- Meeting abstracts
- Open Access
21st Brazilian Diabetes Society Congress
© The Author(s) 2018
- Published: 12 April 2018
A1 A randomized control trial evaluating the effect of acupuncture on glycemic control in dm2 using the freestyle libre® glucose monitoring system
Sérgio Vencio1, Adriana Caiado2, Douglas Morgental2, Natália Bufaiçal Rassi Carneiro3, Rafael Caiado Vencio3
1UFG, Goiás, Brazil; 2Comunidade Espírita Ramatís, Goiânia, Brazil; 3Pontificia Universidade Católica de Goiás, Goiás, Brazil
Correspondence: Sérgio Vencio
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A1
Introduction: Acupuncture is a widely used technique for the treatment of diabetes in Asian countries. Nevertheless, there are few studies with appropriate methodological rigor evaluating its effectiveness and promoting a standardized procedure in the western world. The FreeStyle libre glucose monitoring system has specific characteristics, being diverse from the traditional monitoring methods. It does not require finger prick and identifies glucose variations, especially nocturnal hypoglycemia.
Objectives: Evaluate the short-term effect of acupuncture in the treatment of type 2 diabetes mellitus (DM2) using the FreeStyle libre system.
Method: In a randomized, controlled, prospective, open-label trial, we randomly assigned 20 insulin independent DM2 patients to undergo acupuncture (group 1) or in the control group (group 2). Participants should be between 20 and 75 years old, diagnosed with DM2 for at least 3 years, and with stable glycemic control (evaluated through glycated hemoglobin). Patients should not be in use of glucocorticoids or insulin, be pregnant or have record of nephrotic syndrome, hepatic insufficiency, hyperthyroidism, acromegaly or renal insufficiency. Demographic data, baseline characteristics, biochemical and metabolic profiles were analyzed before the intervention. Participants underwent continuous glucose monitoring for 14 days, period in which they did not change diet, exercise or medication. Group 1 received acupuncture 4, 8 and 12 days after installation of the monitoring system. The acupuncture treatment promotes energetic rebalance and, in this study, diabetes-specific treatment points were used in all patients (B38, IG4, R24, E36 e BP9). This trial was approved by the ethics committee (CAAE—60576616.6.0000.5572) and registered at Brazilian Registry of Clinical Trials (UTN) is U1111-1199-9630.
Conclusion: In this randomized pilot trial, there was an improvement in global glycemic control during the 14 days of monitoring in the acupuncture group. Despite the small sample of this trial, there were no significant differences in baseline characteristics. Further studies with larger cohorts should be performed.
António Chacra1, Denise Reis Franco2, Luis Eduardo Procopio Calliari3, Freddy Goldberg Eliaschewitz4, Graziela Ferreira5, Maurício Aguiar de Paula5, Leila Lima5, Felipe Lauand5
1Diabetes Center of Federal University of São Paulo, Brazil and Diabetes Center at the Sírio-Libanês Hospital, São Paulo, Brazil; 2CPClin Clinical Research Center, São Paulo, Brazil; 3Pediatric Endocrinology Unit, Pediatric Department, Santa Casa de São Paulo School of Medicine, São Paulo, Brazil; 4Hospital Israelita Albert Einstein-São Paulo Brazil and CPClin Clinical Research Center, São Paulo, Brazil; 5Sanofi, São Paulo, Brazil
Correspondence: António Chacra
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A2
Introduction: Real-world data on diabetes mellitus (DM) in Brazil is scarce. Given the complexity of current DM management, an understanding of the disease profile is essential to inform clinical and public health decisions.
Objective: We aimed to describe the proportion of T1DM and T2DM patients with HbA1c < 7.0%, the socio demographic and clinical characteristics of DM patients and the therapeutic strategies adopted in Brazil.
Methods: This was an observational, cross-sectional study, conducted between January and June 2016 in 250 public and private healthcare centers, randomly selected across Brazil.
Results: Overall, 2590 patients (51.8% male) were included, of which 244 (9.4%) had T1DM and 2 346 (90.6%) had T2DM. Most T1DM patients (43.4%) were in the 18-30 age group and most T2DM patients (51.5%) were in the 5170 age group. BMI ≥ 30 kg/m2 was found for 14.6% of T1DM patients and 36.6% of T2DM patients. Mean age at diagnosis was 25.1 (SD 15.8) years for T1DM and 50.8 (SD 12.6) years for T2DM. Most patients (76.9%) are followed in the private healthcare sector. The most frequent comorbidity was dyslipidemia (46.7%; n = 1209), both for T1DM patients (20.1%; n = 49) and T2DM patients (49.4%; n = 1160). HbA1C < 7.0% was found for 41.8% (95% CI [34.7%; 49.0%]) of T1DM patients and for 52.3% (95% CI [50.1%; 54.5%]) of T2DM patients. Among T2DM patients, 14.4% (n = 338) were insulin-treated, of which 55.6% (n = 188) with NPH, 23.7% (n = 80) with fast-acting insulin analogues, 22.8% (n = 77) with long-acting insulin analogues, 13.6% (n = 46) with regular insulin and 3.6% (n = 12) with premixed insulin. The oral antidiabetics most commonly used by T2DM patients were metformin (n = 1538; 65.6%), followed by DDP-4 inhibitors (n = 774; 33.0%) and sulfonylureas (n = 644; 27.5%). On average, patients attend 3.7 appointments per year for diabetes management (T1DM: 4.3; T2DM: 3.6).
