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Abstract Background Post-transplant diabetes mellitus (PTDM) is a specific subtype of diabetes with an uncertain impact on mortality and morbidity in post-transplant patients. Diabetic retinopathy is the most common microvascular complication of diabetes mellitus, but the long-term clinical progression in PTDM is unknown. New technologies are being used to assess pre-clinical signs of retinal changes, such as swept-source optical coherence tomography (OCT) and OCT-angiography. The aim of this study was to detect pre-clinical structural and vascular changes in the retina using swept-source-OCT and OCT-angiography in patients with PTDM. Methods In this retrospective cohort study, post-kidney transplant patients were divided into PTDM and non-PTDM (control) groups. Both eyes of eligible PTDM patients and controls were included in this study. Inner retinal layer thickness was measured with swept-source-OCT. Retinal capillary density and the foveal avascular zone were measured with OCT-angiography. Results In the PTDM group, reduced thickness was found in the inferior ganglion cell layer plus inner plexiform layer (95% CI -8.76 to -0.68; p = 0.022) and the temporal inferior segment (95% CI -10.23 to -0.76; p = 0.024) of the inner retina, as well as in the retinal nerve fiber layer in the temporal (95% CI -34.78 to -9.28 p = 0.001) and temporal inferior segments (95% CI -33.26 to -5.03 p = 0.008). No significant differences were found in the vascular capillary plexus between groups at all depths, segments, or foveal avascular zone (p = 0.088). Conclusions According to OCT-angiography, PTDM patients had reduced inner neurosensory retinal layers but no significant change in vascular density, which suggests that early neuroretinal degeneration might occur prior to vascular changes secondary to PTDM. Prospective studies could help elucidate the clinical course of retinal neuropathy and microvascular pathology in PTDM and provide a better understanding of PTDM complications.

Abstract Background The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020. Methods The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria. Results and conclusions All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.

Abstract Background In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM. Methods MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria. Results and conclusions In non-pregnant adults, the recommended HbA1c target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA1c is 6.5–7.5%. When HbA1c is 7.5–9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-1RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA1c remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction ( 30 mL/min/1.73 m2, metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30–60 mL/min/1.73 m2 or eGFR 30–90 mL/min/1.73 m2 with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP-1RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.

Abstract Background To adapt and validate the Clarke and Gold questionnaires and the Edinburgh Hypoglycemia Symptom Scale (EHSS) to Brazilian Portuguese and to determine the prevalence and risk factors associated with impaired awareness of hypoglycemia (IAH) in patients with type 1 diabetes mellitus (T1DM). Methods The process of translation, cultural adaptation, and validation of the questionnaires followed the recommendations of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR)-Task Force for Translation and Cultural Adaptation. Patients with T1DM for a minimum of 12 months, aged 18 years or older, and with Brazilian nationality were selected to participate. Results A total of 123 patients were enrolled. The Clarke and Gold questionnaires as well as the EHSS exhibited adequate internal consistency, test–retest reliability, and convergent validity. The prevalence of IAH was 38.3% with the Clarke questionnaire and 25.2% with the Gold questionnaire. The prevalence increased with longer duration of diabetes, lower HbA1c, and lower eGFR. Conclusions The validation and cross-cultural adaptation of the proposed questionnaires to Brazilian Portuguese were adequate. In this sample of T1DM, the prevalence of IAH was high and associated with a longer duration of T1DM, lower HbA1C and lower eGFR.

Although advanced age and presence of comorbidities significantly impact the variation observed in the clinical symptoms of COVID-19, it has been suggested that genetic variants may also be involved in the disease. Thus, the aim of this study was to perform a systematic review with meta-analysis of the literature to identify genetic polymorphisms that are likely to contribute to COVID-19 pathogenesis. Pubmed, Embase and GWAS Catalog repositories were systematically searched to retrieve articles that investigated associations between polymorphisms and COVID-19. For polymorphisms analyzed in 3 or more studies, pooled OR with 95% CI were calculated using random or fixed effect models in the Stata Software. Sixty-four eligible articles were included in this review. In total, 8 polymorphisms in 7 candidate genes and 74 alleles of the HLA loci were analyzed in 3 or more studies. The HLA-A*30 and CCR5 rs333Del alleles were associated with protection against COVID-19 infection, while the APOE rs429358C allele was associated with risk for this disease. Regarding COVID-19 severity, the HLA-A*33, ACE1 Ins, and TMPRSS2 rs12329760T alleles were associated with protection against severe forms, while the HLA-B*38, HLA-C*6, and ApoE rs429358C alleles were associated with risk for severe forms of COVID-19. In conclusion, polymorphisms in the ApoE, ACE1, TMPRSS2, CCR5, and HLA loci appear to be involved in the susceptibility to and/or severity of COVID-19.

