Ticiana da Costa Rodrigues

Effect of Antihyperglycemic Agents Added to Metformin and a Sulfonylurea on Glycemic Control and Weight Gain in Type 2 Diabetes: A Network Meta-analysis

BACKGROUND Few studies have examined the effect of adding a third antihyperglycemic drug when blood glucose control is not achieved by using metformin and a sulfonylurea. PURPOSE To compare the efficacy of add-on antihyperglycemic drugs in patients with type 2 diabetes that is not controlled with metformin and a sulfonylurea. DATA SOURCES MEDLINE, EMBASE, Cochrane Library, LILACS, and ClinicalTrials.gov electronic databases. STUDY SELECTION Randomized trials at least 24 weeks in duration. Studies evaluated the effects of adding a third antihyperglycemic drug to treatment of adults aged 18 years or older with type 2 diabetes and a hemoglobin A(1c) (HbA(1c)) level greater than 7.0% who were already receiving a combination of metformin and a sulfonylurea. DATA EXTRACTION Primary end points were change in HbA(1c) level, change in weight, and frequency of severe hypoglycemia. DATA SYNTHESIS Eighteen trials involving 4535 participants that lasted a mean of 31.3 weeks (24 to 52 weeks) were included. Compared with placebo, drug classes did not differ in effect on HbA(1c) level (reduction ranging from -0.70% [95% credible interval {CrI}, -1.33% to -0.08%] for acarbose to -1.08% [CrI, -1.41% to -0.77%] for insulin). Weight increase was seen with insulins (2.84 kg [CrI, 1.76 to 3.90 kg]) and thiazolidinediones (4.25 kg [CrI, 2.76 to 5.66 kg]), and weight loss was seen with glucagon-like peptide-1 agonists (-1.63 kg [CrI, -2.71 to -0.60 kg]). Insulins caused twice the absolute number of severe hypoglycemic episodes than noninsulin antihyperglycemic agents. LIMITATIONS Most of the trials were short term, and trial quality varied. With so few trials relative to antihyperglycemic agents, investigators relied on indirect comparisons, which increased the uncertainty of the findings and conclusions. CONCLUSION There is no clear difference in benefit between drug classes when adding a third agent to treatment of patients with type 2 diabetes who are already receiving metformin and a sulfonylurea. The most appropriate option should depend on each patients clinical characteristics. PRIMARY FUNDING SOURCE Conselho Nacional de Desenvolvimento Científico e Tecnológico and Coordenacăo de Aperfeicoamento de Pessoal de Nível Superior.

Diabetic Retinopathy Predicts All-Cause Mortality and Cardiovascular Events in Both Type 1 and 2 Diabetes: Meta-analysis of observational studies

OBJECTIVE The prognostic significance of diabetic retinopathy (DR) for death and cardiovascular (CV) outcomes is debated. We investigated the association of DR with all-cause mortality and CV events in patients with diabetes by a systematic review and meta-analysis. RESEARCH DESIGN AND METHODS The electronic databases Medline and Embase were searched for cohort studies that evaluated DR in type 2 or type 1 diabetic patients and reported total mortality and/or fatal and nonfatal CV events, including myocardial infarction, angina pectoris, coronary artery bypass graft, ischemic changes on a conventional 12-lead electrocardiogram, transient ischemic attack, nonfatal stroke, or lower leg amputation. Data extraction was performed by two reviewers independently. Pooled effect estimates were obtained by using random-effects meta-analysis. RESULTS The analysis included 20 studies that fulfilled the inclusion criteria, providing data from 19,234 patients. In patients with type 2 diabetes (n = 14,896), the presence of any degree of DR increased the chance for all-cause mortality and/or CV events by 2.34 (95% CI 1.96–2.80) compared with patients without DR. In patients with type 1 diabetes (n = 4,438), the corresponding odds ratio was 4.10 (1.50–11.18). These associations remained after adjusting for traditional CV risk factors. DR was also predictive of all-cause mortality in type 2 diabetes (odds ratio 2.41 [1.87–3.10]) and type 1 diabetes (3.65 [1.05–12.66]). CONCLUSIONS The presence of DR was associated with an increased risk of all-cause mortality and CV events in both type 2 and type 1 diabetic patients.