Conclusion: A high proportion of patients in this cohort did not meet the glycemic control target of HbA1C < 7.0%, even though most were under pharmacological treatment. Given the risk of diabetic complications posed by uncontrolled disease, further action should be taken to address this issue. Globally, this study offers valuable insight into DM’s epidemiology and management in Brazil. Funding: This study was funded by Sanofi.
Daniela Vieira e Silva Vítor1, Luciano Resende Ferreira1, Viviane Aparecida Sotto Bazalia Capeli1, Luciana Avila Furtado Cardillo1, Renan Vieira de Brito1, Cláudio A Baptista2, Priscila I Scardovelli2, Vinícius B Rodrigues2
1Unifae-Centro Universitário das Faculdades Associadas de Ensino, São João da Boa Vista, Brazil; 2UNIFAE, São João da Boa Vista, Brazil
Correspondence: Daniela Vieira e Silva Vítor
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A3
Introduction: Diabetes mellitus (DM) is a disease that has a high prevalence around the world. In 2014, the World Health Organization estimated that 422 million adults had the disease, worldwide. The DM is one of the main causes of disability, which can negatively affect productivity in active workers. In Brazil, the National Institute of Social Security (INSS) is responsible for granting benefits and salaries in cases of absenteeism due to illness.
Objective: The objective of this study was to evaluate the epidemiological profile of INSS beneficiares receiving disability benefits due to DM.
Methods: A retrospective study based on analysis of 184 patients who requested disability benefits due to diabetes mellitus from the INSS, in a city located in the south of Minas Gerais- Brazil. The analyzed data were characterized by age, gender and employment situation through the ICD-10 (E10, E11 and E14) from January 2014 to February 2016.
Results: The results showed that diabetes mellitus represented 34.2% of all disability benefits requests associated with endocrine diseases (n = 538). Considering just the diabetes ICDs, Insulin-dependent diabetes mellitus (E10) represented 63.6%, followed by non-insulin-dependent Diabetes (E11) with 24.4% and unspecified diabetes mellitus (E14) with 12%. The majority of beneficiaries were male (71.7%), associated with urban jobs (53.3%) especially administrative posts, ranging from 50 to 64 years old (63%).
Conclusion: The profile of workers who have requested benefits due to diabetes mellitus showed that the majority of beneficiaries were male adults, working in urban jobs ranging from 50 to 64 years old, mainly affected by Insulin-dependent diabetes mellitus disease. In addition, these beneficiaries can be more susceptible to workplace thermal conditions, stress and other issues inherent to the disease, such as hypo or hyperglycemia. These data should help in the implementation of strategies and measures to prevent the work disability caused by diabetes involving Brazilian workers. As consequence, it is expected that there will be a reduction in costs related to the absence of these workers.
A4 Ability of the pedersen method to stratify hypoglycemia awareness and assess the risk of hypoglicemia
Ticiana Paes Batista da Silva1, Luiz Clemente Rolim1, Celso Sallum Filho1, Sergio Atala Dib1
1UNIFESP, São Paulo; Brazil
Correspondence: Ticiana Paes Batista da Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A4
Introduction: The Perdersen method is a simple method to assess impairment of hypoglycemia awareness, which is a major risk factor for severe hypoglycemia.
Objective: To assess hypoglycemia awareness in consecutive type 1 diabetes patients using the Pedersen method and evaluate their glycemic profile and frequency of hypoglycemia.
Method: The Pedersen consists in confronting patients with the question: “Do you recognize symptoms, when you have a hypoglycemia?” and gives the possibility of one of four answers: (1) “Always”; (2) “Usually”; (3) “Occasionally”; (4) “Never”. The population is then stratified in three groups: Normal awareness of hypoglycemia (NAH)—patients who answered “always”; Impaired awareness (IAH)—patients who answered “usually”; Unawareness of hypoglycemia (UAH)—patients who answered “occasionally” or “never”. For all subjects, glycemic profile and hypoglycemia frequency were prospectively evaluated in detail in a 1 month period.
