Knowledge about the disease and adherence to treatment in patients with diabetes

Introduction: Glycemic decompensation in diabetes is one of the major factors for the development of chronic disease complications. Factors involved in the adequate control of diabetes include adherence to pharmacological treatment and knowledge about the disease.Methods: Cross-sectional study on the factors associated with adherence to drug treatment and knowledge about diabetes in diabetic patients treated at Hospital Universitário de Santa Maria between 2018 and 2019, based on the validated Morisky-Green test and on the Diabetes Knowledge Questionnaire.Results: A total of 201 patients diagnosed with diabetes were included, the majority (85.6%) of which had type 2 diabetes and were white (75.6%), with a mean age of 59.4 years. An association between insufficient knowledge about diabetes and patients with type 2 diabetes was observed. An association was found between patients with type 2 diabetes using insulin and non-adherence to drug treatment compared with patients with type 2 diabetes who did use insulin. The research also showed that non-adherence to drug treatment was associated with higher occurrence of hypoglycemia compared with patients who adhered to drug treatment.Conclusion: The data obtained in our study allows us to conclude that non-adherence to pharmacological treatment makes diabetes therapy more complicated and worsens the prognosis.

Pens versus syringes to deliver insulin among elderly patients with type 2 diabetes: a randomized controlled clinical trial.

BACKGROUND: Diabetes mellitus (DM) is a prevalent disease among elderly population. As the disease progresses, insulin may become necessary. The use of pens application seems to be more practical. However, the influence of this method on glycemic control needs to be defined in elderly people. METHODS: Randomized clinical trial comparing pens and syringes for insulin application among patients with type 2 DM over 60 years old and Glycated Hemoglobin > 8.5% at baseline. The follow-up was 24 weeks, with monthly medical visits to adjust the treatment. All patients received insulin NPH and, if necessary, insulin Regular. We assessed glycemic control, adherence to treatment, hypoglycemia occurrence, need for adjustment in treatment and impact on quality of life, RESULTS: We included 121 patients with mean age of 65.75 years. Sixty-one were randomized for pen group (PG) and 60 patients for syringe group (SG). At baseline, mean HbA1c was 10.34 ± 1.66% and 9.90 ± 1.25% (p = 0.103) in PG and SG respectively. Mean HbA1c was 8.39 ± 1.28% in PG and 8.85 ± 1.74% in SG (p = 0.101) at 24 weeks. However, there was a more significant reduction in PG (- 1.94 ± 1.93% in PG and - 1.04 ± 1.46% in SG, p < 0.05) during follow-up. We found no difference in treatment adherence rates, hypoglycemia, greater need for insulin doses or oral medication, and progression to basal-bolus insulin scheme. We also found no difference in the impact of the disease on quality of life between groups. CONCLUSION: Although we did not find any difference in the impact on quality of life, frequency of hypoglycemia or adherence, the PG showed a reduction in HbA1c higher in 24 weeks of follow-up. CLINICAL TRIAL REGISTRATION: NCT02517242.

Self-monitoring blood glucose improves glycemic control in type 2 diabetes without intensive treatment: A systematic review and meta-analysis.

AIMS: Systematic review and meta-analysis to evaluate the effect of Self-Monitoring of Blood Glucose (SMBG) on glycemic control in patients with type 2 Diabetes (T2D). METHODS: We searched the Medline, Embase, Cochrane Central, and ClinicalTrials.gov databases up to 20 July 2017. We also performed a manual search of abstracts from recent meetings of the American Diabetes Association and the European Association for the Study of Diabetes. STUDY SELECTION: randomized controlled trials (RCTs) conducted in patients with T2D comparing any kind of SMBG to a control group. Two independent reviewers assessed the eligibility of references. Influence of SMBG in glycated hemoglobin (HbA1c) was aggregated as weighted mean difference accessed by direct random effect meta-analyses at 12, 24 weeks and 1 year. Sub-analyses were made to assess the effects of previous glycemic control and number of tests performed. RESULTS: SMBG was associated with a reduction of HbA1c at 12 weeks (-0.31%; 95% CI: -0.57 to -0.05) and 24 weeks (-0.34%; 95%CI: -0.52 to -0.17), but no difference was found for 1 year. Subgroup analysis including studies with baseline HbA1c greater than 8% showed a higher reduction of HbA1c: -0.83% (95% CI: -1.55 to -0.11) at 12 weeks, and -0.48% (95% CI: -0.77 to -0.19) at 24 weeks, with no difference for 1 year nor for the stratification for number the tests. CONCLUSION: SMBG seems to lead to a slightly better glycemic control in the short term in patients with T2D. Patients decompensated at baseline appear to have the greatest benefit. PROSPERO register: CRD42016033558.

