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Abstract Background Gestational diabetes mellitus (GDM) is characterized by hyperglycemia during pregnancy. There are many diabetes-specific tools for collecting information validated in Brazilian Portuguese. However, there are no specific instruments to assess knowledge about GDM in Brazilian Portuguese. The aim of this study was to cross-culturally adapt and validate the Brazilian Portuguese version of the Knowledge of Gestational Diabetes Mellitus questionnaire (GDMKQ). Methods This study was conducted in southern Brazil from January to December 2023. Women with GDM or diabetes identified during pregnancy were considered eligible based on specific criteria. Clinical and demographic data were obtained through a medical records search. The GDMKQ underwent a multistep adaptation process, including translation, back-translation, content validity assessment, and cognitive interviews. After administration to participants, internal consistency, item-total correlation, and intraclass correlation were assessed. Confirmatory factor analysis was also conducted to ensure validity. Results A total of 155 pregnant women were recruited for the study. Most participants were aged 18–30 years, and hypertension was the main comorbidity (25.2%). Regarding education, most participants (58.7%) attended high school. The Brazilian Portuguese version of the GDMKQ consisted of 32 items. The intraclass correlation was established by two independent interviews with 57 participants, yielding a correlation coefficient of 0.79 (p

Abstract Background In healthcare systems in general, access to diabetic retinopathy (DR) screening is limited. Artificial intelligence has the potential to increase care delivery. Therefore, we trained and evaluated the diagnostic accuracy of a machine learning algorithm for automated detection of DR. Methods We included color fundus photographs from individuals from 4 databases (primary and specialized care settings), excluding uninterpretable images. The datasets consist of images from Brazilian patients, which differs from previous work. This modification allows for a more tailored application of the model to Brazilian patients, ensuring that the nuances and characteristics of this specific population are adequately captured. The sample was fractionated in training (70%) and testing (30%) samples. A convolutional neural network was trained for image classification. The reference test was the combined decision from three ophthalmologists. The sensitivity, specificity, and area under the ROC curve of the algorithm for detecting referable DR (moderate non-proliferative DR; severe non-proliferative DR; proliferative DR and/or clinically significant macular edema) were estimated. Results A total of 15,816 images (4590 patients) were included. The overall prevalence of any degree of DR was 26.5%. Compared with human evaluators (manual method of diagnosing DR performed by an ophthalmologist), the deep learning algorithm achieved an area under the ROC curve of 0.98 (95% CI 0.97–0.98), with a specificity of 94.6% (95% CI 93.8–95.3) and a sensitivity of 93.5% (95% CI 92.2–94.9) at the point of greatest efficiency to detect referable DR. Conclusions A large database showed that this deep learning algorithm was accurate in detecting referable DR. This finding aids to universal healthcare systems like Brazil, optimizing screening processes and can serve as a tool for improving DR screening, making it more agile and expanding care access.

ABSTRACT Objective To identify predictors of mental health disorders and self-care worsening in patients with diabetes through 15 months of COVID-19 pandemic. Subjects and methods Prospective study following patients with type 1 and type 2 diabetes during the COVID-19 pandemic in Southern Brazil. Participants were evaluated through phone calls in two moments: first three months of the outbreak, and 15 months later. The outcomes were the assessment of worsening in mental health disorders (increase ≥ 10% in the total score of the Self-Report Questionnaire), the assessment of emotional distress related to diabetes (increase ≥ 10% in the total score of the Brazilian version of the Problem Areas in Diabetes), and worsening in self-care parameters (reduction ≥ 3 points in the Self-Care Inventory-Revised). Logistic regression models were used to determine the odds ratio (OR) and their respective confidence intervals. Point-biserial correlation coefficients (rpb) were used to measure the relationship between the variation in scores and patient characteristics. Results In total, 150 adults were enrolled (54.6 ± 13.9 years old, 58.7% female, 85.9% white), out of which 118 remained during follow up. After 18 months, 34,7% of them (52.2 ± 14.8 years old, 53.7% female, 87.5% white) worsened mental health scores. An increase in mental health disorders was experienced by patients with lower middle-income [OR 4.2 (1.2-15.0)], and those who reported greater difficulty managing diabetes [OR 3.2 (1.4-7.1); rpb 0.32, P < 0.01]. In contrast, those who perceived an improvement in diabetes control showed a reduction in their mental health scores [OR 0.3 (0.1-0.8)]. For self-care, there was a score worsening in patients with longer duration of diabetes [OR 1.1 (1.0-1.1)] and in those using insulin [OR 8.3 (1.7-41.4); rpb 0.23, P = 0.01]. Conversely, those who followed the social distancing guidance had an improvement in self-care [OR 0.4 (0.1-0.9); rpb 0.18, P = 0.05]. Conclusion Some clinical and socioeconomic characteristics may be suitable for identifying patients at higher risk of mental health and self-care worsening, signaling who needs to be monitored more closely during crisis situations.

ABSTRACT Nonketotic hyperglycemia may occur as a cause of chorea in patients with chronic decompensated diabetes. Because it is rare and consequently poorly studied, diagnosis and treatment can be delayed. Therefore, our objective was to summarize clinical and radiological features, as well as treatments performed, from previously reported cases to facilitate adequate management in clinical practice. We searched MEDLINE/PubMed, EMBASE, Cochrane, CINAHL, Web of Science, Scopus, and LILACS databases for studies published before April 23, 2021. We included case reports and case series of adults (aged ≥ 18 years) that described hyperglycemic chorea with measurement of glycated hemoglobin (HbA1c) and cranial magnetic resonance imaging (MRI). Studies were excluded if participants were pregnant women, aged < 18 years, and had no description of chorea and/or physical examination. We found 121 studies that met the inclusion criteria, for a total of 214 cases. The majority of the included studies were published in Asia (67.3%). Most patients were women (65.3%) aged > 65 years (67.3%). Almost all patients had decompensated diabetes upon arrival at the emergency department (97.2%). The most common MRI finding was abnormalities of the basal ganglia (89.2%). There was no difference in patient recovery between treatment with insulin alone and in combination with other medications. Although rare, hyperglycemic chorea is a reversible cause of this syndrome; therefore, hyperglycemia should always be considered in these cases.

Abstract Background Patient navigation helps with better adherence to treatment, as well as better knowledge about diabetes and greater interest in performing, monitoring, and seeking health care. Therefore, this study aims to evaluate the effect of patient navigation on glycemic control, disease knowledge, adherence to self-care in people with type 1 diabetes mellitus. Methods This is an intervention study using a single group pre-test post-test design, carried out in a tertiary public teaching hospital in Southern Brazil. Participants over 18 years of age and diagnosed with type 1 diabetes were included. In total, three teleconsultations and one face-to-face consultation were carried out, with three-month intervals, until completing one year of follow-up. The nurse navigator conducted diabetes education based on the guidelines of the Brazilian Diabetes Society and the Nursing Interventions Classification. The differences between glycated hemoglobin, adherence to self-care, and knowledge about initial and final diabetes were estimated to verify the effect of patient navigation by nurses, according to the tool applied in the first and last consultations. Interaction analyses between variables were also performed. Student’s t-test, Generalized Estimating Equations, Wilcoxon test, and McNemar test were used. Results The final sample consisted of 152 participants, of which 85 (55.9%) were women, with a mean age of 45 ± 12 years, and diabetes duration of 23.6 ± 11.1 years. Nurse navigators conducted 812 teleconsultations and 158 face-to-face consultations. After the intervention, glycemic control improved in 37 (24.3%) participants (p

