Relationship between Proliferative Diabetic Retinopathy and Inflammatory Markers in Patients with Type 1 Diabetes in Brazil: A Nested Case Control Study.

INTRODUCTION: This study examined the relationship between proliferative diabetic retinopathy (PDR) and serum levels of C-reactive protein, VEGF, TNF-α, and IL-6 inflammatory biomarkers, related to the pathophysiology of diabetic retinopathy. METHODS: This cross-sectional, case control study comprised 240 patients with type 1 diabetes (80 cases with PDR and 160 controls without diabetic retinopathy) who were matched for gender and duration of diabetes. RESULTS: C-reactive protein was the only inflammatory biomarker that was positively related to PDR (OR 1.96; 95% CI 1.01-3.78, p = 0.0045). We also noted an association between high glycated hemoglobin levels, the use of angiotensin-converting enzyme inhibitor, low glomerular filtration rate, and PDR. CONCLUSION: Patients with higher levels of C-reactive protein are more likely to present with PDR. We did not find a link between serum levels of VEGF, TNF-α, or IL-6 and PDR. The function of inflammatory biomarkers in PDR must be addressed in further studies.

Current epidemiology of diabetic retinopathy in patients with type 1 diabetes: a national multicenter study in Brazil.

BACKGROUND: Diabetic retinopathy is the leading cause of blindness in economically active populations. The aims of this study were to estimate the prevalence and to identify risk factors for diabetic retinopathy in patients with type 1 diabetes in Brazil. METHODS: This was a nationwide, cross-sectional study conducted between August 2010 and August 2014. The study included 1760 patients with type 1 diabetes. Patients underwent a standard questionnaire, clinical and laboratory analyses and were screened for diabetic retinopathy. To analyze the risk factors related to diabetic retinopathy, two models of logistic regression models were performed, one considering vision-threatening cases and the other with any diabetic retinopathy cases as dependent variables. The group with vision-threatening included patients with severe non-proliferative diabetic retinopathy, proliferative diabetic retinopathy and macular edema. RESULTS: In total, 1644 patients (mean age, 30.1± 12.0 years; duration of diabetes, 15.3 ± 9.3 years; female, 55.8%) were studied. 35.7% presented diabetic retinopathy and 12% presented vision-threatening diabetic retinopathy. Three risk factors associated with diabetic retinopathy were in common to both groups: longer diabetes duration (OR 1.07; 95% CI, 1.05-1.09), higher levels of HbA1c (OR 1.24; CI, 1.17-1.32) and higher levels of serum uric acid (OR 1.22; CI, 1.13-1.31) (p < 0.001 for all comparisons). CONCLUSION: The higher rate of vision-threatening retinopathy found in our study highlights the need to improve access to eye care and screening programs for diabetic retinopathy in Brazil. In addition to traditional risk factors, we found an association between serum uric acid levels and diabetic retinopathy. Further studies are needed to address this association.

Correlation between changes in Timed Up and Go performance and cognition in older people with mild cognitive impairment: A longitudinal study.

BACKGROUND: Compare changes in performance on subtasks of the Timed Up and Go test over 32 months in older adults with and without mild cognitive impairment; analyze the correlation between frontal cognitive functions at baseline and changes in Timed Up and Go subtasks over time. METHODS: A longitudinal study was conducted involving 31 older adults (15 with and 16 without cognitive impairment). Functional mobility was assessed at both evaluations using an adapted version of the Timed Up and Go test and the Qualisys motion system. The test was divided into five subtasks: sit-to-stand, walking forward, turn-to-walk, walking back and turn-to-sit. Cognition was assessed at baseline using the Frontal Assessment Battery and the Clock Drawing Test. FINDINGS: Significant differences in changes in the sit-to-stand subtask over time were found between groups. The difference in the time required to conclude this subtask was greater in the older adults with cognitive impairment. However, the difference in kinematic variables (peak trunk speed and range of motion) was greater in the group without cognitive impairment. Strong and moderate correlations were found between frontal cognitive functions and changes in Timed Up and Go subtasks, especially those involving transitions (sit-to-stand, turn-to-walk and turn-to-sit) in both groups. INTERPRETATION: Motor intervention protocols should incorporate the sit-to-stand subtask in older adults with mild cognitive impairment. Moreover, changes in more complex subtasks seem to be related to frontal cognitive performance at baseline. Therefore, treatments that combine motor and cognitive functions should be administered to older adults regardless of cognitive impairment.

