echocardiography with power Doppler, and the PVPI was obtained by the ratio (maximal velocity [systolic or diastolic peak]-minimal velocity [presystolic peak])/mean velocity. The statistical analysis used t test and exponential correlation studies. Mean distal diameter was 0.33+/-0.10 cm (0.11 to 0.57 cm), and mean proximal diameter was 0.16+/-0.08 cm (0.11 to 0.25 cm) (P<0.0001). Mean distal PVPI was 0.84+/-0.21 (0.59 to 1.38), and mean proximal PVPI was 2.09+/-0.59 (1.23 to 3.11) (P<0.0001). Exponential inverse correlation between pulmonary vein diameter and pulsatility index was highly significant (P<0.0001), with a determination coefficient of 0.439. CONCLUSIONS: In the normal fetus, the pulmonary venous flow pulsatility decreases from the lung to the heart, and this parameter is inversely correlated to the diameter of the pulmonary vein, which increases from its proximal to its distal portion. This study emphasizes the importance of the correct positioning of the Doppler sample volume, adjacent to the venoatrial junction, to assess pulmonary venous flow dynamics.

Pulmonary vein pulsatility in fetuses of diabetic mothers: prenatal Doppler echocardiographic study.

OBJECTIVE: To verify the hypothesis that the pulmonary vein pulsatility index is higher in fetuses of diabetic mothers than it is in normal fetuses of nondiabetic mothers. METHODS: Twenty-four fetuses of mothers with either gestational or previous diabetes (cases), and 25 normal fetuses of mothers without systemic disease (control) were examined. Fetuses were examined through prenatal Doppler and color flow mapping. The pulmonary vein pulsatility index was obtained by placing the pulsed Doppler sample volume over the right superior pulmonary vein and applying the formula (systolic velocity - presystolic velocity)/mean velocity. RESULTS: The mean gestational age of the study fetuses was 30.3 2.7 weeks, and gestational age of the controls was 29 3.3 weeks, with no significant difference in gestational age between groups (p=0.14). Fetuses of diabetic mothers had a mean pulmonary vein pulsatility index of 1.6 1, and those of the control group had an index of 0.86 0.27. CONCLUSION: Fetuses of diabetic mothers had pulmonary vein pulsatility indexes (parameter easily obtained through Doppler echocardiography that may be related to fetal diastolic function) higher than those in fetuses of mothers with normal glycemia.

Associação entre trauma por perda na infância e depressão na vida adulta / Association between childhood loss trauma and depression in adulthood

Observações clínicas efetuadas por psicanalistas sugerem que psicopatologias da idade adulta podem ter sido originadas na infância. Estudos publicados na última década identificaram associaçäo entre trauma na infância e depressäo na vida adulta. Vivências traumáticas na infância, como a perda de vínculos afetivos devido à morte de pais ou de irmäos ou, ainda, a privaçäo de um ou de ambos os pais por separaçäo ou abandono constituem importantes fatores associados à depressäo na vida adulta. O objetivo do presente artigo é revisar a literatura dos últimos dez anos, considerando os fatores associados à depressäo, particularmente aqueles relacionados aos estressores presentes na infância. A metodologia utilizada foi de busca on-line nas bases de dados Medline, PsycINFO, Cochrane e Lilacs, referentes ao período de maio de 1991 a maio de 2001. A maioria dos estudos incluídos nesta revisäo encontrou uma associaçäo significativa entre trauma por perdas na infância e depressäo na vida adulta, com variaçäo na intensidade das associaçöes observadas