Multifactorial intervention for diabetes control among older users of insulin.

OBJECTIVE: To evaluate if the closer follow-up with the supply of insulin pens and the measurement of capillary blood glucose improve the management of older patients with type 2 diabetes without adequate glycemic control despite extensive therapy. METHODS: This is a prospective, non-randomized, quasi-experimental study. We have included 45 patients over 60 years old, from both sexes, with glycated hemoglobin (HbA1c) > 8.5% using oral hypoglycemic agents and insulin. The intervention consisted of monthly medical visits, with the provision of insulin pens and strips for blood glucose measurement. All patients received insulin pen, refills of Neutral Protamine Hagedorn and regular insulin, needles for the pen, blood glucose meter, and capillary blood glucose tests (three tests/day). Treatment was adjusted with the same endocrinologist monthly for six months. Glycated hemoglobin was measured at baseline and 12 and 24 weeks after intervention. RESULTS: Glycated hemoglobin at baseline was 10.34% (SE = 0.22%) and 8.54% (SE = 0.24%, p < 0.001) and 8.09% (SE = 0.21%, p < 0.001) at 12 and 24 weeks after intervention, respectively, with a significant reduction from baseline. CONCLUSIONS: More frequent medical visits, with treatment inputs including the use of insulin pens and self-monitoring, have improved glycemic control (reduction of 2.25% in HbA1C, on average, at 24 weeks of follow-up). Our data support a change in the management and medical behavior of older patients with chronically decompensated diabetes.

The timing of parathyroid hormone measurement defines the cut-off values to accurately predict postoperative hypocalcemia: a prospective study.

PURPOSE: Serum intact parathyroid hormone (iPTH) level is an early marker of post-thyroidectomy hypocalcemia. However, lack of methodological standardization to define timing and cut-off points of iPTH measurement limit its clinical applicability. Here, we evaluated the relationship between two distinct postoperative time sampling and iPTH accuracy on predicting hypocalcemia. METHODS: iPTH was measured within 4 h after surgery (iPTH 4 h) and on the morning of the first postoperative day (iPTH 1st PO). Hypocalcemia was defined by levels of total calcium corrected by serum albumin ≤ 8.0 mg/dL and/or by the presence of symptoms. The most accurate iPTH cut-off point for hypocalcemia prediction was established from a ROC curve comparing both time-points. RESULTS: The study included 101 patients. The mean age was 52.4 ± 12.9 years, 93 were women (92.1%) and 69 patients underwent total thyroidectomy (68.3%). Hypocalcemia occurred in 25 patients (24.8%), of whom 12 were symptomatic. Total thyroidectomy, longer duration of surgery, surgical complications related to parathyroid glands and lower levels of iPTH 4 h and iPTH 1st PO were associated with postoperative hypocalcaemia (all P < 0.05). Using the ROC curve, the optimal cut-off points were 19.55 pg/mL and 14.35 pg/mL for iPTH 4 h and iPTH 1st PO, respectively. The comparison of the AUC showed no significant difference between these two points of evaluation (0.935 vs. 0.940; P = 0.415). CONCLUSIONS: Serum iPTH levels measured within 4 h or on the first morning after surgery are predictors of postoperative hypocalcemia. Notably, both time-points have the same accuracy to predict postoperative hypocalcemia (with different cutoff points).