Behavioral and reproductive effects in Poecilia vivipara males from a tropical estuary affected by estrogenic contaminants.

Contamination of aquatic habitats by endocrine disruptor chemicals is a major concern globally. This study evaluated histochemical, behavioral, and reproductive effects on adult male Poecilia vivipara sampled from Capibaribe River Estuarine System (CRES), compared to laboratory control males after breeding with virgin control females. CRES is contaminated by a mixture of estrogenic contaminants estrone, 17ß-estradiol, estriol, 17α-Ethinylestradiol, bisphenol A and caffeine in concentrations averaging 13.9; 4.2; 19.5; 8.6; 27 and 23.2 ng L-1, respectively. Estrogenic risk in 17ß-estradiol-equivalent-concentrations is above probable no effect concentrations. Males sampled from CRES indicated liver phosphoprotein induction, decreased number of contacts and copulation attempts when paired with control females, slower swimming speed and lower female impregnation success rates, compared to control males. A reduction of 62% in fecundity was observed in control females paired with field sampled males compared with control males. Our results highlight hazards posed to fish reproduction by estrogenic micropollutants.

Human Leukocyte Antigens class II (HLA II) gene profile from an admixed population of patients with type 1 diabetes with severe diabetic retinopathy: a nested case-control study in Brazil.

BACKGROUND: Although the well-established role of the HLA genes on the predisposition of type 1 diabetes (T1D), its contribution to the development and progression of diabetic retinopathy is still unclear, especially in admixed populations. We aimed to study the relationship between HLA alleles and severe diabetic retinopathy in a highly admixed population of T1D patients. METHODS: This was a nested case-control study based on a cross-sectional, nationwide survey conducted in Brazil. We included 117 patients with severe diabetic retinopathy and 117 random controls composed of T1D patients without retinopathy, matched for diabetes duration. HLA-class II genes (HLA-DRB1, -DQA1, and -DQB1) were genotyped using the SSO and NGS methods. RESULTS: Haplotypes HLA-DRB1*04:05 ~ DQA1*03:01 g ~ DQB1*03:02 (OR 1.75, CI 0.97-3.16, p value 0.058) and HLA-DRB1*13:02 ~ DQA1*01:02 ~ DQB1*06:04 (OR 5.18, CI 1.12-23.09, p value 0.019) were more prevalent on the severe DR group but they did not present statistically difference after Bonferroni correction. The most frequent haplotype on both groups was HLA-DRB1*03:01 ~ DQA1*05:01 g ~ DQB1*02:01 (29.6% on severe DR and 33.33% on the control group). CONCLUSIONS: Our study showed no influence of HLA genes on the development of DR. Further longitudinal data is needed to better understand the role of genetic factors on this multifactorial significant microvascular complication.

Prevalence of chronic kidney disease in an admixed population of patients with type 1 diabetes. A multicenter study in Brazil.

AIMS: To evaluate diagnosis, prevalence and associated factors of CKD in Brazilian patients with type 1 diabetes. METHODS: This cross-sectional, multicenter study was conducted in 14 public clinics in 10 Brazilian cities. From 1760 patients, 1736 were included (98.6%): 977 females (56.3%), 932 (54%) Caucasians, aged 29.9 ± 11.9 years, age at diagnosis 14.7 ± 8.9 years, diabetes duration 15.5 ± 9.3 years and 12.2 ± 3.8 years of school attendance. CKD was determined by using estimated glomerular filtration rate and by the presence of albuminuria in two out of three morning urine samples. RESULTS: The prevalence of CKD was 33.7%. Overall, 28.1% of the patients could not be classified due to insufficient number of urine samples for albuminuria determination. Multivariable analysis showed that female gender, diabetes duration, high levels of HbA1c and uric acid, use of renin-angiotensin system inhibitors, retinopathy, high systolic blood pressure, and economic status (medium, low and very low) were associated with CKD. CONCLUSIONS: Although a high prevalence of CKD, associated comorbidities and retinopathy was observed in our study, a large number of patients are still undiagnosed, making CKD a challenge in routine clinical practice in admixed populations with T1D in a developing country like Brazil.

