Evaluation of a 1-h 75-g oral glucose tolerance test in the diagnosis of gestational diabetes.

In order to evaluate the performance of a 1-h 75-g oral glucose tolerance test (OGTT) for the diagnosis of gestational diabetes mellitus (GDM), a cohort of 4998 women, 20 years or older, without previous diabetes being treated in prenatal care clinics in Brazil answered a questionnaire and performed a 75-g OGTT including fasting, 1-h and 2-h glucose measurements between their 24th and 28th gestational weeks. Pregnancy outcomes were transcribed from medical registries. GDM was defined according to WHO criteria (fasting: >/=126 mg/dL; 2-h value: >/=140 mg/dL) and macrosomia as a birth weight equal to or higher than 4000 g. Areas under the receiver operator characteristic curve (AUC) were compared and diagnostic properties of various cut-off points were evaluated. The AUCs for the prediction of macrosomia were 0.606 (0.572-0.637) for the 1-h and 0.589 (0.557-0.622) for the 2-h plasma glucose test. Similar predictability was demonstrable regarding combined adverse outcomes: 0.582 (0.559-0.604) for the 1-h test and 0.572 (0.549-0.595) for the 2-h test. When the 1-h glucose test was evaluated against a diagnosis of GDM defined by the 2-h glucose test, the AUC was 0.903 (0.886-0.919). The cut-off point that maximized sensitivity (83%) and specificity (83%) was 141 mg/dL, identifying 21% of the women as positive. A cut-off point of 160 mg/dL, with lower sensitivity (62%), had higher specificity (94%), labeling 8.6% as positive. Detection of GDM can be done with a 1-h 75-g OGTT: the value of 160 mg/dL has the same diagnostic performance as the conventional 2-h value (140 mg/dL). The simplification of the test may improve coverage and timing of the diagnosis of GDM.

Evaluation of a 1-h 75-g oral glucose tolerance test in the diagnosis of gestational diabetes

In order to evaluate the performance of a 1-h 75-g oral glucose tolerance test (OGTT) for the diagnosis of gestational diabetes mellitus (GDM), a cohort of 4998 women, 20 years or older, without previous diabetes being treated in prenatal care clinics in Brazil answered a questionnaire and performed a 75-g OGTT including fasting, 1-h and 2-h glucose measurements between their 24th and 28th gestational weeks. Pregnancy outcomes were transcribed from medical registries. GDM was defined according to WHO criteria (fasting: greater than or equal to 126 mg/dL; 2-h value: greater than or equal to 140 mg/dL) and macrosomia as a birth weight equal to or higher than 4000 g. Areas under the receiver operator characteristic curve (AUC) were compared and diagnostic properties of various cut-off points were evaluated. The AUCs for the prediction of macrosomia were 0.606 (0.572-0.637) for the 1-h and 0.589 (0.557-0.622) for the 2-h plasma glucose test. Similar predictability was demonstrable regarding combined adverse outcomes: 0.582 (0.559-0.604) for the 1-h test and 0.572 (0.549-0.595) for the 2-h test. When the 1-h glucose test was evaluated against a diagnosis of GDM defined by the 2-h glucose test, the AUC was 0.903 (0.886-0.919). The cut-off point that maximized sensitivity (83%) and specificity (83%) was 141 mg/dL, identifying 21% of the women as positive. A cut-off point of 160 mg/dL, with lower sensitivity (62%), had higher specificity (94%), labeling 8.6% as positive. Detection of GDM can be done with a 1-h 75-g OGTT: the value of 160 mg/dL has the same diagnostic performance as the conventional 2-h value (140 mg/dL). The simplification of the test may improve coverage and timing of the diagnosis of GDM.

Plasmid-mediated extended-spectrum beta-lactamase-producing strains of Enterobacteriaceae isolated from diabetes foot infections in a Brazilian diabetic center.