Abstract Background Functional training may be an effective non-pharmacological therapy for heart failure (HF). This study aimed to compare the effects of functional training with strength training on peak VO2 and quality of life in individuals with HF. Methods A randomized, parallel-design and examiner-blinded controlled clinical trial with concealed allocation, intention-to-treat and per-protocol analyses. Twenty-seven participants with chronic HF were randomly allocated to functional or strength training group, to perform a 12-week physical training, three times per week, totalizing 36 sessions. Primary outcomes were the difference on peak VO2 and quality of life assessed by cardiopulmonary exercise testing and Minnesota Living with Heart Failure Questionnaire, respectively. Secondary outcomes included functionality assessed by the Duke Activity Status Index and gait speed test, peripheral and inspiratory muscular strength, assessed by hand grip and manovacuometry testing, respectively, endothelial function by brachial artery flow-mediated dilation, and lean body mass by arm muscle circumference. Results Participants were aged 60 ± 7 years, with left ventricular ejection fraction 29 ± 8.5%. The functional and strength training groups showed the following results, respectively: peak VO2 increased by 1.4 ± 3.2 (16.9 ± 2.9 to 18.6 ± 4.8 mL.kg−1.min−1; p time = 0.011) and 1.5 ± 2.5 mL.kg−1.min−1 (16.8 ± 4.0 to 18.6 ± 5.5 mL.kg−1.min−1; p time = 0.011), and quality of life score decreased by 14 ± 15 (25.8 ± 14.8 to 10.3 ± 7.8 points; p time = 0.001) and 12 ± 28 points (33.8 ± 23.8 to 19.0 ± 15.1 points; p time = 0.001), but no difference was observed between groups (peak VO2: p interaction = 0.921 and quality of life: p interaction = 0.921). The functional and strength training increased the activity status index by 6.5 ± 12 and 5.2 ± 13 points (p time = 0.001), respectively, and gait speed by 0.2 ± 0.3 m/s (p time = 0.002) in both groups. Conclusions Functional and strength training are equally effective in improving peak VO2, quality of life, and functionality in individuals with HF. These findings suggest that functional training may be a promising and innovative exercise-based strategy to treat HF. Trial registration NCT03321682. Registered date: 26/10/2017.

Abstract Neuromuscular electrical stimulation (NMES) can be an alternative to conventional exercising. This randomized clinical trial evaluated the effect of NMES in type 2 diabetes patients. Twenty-eight individuals with type 2 diabetes were assigned to NMES (n=14) or NMES-placebo (n=14) applied to knee extensor muscles for 60 minutes. Glucose variability, microvascular function and endothelial function were evaluated through continuous glucose monitoring system, near infrared spectroscopy and flow-mediated dilatation, respectively. Glucose levels (mg/dl) decreased 2h (184 ± 11 vs 223 ±15), 3h (179 ± 12 vs 219 ±14) and 4h (177 ± 12 vs 212 ±12) after NMES, in comparison to NMES-placebo. No differences in glucose variability were found: coefficient of variation (%) at 0-6h (11.4±1.3 vs 11.4±1.2), 6-12h (9.8±1.0 vs 11.6±1.6), 12-18h (15.5±2.0 vs 11.4±2.1), 18-24h (12.8±2.3 vs 10.0±1.6); standard deviation (mg/dl) at 0-6h (21.6±2 vs 24.6±3.5), 6-12h (19.5±1.8 vs 20.3±2.8), 12-18h (29.9±3.5 vs 21.3±2.8),18-24h (22.8±4.1 vs 16.6±2.0) and mean amplitude of glycemic excursions (mg/dl) 54.9±25.0 vs 70.3±35.7. Endothelial and microvascular functions did not change. In conclusion, one acute NMES session was strong enough to trigger glucose reduction in individuals with type 2 DM, but it failed to induce any significant change in glucose variability, endothelial and microvascular functions.

Introduction. The triad of hypercalcemia, metabolic alkalosis, and acute kidney injury associated with ingesting high doses of calcium and absorbable bases characterizes the calcium-alkali syndrome. Clinical Case. We report the case of a patient with postthyroidectomy hypoparathyroidism 15 years ago due to differentiated thyroid cancer who presented with severe hypercalcemia. He had adequate control of calcemia for many years on treatment with calcitriol and calcium carbonate and hypertension treated with amlodipine, losartan, and hydrochlorothiazide. After a period of loss to follow-up, he suddenly presents with severe hypercalcemia, metabolic alkalosis, and loss of renal function. Upon hydration and withdrawal of calcitriol and calcium replacements, hypercalcemia resolved. The etiological investigation identified no granulomatous or neoplastic diseases, but an aldosterone-producing adrenal incidentaloma was found. The cause of hypercalcemia in this patient was calcium-alkali syndrome due to calcium carbonate replacement potentiated by hydrochlorothiazide and primary aldosteronism. Six months after the hospitalization and suspension of calcium and vitamin D, the patient returned to hypocalcemia, reinforcing the diagnosis. Conclusion. Although seldom described, the calcium-alkali syndrome is an expected complication for individuals with postoperative hypoparathyroidism, as they require lifelong calcium and vitamin D supplementation. This case also shows the importance of hydrochlorothiazide use and primary aldosteronism as possible triggers of life-threatening hypercalcemia.

The double burden of malnutrition (DBM) is a condition in which malnutrition coexists with overweight, reflecting a new layer of malnutrition. Our objectives were to assess prevalence; test associations between DBM and 24-hour movement behaviors; and investigate whether DBM is associated with clusters of social determinants. Methods: This multicenter cross-sectional study included 1152 adolescents (12 to 17 years old) from four Brazilian cities. Body mass index (BMI, kg/m2) was used to estimate overweight, and the adopted cutoff points took into account the curves established for age and sex: Z-score > 1 and ≤2 (overweight) and Z-score > 2 (obesity). The serum concentration of 25-hydroxyvitamin D [25(OH)D] was stratified into three levels: vitamin D deficiency ≤ 20 ng/mL; vitamin D insufficiency = 21–29 ng/mL; optimal vitamin D ≥ 30 ng/mL. We used multilevel Poisson regression models to estimate prevalence ratios (PRs) and their respective 95% confidence intervals (95%CI) and to analyze the association between DBM and covariates. A significance level of p < 0.05 was considered. Cluster analyses were performed by applying a combination of hierarchical and non-hierarchical methods. Results: A population prevalence of DBM of 7.3% (95% CI: 5.9–8.9) was revealed. A percentage of 19.2% (95% CI: 17.0–21.6) of adolescents were overweight, and 8.3% (95% CI: 6.8–10.1) were obese. A total of 41.5% (95% CI: 38.7–44.4) had vitamin D deficiency, and 25.8% (95% CI: 23.4–28.4) had vitamin D insufficiency. However, 24-hour movement behaviors were not associated with DBM. Adolescents living in the southern region of the country, from public schools whose mothers have higher education, have a 1.94 [PR = 2.94 (95% CI: 1.20–7.23)] times greater chance of developing DBM. These results highlight the importance of specific factors to improve the nutritional health of adolescents, considering the specific social determinants identified in this study.

ABSTRACT Objective: To conduct a systematic review and meta-analysis assessing the cardiorespiratory fitness (CRF) among individuals with and without type 2 diabetes Materials and methods: The current review was registered in PROSPERO under the number CRD42018082718. MEDLINE, EMBASE, and Cochrane Library databases were searched from inception through February 2022. Eligibility criteria consisted of observational or interventional studies that evaluated CRF through cardiopulmonary exercise testing or six-minute walk test in individuals with type 2 diabetes compared with individuals without type 2 diabetes. For data extraction, we used baseline CRF assessments of randomized clinical trials or follow-up CRF assessments in observational studies. We performed a meta-analysis using maximal oxygen consumption (VO2max), and distance walked in the 6MWT as primary outcomes. They were extracted and expressed as mean differences (MDs) and 95% CIs between treatment and comparator groups. The meta-analysis was conducted using Review Manager (RevMan) software. Results: Out of 8,347 studies retrieved, 77 were included. Compared with individuals without type 2 diabetes, individuals with diabetes achieved a lower VO2max (−5.84 mL.kg−1.min−1, 95% CI −6.93, −4.76 mL.kg−1.min−1, p = 0.0001; I2: 94%, p for heterogeneity < 0.0001). Conclusion: Type 2 diabetes was associated with lower cardiorespiratory fitness, as observed by lower VO2max on maximal tests, and smaller distance walked in 6MWT, however the quality of studies was low.