Glomerular filtration rate estimated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in type 1 diabetes based on genomic ancestry.

BACKGROUND: Black individuals have a great risk of developing chronic kidney disease (CKD) that is associated with high morbimortality, so it is important to classify them into the correct renal function group. Some equations used to estimate glomerular filtration rate (eGFR) divide patients only into two categories: African Americans and non-African Americans. The CKD-EPI equation was tested only in African Americans, and not Black patients from other regions, and takes into consideration self-reported color-race instead of genomic ancestry (GA) to determine the use of the ethnic correction factor. So far, this equation has not been evaluated in admixed populations, such as the Brazilian, using the percentage of GA to decide to apply the correction factor. The purpose of our study was to compare, in patients with type 1 diabetes (T1D), the eGFR calculated without the use of the correction factor, with the values obtained using the correction factor in patients presenting 50% or more of African GA. METHODS: This cross-sectional, multicenter study enrolled 1279 patients from all geographic regions of Brazil. The CKD-EPI equation was used and CKD was defined as eGFR < 60 ml/min. GA were inferred using a panel of 46 AIM-INDEL, afterwards patients presenting an African GA ≥ 50% were selected. RESULTS: Initially, all patients with African GA ≥ 50% (n = 85) were considered as non-African Americans when calculating the eGFR and afterwards the ethnic correction factor was applied to recalculate the eGFR. CKD was present in 23 patients and 56.5% of them were redefined as having normal renal function after using the correction factor, mainly women [11 of the 13 patients (84.6%)], with GFR between 52-59.3 ml/min. CONCLUSIONS: More than half of the patients in the study were reclassified to a normal renal function group, showing that GA may be an important tool to decide between the use of the ethnic correction factor in the CKD-EPI equation in a highly admixed population of patients with T1D. A large-scale study involving GA and eGFR in comparison to reference methods should be conducted to better establish whether or not the ethnic correction factor should be used in highly admixed populations.

Occasional tillage in no-tillage systems: A global meta-analysis.

No-tillage (NT) is a major component of conservation agricultural systems. Challenges that have arisen with the adoption of NT include soil compaction, weed management, and stratification of organic matter and nutrients. As an attempt to overcome these challenges, occasional tillage (OT) has been used as a soil management practice in NT systems. However, little is known about the impacts of OT on agronomic and environmental factors. For this reason, the objectives of this meta-analysis were: 1) to summarize the effects of OT on crop productivity, soil physical, chemical and biological properties, soil erosion and weed control; 2) to discuss the main aspects of NT management to optimize the use of OT; 3) to point out shortcomings in the diagnosis of soil compaction in NT systems, which may lead to erroneous decision-making processes regarding the use of OT. Overall, OT did not affect crops yields, although increased crop yields were observed in regions under water restriction and in soils with low retention capacity and water availability; OT improved soil physical properties (penetration resistance, soil bulk density, macroporosity, and total porosity), with persistence, generally, greater than 24 months, and decreased the soil aggregates stability; total organic carbon was reduced, particularly when plow/harrow was used and NT was already consolidated, and there was no effect on pH and available P; OT increased microbial biomass carbon, but had no effect on total microbial activity; soil erosion was reduced due to increased soil-water infiltration and reduced runoff, and finally, weed management was also improved by OT. It is suggested that suitable NT implementation and management, with the correct application of NT principles, will overcome problems associated with NT. As soil compaction is the main justification for the use of OT, methods of diagnosis and monitoring of soil compaction should be improved to assist in decision-making.

Health literacy and glycemic control in patients with diabetes: a tertiary care center study in Brazil.