Results: In total, 98 patients with a mean age of 26 years and 13 years of diabetes duration were classified as UAH = 28.6%, IAH = 22.4%, and NAH = 49%. Patients with hypoglycemia unawareness (UAH) were older and had longer diabetes duration. The proportion of patients who reported at least one episode of severe hypoglycemia in the last year was significantly lower in patients with NAH (p < 0.001). When asked what level of blood glucose triggered their symptoms of hypoglycemia, significantly more patients with UAH reported levels < 40 mg/L (NAH = 4.2%, IAH = 4.5%, UAH = 57.0%, p < 0.001). In the analyses of the 4 weeks period of prospective data collection we observed a progressive increase in the average number of episodes of hypoglycemia as hypoglycemia perception decreased (NAH = 6.5 ± 5.3, IAH = 8.8 ± 4.4, UAH = 11.5 ± 8.4; p = 0.004). The proportion of patients with at least one episode of hypoglycemia with no warning symptoms (i.e. no symptoms and capillary glucose < 52 mg/L) was highest in those with UAH (p < 0.001 vs. NAH and p = 0.011 vs. IAH). On univariable analysis, age (OR = 1.07; p = 0.002), diabetes duration (OR = 1.07; p = 0.027), and creatinine clearance (OR = 0.81; p = 0.014) were associated with unawareness of hypoglycemia. On multivariable analysis, there was no factor independently associated with unawareness of hypoglycemia.
Conclusion: The Pedersen method is a simple and feasible clinical tool that correctly identified patients with high risk for severe hypoglycemia.
Tayse Tâmara da Paixão Duarte, Ana Carla de Macedo Mesquita, Camila Leal Cardoso, Márcia Cristina da Silva Magro
UNB, Brasília, Brazil
Correspondence: Tayse Tâmara da Paixão Duarte
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A5
Introduction: Diabetes Mellitus is a chronic non-communicable disease that occurs due to hereditary and/or environmental factors. Adherence to drug therapy is essential to avoid complications.
Objective: To identify adherence and drug therapy and the difficulty that these individuals with type 2 DM have in relation to treatment adherence through the Morisky-Green Test (MGT) and Brief Medication Questionnaire (BMQ).
Method: Quantitative, descriptive, exploratory cross-sectional study. Study conducted with patients diagnosed with Type II Diabetes Mellitus. The results were analyzed by the Statistical Package for the Social Science (SPSS) 17, using Chi square tests and Fisher‘s exact test, was considered significant p < 0.05. All participants signed the informed consent form—TCLE. This research was approved by the Research Ethics Committee of the Health Sciences Teaching and Research Foundation of the health secretariat—FEPECS/SES, CAAE 45288915.6.0000.5553.
Results: Among the 99 patients interviewed, the majority were female (71.7%), aged 60.4 ± 1.0 years, married (54.5%), household 36 (36.4%), whose family income was constituted up to a minimum wage (34.3%). Regarding adherence to medication therapy, it was found to be moderate for both sexes, 48% (Female) and 50% (Male), through the MGT evaluation. The BMQ showed women with a likely adherence to treatment (55%) with a higher incidence and men focused on a low adherence rate (36%). Regarding the limitations for adherence, 45.5% of the individuals reported having difficulty reading what is written on the medication packages and 24.2% reported having difficulty remembering the time to take the medications.
A6 Achievement of HBA1C targets in the diabetes unmet need with basal insulin evaluation (dune) real-world study
Luigi Meneghini1,2, Didac Mauricio3, Emanuela Orsi4, Nebojsa Lalic5, Anna Cali6, Jukka Westerbacka6, Peter Stella6, Christophe Candelas6, Valerie Pilorget6, Riccardo Perfetti6, Kamlesh Khunti7
1University of Texas Southwestern Medical Center, Dallas, TX, USA; 2Parkland Health & Hospital System, Dallas, TX, USA; 3Hospital Universitari Germans Trias i Pujol, Barcelona, Spain; 4Endocrine and Metabolic Diseases Unit, Fondazione Ca‘Granda IRCCS, Milan, Italy; 5Clinic for Endocrinology, CCS Faculty of Medicine, University of Belgrade, Serbia; 6Sanofi, Paris, France; 7Diabetes Research Centre, University of Leicester, Leicester, UK
Correspondence: Luigi Meneghini
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A6
A7 Action ear acupuncture on glycemic control in people with type 2 diabetes mellitus: systematic review
João Batista Moreira1, Lidiane Aparecida Monteiro2, BIANCA BACELAR DE ASSIS1, THAILA OLIVEIRA ZATITI BRASILEIRO1, Jefferson Felipe Ribeiro1, Denise Hollanda Iunes1, Érika de Cássia Lopes Chaves1
1UNIFAL, Alfenas, Brazil; 2USP Ribeirão Preto, Ribeirão Preto, Brazil
Correspondence: João Batista Moreira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A7
Introduction: Diabetes Mellitus (DM) is a global health problem of the century. It is observed that 90 to 95% of DM cases are of people with Type 2 Diabetes Mellitus (DM2). Complications resulting from this morbidity can be systemic as peripheral. Therapeutic resources such as ear acupuncture have been used for the purpose of maintaining physiological balance and reducing the risks of complications from Diabetes.
