Adagmar Andriolo

Metabolic Profile and Cardiovascular Risk Patterns of an Indian Tribe Living in the Amazon Region of Brazil

AbstractThe Parkatêjê Indians, belonging to the Jê group and inhabiting the Mãe Maria Reservation in the southeast of the state of Pará in the Amazon Region of Brazil, have suffered rapid and intensive cultural changes in recent years. This survey was designed to characterize the metabolic profile and the frequency of cardiovascular risk factors in this community. Ninety subjects (90.0% of the adult population without admixture) were investigated. Anthropometric measurements were performed and the following clinical characteristics measured: glycemia, serum insulin and proinsulin (fasting and 2-hr post 75 g of glucose load), ß-cell function (%B) and insulin sensitivity (%S) estimated by HOMA, HbA1c, GAD65 antibody, serum lipids, uric acid, creatinine, leptin, and blood pressure. Information about alcohol use, smoking, and medical history was obtained through individual interviews. The prevalences were: overweight, 67.8%; obesity, 14.4%; central obesity, 72.2%; hypertension, 4.4%; dyslipidemia, 44.4%; hyperuricemia, 5.6%; GAD65 antibody positivity, 4.4%; smoking, 25.6%; chronic alcohol use, 0.0%. One case of impaired glucose tolerance (1.1%) and one case of impaired fasting glycemia (1.1%) were diagnosed during this study and one case of diabetes (1.1%) was diagnosed previously. The diabetic woman was excluded from the analyses involving HbA1c, glycemia, insulin, proinsulin, %B, and %S. All creatinine values were normal. Blood pressure did not correlate with age, anthropometric measurements, insulin, proinsulin, and natural logarithm (ln) transformed %S. After adjustment for age and sex, there were positive correlations between total cholesterol and body mass index (BMI; r = 0.24), triglycerides and BMI (r = 0.44), triglycerides and waist-to-hip ratio (WHR; r = 0.52), ln leptin and BMI (r = 0.41), ln leptin and WHR (r = 0.29), uric acid and systolic blood pressure (r = 0.34), uric acid and triglycerides (r = 0.22). Systolic (r = 0.04; r = 0.70) and diastolic (r = 0.14; p = 0.18) blood pressure did not correlate with BMI. Ln leptin had a weak positive correlation with 2-hr insulin (r = 0.14) adjusted for age, sex, and BMI. The multiple linear regression model containing the variables sex, BMI, and 2-hr insulin concentrations explained 77.2% of the variation of ln leptin. In conclusion, the high rates of cardiovascular risk factors found among these Indians point to there being a high-risk group to develop diabetes and cardiovascular diseases. To reduce this risk they need to receive preventive interventions.

Atualização sobre hemoglobina glicada (HbA1C) para avaliação do controle glicêmico e para o diagnóstico do diabetes: aspectos clínicos e laboratoriais

Universidade Federal de Sao Paulo (UNIFESP) Hospital do Rim e Hipertensao Centro Integrado de Hipertensao e Metabologia Cardiovascular

Intervalos de referência no laboratório clínico

The definition of reference ranges is a challenging task to all clinical laboratories. It is particularly worth mentioning the definition of their own ranges, the validation of data on reagent directions and the use of information available in medical literature as possibilities for the establishment of these ranges. The creation of their own ranges is undoubtedly the most desirable choice in most tests, inasmuch as it reflects the condition of the population on whom they will be applied on a daily basis, yet it is the most laborious and onerous. The validation of ranges offered by the reagent directions and the use of data from medical literature seem to be the most commonly used options in our country. The choice of appropriate reference ranges is essential so that clinical laboratories offer reliable information and physicians interpret the results correctly and choose the best approach towards the assisted population.