BACKGROUND: The primary objective of our study was to determine which factors influence health literacy (HL) in patients with type 1 diabetes (T1D) and type 2 diabetes (T2D), and the secondary one was to evaluate the influence of HL on glycemic control. METHODS: This was an observational, cross-sectional study with 347 patients (144 with T1D and 203 with T2D), conducted between December 2014/December 2017. Data were obtained from medical records and/or questionnaire. The short test of Functional Health Literacy (S-TOFHLA) was used to evaluate HL. RESULTS: Age and years of school attendance were the most important variables associated with better performance in S-TOFHLA mainly in patients with T1D. A correlation between age and years of school attendance with S-TOFHLA score was observed in both groups of patients. After an unadjusted analysis, more patients with T1D presented adequate HL [119 (82.6%) vs 87 (44.8%, p < 0.001)]. Patients with T1D had higher scores than patients with T2D (84.4 ± 21.4 vs 61.6 ± 26.8 points, p < 0.001), respectively. This difference did not persist after adjustment for age and years of school attendance (73.04 ± 2.14 ± vs 70.04 ± 1.76 points) respectively, p = 0.348). No difference was found in HbA1c levels according to S-TOFHLA. All patients with T1D and HbA1c levels < 7.0% (53 mmol/mol) had adequate HL. CONCLUSIONS: A considerable number of patients with either T1D or T2D did not have adequate HL. Overall, age and years of school attendance were the most important variables associated with better performance of S-TOFHLA. Although no difference was found in HbA1c levels according to S-TOFHLA, patients with T1D who self-reported as White, with more years of school attendance, and higher HL score reached more frequently a good glycemic control. Finally, in addition to therapeutic regimens, approaches on diabetes management should also include patients' HL evaluation along with psychological and social aspects.

Genomic ancestry as a risk factor for diabetic retinopathy in patients with type 1 diabetes from an admixed population: a nested case-control study in Brazil.

AIMS: The influence of genetic factors on the development and progression of diabetic retinopathy is still unclear. Previous studies showed controversial results. We aimed to characterize the relationship between genomic ancestry and self-reported color/race with severe diabetic retinopathy in patients with type 1 diabetes belonging to a highly admixed population. METHODS: This study was a nested case-control based on data collected from a large cross-sectional, nationwide survey conducted in clinics from all five geographic regions of Brazil. For the present study, we included 414 individuals. Cases (n = 176) were considered if they had severe non-proliferative or proliferative diabetic retinopathy, and controls (n = 238) were type 1 diabetes patients without retinopathy, matched for diabetes duration by a range of 5 years. Indirect ophthalmoscopy was performed, and individual genomic ancestry was inferred using a panel of 46 ancestry informative markers. RESULTS: The backward stepwise logistic regression analysis showed that African genomic ancestry (OR 3.9, p = 0.045), HbA1c (OR 1.24, p = 0.001), glomerular filtration rate (OR 0.98, p < 0.001) and hypertension (OR 2.52, p < 0.001) were associated with severe diabetic retinopathy after adjusting for clinical and demographic data. Self-reported color/race was not statistically associated with diabetic retinopathy. CONCLUSIONS: Genomic ancestry, as well as clinical variables such as hypertension, impaired glomerular filtration rate and poor diabetes control (HbA1c), was important risk factor for the development of severe diabetic retinopathy. Further studies are needed, especially in highly admixed populations, to better understand the role of genomic ancestry and possible genes that might be associated with the development and/or progression of diabetic retinopathy.

Avaliação da gravidade dos sinais e sintomas da COVID-19 em pacientes submetidos à cirurgia bariátrica / Assessment of the severity of signs and symptoms of COVID-19 in patients undergoing bariatric surgery / Evaluación de la gravedad de los signos y sintomas de COVID-19 em pacientes sometidos a cirurgía bariátrica

Objetivo: Avaliar a gravidade e a incidência dos sinais e sintomas da COVID-19 em pacientes bariátricos, relacionando-os ao índice de massa corporal (IMC) e a outros fatores considerados de risco para a doença.Método: trata-se de um estudo transversal. Os pacientes responderam a um questionário eletrônico e a avaliação da gravidade dos sinais e sintomas da infecção por SARS-CoV-2 foi realizada seguindo o manual "Orientações para manejo de pacientes com covid-19", do Ministério de Saúde do Brasil. Resultados: um total de 60 pacientes foram incluídos. Dos participantes, 60% apresentaram sintomas graves e a fadiga foi o sintoma mais frequente (90%). A análise mostrou uma associação significativa entre a presença de tosse e a condição de sobrepeso/obesidade (OR=3,720; IC=1,060­13,050; p=0,034). Além disso, apenas 6,7% foram hospitalizados, sem casos de intubação, todos com sobrepeso/obesidade (OR=1,333; IC=1,114­1,554). Conclusão:apesar de uma alta taxa de pacientes categorizados com sinais e sintomas graves, verificou-se uma baixa necessidade de internação hospitalar e ventilação mecânica não invasiva. Isso sugere que a perda de peso e a melhora das comorbidades pós-cirurgia podem contribuir para um risco reduzido de hospitalização em casos de infecção por COVID-19