Objective: To evaluate the evidence found in the literature on the action ear acupuncture on glycemic control in people with T2DM.
Methods: Systematic review in the databases: PubMed, Web of Science, Cinahl, Cochrane, Scoppus, PEDRo, Science Direct, with keywords: Type 2 Diabetes Mellitus · Auriculotherapy/Type 2 Diabetes Mellitus · Acupressure/Type 2 Diabetes Mellitus · Ear acupuncture; adapted to each base, with the inclusion criteria: experimental works published in the last 10 years.
Results: 79 articles found. After reading the title, 22 articles composed the sample for analysis in its entirety. In the final sample, five studies answered the guiding question and presented the inclusion criteria. These showed ear acupuncture as an effective intervention for glycemic control. Despite this diversity, auriculotherapy can be applied by means of seed techniques (3 studies), with manual stimulation and electrical stimulation in the auricular pavilion (2 studies), both with variable number of sessions.
Conclusion: Treatment protocol varied from and there is no consensus among the experts on the number of sessions, duration of treatment and the points applied.
A8 Action planning and coping planning strategies to improve adherence to oral antidiabetics: a secondary analysis of a randomized controlled trial
Danilo Donizetti Trevisan1, Flávia Helena Pereira2, Thaís Moreira São João1, Marilia Estêvam Cornélio1, Fernanda Freire Jannuzzi3, Roberta Cunha Matheus Rodrigues1, Maria Helena de Melo Lima1
1Universidade Estadual de Campinas, Campinas; Brazil; 2Instituto Federal do Sul de Minas Gerais, Minas Gerais, Brazil; 3Colégio Técnico de Campinas, Campinas, Brazil
Correspondence: Danilo Donizetti Trevisan
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A8
Background: Discontinuation of drug treatment may be considered a common problem in patients with type 2 diabetes mellitus (T2DM) and, consequently, contribute to inadequate glycemic control. A systematic approach to improving adherence consists of: assessing adherence, removing barriers to overcoming them, and finally establishing follow-up plans that confirm the change in planned treatment and the evaluation of their goals.
Aim: To describe action plans related to the behavior of adherence to oral antidiabetic drugs (OADs), developed by patients with type 2 diabetes mellitus in primary care, as well as to identify the perceived barriers and respective coping strategies to effect this behavior.
Method: A cross-sectional study derived from a randomized controlled trial. Individuals (n = 44) who used oral antidiabetics and who had the ability to read and write in Brazilian Portuguese, composed the sample and were invited to elaborate behavioral strategies to improve OADs adherence. Ethics Approval: The study was approved by the University of Campinas’ Ethics Board, approval number 1.278.099/2016, 1.408.883/2016 and 1.528.738/2016 and conducted according to the recommendations of the Declaration of Helsinki.
Results: It was evidenced that 97.7% of the action plans were associated with taking OADs after meals, 36.4% of the participants chose to take OADs in the room, and 45.4% associated them with activities of daily living such as preparing breakfast, brushing teeth and bathing. In daily activities, forgetfulness (21.4%), presence of adverse events (59.1%) and absence of routine (6.1%) were the most prevalent barriers raised by patients. The preparation of daily coping plans, such as leaving the tablets in an easily accessible place (17.3%), eating every three hours (14.3%), drinking 2 L or more of water per day (7.2%) and standardized mealtimes (6.1%) were the coping strategies that were most related to overcome the behavioral failure gap.
Conclusion: Most of the action plans were associated with taking OADs to temporal markers or the wake/sleep cycle. The development of coping planning including day-to-day activities were the strategies that most related to overcoming the behavioral failure gap. These findings provide support for the application of these strategies to promote adherence to drug therapy among patients with T2DM.
A9 Acute coronary syndromes with and without elevation of the st segment in diabetic patients type 2: a 5-year follow-up analysis
Tatiana Siqueira Capucci1, Lais de Oliveira Hernandes1, Mariana Accioly Carrazedo1, Wimbles Pires2, Alihene Barros Colombo Aguilera3, Amanda Bissoli Lopes3, Ariella Gimenes Maschio3, Alex Sandro Souza Almeida3, Caroline Alves Machado3, Felipe Emmanuel Jakymiu3, Ricardo Emidio Navarrete de Toledo4
1Beneficência Portuguesa de São Paulo, São Paulo; Brazil; 2FMU, São Paulo, Brazil; 3IEFAP, UNINGÁ, Maringá, Brazil; 4Beneficência Portuguesa de São Paulo, IEFAP, UNINGÁ, Maringá; Brazil
Correspondence: Tatiana Siqueira Capucci
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A9
Introduction: Acute coronary syndromes (ACS) are associated with increased risk of disability, hospitalization and death in populations, especially in diabetic patients. Type 2 diabetes mellitus (DM2) accounts for 90–95% of all cases of diabetes. It usually occurs in obese individuals and is older than 40 years. Approximately 70–80% of patients with T2DM have a set of factors that implies a high cardiovascular risk (abdominal obesity, dyslipidemia, glucose intolerance or diabetes and arterial hypertension), thus denominating the metabolic syndrome (MS). The dyslipidemia found in patients with MS is highly atherogenic, considerably increasing the cardiovascular risk of these patients, since the combination of these multiple risk factors makes this population a group of patients highly susceptible to cardiovascular diseases (CVD), with a risk up to 3× greater for the event cardiovascular, up to 4x for death by CAD and up to 2.4× for death from any cause. The more components of MS the patient has, the greater the risk of CVD and the presence of MS in patients with pre-existing CVD increases the risk of a new event in these people.