Abstract Aims To evaluate the prevalence of diabetic retinopathy (DR) in Brazilian adults with diabetes mellitus via a systematic review with meta-analysis. Methods A systematic review using PubMed, EMBASE, and Lilacs was conducted, searching for studies published up to February 2022. Random effect meta-analysis was performed to estimate the DR prevalence. Results We included 72 studies (n = 29,527 individuals). Among individuals with diabetes in Brazil, DR prevalence was 36.28% (95% CI 32.66–39.97, I2 98%). Diabetic retinopathy prevalence was highest in patients with longer duration of diabetes and in patients from Southern Brazil. Conclusion This review shows a similar prevalence of DR as compared to other low- and middle-income countries. However, the high heterogeneity observed—expected in systematic reviews of prevalence—raises concerns about the interpretation of these results, suggesting the need for multicenter studies with representative samples and standardized methodology.

ABSTRACT Objective: To evaluate the association between knowledge about the disease, adherence to self-care, and glycemic control in people diagnosed with type 1 diabetes mellitus. Subjects and methods: A cross-sectional study of patients aged over 18 years diagnosed with type 1 diabetes mellitus, treated at an outpatient clinic of a Brazilian university hospital. Participants with other types of diabetes, cognitive impairment, pregnancy, and outpatient discharge were excluded. Data were collected from January to March 2021 (by telephone call), with questions about the participants’ profile, diabetes knowledge questionnaire (DKN-A), and self-care inventory revised (SCI-R) translated into and adapted for Brazilian Portuguese. Data analysis involved chi-square associations, Mann-Whitney U tests, and Poisson regression. Results: Among 198 adult participants, the mean age was 42 ± 12 years, 53.5% were women, the mean glycated hemoglobin was 8.6 ± 1.6%, 140 (70.8%) had satisfactory knowledge about diabetes, 65 (32.8%) had adherence to self-care, and 46 (23.2%) had adequate glycemic control. We found an association between knowledge and adherence to self-care (p < 0.001). Knowledge was not associated with glycemic control (p = 0.705). Conclusion: Knowledge about diabetes was associated with greater adherence to self-care in people with type 1 diabetes mellitus, but it did not reflect in better glycemic control.

Abstract The association between type 1 diabetes and mental health disorders could be exacerbated in a stressful environment. This study aimed to evaluate the feasibility of a teleguided intervention on emotional disorders in patients with type 1 diabetes during the COVID-19 outbreak. This study was performed during the social distancing period in the COVID-19 outbreak in Brazil. Individuals with type 1 diabetes aged ≥ 18 years were selected to receive a teleguided multidisciplinary intervention or the usual care plus an educational website access. The proposed intervention aimed addressing aspects of mental health, diabetes care and lifestyle habits during the pandemic. The feasibility outcome included the assessment of recruitment capability and adherence to the proposed intervention. Moreover, we evaluated the presence of positive screening for emotional disorders (Self Report Questionnaire 20) after a 16-week intervention, patients’ perceptions of pandemic-related changes, diabetes-related emotional distress, eating disorders, and sleep disorders. Data were analyzed with the intent‐to‐treat principle. Fifty-eight individuals (mean age, 43.8 ± 13.6 years) were included (intervention group, n = 29; control group, n = 29). At the end of the study, a total of 5 participants withdrew from the study in the intervention group compared to only 1 in the control group. Participants who dropout from the study had similar mean age, sex and income to those who remained in the study. The analysis of mental health disorders was not different between the groups at the follow up: a positive screening result was found in 48.3% and 34.5% of participants in the intervention and control groups, respectively (P = 0.29). The intervention group felt more supported in their diabetes care during the social distancing period (82.8% vs. 48.3% in the control group, P

Abstract Background Optimal glycemic control is the main goal for patients with diabetes. The results of type 1 diabetes patients’ neglected demands during the pandemic can determine a long-term negative clinical, social, and economic impact, and result in worse diabetes control and a higher incidence of chronic complications. Therefore, this study aims to evaluate the impact of the COVID-19 outbreak in the quality of care of patients with type 1 diabetes in Southern Brazil. Methods Cohort study based on electronic medical records of patients with type 1 diabetes, with scheduled appointments between January 1st 2020, and November 6th 2020, at a university public hospital. The quality indicators used were: assessment of albuminuria and/or serum creatinine, lipid profile, thyroid-stimulating hormone, glycated hemoglobin, retinopathy, and neuropathy. McNemar test was used to analyze categorical variables and the Wilcoxon test for continuous variables. Results Out of 289 patients, 49.5% were women aged 40 ± 12 years old. During the pandemic, 252 patients had at least one face-to-face appointment canceled. The quality of care indicators showed a significant worsening during the COVID-19 pandemic compared to the previous year (p

Abstract The association between type 1 diabetes and mental health disorders could be exacerbated in a stressful environment. This study aimed to evaluate the effectiveness of a teleguided intervention on emotional disorders in patients with type 1 diabetes during the COVID-19 outbreak. An open-label clinical trial was performed during the social distancing period in the COVID-19 outbreak in Brazil. Individuals with type 1 diabetes aged ≥ 18 years were randomized to receive a teleguided multidisciplinary intervention or the usual care plus an educational website access. The primary outcome was a positive screening for emotional disorders (Self Report Questionnaire 20) after a 16-week intervention. Secondary outcomes included evaluation of patients’ perceptions of pandemic-related changes, diabetes-related emotional distress, eating disorders, and sleep disorders. Data were analyzed with the intent‐to‐treat principle. Fifty-eight individuals (mean age, 43.8 ± 13.6 years) were included (intervention group, n = 29; control group, n = 29). The primary outcome was not different between the groups. The intervention group felt more supported in their diabetes care during the social distancing period (82.8% vs. 48.3% in the control group, P

ABSTRACT We conducted a cross-sectional study to evaluate the impact of social distancing determined by the COVID-19 pandemic on treatment adherence using the Self-Care Inventory-revised in adults with diabetes mellitus. In type 1 diabetes, the adherence score was lower during than before social distancing.

Abstract This study aimed to assess the psychological impact of the COVID-19 pandemic on guardians of children and adolescents with type 1 diabetes. An online survey was performed to assess the prevalence of pandemic-related emotional burden, mental health disorders and diabetes-specific emotional burden related to diabetes care during the COVID-19 pandemic. Caregivers of children and adolescents with diabetes under the age of 18 and caregivers of youth without diabetes for the non-diabetes group were invited to participate. For the primary outcome, mental health disorders were evaluated using the Self-Reporting Questionnaire (SRQ-20), while pandemic-related emotional burden and diabetes-specific emotional burden related to diabetes care were evaluated in different domains with specific questions. For analyses, a hierarchical testing strategy was performed. A total of 764 participants were included in the study. Regarding the pandemic period, caregivers of youth with type 1 diabetes endorsed significantly more pandemic-related emotional burden for both themselves (OR 1.67; 95% CI, 1.10 to 2.53) and for their child (OR 2.28; 95% CI, 1.54 to 3.38) when compared to the non-diabetes group. The emotional burden evaluation on different age ranges showed that the two groups were similar when the dependent youth was younger than 6 years. Moreover, a positive screening for mental health disorders during social distancing was higher in the diabetes group compared to the non-diabetes group (OR 2.43; 95% CI, 1.70 to 3.47), particularly in those aged under 12 years old. There was no difference between groups in mental health disorders among caregivers of adolescents older than 12 years. Our results allow to conclude that concern, burden and mental health disorders can be present in caregivers of youth with diabetes, and behavioral changes during the COVID-19 pandemic may enhance this situation.

ABSTRACT Objective: The aim of this study was to evaluate the frequency of hypoglycemia and the treatment satisfaction in patients with type 1 diabetes (T1D) using insulin analogues. Subjects and methods: This observational retrospective study included 516 adult patients with T1D from 38 cities in Southern Brazil. Demographics and clinical data were collected using a self-report questionnaire. Hypoglycemia was defined as an event based on either symptoms or self-monitored blood glucose < 70 mg/dL. Treatment satisfaction was evaluated using the Diabetes Treatment Satisfaction Questionnaire status version (DTSQs) and with a specific question with scores ranging from 0–10. Common mental disorders were assessed using the General Health Questionnaire (GHQ-12). Results: Overall, the mean age was 38 ± 14 years and 52% of the participants were women. The median diabetes duration was 18 years. The scores for insulin analogue treatment satisfaction were higher than those for previous treatments. DTSQ scores had a median value of 32 (interquartile range 29–35) and remained unchanged over time. The percentage of patients with hypoglycemia (including severe and nocturnal) was comparable across groups divided according to duration of use of insulin analogues. Most patients (n=395, 77%) screened positive for common mental disorders. Conclusions: Patient satisfaction with insulin analogue treatment was high and remained unchanged with time. Episodes of hypoglycemia also remained unchanged over time among patients using insulin analogues.