Objective: To assess the severity and incidence of COVID-19 signs and symptoms in bariatric patients, relating them to body mass index (BMI) and other risk factors for the disease. Method:This is a cross-sectional study. Patients completed an electronic questionnaire, and the severity of SARS-CoV-2 infection signs and symptoms was assessed following the "Guidelines for the management of COVID-19 patients" by the Brazilian Ministry of Health. Results:A total of 60 patients were included. Among the participants, 60% presented with severe symptoms, with fatigue being the most frequent symptom (90%). The analysis showed a significant association between the presence of cough and the condition of overweight/obesity (OR=3.720; CI=1.060­13.050; p=0.034). Moreover, only 6.7% were hospitalized, with no cases requiring intubation, all within the overweight/obesity subgroup (OR=1.333; CI=1.114­1.554).Conclusion: Despite a high rate of patients categorized with severe signs and symptoms, there was a low need for hospital admission and non-invasive mechanical ventilation. This suggests that weight loss and improvement of comorbidities post-surgery may contribute to a reduced risk of hospitalization in COVID-19 infection case.

Objetivo: Evaluar la gravedad y la incidencia de los signos y síntomas de COVID-19 en pacientes bariátricos, relacionándolos con el índice de masa corporal (IMC) y otros factores de riesgo para la enfermedad. Metodo:Se trata de un estudio transversal. Los pacientescompletaron un cuestionario electrónico, y la gravedad de los signos y síntomas de la infección por SARS-CoV-2 se evaluó siguiendo las "Guías para el manejo de pacientes con COVID-19" del Ministerio de Salud de Brasil. Resultados:Se incluyó un total de 60 pacientes. Entre los participantes, el 60% presentó síntomas severos, siendo la fatiga el síntoma más frecuente (90%). El análisis mostró una asociación significativa entre la presencia de tos y la condición de sobrepeso/obesidad (OR=3.720; IC=1.060­13.050; p=0.034). Además, solo el 6.7% fueron hospitalizados, sin casos que requirieran intubación, todos dentro del subgrupo de sobrepeso/obesidad (OR=1.333; IC=1.114­1.554). Conclusión:A pesar de una alta tasa de pacientes clasificados con signos y síntomasseveros, hubo una baja necesidad de admisión hospitalaria y ventilación mecánica no invasiva. Esto sugiere que la pérdida de peso y la mejora de las comorbilidades postoperatorias pueden contribuir a un riesgo reducido de hospitalización en casos de infección por COVID-19

Performance of an Adapted Version of the Timed Up-and-Go Test in People with Cognitive Impairments.

In clinical practice, older people with cognitive impairment may have difficulties to understand the instructions of the Timed Up-and-Go (TUGT) test and present a bad performance. The purpose of this study was to identify differences in the TUGT performance, in an adapted version, between older adults with preserved cognition (PC), mild cognitive impairment (MCI) and Alzheimer's disease (AD), and to identify the association between the adapted TUGT performance and cognition among groups. A cross-sectional study was conducted with 118 community-dwelling older adults divided in three groups: PC (n = 40), MCI (n = 40) and AD (n = 38). The evaluation was composed by the adapted TUGT and cognitive assessment (Addenbrooke's Cognitive Examination and Frontal Assessment Battery). Only the cadence of TUGT presented significant difference between groups, specifically between AD versus MCI and PC groups. The main correlations were found between time of TUGT with fluency domain and global cognitive function, especially in the AD Group. The findings contribute to the understanding of how cognition interferes on functional mobility in older people with MCI and AD. The adapted TUGT is easy to perform in clinical practice and can be useful when assessing mobility in people with cognitive impairment.

Relationship between health care insurance status, social determinants and prevalence of diabetes-related microvascular complications in patients with type 1 diabetes: a nationwide survey in Brazil.