Aims: We hypothesized that critically ill patients with SARS-CoV-2 infection and insulin resistance would present a reduced Heat Shock Response (HSR), which is a pathway involved in proteostasis and anti-inflammation, subsequently leading to worse outcomes and higher inflammation. In this work we aimed: (i) to measure the concentration of extracellular HSP72 (eHSP72) in patients with severe COVID-19 and in comparison with noninfected patients; (ii) to compare the HSR between critically ill patients with COVID-19 (with and without diabetes); and (iii) to compare the HSR in these patients with noninfected individuals. Methods: Sixty critically ill adults with acute respiratory failure with SARS-CoV-2, with or without diabetes, were selected. Noninfected subjects were included for comparison (healthy, n = 19 and patients with diabetes, n = 22). Blood samples were collected to measure metabolism (glucose and HbA1c); oxidative stress (lypoperoxidation and carbonyls); cytokine profile (IL-10 and TNF); eHSP72; and the HSR (in vitro). Results: Patients with severe COVID-19 presented higher plasma eHSP72 compared with healthy individuals and noninfected patients with diabetes. Despite the high level of plasma cytokines, no differences were found between critically ill patients with COVID-19 with or without diabetes. Critically ill patients, when compared to noninfected, presented a blunted HSR. Oxidative stress markers followed the same pattern. No differences in the HSR (extracellular/intracellular level) were found between critically ill patients, with or without diabetes. Conclusions: We demonstrated that patients with severe COVID-19 have elevated plasma eHSP72 and that their HSR is blunted, regardless of the presence of diabetes. These results might explain the uncontrolled inflammation and also provide insights on the increased risk in developing type 2 diabetes after SARS-CoV-2 infection.

RESUMO Objetivo: Examinar a associação entre os níveis de citocinas no plasma do doador e o desenvolvimento de disfunção primária do enxerto de órgãos transplantados a partir de doadores falecidos. Métodos: Foram incluídos no estudo de forma prospectiva 17 doadores falecidos e os respectivos 47 pacientes receptores de transplante. Os receptores foram divididos em dois grupos: grupo 1, de pacientes que desenvolveram disfunção primária do enxerto, e grupo 2, de pacientes que não desenvolveram disfunção primária do enxerto. Os níveis de TNF, IL-6, IL-1β, e IFN-γ, avaliados por meio de ELISA, foram comparados entre os grupos. Resultados: Obtiveram-se 69 órgãos, sendo realizados 48 transplantes. Os níveis plasmáticos de citocinas nos doadores não diferiram entre os grupos (em pg/mL): TNF no grupo 1, com 10,8 (4,3 - 30,8) versus no grupo 2, com 8,7 (4,1 - 33,1), com valor de p = 0,63; IL-6 no grupo 1: 1.617,8 (106,7 - 5.361,7) versus no grupo 2: 922,9 (161,7 - 5.361,7), com p = 0,56; IL-1β, no grupo 1: 0,1 (0,1 - 126,1) versus no grupo 2: 0,1 (0,1 - 243,6), com p = 0,60; e IFN-γ, no grupo 1: 0,03 (0,02 - 0,2) versus no grupo 2: 0,03 (0,02 - 0,1), p = 0,93). Obtivemos resultados similares ao examinar separadamente os casos de transplante renal. Conclusão: Nesta amostra de receptores de transplante, os níveis plasmáticos das citocinas TNF, IL-6, IL-1β e IFN-γ nos doadores não se associaram com o desenvolvimento de disfunção primária do enxerto.

