Walter José Minicucci

Consenso Brasileiro sobre antipsicóticos de segunda geração e distúrbios metabólicos

Resumo Objetivo: Discutir os aspectos atuais do tratamento com os antipsicoticos, levando-se em consideracao o perfil de efeitos metabolicos, tais como ganho de peso, diabetes, dislipidemias e sindrome metabolica. Tais fatores aumentam o risco de doenca cardiovascular, que e a principal causa de morte nos portadores de esquizofrenia. Metodo: Foi realizada uma reuniao de consenso com psiquiatras especialistas em esquizofrenia e endocrinologistas, os quais, com base nas evidencias provenientes de ampla revisao da literatura, elaboraram um documento com recomendacoes que auxiliam a pratica clinica. Resultados e conclusoes: A avaliacao periodica dos efeitos adversos metabolicos em pacientes que fazem uso de antipsicoticos e fundamental para a pratica clinica, especialmente nos caso de antipsicoticos de segunda geracao. O equilibrio entre eficacia e tolerabilidade deve ser cuidadosamente considerado em todas as etapas do tratamento.

Pubertal growth and final height in 40 patients with type 1 diabetes mellitus

OBJECTIVE Type 1 diabetes mellitus (DM1), the most important chronic endocrine-metabolic disease in children and adolescents, may lead to delayed growth and puberty. In this study we analyzed the influence of DM1 on growth spurt and puberty of patients whose onset of the disease was before or at the beginning of this phase. PATIENTS AND METHODS Data from 40 patients, 25 females, who had attained final height were retrospectively obtained, including duration of disease, patients height and weight SDS at each consultation, parental target height, yearly growth velocities (GV), peak of growth spurt, duration of puberty, magnitude of growth spurt and glycated hemoglobin (HbA1C) levels. RESULTS 37 patients had an adequate final height to parental target height, and only 3 were below the lower limit. There was no significant association among the variables and the appropriate final height to the target height, except for GV on growth spurt, when it was lower than or equal to 6 cm/year. The age of onset of DM1 and the age of peak of growth spurt was similar to previously data reported; regarding the age of the onset of puberty, there was no delay. However, the magnitude of the growth spurt and the peak of GV were lower. According to HbA1C levels, all patients exhibited a bad chronic control of DM1. CONCLUSIONS In this group of inadequately controlled patients, the final height was lower than expected when compared to the height at onset of DM1, probably due to a slow GV during puberty, which however had no influence on the final height to parental target height.

Insulin pump therapy in patients with type 1 diabetes

Both Continuous Subcutaneous Insulin Infusion (CSII) and Multiple Daily Injections (MDI) are effective ways of implementing intensive management of DM1 to attain near normal glycemic levels and a more flexible lifestyle. CSII is as safe as MDI and has some advantages over it mostly in diabetic patients with frequent hypoglycemias with important dawn phenomenum, gastroparesia, during pregnancy, in children and in patients with an erratic way of living. CSII allows a better chance to reach better glycemic control with less hypoglycemia, asymptomatic hypoglycemias and a better quality of life. Besides, risks are lower and adverse events are less frequent in DM1 patients under CSII as compared to MDI. To obtain results like this, a careful adjustment of basal and boluses insulin doses and an adequate patient follow-up are essential.

Prevalência e aspectos clínicos da associação de diabetes melito tipo 1 e doença celíaca

OBJECTIVES: To estimate the prevalence of type 1 diabetes mellitus (DM1) and celiac disease association and to verify the existence of celiac disease symptoms, as well as the occurrence of other autoimmune diseases among the patients, their first-degree relatives and the possible influences of celiac disease in diabetes control. METHODS: It was done a cross-sectional study with 195 patients that answered a questionnaire about gastrointestinal symptoms and the occurrence of autoimmune diseases in their first-degree relatives. IgA was measured and antiendomysial antibody (EMA) was screened. The patients with positive EMA were submitted to intestinal biopsy. Those with celiac disease confirmed by biopsy (case group) were paired with DM1 patients without celiac disease (control group) according to age on diabetes diagnosis, diabetes duration and gender. RESULTS: EMA was positive in nine patients. In seven of them the biopsy has confirmed celiac disease (4.0%). Comparing the cases with controls, the gastrointestinal symptoms were significantly more frequent in the first group, but there was no difference between the groups regarding to the occurrence of autoimmune disease among the first-degree relatives and regarding to the control of diabetes (z weight, z height, insulin dose, HbA1c). CONCLUSIONS: The prevalence found was 4.0%. This sample of celiac patients showed a predominance of gastrointestinal symptoms, although the celiac disease did not influence the diabetes control.