AIMS: To evaluate the relationship between social determinants, health care insurance status and occurrence of diabetes-related chronic complications (DRCC) in Brazilian patients with type 1 diabetes. METHODS: A multicenter cross-sectional study conducted between August 2011 and August 2014 in 14 public clinics in 10 Brazilian cities. Data were obtained from 1760 patients, aged 29.9 ± 11.9 years, with diabetes duration of 15.5 ± 9.3 years; 55.9% female, 54.5% Caucasians, 69.7% were attended exclusively by the public Brazilian National Health Care System (BNHCS) and 30.3% had also private health care insurance. Patients' information was obtained through a questionnaire and a chart review form. RESULTS: The social determinants associated with having both private and public health care insurance were being employed, belonging to medium or high socioeconomic status, having more years of school attendance and having younger age. Regarding DRCC, patients that had private and public health care had lower rates of diabetic retinopathy and of any other DRCC. Chronic kidney disease was not associated with health care coverage status after adjusting for classical clinical risk factors. CONCLUSIONS: Brazilian patients with type 1 diabetes had better clinical control and lower rates of DRCC, mainly retinopathy, when also having private health care insurance. These patients presented less frequently predictors of chronic complications such as high levels of HbA1c and blood pressure. BNHCS should change the approach for screening DRCC such as diabetic retinopathy, using methods such as telemedicine that would lead to earlier diagnosis, better outcomes and will be cost-effective sometime after its implementation.

Impact of telemedicine interventions on mortality in patients with acute myocardial infarction: a systematic review and meta-analysis.

BACKGROUND: Despite the promise of telemedicine to improve care for ischaemic heart disease, there are significant obstacles to implementation. Demonstrating improvement in patient-centred outcomes is important to support development of these innovative strategies. OBJECTIVE: To assess the impact of telemedicine interventions on mortality after acute myocardial infarction (AMI). METHODS: Articles were searched in MEDLINE, Cochrane Central Register of Controlled Trials, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Base de Dados de Enfermagem (BDENF), Indice Bibliográfico Español en Ciencias de la Salud (IBECs), Web of Science, Scopus and Google Scholar, from January 2004 to January 2018. Study selection and data extraction were performed by two independent reviewers. In-hospital mortality (primary outcome), and door-to-balloon (DTB) time, 30-day mortality and long-term mortality (secondary outcomes) were assessed. Random effects models were applied to estimate pooled results. RESULTS: Thirty non-randomised controlled and seven quasi-experimental studies were included (16 960 patients). They were classified as moderate or serious risk of bias by ROBINS-I (Risk Of Bias In Non-randomized Studies-of Interventions tool). In 31 studies, the intervention was prehospital ECG transmission. Telemedicine was associated with reduced in-hospital mortality compared with usual care (relative risk (RR) 0.63(95% confidence interval[CI] 0.55 to 0.72); I2 <0.001%). DTB time was consistently reduced (mean difference -28 (95% CI -35 to -20) min), but showed large heterogeneity (I2=94%). Thirty-day mortality (RR 0.62;95% CI 0.43 to 0.85) and long-term mortality (RR 0.61(95% CI 0.40 to 0.92)) were also reduced, with moderate heterogeneity (I2=52%). CONCLUSIONS: There is moderate-quality evidence that telemedicine strategies, in particular ECG transmission, combined with the usual care for AMI are associated with reduced in-hospital mortality and very-low quality evidence that they reduce DTB time, 30-day mortality and long-term mortality.

Influence of genomic ancestry and self-reported color-race in CKD in a nationwide admixed sample of Brazilian patients with type 1 diabetes.

AIMS: Patients with diabetes that are African-Americans or Asians have a higher chance of developing diabetic nephropathy than Caucasian. Our objective was to evaluate the association between self-reported color-race, genomic ancestry, and the presence of chronic kidney disease (CKD), assessed by glomerular filtration rate and albuminuria in patients with type 1 diabetes. METHODS: This is a multicenter, observational, cross-sectional study with 1564 patients, conducted between August 2011 and August 2014 in 14 public clinics from 10 Brazilian cities. The ethnic aspects of the patients were evaluated using self-reported color-race and genomic ancestry (divided in European, African, and Amerindian). We divided the patients into groups: normal renal function and CKD. RESULTS: More patients self-declared themselves as black and brown in the group with CKD. The multivariate logistic analysis revealed that self-reported color-race was not associated with CKD and that a higher African ancestry was also not associated with CKD (p=0.06). Patients with an African ancestry of 50% or higher had an association with CKD that did not persist after the multivariate analysis. CONCLUSION: In our patients, from an admixed, multi-ethnic population, we did not find an association between self-reported color-race, genomic ancestry and CKD. It is important to note that despite the fact that we did not find a significant p-value in the multivariate analysis concerning African ancestry and CKD, we found a narrow confidence interval (0.961-3.98) with an OR of 1.956. Further studies should be conducted to confirm the lack of association between African ancestry and CKD, especially from populations with higher African or Amerindian ancestries to better understand the association between self-reported color-race and genomic ancestry with CKD.