Objective: The objective of this study was to compare the clinical differences, the impact and the characteristics of hospitalizations for Acute Coronary Syndrome (ACS), either acute myocardial infarction without ST-segment elevation (STEMI) or acute myocardial infarction with ST-segment elevation IAMCSST) in type 2 diabetic patients.
Methodology: Retrospective study from the charts of diabetic patients followed up by the Endocrinology Team who were diagnosed with ACS (IAMSSST and IAMCSST) between March/2012 and March/2017. Clinical data included sex, age, main cause of admission, comorbidities, and mean length of hospital stay. Patients hospitalized with other macrovascular causes (cerebrovascular disease and peripheral arterial insufficiency) were excluded. Data are presented in absolute numbers and percentages.
Result: Of the 446 admissions due to macrovascular causes, 86% were due to ACS (n = 384, 73% male and mean age 62.5 ± 12.4 years). The main age group was between 61 and 70 years (59%). The main diagnoses at hospital discharge were: 34% AMI (with/without SST), 57% AI and 9% noncardiac chest pain. The mean hospital stay was 16.8 ± 2.6 days. Overall mortality occurred in 3% (n = 6), occurring only in patients with AMI/AI.
Conclusion: Our data reaffirm the diabetic condition as an independent risk factor for cardiovascular events, being 2 to 3 times greater in males, which are more prone to the development of coronary diseases, being the main cause of hospitalization in this population. These results reinforce the need for a simultaneous intervention between glycemic control and the traditional cardiovascular risk factors, in order to weaken the central determinants involved in the genesis of atherosclerosis.
A10 Acute lowering of circulating fatty acids does not improve the incretin effect in patients with type 2 diabetes
Valeria B Chueire1, Brenno D Astiarraga2, Ricardo Pereira Moreira1, Aglecio L Souza1, Sylka Rodovalho3, Sarah Monte Alegre1, Andrea Tura4, Andrea Mari4, Ele Ferrannini5, Elza Muscelli1
1Unicamp, Campinas, Brazil; 2University of Pisa, Pisa, Italy; 3PUC-Campinas, Campinas, Brazil; 4CNR Institute of Neuroscience, Padua, Italy; 5CNR Institute of Clinical Physiology, Pisa, Italy
Correspondence: Valeria B Chueire
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A10
Background and aims: Plasma glucose is the main stimulus for insulin secretion (IS), but non-esterified fatty acids (NEFA) and the incretin hormones (GLP-1 and GIP) also are important modulators of IS. The incretin effect (IE) accounts for the ~40–80% higher IS after oral ingestion compared to intravenous glucose. Palmitate impairs IE by downregulating GLP-1 receptor signaling in beta-cell lines and isolated mouse islets. Insulin resistance and defective IE are common in T2DM. Thus, increased NEFA levels could impact beta-cell function through an impairment of IE. Our aim was to test whether an acute NEFA reduction induced by acipimox (ACP, a potent inhibitor of lipolysis) improves IE in T2DM.
Materials and Methods: 13 patients (10F/3 M; 54.8 ± 7.6 years, mean ± SD; BMI = 32.8 ± 5.6 kg/m2; HbA1c = 7.24 ± 0.48%) received a 3 h OGTT (75 g) and a 3 h isoglycaemic glucose infusion (IV) on separate days. Both tests were repeated after ACP ingestion (200 mg 2 h before and 1 h after starting glucose). C-peptide deconvolution was used to calculate IS rates; mathematical model to quantitate ß-cell function and IE. Main parameters: insulin secretion rate (ISR); glucose sensitivity (ßGS), i.e., the slope of the IS/glucose dose–response curve; glucose-induced potentiation (PGLU), a time-dependent modulation of the dose–response; incretin-induced potentiation (PINCR) calculated as the fold IS increment during OGTT compared to IV glucose.