Benefícios da atividade física no perfil lipídico de pacientes com diabetes tipo 1

We assessed the response of lipid profile to short-term non-pharmacological intervention and investigated if lipoprotein abnormalities were present before overt diabetic nephropathy (DN) in 46 type 1 diabetic (DM1) youngsters aged 15.5±1.5 yrs. They were submitted to a 8-day program of adequate diet and exercise, during stable glycemic control (mean glycemia 110.3±27.1mg/dl and HbA1c 6.9±1.3%) to minimize the influence of disturbed glucose homeostasis on urinary albumin excretion and lipid profile. Mean albumin-to-creatinine ratio was 9.0±8.0mg/g creatinine. At the beginning of the program, 65% of the subjects had total cholesterol > 160mg/dl (95% CI 0.51-0.78), whereas only 38% (95% CI 0.51-0.24) maintained such levels at the end. The improvement in lipid profile was even better concerning LDL fraction, considering that initially 67% of the subjects showed values > 100mg/dl (95% CI 0.55-0.78) and 24% (95% CI 0.12-0.36) at the end. Initial HDL-cholesterol was < 40mg/dl in 38% (95% CI 0.24-0.51) and in 11% (95% CI 0.02-0.20) at the end. In addition, HDL-cholesterol increased significantly. Poor correlations were found between albumin-to-creatinine ratio and total cholesterol (r= 0.21), LDL (r= 0.24), VLDL (r= 0.31), HDL (r= -0.17) and triglycerides levels (r= 0.31). A regular exercise program is effective on optimizing lipid profile in DM1 youngsters independently of glycemic control. Since within the normal range of albuminuria no association of urinary albumin excretion and lipids was found in subjects with stable DM1, our data did not support that lipid metabolism changes might precede microalbuminuria in the course of DN.

Comparison of methods for urinary albumin determination in patients with type 1 diabetes

We tested the correlation of the albumin-to-creatinine ratio (A/C) in an early-morning urine sample, measured with a commercial kit (DCA 2000), with the conventional immunoturbidimetric determination in the laboratory and with overnight albumin excretion rate (reference method). Fifty-five type 1 diabetic adolescents had their first-morning urine collected on the 1st and 8th day of the period. Urinary albumin and creatinine were determined immediately using the DCA 2000 kit. Samples were also stored for laboratory analysis. To evaluate the correlation between early-morning urinary A/C ratio and overnight albumin excretion rate, 16 subjects had a timed overnight urine collection. A/C ratios determined with the DCA 2000 kit and by the laboratory method were 13.1 +/- 20.5 and 20.4 +/- 46.3 mg/g, respectively. A/C results by both methods proved to be strongly correlated (r = 0.98, P<0.001). DCA 2000-determined A/C showed 50% sensitivity and 100% specificity when compared to the reference method. Spot urinary A/C of the subset of 16 subjects significantly correlated with their overnight albumin excretion rate (r = 0.98, P<0.001). Intraindividual variation ranged from 17 to 32% and from 9 to 63% for A/C and overnight albumin excretion rate, respectively. In conclusion, an early-morning specimen should be used instead of timed overnight urine and the A/C ratio is an accurate, reliable and easily determined parameter for the screening of diabetic nephropathy. Immediate measurement of the A/C ratio is feasible using the DCA 2000 kit. Intraindividual variability indicates the need for repeated determinations to confirm microalbuminuria and the diagnosis of incipient diabetic nephropathy.

Importância da hemoglobina glicada no controle do diabetes mellitus e na avaliação de risco das complicações crônicas