ObjectivesCopeptin, an equimolar indicator of serum antidiuretic hormone levels, has been associated with higher mortality in critically ill patients and with the development of diabetes in the general population. The aim of the present study was to investigate the association of copeptin levels with glycemic parameters in critically ill patients and to compare the time-course of copeptin in survivors and non-survivors.DesignProspective cohort study.PatientsFrom June to October 2019, critically ill patients were prospectively enrolled and followed for 90 days.MeasurementsPlasma copeptin levels were determined at intensive care unit (ICU) admission (copeptin T1), 24 h (copeptin T2), and 48 h (copeptin T3) after study entry. Blood glucose and glycated hemoglobin levels were measured. ICU, in-hospital, and 90-day mortality, and length of stay in the ICU and hospital were evaluated.Results104 patients were included. No significant correlation was detected between copeptin levels and blood glucose (r = -0.17, p = 0.09), HbA1c (r = 0.01, p = 0.9), glycemic gap (r = -0.16, p = 0.11), and stress hyperglycemia ratio (r = -0.14, p = 0.16). Copeptin T3 levels were significantly higher in survivors than in non-survivors at hospital discharge (561 [370-856] vs 300 [231-693] pg/mL, p = 0.015) and at 90 days (571 [380-884] vs 300 [232-698] pg/mL, p = 0.03).ConclusionsNo significant correlations were found between copeptin levels and glycemic parameters, suggesting that copeptin is not a relevant factor in the induction of hyperglycemia during critical illness. Copeptin levels at ICU day 3 were higher in survivors than in non-survivors.

A pelagra (deficiência de vitamina B6) acomete pacientes cronicamente desnutridos e merece destaque por seu envolvimento multissistêmico. É relatado o caso de um paciente de 48 anos, sexo masculino, com história de alcoolismo crônico, diarréia, insônia, irritabilidade e diminuição da memória. Ao exame físico, apresentava lesões eritematodescamativas, edemaciadas, simétricas no dorso de ambos os pés e região anterior e posterior das pernas, poupando a área da bermuda e as tiras dos chinelos. Após 20 dias de reposição de niacina e complexo B, apresentou melhora significativa das lesões de pele, sem melhora dos sintomas digestivos e neurológicos. Os aspectos da patogênese, fisiopatologia, diagnóstico diferencial e tratamento da pelagra são discutidos. O diagnóstico de pelagra deve ser lembrado em pacientes com lesões de pele e fatores de risco para desnutrição, como pacientes alcoolistas e doentes crônicos. Unitermos: Pelagra, desnutrição, alcoolismo.

BackgroundRenal transplantation is the best modality of renal replacement therapy for patients with end-stage renal disease. However, it is associated with weight gain and metabolic abnormalities, which adversely impact transplant outcomes.ObjectiveThe objective of this study was to identify the risk factors of one-year weight gain after renal transplantation.MethodsA retrospective cohort study was conducted with 374 patients that underwent kidney transplantation between January 2006 and July 2013. Clinical and laboratory variables were collected from electronic records, and the outcome of interest was weight gain during the first year after renal transplantation. The data were reported as mean ± standard deviation, median (interquartile range) or number of subjects (%). The association between variables were assessed via chi-square test and ANOVA. For analysis of risk factors related to the outcomes of interest, multivariable logistic regression models were used.ResultsThere were 181 (48.4%) female patients, 334 (89.3%) with white ethnicity and the mean age was 44.4 ± 12.8 years. The mean BMI pre-transplant was 24.7 ± 4.1 kg/m2, and 35 (9.9%) patients were classified as obese; 119 (33.6%) as overweight; 187 (52.8%) as normal weight; and 13 (3.7%) as malnourished. After one year of follow-up, the mean BMI was 26.2 ± 5.0 kg/m2, and 61 (17.3%) patients were classified as obese; 133 (37.8%) as overweight; 148 (42.0%) as normal weight; and 10 (2.8%) as malnourished. Weight gain was observed in 72.7% patients, and the average increase was 7.12 ± 5.9 kg. The female gender, lower pre-transplant body weight, lower number of hospitalizations, and a kidney received from a living donor were associated with weight gain by more than 5% in the first year post-transplant.ConclusionFemale gender and lower pre-transplant body weight were independently associated with weight gain by more than 5% in the first year after kidney transplantation; lower rates of hospitalization and donation from living donors were also risk factors for this outcome.