We bacteriologically analyzed 156 species of Enterobacteriaceae, isolated from 138 patients with community-acquired diabetic foot ulcers, in a prospective study made at a diabetic center and at the Federal University of Ceará, Brazil, from March, 2000, to November, 2001. The samples were cultured using selective media, and identification, susceptibility tests and detection of plasmid-mediated-extended-spectrum-beta-lactamase (ESBL) producing strains were made with conventional and automated methods. The most frequently occurring pathogens were K. pneumoniae (21.2%), Morganella morganii (19.9%) and E. coli (15.4%). High resistance rates were noted for ampicillin, first generation cephalosporin, trimethoprim/sulfamethoxazole, tetracycline, amoxicillin-clavulanic acid and chloramphenicol. ESBL-producing strains were detected in 6% of the patients. Resistance among gram-negative bacteria has become increasingly common, even in community-acquired infections.

Free radical scavengers improve the impaired endothelium-dependent responses in aorta and kidneys of diabetic rabbits.

The effects of two endogenous antioxidants, alpha-lipoic acid and reduced gluthathione (GSH), were evaluated in the response of the renal vasculature and aortic rings ex vivo of 4-week alloxan-diabetic rabbits to the endothelium-dependent agonists bradykinin (BK) and acetylcholine (Ach) or to the endothelium-independent agonist sodium nitroprusside (SNP) and compared with age and sex-matched euglycemic rabbits. The maximal decrease in perfusion pressure (R(max)) after BK infusion in the renal vasculature from diabetic rabbits was 5.4+/-1.3% (PD(2) 8 [12.6-3.4]) compared with 34.2+/-4.2% (PD(2) 9 [11.3-6.7]) (P<0.05) attained in tissues obtained from euglycemic rabbits. The addition of 1 microM lipoic acid or GSH improved (P<0.05) the R(max) to BK to 18.3+/-2.4% (PD(2) 8.6 [12.4-4.8]) and 19.5+/-3.7% (PD(2) 9.1 [13.3-4.9]), respectively. Similarly, the maximal vasorelaxant response to Ach in kidneys from diabetic rabbits was 16+/-2.0% (PD(2) 7.3 [10.4-4.2] whilst the R(max) in kidneys from euglycemic animals was 52.7+/-4.9% (PD(2) 11.3 [16.4-6.2]). Incubation with 1 microM alpha-lipoic acid or GSH restored the R(max) to Ach to 31+/-3.9% (PD(2) 9.8 [14.3-5.3]) and to 23+/-5.4% (PD(2) 7.6 [11.4-3.8], respectively. The vasodilatory response to SNP was unaltered among tissues from diabetic and euglycemic rabbits and was also unaffected by the treatments utilized. In addition, the R(max) to Ach in aortic rings of diabetic rabbits was 28.7+/-2.4% (PD(2) 8.3 [11.7-4.9]) compared with 100% (PD(2) 7.9 [12.1-3.7]) obtained in tissues gathered from euglycemic rabbits. The pretreatment of the tissues with alpha-lipoic acid restores the R(max) to 47.4+/-4% (PD(2) 11.1 [14.3-7.9]) and the pretreatment with GSH to 52+/-3.2% (PD(2) 9.8 [12.7-6.9]). Similarly, the response to SNP was unaltered in all groups. Lipoic acid and reduced gluthatione directly improved the endothelium-dependent response of renal arterioles and aortic rings of diabetic rabbits.

Plasmid-mediated extended-spectrum beta-lactamase-producing strains of Enterobacteriaceae isolated from diabetes foot infections in a Brazilian diabetic center

We bacteriologically analyzed 156 species of Enterobacteriaceae, isolated from 138 patients with community-acquired diabetic foot ulcers, in a prospective study made at a diabetic center and at the Federal University of Ceará, Brazil, from March, 2000, to November, 2001.The samples were cultured using selective media, and identification, susceptibility tests and detection of plasmid-mediated-extended-spectrum-beta-lactamase (ESBL) producing strains were made with conventional and automated methods. The most frequently occurring pathogens were K. pneumoniae (21.2 percent), Morganella morganii (19.9 percent) and E. coli (15.4 percent). High resistance rates were noted for ampicillin, first generation cephalosporin, trimethoprim/sulfamethoxazole, tetracycline, amoxicillin-clavulanic acid and chloramphenicol. ESBL-producing strains were detected in 6 percent of the patients. Resistance among gram-negative bacteria has become increasingly common, even in community-acquired infections

Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes.

