Renan Magalhães Montenegro

Temporal trends in incidence of Type 1 diabetes between 1986 and 2006 in Brazil

Background: Scarce information is available about the variation in the incidence of Type 1 diabetes in the Brazilian population in the last decades. Aim: The objective of this study was to assess the long-term trends (1986–2006) in the incidence of Type 1 diabetes in Bauru, São Paulo State, Brazil. Subjects and methods: The annual incidence of Type 1 diabetes (per 100,000 per yr) from 1986 to 2006 was determined in children ≤14 yr of age, using the capture and recapture method. Results: A total of 176 cases were diagnosed in the study population. The overall incidence was 10.4/100,000 with a range of 2.82/100,000 in 1987 to 18.49/100,000 in 2002 representing a 6.56-fold increase within the same population. The estimated incidence, using the capture and recapture method varied from 2.82/100,000 per yr in 1987 to 27.20/100,000 per yr in 2002, representing a 9.6-fold variation. The global pattern of incidence variation was categorized as high (10-19.99/100,000 per yr), and very high (≥20/100,000 per yr) in 71.43% of the study-years. Incidence was slightly higher among females, Caucasians, children in the 5–9 yr of age range and belonging to lower socio-economic classes. Most diagnoses were established during the colder months and/or with higher pluviometric indexes. Conclusions: The incidence of Type 1 diabetes in children is increasing in Bauru, São Paulo State, Brazil, and the global pattern of incidence was classified as high or very high, mainly in the last 10 yr. All Brazilian regions should be involved in the study.

Pitfalls in the diagnosis of Cushing's syndrome

Among endocrine disorders, Cushings syndrome (CS) is certainly one of the most challenging to endocrinologists due to the difficulties that often appear during investigation. The diagnosis of CS involves two steps: confirmation of hypercortisolism and determination of its etiology. Biochemical confirmation of the hypercortisolaemic state must be established before any attempt at differential diagnosis. Failure to do so will result in misdiagnosis, inappropriate treatment, and poor management. It should also be kept in mind that hypercortisolism may occur in some patients with depression, alcoholism, anorexia nervosa, generalized resistance to glucocorticoids, and in late pregnancy. Moreover, exogenous or iatrogenic hypercortisolism should always be excluded. The three most useful tests to confirm hypercortisolism are the measurement of 24-h urinary free cortisol levels, low-dose dexamethasone-suppression tests, and determination of midnight serum cortisol or late-night salivary cortisol. However, none of these tests is perfect, each one has different sensitivities and specificities, and several are usually needed to provide a better diagnostic accuracy. The greatest challenge in the investigation of CS involves the differentiation between Cushings disease and ectopic ACTH syndrome. This task requires the measurement of plasma ACTH levels, non-invasive dynamic tests (high-dose dexamethasone suppression test and stimulation tests with CRH or desmopressin), and imaging studies. None of these tests had 100% specificity and their use in combination is usually necessary. Bilateral inferior petrosal sinus sampling is mainly indicated when non-invasive tests do not allow a diagnostic definition. In the present paper, the most important pitfalls in the investigation of CS are reviewed.

Dysglycemias in pregnancy: from diagnosis to treatment. Brazilian consensus statement

There is an urgent need to find consensus on screening, diagnosing and treating all degrees of DYSGLYCEMIA that may occur during pregnancies in Brazil, considering that many cases of DYSGLYCEMIA in pregnant women are currently not diagnosed, leading to maternal and fetal complications. For this reason the Brazilian Diabetes Society (SBD) and the Brazilian Federation of Gynecology and Obstetrics Societies (FEBRASGO), got together to introduce this proposal. We present here a joint consensus regarding the standardization of clinical management for pregnant women with any degree of Dysglycemia, on the basis of current information, to improve medical assistance and to avoid related complications of Dysglycemia in pregnancy to the mother and the fetus. This consensus aims to standardize the diagnosis among general practitioners, endocrinologists and obstetricians allowing the dissemination of information in basic health units, public and private services, that are responsible for screening, diagnosing and treating disglycemic pregnant patients.

Regional differences in clinical care among patients with type 1 diabetes in Brazil: Brazilian Type 1 Diabetes Study Group