Crescimento e composição corporal de crianças com diabetes mellitus tipo 1

OBJECTIVE: To evaluate the growth and body composition of pre-pubertal diabetic children, and to check for influence of the age of diabetes onset and length, sex, insulin requirement and glycosylated hemoglobin. PATIENTS AND METHODS: 59 diabetic children (39 M; 29 F), age 1.2-11.5 years, and 67 controls (36 M; 31 F), age 1.2-11.7 years were included. Weight, height, body mass index (BMI), arm circumference, skin folds, fat mass and muscle areas were evaluated and transformed into standard deviation scores (SDS). RESULTS: Among the diabetic children the mean height SDS was -0.13 (± 0.97) while in the control group it was 0.28 (± 0.86) (p= 0.013). The difference between the first and the current height SDS showed that the height SDS decreased significantly (p< 0.001) and multiple regression analysis indicated correlation with the duration of the disease. The mean arm fat SDS also revealed difference (p< 0.001). The means for weight, BMI, addition of 3 skinfolds and muscle mass did not demonstrate difference between the groups. CONCLUSIONS: The diabetic children showed reduction of height SDS during the period studied and they were significantly shorter than the controls, even though their statures were within the population standards. The arm fat area also showed to be increased in relation with the controls.

Insulin therapy in patients with cystic fibrosis in the pre-diabetes stage: a systematic review

Abstract Objective: To elucidate whether insulin is effective or not in patients with cystic fibrosis before the diabetes mellitus phase. Data source: The study was performed according to the Prisma method between August and September 2014, using the PubMed, Embase, Lilacs and SciELO databases. Prospective studies published in English, Portuguese and Spanish from 2002 to 2014, evaluating the effect of insulin on weight parameters, body mass index and pulmonary function in patients with cystic fibrosis, with a mean age of 17.37 years before the diabetes mellitus phase were included. Data synthesis: Eight articles were identified that included 180 patients undergoing insulin use. Sample size ranged from 4 to 54 patients, with a mean age ranging from 12.4 to 28 years. The type of follow-up, time of insulin use, the dose and implementation schedule were very heterogeneous between studies. Conclusions: There are theoretical reasons to believe that insulin has a beneficial effect in the studied population. The different methods and populations assessed in the studies do not allow us to state whether early insulin therapy should or should not be carried out in patients with cystic fibrosis prior to the diagnosis of diabetes. Therefore, studies with larger samples and insulin use standardization are required.

A importância dos controles domiciliares na redução de internações em portadores de diabetes mellitus do tipo 1

Several therapeutic strategies have been used to improve control of patients with type 1 diabetes mellitus 1 (DM1), most of them based on capillary glycemia determinations. Considering the difficulty to have frequent capillary blood letting due to stress and the high cost of reagent strips for home glycemia determinations, we have often used glycosuria as a parameter of glycemia. In 1990 a group was established in our service to treat DM1 patients. Since 1992 all patients have been asked for home monitoring glycemia and glycosuria/ ketonuria. Free reagent strips were given to destitute patients. The aim of this work was to evaluate the benefits of home monitoring. We have correlated the outpatient number (P); the number of hospital admittances (I); the number of blood (S) and urine (U) reagent strips granted yearly; and the ratio for hospital admittances/followed up patients (I/P). We observed that, besides the increase in the number of patients in regular attendance, there was a decrease of 6 to 8-fold in hospital admittances compared to the same parameters obtained during 1989. These results are accompanied by an increase on the number of reagent strips distributed. An inverse correlation (r= -0.83; p< 0.05) between the number of urinary reagent strips distributed and the percentage of hospital admittances was found. Our results indicate that despite the low importance the literature gives to the urine test it can be considered as an important tool for controlling DM1 pediatric patients.

Somogyi effect as the most common cause of fasting hyperglycemia in T1D patients

Materials and methods We analyzed the glycemic profile measured by 72h-CGMS in 85 patients with T1D (29 female), resulting in 255 overnight periods. We assessed the nocturnal glycemic profile and the accuracy of the CGMS sensor per night. Fasting hyperglycemia was categorized into dawn phenomenon when there was no nocturnal hypoglycemia followed by a minimum 10mg/dL rise plasma between 4: 00h-7: 00h; Somogyi effect when nocturnal hypoglycemia (< 70mg/dL) between 0: 00h-3: 00h was followed by morning hyperglycemia and poor glycemic control when there was sustained overnight hyperglycemia. Clinical data (age, diabetes duration, insulin regime, and HbA1c values) were obtained by chart review and compared to the different causes of fasting hyperglycemia.

Risk factors for ulceration and amputation in patients with diabetic foot at risk: results form a tertiary care center

Background Ulceration and amputation are severe complications of diabetes, leading to great morbidity and mortality. Of all lower limb amputations, about 50% are performed in these patients (1). In their lifetime, diabetics have a chance as high as 25% to develop a foot ulcer (2). After an amputation, mortality rates ranges from 13% to 40% at 1 year, 35% to 65% at 3 yrs., and 39% to 80% at 5 yrs. (3). The aim of this study was to assess the main risk factors of ulceration and amputation in patients with type 1 and type 2 diabetes.

CSII treatment as an option in high-risk pregnant patients with type 1 diabetes.

Background Studies highlight that continuous subcutaneous insulin infusion (CSII) during pregnancy leads to better glycemic control and lower glycated hemoglobin (HbA1c) without an increase in hypoglycemic episodes or diabetic ketoacidosis. Poor glycemic control can lead to birth defects, miscarriages, growth abnormalities and stillbirth. However, how to obtain better gestational outcomes is still debatable.