Abstract Background Excessive weight gain is commonly observed within the first year after kidney transplantation and is associated with negative outcomes, such as graft loss and cardiovascular events. The purpose of this study is to evaluate the effect of a high protein and low glycemic-index diet on preventing weight gain after kidney transplantation. Methods We designed a prospective, single-center, open-label, randomized controlled study to compare the efficacy of a high protein (1.3–1.4 g/kg/day) and low-glycemic index diet versus a conventional diet (0.8–1.0 g/kg/day of protein) on preventing weight gain after kidney transplantation. A total of 120 eligible patients 2 months after transplantation will be recruited. Patients with an estimated glomerular filtration rate through the modification of diet of renal disease (MDRD) formula 300 mg/24 h will be excluded. Patients’ diets will be allocated through simple sequential randomization. Patients will be followed-up for 12 months with nine clinic appointments with a dietitian and the evaluations will include nutritional assessment (anthropometrics, body composition, and resting metabolic rate) and laboratory tests. The primary outcome is weight maintenance or body weight gain under 5% after 12 months. Secondary outcomes include body composition, resting metabolic rate, satiety sensation, kidney function, and other metabolic parameters. Discussion Diets with higher protein content and lower glycemic index may lead to weight loss because of higher satiety sensation. However, there is a concern about the association of high protein intake and kidney damage. Nevertheless, there is little evidence on the impact of high protein intake on long-term kidney function outcome. Therefore, we designed a study to test if a high protein diet with low-glycemic index will be an effective and safe nutritional intervention to prevent weight gain in kidney transplant patients. Trial Registration ClinicalTrials.gov identifier, NCT02883777 . Registered on 3 August 2016.

ABSTRACT Body weight is regulated by the ability of hypothalamic neurons to orchestrate behavioral, endocrine and autonomic responses via afferent and efferent pathways to the brainstem and the periphery. Weight maintenance requires a balance between energy intake and energy expenditure. Although several components that participate in energy homeostasis have been identified, there is a need to know in more detail their actions as well as their interactions with environmental and psychosocial factors in the development of human obesity. In this review, we examine the role of systemic mediators such as leptin, ghrelin and insulin, which act in the central nervous system by activating or inhibiting neuropeptide Y, Agouti-related peptide protein, melanocortin, transcript related to cocaine and amphetamine, and others. As a result, modifications in energy homeostasis occur through regulation of appetite and energy expenditure. We also examine compensatory changes in the circulating levels of several peripheral hormones after diet-induced weight loss.

Abstract The aim of the present study was to evaluate the association between metabolic syndrome (MS) and periodontitis (PD), through a systematic review and meta-analysis. Original observational studies assessing the association between MS and PD in adults, published before May 11th (2017), were identified through electronic searches of MEDLINE, EMBASE and Cochrane Library databases. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was used. For studies to be included, they had to mention the criteria used to diagnose MS and to have used at least one clinical measure to diagnose PD. There was no language restriction. Three reviewers independently identified eligible studies for possible inclusion in the systematic review and meta-analysis. The quality of the studies was evaluated by the Newcastle-Ottawa scale for observational studies. A random model meta-analysis was conducted. The strategies used to investigate heterogeneity were sequential analysis, subgroup analysis, univariate meta-regression and sensitivity analysis. Thirty-three studies met the inclusion criteria for the systematic review, and 26 had enough information to be included in the meta-analysis, totaling 52,504 patients. MS and PD were associated with an odds ratio of 1.38 (95%CI 1.26–1.51; I2 = 92.7%; p < 0.001). Subgroup analysis showed that complete periodontal examination (I2 = 70.6%; p < 0.001) partially explained the variability between studies. The present findings suggest an association between MS and PD. Individuals with MS are 38% more likely to present PD than individuals without this condition. Prospective studies should be conducted to establish cause and effect relations between MS and PD.

Introduction: The intestinal microbiota may undergo changes after solid organ transplantation. The purpose of this systematic review was to characterize the intestinal microbiota of patients undergoing solid organ transplantation. Methods: MEDLINE, EMBASE and Cochrane Library databases were searched from inception to July 21, 2017. Studies of patients undergoing solid organ transplantation that evaluated changes in intestinal microbiota composition and one of the following outcomes were included: post-transplant weight, new-onset diabetes after transplantation, delayed graft function, acute rejection, graft and patient survival, and post-transplant infections. Results: Out of 765 studies found in this search, two studies (86 patients) fulfilled inclusion criteria. Both studies assessed kidney transplantation recipients, and a reduction in bacterial species diversity after transplantation was observed. Changes in intestinal microbiota were associated with acute rejection in both studies. One study reported diarrhea and urinary infections, while the other one reported urinary and respiratory infections. None of them reported other outcomes of interest. Conclusion: Changes in intestinal microbiota were observed after kidney transplantation, and they were associated with higher incidence of acute rejection and infections in transplant recipients. However, data are still scarce and more studies are needed to evaluate if microbiota changes have an impact on post-transplant outcomes. Keywords: Transplantation; intestinal microbiota; outcomes