Multifactorial intervention for diabetes control among older users of insulin

ABSTRACT OBJECTIVE: To evaluate if the closer follow-up with the supply of insulin pens and the measurement of capillary blood glucose improve the management of older patients with type 2 diabetes without adequate glycemic control despite extensive therapy. METHODS: This is a prospective, non-randomized, quasi-experimental study. We have included 45 patients over 60 years old, from both sexes, with glycated hemoglobin (HbA1c) > 8.5% using oral hypoglycemic agents and insulin. The intervention consisted of monthly medical visits, with the provision of insulin pens and strips for blood glucose measurement. All patients received insulin pen, refills of Neutral Protamine Hagedorn and regular insulin, needles for the pen, blood glucose meter, and capillary blood glucose tests (three tests/day). Treatment was adjusted with the same endocrinologist monthly for six months. Glycated hemoglobin was measured at baseline and 12 and 24 weeks after intervention. RESULTS: Glycated hemoglobin at baseline was 10.34% (SE = 0.22%) and 8.54% (SE = 0.24%, p < 0.001) and 8.09% (SE = 0.21%, p < 0.001) at 12 and 24 weeks after intervention, respectively, with a significant reduction from baseline. CONCLUSIONS: More frequent medical visits, with treatment inputs including the use of insulin pens and self-monitoring, have improved glycemic control (reduction of 2.25% in HbA1C, on average, at 24 weeks of follow-up). Our data support a change in the management and medical behavior of older patients with chronically decompensated diabetes.

Adesão medicamentosa em pacientes com m¨²lltiplas doenças crônicas: estudo de preval¨ºncia em ambulat¨®rio de medicina interna de um hospital terci¨¢rio / Medication adherence in patients with multiple chronicdiseases: a prevalence study in an outpatient internalmedicine service of a tertiary hospital

Introdução: É frequente a associação de v¨¢rios medicamentos para controlardoenças em pacientes crônicos. Contudo, a adesão medicamentosa ¨¦ vari¨¢vel, eos fatores associados diferem, não havendo dados uniformes sobre o assunto.M¨¦todos: Estudo transversal em pacientes do ambulat¨®rio de Medicina Interna deum hospital terci¨¢rio, maiores de 18 anos, com duas ou mais doenças crônicas,visando a estimar a adesão medicamentosa pela Escala de Adesão Medicamentosade Morisky. Fatores associados ¨¤ adesão foram avaliados pela regressão dePoisson. O controle das doenças crônicas foi avaliado e definido como alvosatingidos de hipertensão, diabetes e dislipidemia.Resultados: Um total de 170 pacientes (idade m¨¦dia 65¡À9,8 anos), 61 homens(36%), foram inclu¨ªdos. Sessenta e sete pacientes tinham at¨¦ 4 anos de estudo;uma renda menor que mil reais foi referida por 56 pacientes. O n¨²mero m¨¦diode comorbidades foi 4¡À1,14, sendo hipertensão arterial sist¨ºmica a doença maisprevalente (96,5%), seguido de diabetes mellitus tipo 2 (67%). Cada paciente usava7,5¡À2,5 medicamentos. A taxa de controle das doenças crônicas mais prevalentesfoi: hipertensão arterial sist¨ºmica 72% (IC95% 65-79%), diabetes mellitus 53%(IC95%: 42¨C63%) e dislipidemia 51% (IC95% 41¨C61%). A preval¨ºncia de m¨¦dia ealta adesão foi 43%. Os fatores que se associaram independentemente ¨¤ adesãomedicamentosa foram pr¨¢tica de exerc¨ªcio f¨ªsico (RP= 1,63; IC 95%: 1,09¨C2,44;p= 0,017) e idade (RP= 1,02; IC 95%: 1,00¨C1,03; p= 0,032).Conclusão: Menos da metade dos pacientes do ambulat¨®rio de Medicina Internaadere ¨¤ prescrição m¨¦dica. É necess¨¢rio instituir novas estrat¨¦gias para que ospacientes se beneficiem das prescrições de medicamentos.