Results: On the OGTT, ACP decreased NEFA OGTT-area-under-curve (AUC) by 55 ± 14% (64 ± 28 vs 27 ± 9 mol L−1 h−1, p < 0.01). Fasting glycaemia, OGTT and IV glucose AUCs were similar before and after ACP, while ACP decreased incremental OGTT-glucose AUC (744 ± 163 vs 902 ± 262 mol L−1 3 h−1, p < 0.05). ISR was lower during IV than OGTT both in the control (58 ± 19 vs 70 ± 23 nmol m−2; p < 0.01) and ACP studies (53 ± 15 vs 64 ± 20 nmol m−2; p < 0.01). ACP reduced ISR (64 ± 20 vs 70 ± 23 nmol m−2, p < 0.05) and did not change ßGS (32 ± 11 vs 26 ± 9 pmol min−1 m−2 mM−1), PINCR (1.17 ± 0.14 vs 1.12 ± 0.19 fold), PGLU, plasma glucagon and GIP (all p = ns). In contrast, ACP improved insulin sensitivity, estimated as the oral glucose sensitivity index, OGIS (326 ± 44 vs 291 ± 60 ml min−1 m−2, p < 0.05). Changes in ISR were directly related to changes in NEFA (rho = 0.62, p = 0.03) and inversely related to OGIS (rho = −0.73, p = 0.01).
Conclusion: In patients with type 2 diabetes, acute pharmacological NEFA reduction lowers glycaemia and enhances insulin sensitivity but does not improve the incretin effect.
Susana Castelo Branco Ramos Nakandakari1, Patricia Brito Rodrigues1, Marcella Ramos Sant‘Ana1, Rafael Calais Gaspar1, Vitor Rosetto Muñoz1, Camilla Bertuzzo Veiga1, Adelino Sanchez Ramos da Silva2, Eduardo Rochete Ropelle1, Leandro Pereira Moura1, José Rodrigo Pauli1, Dennys Esper Cintra1
1UNICAMP, Campinas, Brazil; 2USP, São Paulo, Brazil
Correspondence: Susana Castelo Branco Ramos Nakandakari
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A11
Introduction: The short-term consumption of saturated or unsaturated fatty acids it is enough to change the metabolism. The adipose tissue hypertrophy and dysfunction induced by saturated fatty acids consumption represent strong markers to cardiometabolic risk. On the other hand, omega-3 food sources seems to protect from excess of adiposity, inflammation and hyperphagy.
Objective: The aim of this study was to test the short effects of flaxseed oil, riches in 3, against high-fat diet disturbances in adipose visceral tissues.
Materials and methods: Animals C57BL6 J, 4 weeks old, were distributed in 3 groups (N = 6 each), maintained during 3 days under specific diets: control diet (CTL—4% soy oil), High-fat diet (HFD—35% lard), and High-fat diet with 10% of flaxseed oil in substitution of lard (FS—25% from lard). It was carried out food intake, fasting glucose, body weight gain, metabolic and physiological parameters, lipidomics and histopathological analysis.
Results: On the 1st., the food intake significantly increased in the HFD group compared to CTL (P < 0.05) while in the last day (3rd day), there was a significant increase in the HFD group, compared to FS (P < 0.05). FS diet did not protected mice from weight gain in comparison to HFD group. However, surprisingly, the total fat depots in mesenteric adipose tissue from FS group was smaller than HFD group (P < 0.05), and the difference between HFD and CTL group on mesenteric, epididymal and retroperitoneal tissues was extremely significant (P < 0.001). Interestingly, the 3 fatty acid (C18:3 α-linolenic) bioavailability was confirmed by lipidomics, through its incorporation into adipose tissues from FS group in comparison to HFD group (P < 0.001). In addition, FS oil replaced diet was able to restore 6:3 balance (5:1), even under high fat conditions, when compared to HFD group (14:1).
A12 Acute response to high intensity intermittent exercise in children and adolescents with type 1 diabetes
Andreia Araújo Porchat de Leão1, Valderi Abreu de Lima1, Juliana Pereira Décimo1, Camilla Kapp Fritz1, Marcia Regina Messaggi Gomes Dias1, Neiva Leite1, Suzana Nesi França1, Luis Paulo Mascarenhas2
1Universidade Federal do Paraná, Paraná, Brazil; 2Universidade Estadual do Centro-oeste, Paraná, Brazil
Correspondence: Andreia Araújo Porchat de Leão
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A12
Introduction: The risk of hypoglycemia during and after exercise is a limiting factor to regular exercise in patients with type 1 diabetes. Studies related to intermittent exercise, characteristic of most sports and games, present contradictory results regarding glycemic responses and the risk of hypoglycemia induced by exercise.
Objective: The objective of this study was to evaluate the influence of intermittent high intensity exercise on the glucose response of children and adolescents with type 1 diabetes, related to the insulin application schedule.
Materials and Methods: Participated in the study 30 patients with type 1 diabetes mellitus, Z score of BMI 0.13 ± 0.93; Chronological age 13.09 ± 1.90; duration of disease 6.47 ± 3.77; Concentration of HbA1c 9.69 ± 1.56%. The patients had a standardized meal and insulin application was performed in the clinic (mean basal insulin 25.75 ± 8.47 U/kg/d and fast acting insulin 17.31 ± 11.35 U/kg/d). Two tests were performed in cycle ergometer, intensity of 60% VO2max, interspersed by five high-intensity sprints every 5 min, tests were performed one and 2 h after the application of insulin (T1 h and T2 h). Blood glucose was assessed at the beginning and at the end of the tests and for 8 h after the end of the tests using the continuous glucose monitor (MCG).