ABSTRACT Objective: To evaluate the precipitating factors of diabetic ketoacidosis (DKA) in patients with type 1 diabetes hospitalized through the emergency department of a tertiary hospital. Materials and methods: Individuals with type 1 diabetes hospitalized for DKA from January 2005 to March 2010 (first period [P1], n = 75) and from April 2010 to January 2017 (second period [P2], n = 97) were identified through a query of electronic medical records. Data were collected by reviewing medical records. Only the first hospitalization of each participant in each period was included. Results: In P2, 44 patients (45.4%) were women, mean age was 26.2 ± 14.5 years, and 74 patients (76.3%) had a previous diagnosis of type 1 diabetes. Only 1 patient had glycated haemoglobin (HbA1c) below 64 mmol/mol (8.0%). Most patients (62.2%) had had a previous episode of DKA. In P1, non-adherence was the main cause of DKA (38.7%), followed by infection (24.0%). In P2, these rates were 34.0% and 24.7%, respectively; no statistical difference was observed between the two study periods (p = 0.790). Conclusion: Over time, non-adherence remained the main precipitating factor of DKA, followed by infection, and no significant difference was observed between the two study periods. Elevated HbA1c, outside the therapeutic range, indicates suboptimal diabetes care and may explain, at least in part, poor adherence as a precipitating factor of decompensation. Health strategies, such as improved self-management of type 1 diabetes, may contribute to a future reduction in DKA episodes.

ABSTRACT Objective: To assess caregivers’ perception about the changes in the daily habits of children and adolescents with type 1 diabetes during the COVID-19 pandemic. Subjects and methods: Primary caregivers of youth aged ≤18 with or without type 1 diabetes were selected for the diabetes and the control groups. Caregivers estimated the youth's time (hours) of physical activity and screen time before and during the pandemic, and rated the quality of eating habits and medication adherence from 0 to 10. The primary outcome was the change in physical activity time, screen time, and eating habits scores during isolation. Between-group analyses and within-group comparisons were conducted. A post hoc analysis was performed using logistic regression to correct for confounding factors. Results: In total, 764 participants were included (381 diabetes group vs. 383 control group). Before the pandemic, the diabetes group presented a reduced median of physical activity (P < 0.001) and screen time (P < 0.001). During the pandemic, the difference between both groups remained similar (P = 0.58). Scores of quality of eating habits were similar in both groups before the pandemic [8.0 (7.0-9.0) vs. 8.0 (7.0-9.0), P = 0.31] but decreased during the pandemic [7.0 (5.1-8.1) vs. 8.0 (6.0-9.0), P < 0.001]. The diabetes group had a significantly worse change in eating habits scores (P < 0.01). Conclusion: During the pandemic, eating habits were significantly worse in youth with diabetes than in those without diabetes.

ABSTRACT Objective: The present study aimed to evaluate glucose variability and hormonal responses during and after an aerobic exercise session performed after breakfast in type 2 diabetes patients treated with metformin. Materials and methods: In this quasi-experimental study individuals underwent clinical and laboratory evaluations and maximal exercise test. After two weeks an aerobic exercise session (30 minutes at 60%-70% of the peak heart rate) was performed. At rest, during and after the exercise session, glucose variability (mean amplitude glucose excursions, glucose coefficient of variation, and glucose standard deviation) and levels of plasma glucose, insulin, glucagon, and glucagon-like-peptide-1 were evaluated. Results: Thirteen patients were enrolled in the study. Plasma glucose increased at 15 minutes during the exercise session (244.6 ± 61.9 mg/dL), and decreased at 60 min after exercise (195.6 ± 50.0 mg/dL). Glucose variability did not show any difference before and after exercise. Insulin levels at 15 min [27.1 µU/mL (14.2-42.1)] and 30 min [26.3 µU/mL (14.6-37.4)] during the exercise were higher than those at fasting [11.2 µU/mL (6.7-14.9)] but decreased 60 minutes after exercise (90 minutes) [16.6 µU/mL (8.7-31.7)]. Glucagon levels did not show any difference. GLP-1 levels increased at 30 min [7.9 pmol/L (7.1-9.2)] during exercise and decreased 60 min after exercise (90 minutes) [7.7 pmol/L (6.8-8.5)]. Conclusion: Subjects with type 2 diabetes presented expected changes in insulin, glucagon and GLP-1 levels after breakfast and a single aerobic exercise session, not accompanied by glycemic variability changes.

Abstract Background The disclosure in the media of a benefit with the use of dexamethasone in patients with COVID-19 infection sets precedents for self-medication and inappropriate use of corticosteroids. Methods This is a critical interpretive synthesis of the data available in the literature on the effects of the use of corticosteroids and the impact that their indiscriminate use may have on patients with diabetes. Reviews and observational and experimental studies published until June 18, 2020 were selected. Results Corticosteroids are substances derived from cholesterol metabolism that interfere with multiple aspects of glucose homeostasis. Interactions between corticoid receptors and target genes seem to be among the mechanisms responsible for the critical functions of glucocorticoids for survival and anti-inflammatory effects observed with these medications. Corticosteroids increase hepatic gluconeogenesis, reduce peripheral use of glucose and increase insulin levels. Previous studies have shown that glucocorticoids have a pro-adipogenic function, increasing deposition of abdominal fat, and lead to glucose intolerance and hypertriglyceridemia. In addition, these drugs play a role in controlling liver metabolism and can lead to the development of hepatic steatosis. Glucocorticoids reduce the recruitment of osteoblasts and increase the number of osteoclasts, which results in increased bone resorption and greater bone fragility. Moreover, these medications cause water and sodium retention and increase the response to circulating vasoconstrictors, which results in increased blood pressure levels. Chronic or high-dose use of corticosteroids can, by itself, lead to the onset of diabetes. For those who were already diagnosed with diabetes, studies show that chronic use of corticosteroids leads to a 94% higher risk of hospitalization due to diabetes complications. In addition to the direct effects on glycemic control, the effects on arterial pressure control, lipids and bone metabolism also have a potential for severe consequences in patients with diabetes. Conclusion Fear and uncertainty toward a potentially serious infection may lead people to self-medication and the inappropriate and abusive use of corticosteroids. More than ever, it is necessary for health professionals to be alert and able to predict damages related to the use of these drugs, which is the first step to minimize the potential damages to come.

Abstract Background In patients with diabetes, the prevalence of depression and anxiety symptoms is about two to four times greater than in the general population. The association between diabetes and mental health disorders could be exacerbated in a stressful environment, and psychological distress could increase depressive symptoms and cause adverse diabetes outcomes. Objectives To assess the prevalence of mental health disorders in patients with diabetes during the social distancing period due to COVID-19 pandemic. Methods This is a cross-sectional study developed to assess the impact of social distancing on a cohort of adults with type 1 (n = 52) and type 2 diabetes (n = 68) in Brazil. Inclusion criteria involved having an HbA1c test collected in the past 3 months and having a valid telephone number in electronic medical records. The primary outcome was the prevalence of minor psychiatric disorders, assessed by survey (SRQ-20). Secondary outcomes included the prevalence of diabetes related emotional distress, eating and sleeping disorders, all assessed by validated surveys at the moment of the study. Statistical analyses included unpaired t-test for continuous variables and χ 2 test for categorical variables. Results Overall (n = 120), participants had a mean age of 54.8 ± 14.4 years-old, and HbA1c of 9.0 ± 1.6% (75 ± 17.5 mmol/mol); 93% of patients showed signs of current mental suffering based on the surveys measured. Almost 43% of patients showed evidence of significant psychological distress, with a significant greater tendency in patients with type 2 diabetes. The presence of diabetes related emotional distress was found in 29.2% of patients; eating disorders in 75.8%; and moderate/severe sleeping disorders in 77.5%. Conclusions We found a high prevalence of evidence of psychological distress among patients with diabetes during the COVID-19 pandemic and this highlights the need for mental health access and support for patients with type 1 and type 2 diabetes.