OBJECTIVE: To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. RESEARCH DESIGN AND METHODS: This cohort study consecutively enrolled Brazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values > or = 5.3 mmol/l (fasting), > or = 10 mmol/l (1 h), and > or = 8.6 mmol/l (2 h). WHO criteria require a plasma glucose > or = 7.0 mmol/l (fasting) or > or = 7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded. RESULTS: Among the 4,977 women studied, 2.4% (95% CI 2.0-2.9) presented with GDM by ADA criteria and 7.2% (6.5-7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73-2.18), preeclampsia (2.28, 1.22-4.16), and perinatal death (3.10, 1.42-6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06-1.95), preeclampsia (1.94, 1.22-3.03), and perinatal death (1.59, 0.86-2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria. CONCLUSIONS: GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.

Capture-recapture method to estimate lower extremity amputation rates in Rio de Janeiro, Brazil.

OBJECTIVE: To estimate rates of lower extremity amputations (LEAs) in persons with peripheral vascular disease, diabetes mellitus, trauma, neoplasm, osteomyelitis, or emphysematous gangrene. METHODS: Regional amputee registries were used to estimate the rate of lower extremity amputations with the capture-recapture (CR) technique. Data were extracted from three amputee registries in Rio de Janeiro: source 1, with 1,191 cases from 23 hospitals; source 2, with 157 cases from a limb-fitting center; and source 3, with 34 cases from a rehabilitation center. Amputee death certificates from source 1 identified 257 deaths from 1992 to 1994. Three CR models were evaluated using sources 2 and 3. In order to avoid an overestimation of the rate of LEAs, two models were applied for the data analysis: in one case, deceased patients listed in source 1 were excluded from the model, and in the other case, deceased patients were included as well. RESULTS: Excluding the 257 deaths, the estimated number of amputations in the municipality of Rio de Janeiro from 1992 to 1994 was 3,954, for a mean annual incidence rate of 13.9 per 100,000 inhabitants. Among persons with diabetes, the annual incidence rate of lower extremity amputations was substantially higher (180.6 per 100,000 persons per year), representing 13 times the risk of individuals without diabetes. The yearly rate of LEAs according to the routine surveillance system was estimated at 5.4 and 96.9 per 100,000 in the general population and in diabetics, respectively. If data from the three registries are added, 1,382 patients with LEAs were identified, with the reasons for the amputations distributed as follows: peripheral vascular disease = 804 (58.1%); diabetes mellitus = 379 (27.4%); trauma = 103 (7.4%); osteomyelitis = 44 (3.1%); gangrene = 36 (2.6%), and neoplasm = 16 (1.1%). CONCLUSIONS: These findings show a high incidence of LEAs in Brazil, when compared to countries such as Spain, that is attributable mainly to peripheral vascular disease and diabetes mellitus.

Prevalence of gestational diabetes mellitus--do the new WHO criteria make a difference? Brazilian Gestational Diabetes Study Group.

AIMS: To describe the prevalence of gestational diabetes mellitus (GDM) according to the 1998 WHO provisional recommendations and compare it to that found with previous 1985 WHO criteria. METHODS: A total of 5564 consecutive women aged 20 years or more without diagnosis of diabetes mellitus outside of pregnancy in general prenatal care clinics of the National Health Service in 6 state capitals of Brazil, between their 20th and 28th gestational weeks were enrolled. RESULTS: Of the 5004 women who completed a 75-g oral glucose tolerance test, 379 (7.6%, 95% confidence interval (CI) 6.9% to 8.4%) had GDM by the 1998 criteria (fasting glucose > or = 7.0 mmol/l or 2 h glucose > or = 7.8 mmol/l). Of these 379 cases, only 21 (5.5%) had hyperglycaemia in the range considered diabetes mellitus outside pregnancy (fasting glucose > or = 7.0 mmol/l or 2 h glucose > or = 11.1 mmol/l); the remaining 358 (94.5%) had hyperglycaemia in the impaired glucose tolerance range (fasting glucose < 7.0 and 2 h glucose > or = 7.8 mmol/l and < 11.1 mmol/l). Using the 1985 criteria (fasting or 2 h glucose > or = 7.8 mmol/l), 378 cases of GDM were found, 15 in the diabetes range and 363 in the impaired glucose tolerance range. CONCLUSIONS: Prevalence of GDM is minimally altered by the new WHO definition. Although GDM is a common condition, the vast majority of the cases have hyperglycaemia in the range considered impaired glucose tolerance outside pregnancy.