BackgroundTo determine the characteristics of clinical care offered to type 1 diabetic patients across the four distinct regions of Brazil, with geographic and contrasting socioeconomic differences. Glycemic control, prevalence of cardiovascular risk factors, screening for chronic complications and the frequency that the recommended treatment goals were met using the American Diabetes Association guidelines were evaluated.MethodsThis was a cross-sectional, multicenter study conducted from December 2008 to December 2010 in 28 secondary and tertiary care public clinics in 20 Brazilian cities in north/northeast, mid-west, southeast and south regions. The data were obtained from 3,591 patients (56.0% females and 57.1% Caucasians) aged 21.2 ± 11.7 years with a disease duration of 9.6 ± 8.1 years (<1 to 50 years).ResultsOverall, 18.4% patients had HbA1c levels <7.0%, and 47.5% patients had HbA1c levels ≥ 9%. HbA1c levels were associated with lower economic status, female gender, age and the daily frequency of self-blood glucose monitoring (SBGM) but not with insulin regimen and geographic region. Hypertension was more frequent in the mid-west (32%) and north/northeast (25%) than in the southeast (19%) and south (17%) regions (p<0.001). More patients from the southeast region achieved LDL cholesterol goals and were treated with statins (p<0.001). Fewer patients from the north/northeast and mid-west regions were screened for retinopathy and nephropathy, compared with patients from the south and southeast. Patients from the south/southeast regions had more intensive insulin regimens than patients from the north/northeast and mid-west regions (p<0.001). The most common insulin therapy combination was intermediate-acting with regular human insulin, mainly in the north/northeast region (p<0.001). The combination of insulin glargine with lispro and glulisine was more frequently used in the mid-west region (p<0.001). Patients from the north/northeast region were younger, non-Caucasian, from lower economic status, used less continuous subcutaneous insulin infusion, performed less SBGM and were less overweight/obese (p<0.001).ConclusionsA majority of patients, mainly in the north/northeast and mid-west regions, did not meet metabolic control goals and were not screened for diabetes-related chronic complications. These results should guide governmental health policy decisions, specific to each geographic region, to improve diabetes care and decrease the negative impact diabetes has on the public health system.

Fisiopatologia da osteoporose induzida por glicocorticóide

Chronic hypercortisolism is the most frequent cause of secondary osteoporosis involving mainly trabecular bone. Approximately 30-35% of the patients with Cushings syndrome present with compression fractures of vertebrae, and the risk of femoral neck fracture is increased in 50% in that population. Several mechanisms have been proposed to explain the association between hypercortisolism and osteoporosis, as the direct action of glucocorticoids in parathyroid glands and bone cells, alterations in the production of prostaglandins, citokines, interleukines, growth hormone (GH), insulin like growth factor I (IGF-I) and gonadal steroids. Contradictory results have been presented in relation to PTH secretion, where normal and high levels have been described. Elevated PTH secretion can occur as a consequence of disturbances in mineral metabolism, i.e. decrease in the intestinal absortion and elevation in the renal excretion of calcium, decrease in the number of parathyroid receptors for 1,25(OH)2D3, abnormalities in the calcium set point for PTH secretion, and alteration in PTH activity. In this review, several pathophysiologic aspects and possible mechanisms involved in the association between osteoporosis and hypercortisolism are discussed.

Prevalence of diabetes and associated factors in an urban adult population of low educational level and income from the Brazilian Northeast wilderness.

BACKGROUND Diabetes mellitus (DM) is a public health problem in Brazil. The objective of this study was to investigate the prevalence of DM and its relation with socio-demographic features and other cardiovascular risk factors in a adult population from the wilderness of Pernambuco, Brazil. SUBJECTS AND METHODS In 2008/2009 a cross-sectional study in the adult urban population of Canãa district, city of Triunfo, in the wilderness of Pernambuco/Brazil was conducted. A representative sample of 198 individuals, with average age of 57.7 years, 80% with primary education and 81.3% with a monthly income of less than 1 minimum wage was randomly selected. RESULTS A prevalence of diabetes of 13.6% and 7.6% of disglycemia (6.6% of impaired fasting glycemia, and 1.0% of impaired glucose tolerance) was found. Among those with diabetes, 24% had no prior diagnosis. Among diabetics, metabolic syndrome (MS) and arterial hypertension (AH) were diagnosed in 87.5% and 68%, respectively. Besides these, there was a positive and significant association between DM and BMI, and between DM and MS. CONCLUSION These data demonstrate a high prevalence of DM in the adult urban population from the wilderness of Pernambuco/Brazil. These results as well as their association with obesity and MS, indicate that more effective interventions are necessary for the prevention of these diseases also outside principal urban centers.

Leprosy-related mortality in Brazil: a neglected condition of a neglected disease.

BACKGROUND Leprosy is a public health problem and a neglected condition of morbidity and mortality in several countries of the world. We analysed time trends and spatiotemporal patterns of leprosy-related mortality in Brazil. METHODS We performed a nationwide population-based study using secondary mortality data. We included all deaths that occurred in Brazil between 2000 and 2011, in which leprosy was mentioned in any field of death certificates. RESULTS Leprosy was identified in 7732/12 491 280 deaths (0.1%). Average annual age-adjusted mortality rate was 0.43 deaths/100 000 inhabitants (95% CI 0.40-0.46). The burden of leprosy deaths was higher among males, elderly, black race/colour and in leprosy-endemic regions. Lepromatous leprosy was the most common clinical form mentioned. Mortality rates showed a significant nationwide decrease over the period (annual percent change [APC]: -2.8%; 95% CI -4.2 to -2.4). We observed decreasing mortality rates in the South, Southeast and Central-West regions, while the rates remained stable in North and Northeast regions. Spatial and spatiotemporal high-risk clusters for leprosy-related deaths were distributed mainly in highly endemic and socio-economically deprived regions. CONCLUSIONS Leprosy is a neglected cause of death in Brazil since the disease is preventable, and a cost-effective treatment is available. Sustainable control measures should include appropriate management and systematic monitoring of leprosy-related complications, such as severe leprosy reactions and adverse effects to multidrug therapy.