Abstract Background Surgical theater (ST) operations planning is a key subject in the healthcare management literature, particularly the scheduling of procedures in operating rooms (ORs). The OR scheduling problem is usually approached using mathematical modeling and made available to ST managers through dedicated software. Regardless of the large body of knowledge on the subject, OR scheduling models rarely consider the integration of OR downstream and upstream facilities and resources or validate their propositions in real life, rather using simulated scenarios. We propose a heuristic to sequence surgeries that considers both upstream and downstream resources required to perform them, such as surgical kits, post anesthesia care unit (PACU) beds, and surgical teams (surgeons, nurses and anesthetists). Methods Using hybrid flow shop (HFS) techniques and the break-in-moment (BIM) concept, the goal is to find a sequence that maximizes the number of procedures assigned to the ORs while minimizing the variance of intervals between surgeries’ completions, smoothing the demand for downstream resources such as PACU beds and OR sanitizing teams. There are five steps to the proposed heuristic: listing of priorities, local scheduling, global scheduling, feasibility check and identification of best scheduling. Results Our propositions were validated in a high complexity tertiary University hospital in two ways: first, applying the heuristic to historical data from five typical ST days and comparing the performance of our proposed sequences to the ones actually implemented; second, pilot testing the heuristic during ten days in the ORs, allowing a full rotation of surgical specialties. Results displayed an average increase of 37.2% in OR occupancy, allowing an average increase of 4.5 in the number of surgeries performed daily, and reducing the variance of intervals between surgeries’ completions by 55.5%. A more uniform distribution of patients’ arrivals at the PACU was also observed. Conclusions Our proposed heuristic is particularly useful to plan the operation of STs in which resources are constrained, a situation that is common in hospital from developing countries. Our propositions were validated through a pilot implementation in a large hospital, contributing to the scarce literature on actual OR scheduling implementation.

Abstract Background Exercise intolerance is a common finding in heart failure that generates a vicious cycle in which the individual starts to limit his activities even more due to progressive fatigue. Regular physical exercise can increase the cardiopulmonary exercise capacity of these individuals. A new approach to physical exercise, known as functional training, could improve the oxygen consumption and quality of life of patients with heart failure; however, there is no information about the effect of this modality of exercise in this patient population. This randomized trial will compare the effects of 36 sessions of functional training versus strength training in heart failure patients. Methods This randomized parallel-design examiner-blinded clinical trial includes individuals of both sexes aged ≥40 years receiving regular follow-up at a single academic hospital. Subjects will be randomly allocated to an intervention group (for 12-week functional training) or an active comparator group (for 12-week strength training). The primary outcomes will be the difference from baseline to the 3-month time point in peak oxygen consumption on cardiopulmonary exercise testing and quality of life assessed by the Minnesota Living with Heart Failure Questionnaire. Secondary outcome measures will include functionality assessed by the Duke Activity Status Index and gait speed test; peripheral and inspiratory muscular strength, assessed by hand grip and manovacuometry testing, respectively; endothelial function by brachial artery flow-mediated dilation; lean body mass by arm muscle circumference; and participant adherence to the exercise programs classified as a percentage of the prescribed exercise dose. Discussion The functional training program aims to improve the functional capacity of the individual using exercises that relate to his specific physical activity transferring gains effectively to one’s daily life. In this context, we believe that that functional training can increase the cardiopulmonary exercise capacity and quality of life of patients with heart failure. The trial has been recruiting patients since October 2017. Trial registration NCT03321682 . Registered on October 26, 2017.

ABSTRACT Two researchers conducted independent searches on five different electronic databases: PubMed/MEDLINE, Embase, SciELO, LiLACS and Web of Science. Studies were selected that covered cross-cultural adaptation methodology and validation in Brazil with type 1 and type 2 diabetes patients of any age. After reading the full-text articles, data related to psychometric characteristics were extracted from each study selected. Reliability was assessed with Cronbach’s α (Cα). The initial searches identified 2,211 studies. After exclusions, 26 were included, covering a total of 31 questionnaires. Questionnaires were grouped into 11 domains based on their main focus of interest: adherence (n = 8), quality of life (n = 7), diabetes knowledge (n = 3), hypoglycemia (n = 3), self-efficacy (n = 3), satisfaction with pharmaceutical services (n = 1), emotional stress (n = 2), hope (n = 1), attitude towards diabetes (n = 1), perception of disease severity (n=1), and risk of developing diabetes (n = 1). This study identified and reviewed all of the diabetes-specific questionnaires that have been validated for Brazilian Portuguese, which should facilitate selection of the most appropriate instrument for each domain of interest in future research and clinical settings.

ABSTRACT Objective The aim of this study was to cross-culturally adapt and validate the Brazilian Portuguese version of SCI-R to adults with type 2 diabetes. Materials and methods The SCI-R is a 15-question survey that reflects how well patients with diabetes have adhered to treatment recommendations. A pretest (n = 40) was first performed to improve comprehension of the survey items. A final version was then self-administered in another 75 adults with type 2 diabetes to determine the survey’s reliability and validity according to its association with HbA1c. Finally, we conducted a test-retest reliability analysis over three weeks to stabilize the sample and determine intra-observer variability. Results After the pretest phase, the final sample’s (N = 75) mean age was 59.9 ± 7.5 years and mean HbA1c level was 8.6 ± 1.5% (70 ± 16.4 mmol/mol). The initial Cronbach’s alpha was 0.61; however, further analysis showed that four items had low item correlation and were excluded from the final version, which increased the Cronbach’s alpha to 0.63. In predictive validity analysis, HbA1c levels correlated significantly with total survey scores (r = -0.38, P = 0.001). The intra-class correlation coefficient between baseline and three-week scores was 0.93, which indicates high reproducibility. Conclusions The Brazilian Portuguese version of the SCI-R is a valid tool for measuring treatment adherence in adults with type 2 diabetes.

Objectives: The purpose of this study was to evaluate the agreement and risk factors for underestimation and overestimation between nutritional status and self‐perceived body image and to assess the prevalence and associated factors for dissatisfaction with body weight among Brazilian adolescents. Methods: Students aged 12–17 years participating in the Study of Cardiovascular Risk in Adolescents (“ERICA”), a multicenter, cross‐sectional, school‐based country‐wide study, were included (n = 71,740). Variables assessed as covariates were sex, age, skin color, socioeconomic status, and common mental disorders (screened by the General Health Questionnaire, GHQ‐12). Multinomial logistic regression was used to explore the association between covariates and combinations between self‐perceived body image and body mass index (agreement, underestimation and overestimation). The associations between dissatisfaction with body weight and exposure variables were investigated using multivariable Poisson regression models. Results: Approximately 66% students rightly matched their body mass index with self‐perceived weight (kappa coefficient was 0.38 for boys and 0.35 for girls). Agreement was higher among younger students and adolescents from low income households. Male sex, older age, and GHQ‐12 score ≥3 were associated with weight overestimation. Prevalence of dissatisfaction with body weight was 45.0% (95% CI: 44.0–46.0), and higher among girls, older adolescents, those with underweight or overweight/obesity, as well as those who were physically inactive and with GHQ‐12 ≥3. Conclusions: Most of the sample rightly self‐perceived their body image according to body mass index. Students with body image misperception and those dissatisfied with their weight were more likely to present a positive screening for common mental disorders. Resumo: Objetivos: A finalidade deste estudo foi avaliar a concordância e os fatores de risco para subestimação e superestimação entre o estado nutricional e a autoimagem corporal e para avaliar a prevalência e os fatores associados à insatisfação com o peso corporal entre adolescentes brasileiros. Métodos: Foram incluídos estudantes entre 12 e 17 anos que participavam do Estudo de Riscos Cardiovasculares em Adolescentes (“ERICA”), um estudo multicêntrico, transversal, nacional e de base escolar (n = 71.740). As variáveis analisadas como covariáveis foram sexo, idade, cor da pele, situação socioeconômica e transtornos mentais comuns (triados pelo Questionário de Saúde Geral, QSG‐12). A regressão logística multinomial foi usada para explorar a associação entre as covariáveis e as combinações entre a autoimagem corporal e o índice de massa corporal (concordância, subestimação e superestimação). As associações entre a insatisfação com o peso corporal e as variáveis de exposição foram investigadas com os modelos multivariáveis de regressão de Poisson. Resultados: Aproximadamente 66% dos estudantes associaram corretamente seu índice de massa corporal com o peso autopercebido (o coeficiente kappa foi 0,38 para meninos e 0,35 para meninas). A concordância foi maior entre jovens e adolescentes de baixa renda. Sexo masculino, adolescentes mais velhos e um escore QSG 12 ≥ 3 foram associados à superestimação do peso. A prevalência de insatisfação com o peso corporal foi 45,0% (IC de 95%: 44,0‐46,0), maior entre meninas, adolescentes mais velhos, aqueles abaixo do peso ou com sobrepeso/obesidade, fisicamente inativos e com QSG‐12 ≥ 3. Conclusões: A maior parte da amostra associou corretamente sua imagem corporal de acordo com o índice de massa corporal. Estudantes com distorção da autoimagem corporal e aqueles insatisfeitos com seu peso foram mais propensos a apresentar rastreamento positivo para transtornos mentais comuns. Keywords: Adolescents, Self‐perceived body image, Body dissatisfaction, Body image perception, General Health Questionnaire, Mental health, Palavras‐chave: Adolescentes, Auto‐imagem corporal, Insatisfação com o corpo, Percepção da imagem corporal, Questionário de Saúde Geral, Saúde mental