Diabetic Retinopathy May Indicate an Increased Risk of Cardiovascular Disease in Patients With Type 1 Diabetes-A Nested Case-Control Study in Brazil.

Objective: Cardiovascular disease, the leading cause of death worldwide, and diabetic retinopathy, the main cause of blindness in economically active populations, share clinical risk factors, and pathophysiological features. The aim of this study is to examine the association between diabetic retinopathy, cardiovascular disease, and common risk factors in patients with type 1 diabetes. Design and Methods: This nested case-control study was performed in patients from the Brazilian Type 1 Diabetes Study Group, a nationwide survey that was conducted in Brazil and enrolled 1,760 patients with type 1 diabetes. A total of 342 patients were selected (57 cases with macrovascular disease and 285 controls who were matched for duration of diabetes and gender). Results: In the exploratory analysis, stratified by cardiovascular disease, the following variables were statistically significant: age (p=0.037), hypertension (p=0.035), high BMI (p = 0.046), diabetic retinopathy (p = 0.003), and chronic kidney disease (p = 0.026). By multivariate logistic regression, patients with diabetic retinopathy were more likely to develop cardiovascular disease (OR 2.16, 95% CI 1.16-4.02, p = 0.015). Although to a lesser extent than diabetic retinopathy, higher BMI levels were also related to an increase in the risk of cardiovascular disease of 1.08 (95% CI 1.01-1.15, p = 0.024). Conclusion: The presence of diabetic retinopathy indicates a greater risk for cardiovascular disease in Brazilian patients with type 1 diabetes. Further studies are warranted to determine whether a noninvasive exam, such as fundoscopy, could help identify patients who show an increased risk for cardiovascular disease.

Serum uric acid and renal function in patients with type 1 diabetes: a nationwide study in Brazil.

BACKGROUND: Diabetes nephropathy is a microvascular complication associated with high morbidity and mortality in patients with type 1 diabetes, and its pathogenesis is not fully understood. Our aim was to evaluate the association between levels of serum uric acid and renal function assessed by glomerular filtration rate (GFR) and albuminuria in patients with type 1 diabetes. METHODS: This is a multicenter, cross-sectional, observational study with 1686 patients, conducted between August 2011 and August 2014 in 14 public clinics from ten Brazilian cities. Renal function was estimated by CKD-EPI (adults) and by Schwartz (adolescents). RESULTS: We analyzed 1686 patients, aged 30.1 ± 12.0, with 15.4 ± 9.3 years of duration of diabetes; 55.8% were female and 54.0% were Caucasians. Serum uric acid was related to renal function, with a mean of 4.8 ± 1.4 (in the normal renal function group) vs 5.2 ± 2.0 (GFR ≥ 60 ml/min and albuminuria) vs 6.5 ± 2.6 mg/dl (GFR < 60 ml/min). In the pooled group, multivariate analysis showed an inverse correlation between serum uric acid and GFR (r = - 0.316, p < 0.001) with a decrease of 4.11 ml/min in the GFR for every increase of 1 mg/dl in serum uric acid. Considering only patients with normal renal function (n = 1170), a decrease of 2.04 ml/min in the GFR for every increase of 1 mg/dl in Serum uric acid was noted using multivariate analysis. CONCLUSIONS: Patients with higher levels of serum uric acid have worse renal function, independently of HbA1c or duration of diabetes, which persisted even in patients with normal renal function. Further prospective studies are necessary to establish if patients with higher serum uric acid may have an elevated risk for developing chronic kidney disease.

Prevalence and risk factors of toxoplasmosis among adults in a small Brazilian city.