Imaging studies are expected to produce reliable information regarding the size and fat content of the pancreas. However, the available studies have produced inconclusive results. The aim of this study was to perform a systematic review and meta-analysis of imaging studies assessing pancreas size and fat content in patients with type 1 diabetes (T1DM) and type 2 diabetes (T2DM).Medline and Embase databases were performed. Studies evaluating pancreatic size (diameter, area or volume) and/or fat content by ultrasound, computed tomography, or magnetic resonance imaging in patients with T1DM and/or T2DM as compared to healthy controls were selected. Seventeen studies including 3,403 subjects (284 T1DM patients, 1,139 T2DM patients, and 1,980 control subjects) were selected for meta-analyses. Pancreas diameter, area, volume, density, and fat percentage were evaluated.Pancreatic volume was reduced in T1DM and T2DM vs. controls (T1DM vs. controls: -38.72 cm3, 95%CI: -52.25 to -25.19, I2 = 70.2%, p for heterogeneity = 0.018; and T2DM vs. controls: -12.18 cm3, 95%CI: -19.1 to -5.25, I2 = 79.3%, p for heterogeneity = 0.001). Fat content was higher in T2DM vs. controls (+2.73%, 95%CI 0.55 to 4.91, I2 = 82.0%, p for heterogeneity

[This corrects the article DOI: 10.1371/journal.pmed.1001992.].

BackgroundSulfonylureas are an effective and inexpensive treatment for type 2 diabetes. There is conflicting data about the safety of these drugs regarding mortality and cardiovascular outcomes. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyze whether the available sample was powered enough to support the results.Methods and findingsElectronic databases were reviewed from 1946 (Embase) or 1966 (MEDLINE) up to 31 December 2014. Randomized clinical trials (RCTs) of at least 52 wk in duration evaluating second- or third-generation sulfonylureas in the treatment of adults with type 2 diabetes and reporting outcomes of interest were included. Primary outcomes were all-cause and cardiovascular mortality. Additionally, myocardial infarction and stroke events were evaluated. Data were summarized with Peto odds ratios (ORs), and the reliability of the results was evaluated with TSA. Forty-seven RCTs with 37,650 patients and 890 deaths in total were included. Sulfonylureas were not associated with all-cause (OR 1.12 [95% CI 0.96 to 1.30]) or cardiovascular mortality (OR 1.12 [95% CI 0.87 to 1.42]). Sulfonylureas were also not associated with increased risk of myocardial infarction (OR 0.92 [95% CI 0.76 to 1.12]) or stroke (OR 1.16 [95% CI 0.81 to 1.66]). TSA could discard an absolute difference of 0.5% between the treatments, which was considered the minimal clinically significant difference. The major limitation of this review was the inclusion of studies not designed to evaluate safety outcomes.ConclusionsSulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded.Review registrationPROSPERO CRD42014004330.

Abstract: The aim of the study was to evaluate the effect of a structured group education program administered by a primary care nurse in patients with type 2 diabetes mellitus. The sample included 137 patients with type 2 diabetes mellitus, randomized into two groups: intervention (5-week educational course and reinforcements every 4 months for one year) and control (with no structured diabetes mellitus education) with an evaluation of metabolic control, weight, blood pressure, distress scores, and knowledge on diabetes. There were no differences between the two groups in HbA1c at 4, 8, or 12 months when compared to baseline values. An increase in HbA1c was observed in the control group after adjusting for baseline HbA1c and insulin dose (p = 0.044 between groups). Knowledge scores and diabetes-related distress improved after the intervention. A structured educational program administered to type 2 diabetes mellitus patients seen at a primary care unit improved the knowledge and distress associated with the disease. The results also suggest the prevention of an increase in HbA1c.