ABSTRACT Objectives: To describe the oral health profile and evaluate the impact of tooth loss on diet quality and glycemic control among 66 patients with type 2 diabetes (T2DM) treated in an endocrinology outpatient clinic at a teaching hospital. Materials and methods: Questionnaires about diabetes self-care (SDSCA), masticatory ability, diet quality, anxiety level about dental treatment, and oral health were applied. Laboratory tests were retrieved from medical records or newly collected samples. Results: The presence of fewer than 21 teeth was associated with an unsatisfactory self-perceived masticatory ability (r = 0.44; p = 0.007). Most participants reported not having received guidance on oral health from their endocrinologists (81.8%) and having had the last visit to the dentist 2 years or more before the study (36.8%). The mean HbA1c level in the group with fewer than 21 teeth was comparable to that in the group with functional dentition (8.9 ± 1.5 and 8.7 ± 1.6%, respectively; p = 0.60). Conclusion: Adults with T2DM have a high prevalence of tooth loss and lack of information about oral hygiene care. Our results reinforce the need for more effective communication between medical and dental care teams.

ABSTRACT This is a retrospective report of the frequency of severe hypoglycemia and the association between common mental disorders and type 1 diabetes mellitus treated with insulin analogues. Patients with severe hypoglycemia compared with those without this complication had a higher prevalence of positive screening for common mental disorders (88% vs.77%, respectively, p = 0.03).

Abstract Background Excessive screen time has been associated with metabolic syndrome (MetS) among adolescents; however, snack intake in front of screens may play a role in this association. Therefore, our objective was to investigate the association between screen-based sedentary time with MetS and whether this association is modified by unhealthy snack intake in front of screens. Methods This study was a nationwide, cross-sectional, school-based survey in Brazil including adolescents aged 12 to 17 years. The frequency of snack consumption in front of screen and screen-based sedentary time (TV view, computers and videogames use) were self-reported. Thereafter, screen time was categorized (≤2, 3–5 and ≥ 6 h/day); snack consumption in front of screens was dichotomized. Metabolic syndrome diagnosis was defined based on the International Diabetes Federation criteria. Associations between screen time and MetS were investigated using logistic regression in overall sample and after stratification by snack intake in front of screens. Results A total of 33,900 adolescents were included in the analysis. The final adjusted model, which included sociodemographic data, physical activity, and energy intake, showed that adolescents who spent ≥6 h/day in front of screens had an increased odds ratio for MetS (OR = 1.68, 95%CI: 1.03–2.74). However, after stratifying the sample according to reported snack intake, the association between higher screen-based sedentary time and MetS remained significant only for adolescents who reported consumption of snacks in front of screens. Conclusion Longer screen-based sedentary times were directly associated with MetS. However, this association seems to be modified by reported snack intake in front of screens.

Objectives: This study aimed to assess the quality of systematic reviews on prevention and non‐pharmacological treatment of overweight and obesity in children and adolescents. Data source: A search was done in electronic databases (Medline via PubMed, Web of Science, Scopus, LILACS, the Cochrane Library, and Clinical Trials), including only systematic reviews with meta‐analysis. Reviews were selected by two researchers, and a third one solved the divergences. PRISMA statement and checklist were followed. Summary of data: A total of 4574 records were retrieved, including 24 after selection. Six reviews were on obesity prevention, 17 on obesity treatment, and one on mixed interventions for prevention and treatment of obesity. The interventions were very heterogeneous and showed little or no effects on weight or body mass index. Mixed interventions that included dieting, exercise, actions to reduce sedentary behavior, and programs involving the school or families showed some short‐term positive effects. Reviews that analyzed cardiovascular risk factors demonstrated significant improvements in the short‐term. Conclusion: The systematic reviews of interventions to prevent or reduce obesity in children and adolescents generally showed little or no effects on weight or body mass index, although cardiovascular profile can be improved. Mixed interventions demonstrated better effects, but the long‐term impact of obesity treatments of children and adolescents remains unclear. Resumo: Objetivos: Este estudo teve como objetivo avaliar a qualidade das revisões sistemáticas sobre prevenção e tratamento não farmacológico do sobrepeso e da obesidade em crianças e adolescentes. Fontes de dados: Foi realizada uma busca em bases de dados eletrônicas (Medline via Pubmed, Web of Science, Scopus, LILACS, The Cochrane Library e Ensaios Clínicos), incluindo apenas revisões sistemáticas com meta-análise. As revisões foram selecionadas por dois pesquisadores e um terceiro resolveu as divergências. A lista de recomendações do PRISMA foi seguida. Síntese dos dados: Foram identificados 4.574 publicações, e 24 foram incluídas após seleção. Seis publicações eram sobre prevenção da obesidade, 17 sobre tratamento da obesidade e 1 sobre intervenções mistas para prevenção e tratamento da obesidade. As intervenções eram muito heterogêneas e mostraram pouco ou nenhum efeito sobre o peso ou índice de massa corporal. Intervenções mistas que incluíam dieta, exercícios, ações para reduzir o comportamento sedentário e programas que envolviam a escola ou as famílias mostraram alguns efeitos positivos de curto prazo. Revisões que analisaram fatores de risco cardiovascular demonstraram melhoras significativas em curto prazo. Conclusão: As revisões sistemáticas de intervenções para prevenir ou reduzir a obesidade em crianças e adolescentes geralmente mostraram pouco ou nenhum efeito sobre o peso ou índice de massa corporal, embora o perfil cardiovascular possa ter melhorado. Intervenções mistas demonstraram melhores efeitos, mas o impacto em longo prazo dos tratamentos da obesidade de crianças e adolescentes ainda não está claro. Keywords: Child, Adolescent, Obesity, Palavras‐chave: Criança, Adolescente, Obesidade

Abstract Background Hypertension is a clinical condition highly prevalent in the elderly, imposing great risks to cardiovascular diseases and loss of quality of life. Current guidelines emphasize the importance of nonpharmacological strategies as a first-line approach to lower blood pressure. Exercise is an efficient lifestyle tool that can benefit a myriad of health-related outcomes, including blood pressure control, in older adults. We herein report the protocol of the HAEL Study, which aims to evaluate the efficacy of a pragmatic combined exercise training compared with a health education program on ambulatory blood pressure and other health-related outcomes in older individuals. Methods Randomized, single-blinded, multicenter, two-arm, parallel, superiority trial. A total of 184 subjects (92/center), ≥60 years of age, with no recent history of cardiovascular events, will be randomized on a 1:1 ratio to 12-week interventions consisting either of a combined exercise (aerobic and strength) training, three times per week, or an active-control group receiving health education intervention, once a week. Ambulatory (primary outcome) and office blood pressures, cardiorespiratory fitness and endothelial function, together with quality of life, functional fitness and autonomic control will be measured in before and after intervention. Discussion Our conceptual hypothesis is that combined training intervention will reduce ambulatory blood pressure in comparison with health education group. Using a superiority framework, analysis plan prespecifies an intention-to-treat approach, per protocol criteria, subgroups analysis, and handling of missing data. The trial is recruiting since September 2017. Finally, this study was designed to adhere to data sharing practices. Trial registration NCT03264443. Registered on 29 August, 2017.

