The impact of a daily smartphone-based feedback system among women with gestational diabetes on compliance, glycemic control, satisfaction, and pregnancy outcome: a randomized controlled trial.

BACKGROUND: Patient compliance and tight glycemic control have been demonstrated to improve outcome in pregnancies complicated by gestational diabetes mellitus. The use of advanced technological tools, including smartphone-based platforms, to improve medical care and outcomes has been demonstrated in various fields of medicine, but only a few small studies were performed with gestational diabetes mellitus patients. OBJECTIVE: We aimed to study the impact of introducing a smartphone-based daily feedback and communication platform between gestational diabetes mellitus patients and their physicians, on patient compliance, glycemic control, pregnancy outcome, and patient satisfaction. STUDY DESIGN: This is a prospective, single-center, randomized controlled trial. Newly diagnosed gestational diabetes mellitus patients presenting to our multidisciplinary diabetes-in-pregnancy clinic were randomized to: (1) routine biweekly prenatal clinic care (control group); or (2) additional daily detailed feedback on their compliance and glycemic control from the clinic team via an application installed on their smartphone (smartphone group). The primary outcome was patient compliance defined as the actual blood glucose measurements/instructed measurements ×100. The secondary outcomes included diabetes-control parameters, pregnancy, and neonatal outcomes. The study was adequately powered to detect a 20% difference in patient compliance, based on a preliminary phase that demonstrated 70% baseline compliance to glucose measurements. RESULTS: A total of 120 newly diagnosed gestational diabetes mellitus patients were analyzed. The 2 groups did not differ in terms of age, parity, education, body mass index, family history, maternal comorbidities, oral glucose tolerance test values, and hemoglobin A1C at randomization. The smartphone group demonstrated higher level of compliance (84 ± 0.16% vs 66 ± 0.28%, P < .001); lower mean blood glucose (105.1 ± 8.6 mg/dL vs 112.6 ± 7.4 mg/dL, P < .001); lower rates of off-target measurements both fasting (4.7 ± 0.4% vs 8.4 ± 0.6%, P < .001) and 1-hour postprandial (7.7 ± 0.8% vs 14.3 ± 0.8%, P < .001); and a lower rate of pregnancies requiring insulin treatment (13.3% vs 30.0%, P = .044). The rates of macrosomia, neonatal hypoglycemia, shoulder dystocia, and other delivery and neonatal complications did not differ between the groups. Patients in the smartphone group reported excellent satisfaction from the use of the application and from their overall prenatal care. CONCLUSION: Introduction of a smartphone-based daily feedback and communication platform between gestational diabetes mellitus patients and the multidisciplinary diabetes-in-pregnancy clinic team improved patient compliance and glycemic control, and lowered the rate of insulin treatment.

Calciuria and preeclampsia: a case-control study.

AIM: Calciuria has been reported to decrease in preeclampsia. We compared calciuria among groups of normal, hypertensive and preeclamptic pregnant women, and assessed its correlation with the severity of the disease. MATERIAL AND METHODS: We conducted a case-control study of mild and severe preeclampsia, chronic hypertension, and normal pregnancy, with 14 patients in each group. The groups were analyzed by one-way anova (variance analysis) for symmetrical distribution and Kruskal-Wallis test for asymmetrical distribution when comparing quantitative variables, and by crossed tables when comparing qualitative variables. RESULTS: There were statistically significant differences between the groups when comparing severe preeclampsia with chronic hypertension, and severe preeclampsia with the control group (P < 0.0001). The calciuria medians were 81.5 mg/24 h for severe preeclampsia, 118 mg/24 h for mild preeclampsia, 226 mg/24 h for chronic hypertension, and 272 mg/24 h for the control group. In a ROC (receiver operating characteristic) curve analysis, the best cutoff point for preeclampsia diagnosis was 167 mg/24 h, with a sensitivity of 75% and a specificity of 85%. The outcomes were more severe as the level of calciuria dropped. CONCLUSION: Measurement of calciuria can differentiate between severe preeclampsia and chronic hypertension, and hypocalciuria is also a marker for disease severity.

Prenatal diagnosis of major aortopulmonary collateral arteries (MAPCA) in fetuses with pulmonary atresia with ventricular septal defect and agenesis of ductus arteriosus.