Results: Pre-and post-test glycemic variation was higher in T2 h (−30.66 mg/dl) than in T1 h (−19.78 mg/dl, p = 0.007). There was a significant difference between the mean number of occurrences of hypoglycemia in the 8 h following the tests (p = 0.017). The hypoglycemic odds ratio showed a higher odds ratio for hypoglycaemia after exercise and up to 8 h after insulin administration (OR: 37.94% CI 9.30–15.75).
Patrícia Veras Tavares, Lilian Barros de Sousa Moreira Reis
Hospital Regional da Asa Norte-Hran, Brasília, Brazil
Correspondence: Patrícia Veras Tavares
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A13
Introduction: The evaluation of the autocare in patients with diabetes mellitus has as checking finality if the patients put in practice the directions that they receive of the health professionals to reach a better control glicêmico and lipídico, to maintain the appropriate weight and to obstruct or to delay complications resulting from the disease.
Objective: This study aimed to value the autocare of the patient at the next dimensions: general food, specific food, physical activity, monitorização of the glicemia, care with the feet, use of the medication and the practice of the tobaccoism.
Method: Cross study carried out in a public hospital of Brasilia, DF—in the period from 12th of January till 21st of May of 2016. The sample was composed by 100 patients with DM1 and DM2, both sexes, ages between 18 and 64 years attended in the outpatient department of endocrinologia of this hospital more than a year ago. A validated questionnaire was applied, QAD—Questionnaire of Activity of Autocare with Diabetes.
Resulted: The care with to the food was satisfactory with reduced consumption of sweets and fats in the diet; the practice of physical activity between the participants of this sample was low. The use of prescribed medicines and direction as for the care they was with the feet that they had bigger adhesion as the patients. Regarding tobaccoism practice, 41% of the interviewed ones said to have smoked in some phase of the life, nevertheless, in the moment of the inquiry, only 6% maintains the habit.
A14 Adverse perinatal outcomes of diabetic pregnant women treated with metformin in a tertiary hospital between 2009 and 2016
Tabita Furukita Thomazini, Penelope Tabatinga Castro, Adriano Roberto Manoel Radin, Juliana Rodrigues de Paula, Beatriz Graciano Sant‘anna, Claudio Capuano, Wagner Rodrigo Brida Gonçalves, Ji Hoon Yang, Daniela Yone Veiga Iguchi, Leila Guastapaglia
HSPM, São Paulo, Brazil
Correspondence: Tabita Furukita Thomazini
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A14
Background: Diabetes mellitus (DM) is the main endocrinopathy in pregnancy and its treatment aims to reach an adequate maternal glycemic control and reduce the adverse perinatal outcomes. The classic treatment is diet (D), physical activity (PA) and insulin (I), the last one associated to hypoglycemia and weight gain. On the other hand, metformin (MTF) does not lead to hypoglycemia neither weight gain. However, there are limited data regarding the use of metformin during pregnancy.
Goals: The aim of the study was to retrospectively analyze the impact of the glycemic control on perinatal outcomes of the diabetic pregnant women who received MTF, alone or associated with insulin, and to compare the results with those on conventional treatment.
Methods: We analyzed the medical records of the diabetic pregnant women who were attended at the Endocrinology Clinic of Hospital do Servidor Público Municipal between 2009 and 2016. The incidence of fetal macrosomia, prematurity, respiratory distress, hospitalization in intensive care unit and abortion were analyzed and correlated to the glycemic control. Good glycemic control was defined by the presence of at least 80% of capillary blood glucose within the following range: pre-prandial < 90 mg/dL, 1 h postprandial < 140 mg/dL, 2 h postprandial < 120 mg/dL
Clara Machado Campolim1, Clílton Kraüss de Oliveira Ferreira1, Vitor Ferreira Boico1, Olívia Pizetta Zordão1, Daisuke Hayashi Neto1, Mariana Matera Veras2, Patricia Oliveira Prada1
1UNICAMP, Campinas, Brazil; 2USP, São Paulo, Brazil
Correspondence: Clara Machado Campolim
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A15
Background: Exposure to air pollution has unfavorable cardiometabolic effects. Particulate matter 2.5 (PM2.5) is associated with the induction of chronic inflammation in many tissues. Leptin signaling in the hypothalamus participates in the maintenance of energy homeostasis. Leptin resistance may occur due to hypothalamic low grade inflammation in obese models. One of the mechanisms that triggers the low grade inflammation is the activation of toll-like receptor 4 (TLR4) pathway by lipopolysaccharide (LPS), which is one of the components of MP2.5.