INTRODUCTION: The prevalence of Toxoplasma gondii infection varies markedly among different populations, especially depending on factors related to socioeconomic development and eating habits. Cássia dos Coqueiros is a small city in Brazil with rural characteristics and increased risk factors traditionally associated with T. gondii infection. METHODS: We carried out a cross-sectional study involving 970 inhabitants aged 18 years or more, selected from patients of the local health unit and home visits in urban and rural areas. Each participant completed a survey with questions regarding demographic, socioeconomic, and risk factors for toxoplasmosis. Blood samples from participants were tested for presence of IgG and IgM antibodies against T. gondii using a chemiluminescent microparticle immunoassay. RESULTS: The prevalence of IgG and IgM antibodies was 62.3% and 2.5%, respectively. Variables that proved to be independent predictors of infection were age, low levels of education, and previous diagnosis of toxoplasmosis. CONCLUSIONS: The high prevalence of toxoplasmosis serological markers in this adult population highlights the need to promote preventive practices, especially those directed toward women of childbearing age, in this part of Brazil.

Does knowledge on diabetes management influence glycemic control? A nationwide study in patients with type 1 diabetes in Brazil.

OBJECTIVE: The purpose of this study is to establish demographic and clinical data associated with the knowledge on diabetes management and its influence on glycemic control in patients with type 1 diabetes. METHODS: This was a retrospective, observational, multicenter study conducted with 1,760 patients between August 2011 and August 2014 in 10 cities of Brazil. RESULTS: Overall, 1,190 (67.6%) patients knew what glycated hemoglobin (HbA1c) means. These patients were older, had longer disease duration, longer follow-up in each center, reported lower frequency of self-reported hypoglycemia, and were more frequently Caucasians and at glycemic goal. Multivariate analysis showed that knowledge on what HbA1c means was related to more years of school attendance, self-reported ethnicity (Caucasians), severe hypoglycemia, economic status, follow-up time in each center, and participation on diabetes educational programs. Good glycemic control was related to older age, more years of school attendance, higher frequency of daily self-monitoring of blood glucose, higher adherence to diet, and knowledge on what HbA1c means. CONCLUSION: Patients with a knowledge on what HbA1c means had a better chance of reaching an adequate glycemic control that was not found in the majority of our patients. Diabetes care teams should rethink the approaches to patients and change them to more proactive schedules, reinforcing education, patients' skills, and empowerment to have positive attitudes toward reaching and maintaining a better glycemic control. Finally, the glucocentric approach to diabetes management should be changed to actions that include patients' psychosocial aspects aiming to reduce the stress of living with diabetes, improving glycemic control, and avoiding adverse outcomes.

Does ancestry influence health-related quality of life in type 1 diabetes patients? A nationwide study in Brazil.

AIMS: The aim of the present study was to evaluate the relationship between self-reported color/race and genomic ancestry with HRQoL of patients with type 1 diabetes in a highly admixed population. METHODS: This was a nationwide, cross-sectional study conducted with 1760 patients with type 1 diabetes from 2011 to 2014 at public clinics in all five Brazilian geographical regions. Information on HRQoL was obtained from two self-completed questionnaires: Short Form-6 Dimensions (SF-6D) and EuroQol-5 Dimensions (EQ-5D) with a visual analogue scale (EQ-VAS). Genomic ancestry was assessed using a Multiplex PCR methodology. Utility scores generated from the questionnaires were analyzed with multivariate logistic regression models. RESULTS: We included 1698 patients. Those patients who self-reported as black had lower EQ-VAS scores compared to the patients who self-reported as white (67.46 ± 18.45; 72.37 ± 16.44, respectively, p = 0.02). In a linear regression model, each 1% increase in African ancestry resulted in a 9.5 point decrease in EQ-VAS score (p < 0.001). In a multivariate logistic regression, after adjusting for demographic, socioeconomic status and diabetes-related variables, African ancestry remained associated with lower EQ-VAS scores. CONCLUSION: A higher level of African ancestry implicates on lower quality of life even after adjustments for sociodemographic and diabetes-related data. Gender, physical activity and diabetes-related microvascular complications were strongly associated with low HRQoL in all three questionnaires used. This fact highlights the importance of social aspects when assessing quality of life, as well as the need for regular practice of physical activity and prevention of chronic complications to improve patients' quality of life.