OBJECTIVE: The aim of this study was to describe the prenatal diagnosis of Major Aortopulmonary Collateral Arteries (MAPCAs), and to present a systematic ultrasound method for evaluating lung vascularity in fetuses with pulmonary atresia with ventricular septal defect (PAVSD) and agenesis of ductus arteriosus (DA). METHOD: This retrospective study evaluated fetuses diagnosed with PAVSD with agenesis of DA, for the presence of the MAPCAs anomaly. Fetal pulmonary vasculature was investigated by 2D and 4D Spatio Temporal Image Correlation (STIC) technology using High Definition Color Doppler. RESULTS: Over a 10 year period, six fetuses were diagnosed with MAPCAs. Prenatal diagnosis was made between 17 w 6 d and 28 w 4 d in five fetuses, with the sixth diagnosed at 37 w 6 d. All six had PAVSD with agenesis DA, four exhibited pulmonic atresia without any arterial outflow, while two fetuses presented with absent left pulmonary artery, and a miniscule right pulmonary artery. In five cases, the parents elected to terminate the pregnancy and the last, although born alive, did not survive an attempt at restorative surgery and died at the age of 5 months. Postnatal CT angiography imaging of this case revealed the subclavian origin of the MAPCAs. Chromosomal micro array analysis of the amniotic fluid revealed that five of the six fetuses were normal and one was lost to follow up. CONCLUSION: MAPCAs should be investigated in cases of PAVSD with agenesis DA. A meticulous ultrasound evaluation using 2D and 4D STIC can permit the prenatal diagnosis of this anomaly and provide the parents with the opportunity for prenatal consultation.

Placental pathology and neonatal outcome in small for gestational age pregnancies with and without abnormal umbilical artery Doppler flow.

OBJECTIVE: To compare neonatal outcome and placental pathology in cases of small for gestational age (SGA) according to umbilical artery (UA) Doppler flow. STUDY DESIGN: Pregnancy and placental reports of SGA neonates (birth-weight <10th), born between 2008 and 2017 were compared between cases with normal and abnormal UA Doppler indices. Placental lesions were classified to malperfusion lesions and inflammatory responses. RESULTS: The abnormal Doppler group (n = 66) delivered at an earlier gestational age, compared to the normal Doppler group (n = 92). Placentas from the abnormal Doppler group were characterized by a higher rate of maternal malperfusion lesions, while placentas from the normal Doppler group exhibited a higher rate of chronic villitis. Neonatal outcome was independently associated with abnormal Doppler, gestational age and birth weight <5th percentile. CONCLUSION: SGA may involve a vascular mechanism, associated with abnormal Doppler flow and placental malperfusion, and an inflammatory mechanism, with normal Doppler flow and chronic villitis.

Natriuria and calciuria levels in preeclampsia: a cross-sectional study.

CONTEXT AND OBJECTIVE: Sodium excretion abnormalities in preeclampsia have been studied in relation to several factors. The objective of this study was to compare natriuria (mEq/24 h) and calciuria levels (mg/24 h) in preeclamptic patients. DESIGN AND SETTING: An analytical cross-sectional study with a control group was conducted in the obstetric center and the high-risk pregnancy outpatient clinic at a university hospital in southern Brazil, and in a primary healthcare unit in the same city, including pregnant women with mild preeclampsia, severe preeclampsia or chronic hypertension, and women with normal pregnancies (14 patients in each group). METHOD: Natriuria was measured using an ion-selective electrode in an automated clinical chemistry analyzer (Hitache 917, Roche). All the patients collected 24-hour urine, at home or at the hospital, for analysis of proteins, creatinine, calcium, sodium and uric acid. Quantitative variables with asymmetrical distribution were described using the median, minimum and maximum, and were compared using the Kruskal-Wallis test. The results were logarithmically transformed, with one-way analysis of variance (ANOVA) by ranks and then the post-hoc Tukey test, and were analyzed by means of the Spearman correlation and receiver operating characteristic (ROC) curve. The significance level used was 0.05. RESULTS: There were significant differences between the groups in comparing severe preeclampsia with chronic hypertension and severe preeclampsia with controls (P < 0.0001 for both measurements). CONCLUSION: Natriuria levels may be lower in preeclampsia when associated with calciuria. Natriuria assessment is an additional test for differential diagnosis of hypertensive diseases in pregnancy, but is a poor predictor when used alone.

Calcium-to-creatinine ratio in pregnancy-induced hypertension.