O diabetes mellitus (DM) continua sendo objeto de pesquisa, dadas as constantes informacoes que os estudos clinicos e os novos recursos laboratoriais incorporam a pratica medica a cada dia e com maiores rapidez e eficiencia. Niveis glicemicos persistentemente elevados sao danosos ao organismo e o descontrole prolongado resulta em complicacoes, incluindo danos em diversos tecidos, perda da funcao normal e falencia de varios orgaos. Para o acompanhamento do portador de DM, a hemoglobina glicada (A1C) tem se firmado como ferramenta util depois de ter sido validada pelos dois estudos clinicos mais importantes sobre a avaliacao do impacto do rigido controle glicemico sobre a incidencia e a progressao das complicacoes do diabetes: o Diabetes Control and Complications Trial (DCCT, 1993) e o United Kingdom Prospective Diabetes Study (UKPDS, 1998). Essas pesquisas demonstraram que manter o nivel de A1C abaixo de 7% reduz o risco de desenvolvimento das complicacoes dessa doenca. O Grupo Interdisciplinar de Padronizacao da Hemoglobina Glicada - A1C, criado pela associacao de diversas sociedades cientificas e farmaceuticas do Brasil, publicou, em 2004, um documento de posicionamento oficial acerca da importância da A1C para a avaliacao do controle glicemico, abordando os principais aspectos clinicos e laboratoriais, incluindo as condicoes de variacao pre-analitica e analitica. Foram estabelecidas as recomendacoes a respeito das indicacoes do teste e dos valores ideais de controle para adultos, criancas e idosos. Segundo este posicionamento, os testes de A1C devem ser realizados pelo menos duas vezes ao ano por todos os portadores de DM. Quando os resultados nao forem adequados e/ou forem realizadas alteracoes no esquema terapeutico, a dosagem deve ser feita depois de tres meses. A dosagem esta indicada tanto para os portadores de diabetes mellitus tipo 1 (DM1) quanto tipo 2 (DM2), sendo que a meta a ser atingida, representando efetivo controle, em ambas as condicoes e abaixo de 7%, tanto no adulto como no adulto jovem. Para as criancas durante a fase pre-puberal, o nivel aceitavel de A1C e de ate 8% e, na fase puberal, ate 8,5%. Nos pacientes idosos, a A1C de ate 8% e considerada apropriada, uma vez que a tentativa de um controle muito rigido da glicemia nesta faixa etaria, assim como nas fases pre-puberal e puberal, pode induzir a efeitos colaterais indesejados, como, por exemplo, hipoglicemia. Para a paciente gestante nao esta indicado o acompanhamento do controle glicemico pela dosagem de A1C, sendo mais eficiente o controle dos niveis das glicemias de jejum e duas horas apos as refeicoes e a dosagem de frutosamina, que corresponde ao conjunto das proteinas plasmaticas glicosadas. O grande diferencial da A1C em relacao a glicemia de jejum e que os niveis daquela variam mais lentamente, dependendo da meia-vida das hemacias, portanto nao retornam ao normal imediatamente depois da normalizacao da glicose no sangue. O tempo para que a A1C atinja os niveis adequados apos um periodo de hiperglicemia e de aproximadamente dez semanas. Assim, a repeticao do exame de A1C para avaliar a eficacia de um tratamento deve ser realizada somente dois a tres meses depois do inicio ou da modificacao do esquema terapeutico. Doencas que alteram a sobrevida das hemacias, como anemia hemolitica e hemorragia, por reduzirem sua vida media, podem resultar em valores falsamente baixos de Hb A1C, enquanto as anemias por carencia de ferro, de vitamina B12 ou de folato, que aumentam a vida media das hemacias, resultam em valores falsamente elevados. Na dependencia da metodologia utilizada, outras condicoes clinicas podem interferir no resultado de A1C, como hipertrigliceridemia, hiperbilirrubinemia, uremia, alcoolismo cronico, uso prolongado de opiaceos ou de salicilatos. O posicionamento oficial brasileiro recomenda a utilizacao de metodos rastreaveis do Diabetes Control and Complications Trial (DCCT), conforme certificado pelo National Glycohemoglobin Standardization Program (NGSP), e estimula a participacao em programas de ensaios de proficiencia especificos para A1C.

Clinical correlation between a point-of-care testing system and laboratory automation for lipid profile.