Coronary artery calcium score prediction of all cause mortality and cardiovascular events in people with type 2 diabetes: systematic review and meta-analysis

Objective To investigate the association of coronary artery calcium score with all cause mortality and cardiovascular events in people with type 2 diabetes. Design Systematic review and meta-analysis of observational studies. Data sources Studies were identified from Embase, PubMed, and abstracts from the 2011 and 2012 annual meetings of the American Diabetes Association, European Association for the Study of Diabetes, American College of Cardiology, and American Heart Association (2011). Eligibility criteria Prospective studies that evaluated baseline coronary artery calcium score in people with type 2 diabetes and subsequent all cause mortality or cardiovascular events (fatal and non-fatal). Data extraction Two independent reviewers extracted the data. The predictive value of the coronary artery calcium score was assessed by random effects model. Results Eight studies were included (n=6521; 802 events; mean follow-up 5.18 years). The relative risk for all cause mortality or cardiovascular events, or both comparing a total coronary artery calcium score of ≥10 with a score of <10 was 5.47 (95% confidence interval 2.59 to 11.53; I2=82.4%, P<0.001). The overall sensitivity of a total coronary artery calcium score of ≥10 for this composite outcome was 94% (95% confidence interval 89% to 96%), with a specificity of 34% (24% to 44%). The positive and negative likelihood ratios were 1.41 (95% confidence interval 1.20 to 1.66) and 0.18 (0.10 to 0.30), respectively. For people with a coronary artery calcium score of <10, the post-test probability of the composite outcome was about 1.8%, representing a 6.8-fold reduction from the pretest probability. Four studies evaluated cardiovascular events as the outcome (n=1805; 351 events). The relative risk for cardiovascular events comparing a total coronary artery calcium score of ≥10 with a score of <10 was 9.22 (2.73 to 31.07; I2=76.7%, P=0.005). The positive and negative likelihood ratios were 1.67 (1.30 to 2.17) and 0.11 (0.04 to 0.29), respectively. Conclusion In people with type 2 diabetes, a coronary artery calcium score of ≥10 predicts all cause mortality or cardiovascular events, or both, and cardiovascular events alone, with high sensitivity but low specificity. Clinically, the finding of a coronary artery calcium score of <10 may facilitate risk stratification by enabling the identification of people at low risk within this high risk population.

Side-by-side comparison of areas with and without cellulite depressions using magnetic resonance imaging.

BACKGROUND Cellulite is characterized by alterations in the relief of the skin surface. Magnetic resonance imaging (MRI) is recognized as a reliable technique for measuring adipose volume according to body site and for the visualization of the subcutaneous structures. OBJECTIVE To compare subcutaneous tissue in areas with and without cellulite on the buttocks of same subjects using a noninvasive technique. METHODS AND MATERIALS Thirty female patients with cellulite on the buttocks underwent MRI. An area with cellulite and another without cellulite on the contralateral buttock were selected. Two soft gelatin capsules of different sizes were used as skin markers to differentiate the areas with and without cellulite. RESULTS Fibrous septa were visualized in 96.7% of the area with cellulite depressions; most of them were ramified (73.3%) and presented a high‐intensity signal on T2 images (70%). All fibrous septa found in the examined areas were perpendicular to the skin surface. The average fibrous septa thickness was 2.18 ± 0.89 in the area with cellulite and 0.27 ± 0.64 in the area without cellulite. CONCLUSION Results of the MRI analysis showed that cellulite depressions on the buttocks were significantly associated with the presence of underlying fibrous septa.

Shift work and its association with metabolic disorders

Although the health burden of shift work has not been extensively studied, evidence suggests that it may affect the metabolic balance and cause obesity and other metabolic disorders. Sleep deprivation, circadian desynchronization and behavioral changes in diet and physical activity are among the most commonly mentioned factors in studies of the association between night work and metabolic disorders. Individual adaptation to night work depends greatly on personal factors such as family and social life, but occupational interventions may also make a positive contribution to the transition to shift work, such as exposure to bright lights during the night shift, melatonin use, shift regularity and clockwise rotation, and dietary adaptations for the metabolic needs of night workers. The evaluation of the impact of night work on health and of the mechanisms underlying this relationship can serve as a basis for intervention strategies to minimize the health burden of shift work. This review aimed to identify highlights regarding therapeutic implications following the association between night and shift work and metabolic disorders, as well as the mechanisms and pathways responsible for these relationships.

Evaluation of Cushing's disease remission after transsphenoidal surgery based on early serum cortisol dynamics

To evaluate the ability of post‐transsphenoidal pituitary surgery (TSS) serum cortisol levels (s‐cortisol) to predict surgical remission and recurrence of Cushings disease (CD).

Evaluation of Self-Esteem and Depression Symptoms in Depressed and Nondepressed Subjects Treated with OnabotulinumtoxinA for Glabellar Lines

BACKGROUND Botulinum toxin type A (BoNT‐A) injection has become the most popular cosmetic nonsurgical procedure, and it has been suggested that BoNT‐A injections may improve emotional states when frown lines are treated. OBJECTIVES To evaluate symptoms of depression and self‐esteem before and after onabotulinumtoxinA (ONA) injections in the glabella in subjects with and without depression. METHODS Twenty‐five subjects with depression were allocated into one group and 25 subjects without depression were matched to those according to demographic characteristics. The Beck Depression Inventory (BDI) and Rosenberg Self‐Esteem Scale (RSES) were used to assess depression symptoms and self‐esteem, respectively. Patients were assessed up to 12 weeks after the intervention. RESULTS Patients with depression had significant improvement in depression symptoms after ONA injections. The maximum effect occurred within the first 8 weeks after treatment. A significant reduction from baseline in BDI score and significant improvement in self‐esteem were also observed in patients with depression. CONCLUSION This research presents new data regarding BoNT‐A as a potential treatment to improve depression symptoms in patients with Major Depressive Disorder. Self‐esteem scores alone cannot explain the improvement in depression symptoms.