OBJECTIVES: Hypocalciuria has been correlated with preeclampsia. This study compared the calcium-to-creatinine ratio among the groups, and the correlation with the 24-h measurement of this ratio and a diagnosis of preeclampsia. STUDY DESIGN: Case-control study including mild and severe preeclampsia, chronic hypertension and normal pregnancy. MAIN OUTCOME MEASUREMENTS: The calcium-to-creatinine ratio differentiates severe preeclampsia from mild preeclampsia, chronic hypertension and normal pregnancy. RESULTS: There were statistically significant differences between the groups when comparing severe preeclampsia and chronic hypertension, severe preeclampsia and normal pregnancy, and mild and severe preeclampsia (p<0.0001). The Spearman index between the calcium-to-creatinine ratio and 24-h calciuria was 0.65 (high correlation). CONCLUSIONS: The calcium-to-creatinine ratio can reliably estimate 24-h calciuria, differentiating severe preeclampsia from mild preeclampsia, chronic hypertension and normal pregnancy.

Individual serological follow-up of patients with suspected or confirmed abdominal angiostrongyliasis.

Abdominal angiostrongyliasis (AA) is a zoonotic nematode infection caused by Angiostrongylus costaricensis, with widespread occurrence in the Americas. Although the human infection may be highly prevalent, morbidity is low in Southern Brazil. Confirmed diagnosis is based on finding parasitic structures in pathological examination of biopsies or surgical resections. Serology stands as an important diagnostic tool in the less severe courses of the infection. Our objective is to describe the follow up of humoral reactivity every 2-4 weeks up to one year, in six individuals with confirmed (C) and ten suspected (S) AA. Antibody (IgG) detection was performed by ELISA and resulted in gradually declining curves of reactivity in nine subjects (56%) (4C + 5S), that were consistently negative in only three of them (2C + 1S) after 221, 121 and 298 days. Three individuals (2C + 1S) presented with low persistent reacitivity, other two (1C + 1S) were serologically negative from the beginning, but also presenting a declining tendency. The study shows indications that abdominal angiostrongyliasis is usually not a persistent infection: although serological negativation may take many months, IgG reactivity is usually declining along time and serum samples pairing may add valuable information to the diagnostic workout.

Natriuria and calciuria levels in preeclampsia: a cross-sectional study / Valores de natriúria e calciúria na pré-eclâmpsia: estudo transversal

CONTEXT AND OBJECTIVE Sodium excretion abnormalities in preeclampsia have been studied in relation to several factors. The objective of this study was to compare natriuria (mEq/24 h) and calciuria levels (mg/24 h) in preeclamptic patients. DESIGN AND SETTING An analytical cross-sectional study with a control group was conducted in the obstetric center and the high-risk pregnancy outpatient clinic at a university hospital in southern Brazil, and in a primary healthcare unit in the same city, including pregnant women with mild preeclampsia, severe preeclampsia or chronic hypertension, and women with normal pregnancies (14 patients in each group). METHOD Natriuria was measured using an ion-selective electrode in an automated clinical chemistry analyzer (Hitache 917, Roche). All the patients collected 24-hour urine, at home or at the hospital, for analysis of proteins, creatinine, calcium, sodium and uric acid. Quantitative variables with asymmetrical distribution were described using the median, minimum and maximum, and were compared using the Kruskal-Wallis test. The results were logarithmically transformed, with one-way analysis of variance (ANOVA) by ranks and then the post-hoc Tukey test, and were analyzed by means of the Spearman correlation and receiver operating characteristic (ROC) curve. The significance level used was 0.05. RESULTS There were significant differences between the groups in comparing severe preeclampsia with chronic hypertension and severe preeclampsia with controls (P < 0.0001 for both measurements). CONCLUSION Natriuria levels may be lower in preeclampsia when associated with calciuria. Natriuria assessment is an additional test for differential diagnosis of hypertensive diseases in pregnancy, but is a poor predictor when used alone. .