Introduction: The combination of several medications to control diseases inchronic patients is very common. However, medication adherence is variable, andassociated factors differ. Besides, there is no uniform data on this subject.Methods: Cross-sectional study in an outpatient Internal Medicine Service of atertiary care hospital, with patients ¡Ý 18 years old with two or more chronic diseases,aimed at assessing medication adherence using the Morisky Medication AdherenceScale. Factors associated with adherence were assessed by Poisson regression.The control of hypertension, diabetes and dyslipidemia was assessed.Results: A total of 170 patients (mean age 65¡À9.8 years), 61 of them men (36%), wasincluded. Sixty-seven patients had up to 4 years of study, and 56 patients reporteda monthly income of less than a thousand Brazilian reais. The average number ofcomorbidities was 4¡À1.14. Hypertension was the most prevalent disease (96.5%),followed by type 2 diabetes mellitus (67%). Each patient used 7.5 ¡À 2.5 medications.The control rate of the most prevalent chronic diseases was: hypertension 72%(95% CI 65-79%), diabetes mellitus 53% (95% CI 42-63%), and dyslipidemia 51%(95% CI 41-61%). The prevalence of medium and high adherence was 43%. Thefactors independently associated with medication adherence were physical exercise(PR = 1.63; 95%CI: 1.09-2.44; p= 0.017) and age (PR= 1.02; 95%CI: 1.00-1.03; p=0.032).Conclusion: Less than half of the chronic clinical patients adheres to the prescription.It is necessary to establish new strategies for patients to benefit from prescriptionmedication.

Desnutrição em pacientes com câncer avançado: uma revisão com abordagem para o clínico / Malnutrition in patients with advanced cancer: review with an approach for clinicians

Muitos pacientes com câncer apresentam quadro clínico de desnutrição. Geralmente, a etiologia clínica da diminuição energética adquirida é reconhecida, incluindo anorexia, náuseas, obstrução mecânica do trato gastrointestinal, perdas sanguíneas crônicas, proteinúria e perda gastroduodenal de albumina. Em outras instâncias, a causa pode ser a competição do tumor por nutrientes e a indução tumoral de anormalidades dos metabolismos de carboidratos, lipídios e proteínas. O quadro clínico do paciente desnutrido inclui sintomas como a perda de peso e a anorexia. A Avaliação Nutricional Subjetiva (ANS) e a Avaliação Subjetiva Global do Estado Nutricional Produzida pelo Paciente (ANSPPP) são questionários que avaliam o seu risco nutricional. As avaliações antropométrica e laboratorial fazem parte da abordagem diagnóstica do paciente com sintomas de desnutrição. O uso da via oral, com o sem suplementos nutricionais orais deve ser estimulado. A terapia nutricional enteral ou parenteral pode ser indicada. A terapia medicamentosa envolve o uso de glicocorticoides, acetado de megestrol e agentes procinéticos. A intervenção psicossocial é de importância fundamental. A abordagem da desnutrição no paciente oncológico deve ser de caráter multidisciplinar. Esta revisão visa orientar o manejo de pacientes oncológicos desnutridos por médicos não oncologistas, além de abordar a fisiopatologia e o diagnóstico da desnutrição leve à caquexia.

Many cancer patients have a clinical picture of malnutrition. Usually the clinical etiology of acquired energy decrease is recognized, including anorexia, nausea, mechanical obstruction of the gastrointestinal tract, chronic blood loss, proteinuria and gastroduodenal loss of albumin. In other instances the cause may be tumor competition for nutrients and tumor induction of abnormal metabolism of carbohydrates, lipids and proteins. The malnourished patient’s clinical picture includes such symptoms as weight loss and anorexia. The subjective nutritional assessment (SNA) and global subjective nutritional assessment produced by patient (SNAPBP) are questionnaires that assess his/her nutritional risk. Anthropometric and laboratory evaluations are part of the workup of patients with symptoms of malnutrition. Use of oral route, with or without oral nutritional supplements, should be encouraged. Enteral or parenteral nutritional therapy may be indicated. Drug therapy involves the use of glucocorticoids, megestrol acetate and prokinetic agents. Psychosocial intervention is crucial. The approach to malnutrition in cancer patients should be multidisciplinary. This review aims to guide the management of malnourished cancer patients by non-oncologists, as well as discussing the pathophysiology and diagnosis from mild malnutrition through cachexia.