Abstract Objective To evaluate the association between adiponectin concentrations and metabolic syndrome (MetS) risk and to investigate if this association is independent of weight status in adolescents. Methods Adiponectin concentrations and MetS risk were assessed in 4546 Brazilian adolescents (12–17 years old) enrolled in The Study of Cardiovascular Risks in Adolescents (“ERICA”), a cross-sectional multicenter study in Brazil. For analyses, adiponectin was categorized in sex and age-specific quartiles and MetS risk was expressed as a continuous score, calculated as the average of the standardized values (z-score) of the five MetS components. Multiple linear regression models were used to investigate the association between the quartiles of adiponectin and MetS risk. Results Adiponectin was inversely associated with waist circumference and log-transformed triglycerides, and positively associated with HDL-c. We also observed an inverse association between adiponectin concentrations and MetS risk. After adjustment for sociodemographic variables, physical activity, skipping breakfast and body mass index (BMI), higher quartiles of adiponectin remained inversely associated with waist circumference and MetS risk. A direct association between adiponectin and HDL-c was also observed. In further analysis, the sample was stratified by weight status and an inverse association between quartiles of adiponectin and MetS risk was observed in both normal weight and overweight/obese adolescents. Conclusion Higher adiponectin concentrations were independently and inverse associated with MetS risk in Brazilian adolescents, even after adjusting for BMI. These results were similar in normal weight and overweight/obese adolescents, suggesting that adiponectin may play a role in early development of MetS.

Abstract Background This study was developed to evaluate quality indicators in type 2 diabetes patient care at the Unified Public Health System’s primary and tertiary health care centers within a local population. Methods This was a retrospective cohort of 488 patients with type 2 diabetes (148 in each primary health care unit, ESF and UBS, and 192 at the tertiary health care unit) with a 1-year follow-up to evaluate the following care quality indicators: nephropathy, neuropathy and retinopathy tests, yearly lipid profile and nutritional assessments, and an inquiry about tobacco use. The presence of > 50% of the quality of care assessment measures was considered acceptable. Indicators were also evaluated in relation to patients without proper diabetes control (HbA1c > 8.5%). Results In the results, a high percentage of patients were excluded specifically for not presenting the two HbA1c tests within a year (n = 208, 58.1% at ESF; n = 225, 58.4% at UBS; and n = 39, 16.9% at the tertiary health care unit). From the included patients, only 7 (4.7%) at ESF, 7 (4.7%) at UBS, and 52 (27.0%) at the tertiary health care unit showed > 50% of the quality criteria covered. When only patients without proper diabetes control were evaluated, none of them at any of the health care units showed all the quality criteria covered. Conclusions Our results show a low percentage of care assessment measures at each evaluated health care unit, pointing out the need to improve the protocols and care lines of diabetic patients.

Purpose: To evaluate the prevalence of excessive screen‐based behaviors among Brazilian adolescents through a systematic review with meta‐analysis. Data source: Systematic review and meta‐analysis were recorded in the International Prospective Register of Ongoing Systematic Reviews (PROSPERO‐CRD 2017 CRD42017074432). This review included observational studies (cohort or cross‐sectional) that evaluated the prevalence of excessive screen time (i.e. combinations involving different screen‐based behaviors) or TV viewing (≥2 h/day or >2 h/day in front of screen) through indirect or direct methods in adolescents aged between 10 and 19 years. The research strategy included the following databases: MEDLINE, LILACS, SciELO and ADOLEC. The search strategy included terms for “screen time”, “Brazil”, and “prevalence”. Random effect models were used to estimate the prevalence of excessive screen time in different categories. Data summary: Twenty‐eight out of 775 studies identified in the search met the inclusion criteria. The prevalence of excessive screen time and TV viewing was 70.9% (95% CI: 65.5–76.1) and 58.8% (95% CI: 49.4–68.0), respectively. There was no difference between sexes in both analyses. The majority of studies included showed a low risk of bias. Conclusions: The prevalence of excessive screen time and TV viewing was high among Brazilian adolescents. Intervention are needed to reduce the excessive screen time among adolescents. Resumo: Objetivo: Avaliar a prevalência de tempo excessivo de tela e de TV em adolescentes brasileiros através de revisão sistemática com metanálise. Fontes de dados: A revisão sistemática e a metanálise foram registradas no Registro Prospectivo Internacional da Base de Dados de Análises Sistemáticas (Prospero-CRD 2017 CRD 42017074432). Esta análise incluiu estudos observacionais (coorte ou transversais) que avaliaram a prevalência de tempo excessivo de tela (ou seja, combinações que envolvem diferentes comportamentos baseados em tempo de tela) ou tempo em frente à TV (≥ 2 horas/dia ou > 2 horas/dia em frente à tela) por avaliação direta ou indireta em adolescentes com idades entre 10 a 19 anos. A estratégia de pesquisa incluiu as seguintes bases de dados: MEDLINE, LILACS, SciELO e ADOLEC. A estratégia de busca incluiu termos como “tempo de tela”, “Brasil” e “prevalência”. Os modelos de efeito aleatório foram utilizados para estimar a prevalência de tempo excessivo de tela em diferentes categorias. Resumo de dados: Dos 775 estudos identificados na busca 28 atenderam aos critérios de inclusão. A prevalência de tempo excessivo de tela e tempo de TV foi 70,9% (IC de 95%: 65,5 a 76,1) e 58,8% (IC de 95%: 49,4 a 68,0), respectivamente. Não houve diferença entre os sexos nas duas análises. A maior parte dos estudos incluídos mostrou baixo risco de viés. Conclusões: A prevalência de tempo excessivo de tela e tempo de TV foi alta entre os adolescentes brasileiros. São necessárias intervenções para reduzir o tempo excessivo de tela entre os adolescentes. Keywords: Sedentary lifestyle, Adolescent, Meta‐analysis, Palavras‐chave: Estilo de vida sedentário, Adolescente, Metanálise

The aim of this study was to evaluate the acute effect of aerobic (AER) and eccentric (ECC) exercise on glucose variability, correlating it with circulating markers of inflammation and oxidative stress in healthy subjects. Sixteen healthy subjects (32 ± 12 years old) wore a continuous glucose monitoring system for three days. Participants randomly performed single AER and ECC exercise sessions. Glucose variability was evaluated by glucose variance (VAR), glucose coefficient of variation (CV%) and glucose standard deviation (SD). Blood samples were collected to evaluate inflammatory and oxidative stress markers. When compared with the preexercise period of 0-6 h, all the indices of glucose variability presented comparable reductions 12-18 h after both exercises (∆AER: VAR= 151.5, ∆CV% = 0.55 and ∆SD = 3.1 and ECC: ∆VAR = 221.2 , ∆CV% = 3.7 and ∆SD = 6.5). Increased interleukin-6 (IL-6) levels after AER (68.5%) and ECC (30.8%) (P