BACKGROUND We evaluated the clinical correlation between the CardioChek PA analyzer and a clinical laboratory reference method to use for screening program purposes. METHODS Fasting blood samples were collected on 516 patients (age 20-85 y). One venous sample was collected using a serum tube for the evaluation on a COBAS reference analyzer. A second venous sample was collected in a lithium heparin tube and was evaluated on the CardioChek PA analyzer (CCPA venous). A fingerstick sample (CCPA fingerstick) was evaluated only on the CardioChek PA analyzer. Linear regression analyses were performed for each measured analyte, total cholesterol, HDL-cholesterol and triglycerides. RESULTS The correlation between the CCPA fingerstick and CCPA venous was extremely high for HDL-C and triglycerides, and good for total cholesterol. Our results demonstrated a good clinical agreement for total cholesterol, HDL-C and triglycerides between 97.7% and 94.6% in the comparison of the CCPA to the reference analyzer. CONCLUSIONS We identified the pre-analytic phase as an important step to guarantee the quality of results and indicate that the CardioChek PA is a reliable lipid point-of-care testing system that can be used for the application of clinical screening anywhere.

Effect of shock wave reapplication on urinary n-acetyl-beta-glucosaminidase in canine kidney

OBJECTIVE Renal tubular damage can be assessed with the aid of urinary dosing of N-acetyl-beta-glucosaminidase (NAG) and it is possible to demonstrate a significant correlation between shock wave and damage to renal parenchyma. The objective of this study was to assess the effect of shock wave reapplication over urinary NAG in canine kidney. MATERIALS AND METHODS The authors submitted 10 crossbred dogs to 2 applications of 2000 shock waves in a 24-hour interval in order to assess urinary NAG values after 12, 24, 36 and 48 hours. RESULTS Twelve hours following the first shockwave application there was an increase in NAG of 6.47 +/- 5.44 u/g creatinine (p < 0.05). Twelve hours and 24 h following the second application there was no increase in the urinary enzyme, -2.56 +/- -7.36 u/g creatinine and 2.89 +/- -7.27 u/g creatinine, respectively (p > 0.05). CONCLUSION Shock wave reapplication with a 24-hour interval did not cause any increase in urinary NAG.

Pró-calcitonina e proteína C reativa em processos infecciosos graves

Marcadores bioquimicos da resposta inflamatoria sao necessarios para a obtencao de evidencias objetivas da existencia de processos infecciosos. A proteina C reativa (PCR) tem sido utilizada para essa finalidade, com baixa especificidade. A pro-calcitonina (PCT) foi proposta como marcador mais especifico, mas seu valor prognostico ainda nao esta bem estabelecido. Avaliamos qual desses marcadores teria maior poder em prever a evolucao clinica de pacientes com sepse. Dosamos PCT e PCR no soro de 19 pacientes internados na unidade de tratamento intensivo do Hospital Sao Paulo, na Escola Paulista de Medicina (EPM), a pro-calcitonina por ensaio imunoluminometrico (LUMItest PCT, Brahms Diagnostica GmbH, Berlin, Germany) e a proteina C reativa por imunonefelometria (High Sensitivity CRP, Dade Behring, Marburg, Germany). As concentracoes de PCT foram significativamente mais elevadas no grupo de pacientes que faleceram do que no grupo dos que tiveram alta hospitalar (p < 0,002), o mesmo nao acontecendo com as concentracoes de PCR. Nao observamos correlacao entre as concentracoes de PCT e PCR tanto no grupo dos pacientes que faleceram quanto no grupo dos que se recuperaram (RS = 0,205, valor critico 0,553 e RS = 0,029, valor critico 0,811, respectivamente). Concluimos que ambos sao marcadores sensiveis de processo septico e que a concentracao de pro-calcitonina mais elevada parece estar associada a pior prognostico.

Determination of erythrocyte uroporphyrinogen I synthetase activity in chronic renal failure

To obtain some information on porphyrin metabolism in uraemic patients, the activity of erythrocyte uroporphyrinogen I synthetase was measured in patients with chronic renal failure. The results indicate a decreased enzymatic activity which is not due to urea interference, in the hemolysates of these patients.