CONTEXTO E OBJETIVO Alterações na excreção de sódio têm sido estudadas na pré-eclâmpsia relacionadas a vários fatores. O objetivo deste estudo foi comparar natriúria (mEq/24 h) com os níveis de calciúria (mg/24 h) em pacientes pré-eclâmpticas. ESTUDO E LOCAL Estudo transversal analítico com grupo controle foi realizado no Centro Obstétrico e no Ambulatório de Gestação de Alto Risco em um hospital universitário no sul do Brasil, e na Unidade Básica de Saúde na mesma cidade, incluindo gestantes com pré-eclâmpsia leve e grave, hipertensão crônica e gestações normais, com 14 pacientes em cada grupo. MÉTODO A natriuria foi dosada através da medida de íon eletrodo seletivo, utilizando analizadores automáticos de química clínica (Hitache 917 Roche). Todas as pacientes coletaram urina de 24 h, em casa ou no hospital, para análise de proteínas, creatinina, cálcio, ácido úrico e sódio. As variáveis quantitativas com distribuição assimétrica foram descritas por mediana, mínimo e máximo, e comparadas por teste Kruskal-Wallis. Os resultados foram transformados logaritmicamente, com ANOVA one-way por ranking e, posteriormente, teste post-hoc de Tukey, e foram analisados por médias de correlações de Spearman e curva ROC (receiver operating characteristic). O nível de significância adotado foi de 0.05. RESULTADOS Foram encontradas diferenças significativas entre os grupos quando comparados pré-eclâmpsia grave com hipertensão crônica e pré-eclâmpsia grave com controles (P < 0.0001 para ambas as medidas). CONCLUSÃO Natriúria pode estar reduzida na pré-eclâmpsia ...

Individual serological follow-up of patients with suspected or confirmed abdominal angiostrongyliasis

Abdominal angiostrongyliasis (AA) is a zoonotic nematode infection caused by Angiostrongylus costaricensis, with widespread occurrence in the Americas. Although the human infection may be highly prevalent, morbidity is low in Southern Brazil. Confirmed diagnosis is based on finding parasitic structures in pathological examination of biopsies or surgical resections. Serology stands as an important diagnostic tool in the less severe courses of the infection. Our objective is to describe the follow up of humoral reactivity every 2-4 weeks up to one year, in six individuals with confirmed (C) and ten suspected (S) AA. Antibody (IgG) detection was performed by ELISA and resulted in gradually declining curves of reactivity in nine subjects (56 percent) (4C + 5S), that were consistently negative in only three of them (2C + 1S) after 221, 121 and 298 days. Three individuals (2C + 1S) presented with low persistent reacitivity, other two (1C + 1S) were serologically negative from the beginning, but also presenting a declining tendency. The study shows indications that abdominal angiostrongyliasis is usually not a persistent infection: although serological negativation may take many months, IgG reactivity is usually declining along time and serum samples pairing may add valuable information to the diagnostic workout.

Avaliação do registro do exame físico realizado por doutorandos e residentes no Serviço de Medicina Interna do Hospital São Lucas: PUCRS / Evaluation of the physical examination performed by last years medical students and residents of the Internal Medicine Service of Hospital São Lucas: PUCRS

Neste estudo avaliamos o registro de determinados segmentos do exame físico realizado por acadêmicos do 6º ano e médicos residentes em pacientes internados na unidade de Medicina Interna no Hospital São Lucas da PUCRS. Seguindo um protocolo previamente estabelecido, foram avaliados retrospectivamente 120 prontuários escolhidos de forma aleatória, entre o período de janeiro de 2000 a março de 2002. Embora alguns segmentos do exame são registrados em mais de 90% dos casos (exame cardiovascular, pulmonar e abdominal), o exame é incompleto em todos os prontuários. O exame neurológico exemplifica um problema particularmente sério que identificamos nesta avaliação. Mesmo em pacientes que apresentam sintomas ou queixas neurológicas o exame não é realizado ou registrado adequadamente. Alguns segmentos específicos como exame de linfonodos, tireóide, fundoscopia, otoscopia, toque renal, testículos ou mamas são registrados somente numa minoria absoluta dos casos. Entendemos que a falta de modelo e orientação por parte do corpo de professores é o principal motivo que explica esta situação. A necessidade de reverter esta realidade, desenvolvendo estratégias eficazes é imperativa.

Manejo clínico na fibrllaçáo atrial / Clinical handling of the atrial fibrillation

Os autores fazem uma revisão bibliográfica sobre o manejo clínico da fibrilação atrial de acordo com as diretrizes do American College af Cardiology, European Society of Cardiology e American Heart Association e conforme dois estudos realizados comparando controle do ritmo x controle da freqüência ventricular no tratamento de pacientes com fibrilação atrial

Avaliação cardiológica pré-operatória em cirurgia não cardíaca / Evaluation cardiovascular preoperative in non-cardiac surgery

Revisão bibliográfica sobre avaliação e manejo de pacientes com risco de eventos cardiovasculares perioperatórios, com base nas diretrizes da American College of Cardiology/American Heart Association e na rotina de avaliação do serviço de Cardiologia do Hospital São Lucas da PUCRS