Freqüência e atividade enzimática de Candida spp. na cavidade oral de pacientes diabéticos do serviço de endocrinologia de um hospital de Fortaleza-CE

Diabetes mellitus, a endocrine-metabolic disease, of high and increasing prevalence, is cited as responsible by the occurrence of oral candidiasis. Candidiasis constitutes a specter of infections caused by fungi of genera Candida; the most common agent is Candida albicans, but other species have also been identified (Candida tropicalis, Candida guillermondii, Candida glabrata, Candida krusei). The objective of this work was to evaluate frequency and enzymatic activity of Candida spp. in the oral cavity of diabetic patients taken care in the service of endocrinology of the University Hospital Walter Cantidio of the Federal University of the Ceara. Samples had been collected of 48 diabetic patients, men and women, with various situations of glicemic control. Clinical materials had been collected with aid of swab and harvested in plates of Petri contend Sabouraud agar dextrose with cloranfenicol and incubated to 37°C. The grown were identified by the used classic tests in mycology. In the following, these Candida strains were submitted to tests to detect phospholipase and proteinase enzymes. Of these, 15 samples (31,35%) presented positive culture for the genera Candida. The species more frequent was C. albicans with 80%, followed by C. tropicalis (13.3%) and C. guilliermondii (6.7%). Asfor the research on the enzymatic activity of Candida sp. it was observed that 86.6% presented activity of proteinase and 80% of phospholipase. It was concluded with these results that C. albicans is more frequent and that Candida spp. isolated species have strong enzymatic activity.

Influence of Periodontal Disease on Changes of Glycated Hemoglobin Levels in Patients With Type 2 Diabetes Mellitus: A Retrospective Cohort Study

BACKGROUND Little evidence is available regarding the effects of long-term periodontal infection on diabetes mellitus (DM) control. The aim of this retrospective cohort study is to evaluate influence of periodontal status on changes of glycated hemoglobin (HbA1c) levels of patients with type 2 DM (DMt2). METHODS Eighty patients (mean age: 56.0 ± 8.9 years) with DMt2 were included. Patients were non-smokers, aged ≥40 years, and using antidiabetic drugs. Demographics, health history, and HbA1c levels were retrieved from medical charts. Probing depth and clinical attachment loss (AL) were recorded. RESULTS Patients were examined at two time points within a mean interval of 38.6 ± 6.6 months. Increase in HbA1c over time was statistically significant when severe periodontitis was diagnosed at baseline (2.32%, 95% confidence interval [CI]: 1.50% to 3.15%), in patients showing at least one tooth with ≥2 mm of AL progression (2.24%, 95% CI: 1.56% to 2.91%), in males (2.75%, 95% CI: 1.72% to 3.78%), and in those with HbA1c <6.5% at baseline (3.08%, 95% CI: 2.47% to 3.69%). After adjusting for baseline HbA1c, significant changes were still observed for severe periodontitis and progression of AL with increases of 0.85% and 0.9%, respectively. After adjusting for sex and HbA1c, AL progression was also statistically significant, with increases of 0.84%. CONCLUSIONS Periodontitis progression was associated with increase in HbA1c in patients with DMt2. Identification of these risk factors suggests that periodontal treatment may improve glycemic control of patients with DMt2 by eliminating periodontal infection.

Estudo comparativo do conhecimento e prática de atividade física de idosos diabéticos tipo 2 e não diabéticos

Objetivo: caracterizar o conhecimento e a pratica de atividades fisicas em idosos diabeticos tipo 2, assistidos em um ambulatorio de referencia da cidade de Fortaleza, comparando-os com idosos nao-diabeticos. Metodos : O estudo, do tipo transversal, envolveu 44 idosos com Diabetes Mellitus tipo 2 (DM2) e 44 sem DM2, avaliados por meio de um questionario sobre pratica, recomendacoes, orientacoes e conhecimentos de atividades fisicas. Os dados foram analisados por meio do teste Qui-quadrado. O nivel de significância foi de p<0,05. Resultados: Em relacao a pratica e a frequencia semanal de alguma atividade fisica, verificou-se que aproximadamente metade dos participantes dos dois grupos nao praticava nenhuma atividade fisica. Dentre as recomendacoes recebidas de profissionais da saude sobre a pratica de atividades fisicas, 84,1% (N=37) dos idosos diabeticos responderam que as tinham recebido, enquanto que entre os idosos nao-diabeticos apenas 58,7% (N=27) afirmaram que essas recomendacoes foram dadas. As orientacoes verbais predominaram em ambos os grupos. Em relacao a opiniao dos individuos a respeito dos beneficios da atividade fisica para os portadores de diabetes, a maioria dos idosos DM2 afirmou que a atividade fisica pode beneficia-los. Conclusao: Os idosos DM2 mostraram melhor conhecimento e pratica regular de atividade fisica do que os idosos nao-diabeticos. E necessaria a elaboracao de acoes em que o idoso adquira conhecimentos para a descoberta de seus limites fisicos e motores.