A hipertensão arterial sistêmica (HAS) é um dos principais fatores de risco para a instalação e progressão das complicações crônicas do diabetes melito (DM) tipo 2. A medida da pressão arterial (PA) através da monitorização ambulatorial da PA (MAPA) apresenta melhor correlação com o desenvolvimento de lesões em órgãos-alvo do que a medida no consultório. Além disso, permite a avaliação de parâmetros pressóricos distintos como as médias das PAs sistólica e diastólica das 24 h, do dia e da noite, cargas pressóricas e ausência do descenso noturno, além da identificação de pacientes com HAS do avental branco e mascarada. Os pacientes com DM apresentam maiores médias de PA diurna e noturna do que os sem DM. Além disso, um terço do pacientes normotensos com DM tipo 2 apresentam HAS mascarada, que está associada a um aumento da albuminúria e da espessura das paredes do ventrículo esquerdo. Por outro lado, a prevalência e o efeito da HAS do avental branco nos pacientes com DM ainda não foram adequadamente avaliados. A determinação da ausência do descenso noturno da PA não acrescenta informação às medidas da PA nas 24 h, no dia ou na noite, mas a medida da PA noturna parece ser relevante na retinopatia do DM. Em conclusão, a determinação da PA através da MAPA é capaz de estratificar de forma mais adequada os pacientes em risco para o desenvolvimento das complicações crônicas do DM e tornou-se um instrumento indispensável para o controle efetivo da PA nestes pacientes.Hypertension is one of the main risk factors for the onset and progression of chronic complications in type 2 diabetes mellitus (DM). Ambulatory blood pressure (BP) monitoring (ABPM) provides a better correlation with target organ lesions than BP obtained in the office. Furthermore, it allows the evaluation of distinct BP parameters such as the 24-h, daytime and nighttime systolic and diastolic BP means, BP loads and the absence of nocturnal drop of BP, as well as the identification of white-coat and masked hypertension. DM patients have higher daytime and nighttime BP means than non-DM patients. In addition, one third of normotensive type 2 DM patients have masked hypertension, which is associated with an increase in albuminuria and in left ventricle wall thickness. On the other hand, the prevalence and effect of white-coat hypertension in type 2 DM patients have not yet been properly evaluated. The absence of nocturnal drop of BP does not add information to the 24 h, daytime or nighttime BP measurements, but the nighttime BP means seem to be relevant in DM retinopathy. In conclusion, BP determination by ABPM allows better patient risk stratification for the development of DM chronic complications and is an essential instrument for effective BP control in these patients.

Our objective is to evaluate if there is an association between liver fat accumulation after islet transplantation (ITx) and graft survival. A cohort study was conducted in 34 subjects with type 1 diabetes postallogeneic ITx. Liver fat content was evaluated by magnetic resonance imaging (MRI) (change in liver signal intensity on in-phase and opposed-phase images). Kaplan–Meier curves and Cox regression analysis were performed with islet dysfunction duration as the dependent variable and fat liver content as an independent one. Values of p < 0.05 were significant (SSPS ® 18.0 and MedCalc ® 12.5). Patients' mean age was 40 ± 8 years (diabetes duration: 31 ± 12 years; male: 41%). Islet survival did not differ in patients without (51 months, 95% CI 40–62 months) or with steatosis (48 months, 95% CI 38–58 months; p = 0.55) during islet dysfunction period. Nevertheless, survival curves appear to separate late in the follow-up, and after 40 months steatosis was associated with shorter graft survival ( p log rank = 0.049). This association remained (RR 23.5, 95% CI 1.1–516.0; p = 0.045) after adjustments for possible confounding factors. In this sample of subjects with type 1 diabetes submitted to ITx, steatosis was not associated with islet failure in the whole cohort. However, in subjects with functional islets after 40 months, a shorter graft survival was observed in those with steatosis during the islet dysfunction period, even after adjustments to variables known to be associated with islet failure.

Transrectal ultrasonography-guided prostate needle biopsy is the ideal method to obtain prostate specimens for histological analysis and is therefore frequently used in clinical practice. In the majority of the studies, prostate biopsy is considered a safe procedure with few major complications. In the present report, we describe a case of endocarditis with spondylodiscitis, two very rare complications of prostate biopsy.

OBJETIVO: Comparar a gravidade da doença coronária e a presença de fatores de risco cardiovasculares entre pacientes com angina e infarto do miocárdio (IM). MÉTODOS: Estudaram-se 62 pacientes com IM e 129 com angina, através de cineangiocoronariografia, avaliando-se a oclusão (lesão de 99% ou 100%), a severidade (escore de 0 a 5 de acordo com o número de vasos afetados) e a extensão (3 grupos com diferentes graus de estenose). Dois observadores experientes interpretaram cegamente os angiogramas. RESULTADOS: Os pacientes com IM tiveram maior oclusão (50% vs 13,2% [p