Field effect of two commercial preparations of botulinum toxin type A: A prospective, double-blind, randomized clinical trial

BACKGROUND The dose equivalence of commonly used commercial preparations of botulinum toxin type A, Dysport (abotulinumtoxinA [ABO] 500 U, Ipsen Biopharm Limited, Wrexham, United Kingdom) and Botox (onabotulinumtoxinA [ONA] 100 U, Allergan, Irvine, CA), remains unclear. OBJECTIVE We sought to evaluate the field effect for ABO and ONA at dose equivalences of 2.5:1.0 U and 2.0:1.0 U, in both muscular and sweat gland activity. METHODS In all, 59 female patients with forehead wrinkles were enrolled. Patients were randomized for dose equivalence between ABO and ONA, group A (2.0:1.0 U, ABO:ONA) or group B (2.5:1.0 U, ABO:ONA) administered in the frontalis muscles. Clinical assessment, Minor test, and electromyography evaluations were performed at baseline, 28 days, and 112 days. RESULTS In group B, the field of anhidrotic effect of ABO showed a greater area and larger horizontal diameter than ONA at 28 and 112 days. At maximum frontalis muscle activity (day 112) patients receiving ABO demonstrated greater improvement based on the Wrinkle Severity Scale. No differences were found in frontalis muscle activity at rest between groups A and B based on results of Wrinkle Severity Scale, electromyography, and interindividual variability data at 28 and 112 days. LIMITATIONS Currently, there are no objective measurements other than electromyography to evaluate the field effect of botulinum toxin type A in muscles. CONCLUSION At a dose equivalence of 2.0:1.0 U (ABO:ONA), similar field effects were found for both muscle and sweat gland activity. At a higher dose equivalence of 2.5:1.0 U (ABO:ONA), injections of ABO showed greater area and larger horizontal diameter in field of anhidrotic effect at 28 and 112 days than ONA.

Prevalence of diabetic retinopathy in patients with type 1 diabetes mellitus

OBJECTIVES Diabetic retinopathy (DR) is the leading cause of legal blindness in young adults. Scarce data from Brazilian subjects with type 1 diabetes mellitus (DM) are available. AIMS The objectives of this study were to determine the prevalence of DR and its risk factors in type 1 diabetes mellitus (DM) outpatients from a general hospital. METHODS A cross-sectional study of 437 type 1 DM (50.3% males, 82.4% whites) was conducted. DR was graded as absent, mild and moderate non-proliferative DR (mild/moderate NPDR) or severe non-proliferative and proliferative DR (advanced DR). Presence of clinically significant macular edema (CSME) was also recorded. RESULTS Any DR was present in 44.4% of subjects. In multivariate analysis, DM duration, systolic blood pressure (SBP) and A1C test were associated with mild/moderate NPDR (P<0.005). Advanced DR, was associated with DM duration, SBP, smoking [odds ratio (OR) 2.75, 95%CI 1.15-6.60] and micro-or macroalbuminuria (OR 8.53, 95%CI 3.81-18.05). CSME was present in 21 (9.4%) patients and was associated with smoking (OR 3.19, 95%CI 1.24-8.2). Its frequency increased with the severity of DR (16.4% in advanced DR, 9.6% in mild/moderate NPDR, and 4.7% in the group without DR; P = 0.020). CONCLUSION Patients with type 1 DM attending an endocrine out-patient clinic at a general hospital had a high prevalence of DR associated with traditional risk-factors and smoking.

Caracterização de pacientes com diabetes mellitus tipo 1 do sul do Brasil: complicações crônicas e fatores associados

OBJETIVO: Avaliar a prevalencia de complicacoes cronicas vasculares e fatores associados em pacientes com diabetes mellitus (DM) tipo 1. METODOS: Estudo transversal com pacientes DM tipo 1 atendidos no Servico de Endocrinologia do Hospital de Clinicas de Porto Alegre. Os pacientes foram avaliados quanto a presenca de complicacoes cronicas vasculares. RESULTADOS: Avaliamos 573 pacientes, idade media de 33 anos. A presenca de retinopatia diabetica (RD) foi observada em 43,3%, o tempo de DM [RC: 1,07; IC95% 1,03-1,11; P 100 mg/dl. CONCLUSAO: Observamos elevadas prevalencias de complicacoes microvasculares e de HAS. A duracao do DM, HAS e presenca de ND foram associados a RD. HAS e dislipidemia foram associados a ND. A maioria dos pacientes encontrava-se fora dos alvos desejados de controle glicemico, pressorico e lipidico. Maiores esforcos sao necessarios para intensificar o controle metabolico e pressorico de pacientes com DM tipo 1.