Abstract Introduction Strict glucose control using multiple doses of insulin is the standard treatment for type 1 diabetes mellitus (T1DM), but increased risk of hypoglycemia is a frequent drawback. Regular insulin in multiple doses is important for achieving strict glycemic control for T1DM, but short-acting insulin analogues may be better in reducing hypoglycemia and postprandial glucose levels. Objective We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose in patients with T1DM. Methods Searches were run on the electronic databases MEDLINE, Cochrane-CENTRAL, EMBASE, ClinicalTrials.gov, LILACS, and DARE for RCTs published until August 2017. To be included in the study, the RCTs had to cover a minimum period of 4 weeks and had to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose levels in patients with T1DM. Two independent reviewers extracted the data and assessed the quality of the selected studies. The primary outcomes analyzed were hypoglycemia (total episodes, nocturnal hypoglycemia, and severe hypoglycemia) and postprandial glucose (at all times, after breakfast, after lunch, and after dinner). Glycated hemoglobin (HbA1c) levels and quality of life were considered secondary outcomes. The risk of bias of each RCT was assessed using the Cochrane Collaboration Risk of Bias table, while the quality of evidence for each outcome was assessed using the GRADEpro software. The pooled mean difference in the number of hypoglycemic episodes and postprandial glucose between short-acting insulin analogues vs. regular human insulin was calculated using the random-effects model. Results Of the 2897 articles retrieved, 22 (6235 patients) were included. Short-acting insulin analogues were associated with a decrease in total hypoglycemic episodes (risk rate 0.93, 95% CI 0.87–0.99; 6235 patients; I2 = 81%), nocturnal hypoglycemia (risk rate 0.55, 95% CI 0.40–0.76, 1995 patients, I2 = 84%), and severe hypoglycemia (risk rate 0.68, 95% CI 0.60–0.77; 5945 patients, I2 = 0%); and with lower postprandial glucose levels (mean difference/MD − 19.44 mg/dL; 95% CI − 21.49 to − 17.39; 5031 patients, I2 = 69%) and lower HbA1c (MD − 0,13%; IC 95% − 0.16 to − 0.10; 5204 patients; I2 = 73%) levels. Conclusions Short-acting insulin analogues are superior to regular human insulin in T1DM patients for the following outcomes: total hypoglycemic episodes, nocturnal hypoglycemia, severe hypoglycemia, postprandial glucose, and HbA1c.

Abstract Background Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes. Main body The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy. Conclusions Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk.

Abstract Background In an attempt to increase the therapeutic potential for myocardial regeneration, there is a quest for new cell sources and types for cell therapy protocols. The pathophysiology of heart diseases may affect cellular characteristics and therapeutic results. Methods To study the proliferative and differentiation potential of mesenchymal stem cells (MSC), isolated from bone marrow (BM) of sternum, we made a comparative analysis between samples of patients with ischemic (IHD) or non-ischemic valvular (VHD) heart diseases. We included patients with IHD (n = 42) or VHD (n = 20), with average age of 60 years and no differences in cardiovascular risk factors. BM samples were collected (16.4 ± 6 mL) and submitted to centrifugation with Ficoll-Paque, yielding 4.5 ± 1.5 × 107 cells/mL. Results Morphology, immunophenotype and differentiation ability had proven that the cultivated sternal BM cells had MSC features. The colony forming unit-fibroblast (CFU-F) frequency was similar between groups (p = 0.510), but VHD samples showed positive correlation to plated cells vs. CFU-F number (r = 0.499, p = 0.049). The MSC culture was established in 29% of collected samples, achieved passage 9, without significant difference in expansion kinetics between groups (p > 0.05). Dyslipidemia and the use of statins was associated with culture establishment for IHD patients (p = 0.049 and p = 0.006, respectively). Conclusions Together, these results show that the sternum bone can be used as a source for MSC isolation, and that ischemic or valvular diseases do not influence the cellular yield, culture establishment or in vitro growth kinetics.

Abstract Background: Children and adolescents with congenital heart disease often have alterations in their exercise capacity that can be evaluated by various functional testing. Objective: To evaluate the functional capacity of children and adolescents with congenital heart disease (CHD) with systematic review and meta-analyses. Methods: The review included observational studies, data from the first evaluation of randomized clinical trials or observational follow-up periods after clinical trials which evaluated functional capacity by cardiopulmonary exercise test, stress testing, six-minute walk test or step test, in children and adolescents with CHD, aged between six and 18 years, and comparisons with healthy controls in the same age group. The quantitative assessment was performed by meta-analysis, by comparing the maximal oxygen consumption (VO2max) of children and adolescents with CHD and respective control groups. Results: Twenty-five of 2.683 studies identified in the search met the inclusion criteria. The VO2max measurement showed that patients with CHD have a decrease of 9.31 ml/Kg/min (95% CI. -12.48 to -6.13; I2, 94.3%, P for heterogeneity < 0.001) compared with the control group. The meta-analysis of the data of maximum heart rate (HR) reached during cardiopulmonary test and stress testing, retrieved from 18 studies, showed a HR value of -15.14 bpm (95% CI. -20.97 to -9.31; I2, 94.3%, P for heterogeneity < 0.001) compared with the control group. Conclusion: Children and adolescents with CHD have lower VO2max and HR compared to controls.

The aim of this study is to evaluate the association between usual physical activity and 24 h blood pressure (BP) profile in people with type 2 diabetes mellitus (DM). This is a cross-sectional study of 151 participants with type 2 DM. Usual physical activity was assessed by step counting and self-reported questionnaire. BP was measured in office and by 24 h ambulatory BP monitoring (ABPM; 24 h, daytime and nighttime). Mean participant age was 61.1 ± 8.4 years, 64% was women, and mean duration of diabetes was 14.3 ± 8.5 years. Ninety-two percent of participants had hypertension, and office BP was 138 ± 18/78 ± 10 mmHg. Inverse correlations were observed between step count and 24 h BP (systolic, r=−0.186; p=0.022), daytime BP (systolic, r=−0.198; p=0.015), and nighttime BP (pulse pressure, r=−0.190; p=0.019). People were categorized into tertiles of daily step count, and the 1st tertile had higher 24 h systolic BP, daytime systolic BP, daytime mean BP, and daytime systolic BP load than those in the other tertiles, even after adjusting for age and HbA1c. Participants with type 2 DM and low levels of physical activity exhibit higher 24 h and daytime systolic ambulatory BP values as compared with those who performed more steps per day, even after adjustments for confounding factors.

OBJECTIVE: To assess the effectiveness of healthcare team guidance in the implementation of a glycemic control protocol in the non-intensive care unit of a cardiology hospital. METHODS: This was a randomized clinical trial comparing 9 months of intensive guidance by a healthcare team on a protocol for diabetes care (Intervention Group, n = 95) with 9 months of standard care (Control Group, n = 87). Clinicaltrials.gov: NCT01154413. RESULTS: The mean age of the patients was 61.7±10 years, and the mean glycated hemoglobin level was 71±23 mmol/mol (8.7±2.1%). The mean capillary glycemia during hospitalization was similar between the groups (9.8±2.9 and 9.1±2.4 mmol/l for the Intervention Group and Control Group, respectively, p = 0.078). The number of hypoglycemic episodes (p = 0.77), hyperglycemic episodes (47 vs. 50 in the Intervention Group and Control Group, p = 0.35, respectively), and the length of stay in the hospital were similar between the groups (p = 0.64). The amount of regular insulin administered was 0 (0-10) IU in the Intervention Group and 28 (7-56) IU in the Control Group (p

INTRODUCTION: The evaluation of endothelial function has been performed in the arterial bed, but recently evaluation within the venous system has also been explored. Endothelial function studies employ different drugs that act as endothelium-dependent vasodilatory response inductors. OBJECTIVES: The aim of this study is to compare the endothelium-dependent venous vasodilator response mediated by either acetylcholine or bradykinin in healthy volunteers. METHODS AND RESULTS: Changes in vein diameter after phenylephrine-induced venoconstriction were measured to compare venodilation induced by acetylcholine or bradykinin (linear variable differential transformer dorsal hand vein technique). We studied 23 healthy volunteers; 31% were male, and the subject had a mean age of 33 ± 8 years and a mean body mass index of 23 ± 2 kg/m². The maximum endothelium-dependent venodilation was similar for both drugs (p = 0.13), as well as the mean responses for each dose of both drugs (r = 0.96). The maximum responses to acetylcholine and bradykinin also had good agreement. CONCLUSION: There were no differences between acetylcholine and bradykinin as venodilators in this endothelial venous function investigation.