A associação de hipertensão arterial sistêmica (HAS) e diabetes melito (DM) é bastante comum, acometendo mais de 60% dos pacientes com DM tipo 2. Os benefícios do tratamento da HAS nesses pacientes são bem definidos, entretanto há controvérsia em relação a qual o alvo de pressão a ser atingido nesses pacientes com o tratamento. O esquema terapêutico a ser utilizado deve levar em consideração não só o efeito dos medicamentes sobre a pressão arterial, mas também seus efeitos em mortalidade e complicações do DM. Na maior parte das recomendações nacionais e internacionais, os inibidores da enzima conversora da angiotensina são considerados drogas de primeira linha no tratamento desses pacientes, devido a seu efeito benéfico sobre a albuminúria, mas se discute o uso de diuréticos tiazídicos como terapia inicial, da mesma maneira que na população sem DM. Nessa revisão abordaremos as evidências em relação aos benefícios do tratamento da HAS em pacientes com DM, o alvo de pressão a ser atingido com esse tratamento e as vantagens e riscos do uso das diferentes classes de antihipertensivos nessa população

O diabetes melito tipo 1 (DM1) está associado ao desenvolvimento de complicações crônicas de elevada morbi-mortalidade em indivíduos jovens em idade produtiva. A terapia intensiva com insulina comprovadamente diminui o aparecimento das complicações crônicas da doença. Entretanto, essa terapia ainda está associada ao aumento da incidência de hipoglicemia. Em pacientes com “DM1 lábil”, os quais apresentam hipoglicemias graves sem sintomas de alerta, o transplante de ilhotas pancreáticas humanas é uma das melhores alternativas para restaurar a secreção de insulina e a percepção da hipoglicemia. Cerca de 80% dos pacientes que receberam transplante de ilhotas de mais de um doador, submetidos ao tratamento imunossupressor do protocolo de Edmonton, adquiriram independência de insulina após 1 ano do transplante. Porém, apenas 10% destes pacientes permaneceram livres de insulina após 5 anos. Entretanto, mesmo aqueles pacientes que necessitaram utilizar novamente insulina tiveram a normalização da homeostase glicêmica e da percepção da hipoglicemia, com prevenção da hipoglicemia grave. Sendo assim, o transplante de ilhotas é capaz de diminuir os níveis de glicose plasmática e HbA1c, reduzir a ocorrência de hipoglicemias graves e melhorar a qualidade de vida dos pacientes. O objetivo deste artigo foi fazer uma breve revisão da literatura sobre o isolamento e transplante de ilhotas pancreáticas humanas e relatar a implantação de um laboratório de isolamento de ilhotas humanas no Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre.

A nefropatia do contraste é definida como piora na função renal que se segue à administração de contraste intravenoso, tendo sido excluídas outras causas. A nefropatia do contraste manifesta-se, usualmente, como uma insuficiência renal aguda não oligúrica. Por definição, deve haver um aumento na creatinina basal de 25-50% ou um aumento superior a 0,5 mg/dl em 24-48 horas após o uso intravenoso de contraste, na ausência de outras causas de piora da função renal. As medidas de prevenção são baseadas na correção dos fatores que levam ao desenvolvimento da nefropatia do contraste e dividem-se em: escolha de agentes de contraste menos nefrotóxicos (não-iônicos) e utilização de doses menores; melhora no estado clínico do paciente com hidrata-ção; uso de drogas que reduzam vasoconstrição renal e estresse oxidativo; e suspensão temporária de drogas com potencial nefro-tóxico ou prejudiciais no caso de diminuição da filtração glomerular. A instituição de um protocolo com medidas preventivas em pacientes em risco e, especialmente, em diabéticos submetidos a contraste potencialmente nefrotóxico poderá reduzir a morbidade e custos associados ao seu desenvolvimento. A presente revisão tem o objetivo de descrever a definição e patogênese de nefropa-tia do contraste, enfatizando as principais recomendações de manejo para prevenir sua ocorrência.

Nefrite intersticial aguda é uma causa comum de perda aguda de função renal. Exposição a drogas é o fator desencadeante mais freqüentemente relatado, porém auto-imunidade e infecções também estão associadas. Os inibidores da enzima de conversão da angiotensina têm sido relatados como possíveis agentes, porém não há relato na literatura de nefrite intersticial com uso de losartan. Descrevemos então, o caso de perda aguda de função renal após exposição a losartan, em paciente com dano renal prévio por nefropatia diabética, cuja biópsia renal diagnosticou nefrite intersticial aguda.