Effect of insulin on renal vascular escape in normal and diabetic kidney.

Renal Vascular Escape was studied in the isolated perfused kidney harvested from diabetic and normal rabbits. Diabetes was induced 3-4 weeks earlier by injecting the animals with 150 mg/kg alloxan IP. To induce vasoconstriction, norepinephrine (10(-6) M) (NOR) was infused to the renal artery for 20 min, during 3 cycles, with intervals of 10 min for drug wash out, with a total duration of 90 min of observation. Administration of NOR induced intense vasoconstriction which was followed by a period of relaxation, in spite of the continued infusion of the adrenergic neurohormone. This was named renal vascular escape (RVE). RVE was present in all control animals but was severely impaired in diabetic kidneys. The administration of insulin (20 mU/ml or 2 mU/ml) to the perfusate promoted a significant blockade of escape (p < 0.001) in normal kidneys, which was time dependent, and only a slight effect in the diabetic group. These data show an interaction between insulin and RVE in normal animals and could point out another defect in diabetes, as related to insulin resistance.

Alloxan diabetes blocks noradrenergic tachyphylaxis in the isolated rabbit kidney--effects of insulin.

Normal and alloxan treated diabetic rabbit kidneys were perfused with Krebs-Henseleit solution in a non-recirculating system and the effects of norepinephrine (NOR) 10(-6)M were tested by infusion of this drug for three subsequent periods of 20 min each, with an interval of 10 min for drug wash-out. In the control kidneys the infusion of NOR promoted an intense vasoconstriction, which was less intense during the second and the third periods. This was known as tachyphylaxis. In contrast to the controls, kidneys from diabetic animals did not show tachyphylaxis to NOR, but when insulin was added to the perfusate, tachyphylaxis appeared. Normal kidneys perfused with hyperosmolar solutions show, as in controls, the same phenomenon. The data presented here demonstrate a defect of adrenergic vascular receptors in alloxan treated kidneys, which can be acutely reversed by insulin. These facts are of importance for the understanding of the vascular disease in diabetes.

Insulin blockade of norepinephrine tachyphylaxis in the perfused kidney.

Tachyphylaxis to norepinephrine (NOR) was determined in the rabbit kidney perfused with Krebs-Henseleit solution by using different calcium concentrations (2.5 mM; 5 mM; 12.5 mM) in the perfusate. The addition of insulin to the perfusion fluid causes a reversion of the tachyphylaxis which is seen at those Ca2+ concentrations. This effect is demonstrated mainly at 5 mM Ca2+. When kidneys were perfused with 12.5 mM calcium there was disappearance of NOR-mediated tachyphylaxis, both in the absence and in the presence of insulin. In this calcium concentration, insulin decreases vascular reactivity to NOR. These results suggest that insulin blockade of alpha adrenergic tachyphylaxis is a calcium-mediated effect which is thought to be due to an enhancement of calcium pumping inside the cells.

Etiopatogenia da microangiopatia renal no diabetes mellitus. / Pathogenesis of renal microangiopathy in diabetes mellitus

A autora faz uma abordagem da literatura pertinente aos mecanismos geradores da microangiopatia diabetica, focalizando sobretudo a nefropatia e seus aspectos bioquimico-estruturais, no sentido de correlacionar alteracoes de membranas e sensibilidade de receptores. Apresentam tambem um enfoque sobre o controle metabolico dos receptores adrenergicos e suas alteracoes no diabetes mellitus.Conclusoes de seus estudos sobre o receptor vascular adrenergico de rins de coelhos diabeticos sao enfatizados. Uma hipotese e sugerida, na qual alteracoes na sensibilidade do receptor a agonistas adrenergicos poderia ser o sitio primario de um fenomeno mais geral, isto e, a nefropatia diabetica