Objectives: Therefore, the aims of the present study are to investigate: 1) TLR4 gene expression in the hypothalamus of C57BL/6 J mice (C57) exposed to PM2.5 (polluted) compared to C57 exposed to filtered air (FA); 2) the changes in weight gain, energy intake and energy expenditure (respirometry), glucose tolerance (GTT) and insulin tolerance (ITT) in TLR4- knockout mice (TLR4KO) exposed to PM2.5 or FA.
Materials and methods: 6 weeks-old male mice were exposed to PM2.5/FA in the Harvard Ambient Fine Particles Concentrator at University of Sao Paulo during 3 months. All mice received standard diet (Nuvilab®) and potable water ad libtum. After this period, part of these mice was submitted to intraperitoneal leptin sensitivity protocol, which consisted of daily injections of leptin for 2 days followed by saline injections for 3 days. During this protocol, body weight and food intake were measured daily. Another part of the mice underwent to glucose and insulin tolerance tests (GTT and ITT) made in different weeks. At the end of all in vivo experiments, mice were killed for tissues dissections after intraperitoneal leptin or saline stimulation. Hypothalamus and epididymal adipose tissue were collected and kept under −80 °C.
Results: As a result, it was observed that the polluted C57 mice had increased body weight, adipose mass and serum insulin concentration. The GTT and ITT were altered in the polluted C57 compared to C57 FA. There was no difference on food intake between groups; however, the oxygen consumption was significantly lower in polluted C57 compared to FA mice, suggesting lower energy expenditure in this group. Leptin resistance in the hypothalamus was observed in the polluted C57 mice compared to FA mice, because body weight and food intake in response to leptin only decrease in the FA C57 mice. TLR4 gene expression levels were elevated in the hypothalamus of polluted C57 mice. The TLR4KO exposed to MP2.5 did not present changes in body weight or adipose mass and hypothalamic leptin sensitivity was similar to FA C57 mice. In addition, GTT and ITT were similar between polluted TLRKO and FA C57 mice.
Conclusion: Together, the data suggest that the air pollution participates in the genesis of obesity, insulin resistance and glucose intolerance. The increase of adiposity was due, at least in part, to the reduction of energy expenditure. Hypothalamic inflammatory pathways may be involved in leptin resistance induced by air pollution, because the TLR4 deletion protected the animal from obesity, insulin resistance and glucose intolerance.
A16 Albuminuria reduction after high dose of vitamin D in patients with type 1 diabetes mellitus: a pilot study
João Soares Felício1, João Felício Abrahão Neto2, Manuela Nascimento de Lemos1, Fabrício de Souza Resende1, Lorena Margalho Sousa1, Fernando Costa Araújo1, Luciana Marques da Costa1, Lorena Regina Velasco Guimarães Silva1, Ana Carolina Contente Braga de Souza1, Franciane Trindade Cunha de Melo1, Marcia Costa dos Santos1, Amanda Soares Peixoto1, Alana Ferreira de Oliveira1, Natércia Neves Marques de Queiroz1, Luísa Corrêa Janaú2, Isabela Imbelloni Farias de Franco1, Karem Miléo Felício1
1Universidade Federal do Pará, Pará, Brazil; 2Universidade do Estado do Pará, Pará, Brazil
Correspondence: João Soares Felício
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A16
Background: Some studies suggest an association between diabetic kidney disease (DKD) and vitamin D (VD), but there is no data about the effect of high dose of VD on DKD in type 1 diabetes mellitus (T1DM). Our pilot study aims to evaluate albuminuria reduction in patients with T1DM supplemented with high dose of VD.
Methods: 22 patients received doses of 4000 and 10000 IU/day of cholecalciferol for 12 weeks according to patient’s previous VD levels. They were submitted to continuous glucose monitoring system (CGMS), 24-h ABPM and urine albumin-to-creatinine ratio (UACR) before and after VD supplementation.
Results: There was a reduction of DKD prevalence at the end of the study (68 vs 32%; p = 0.05), with no changes on insulin doses, HbA1c, glycemic variability (GV) and blood pressure (BP) values. A correlation between percentage variation of VD levels (∆VD) and albuminuria at the end of the study was presented (r = −0.5; p < 0.05). Among T1DM patients with DKD at the beginning of the study, 8/13 (62%) had their DKD stage improved, while the other five ones (38%) showed no changes (p < 0.05).
Conclusions: Our pilot study suggests an association between VD high dose supplementation, lower prevalence and improvement in stages of DKD in T1DM.
Jessica Tatiana Mendoza Peña, Davi Francisco Machado, Janaina Petenuci, Egle Bastos Targino Puppim, Karen Viviana ivasiuten Gorejko, Patricia Borges, Diego Santos Rocha, Thais Braga Meira, Mara Barbosa Gayoso, Rosane Kupfer
IEDE-Instituto Estadual de Diabetes e Endocrinologia, Rio de Janeiro, Brazil
Correspondence: Jessica Tatiana Mendoza Peña
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A17
Introduction: Allergy to human insulin or its analogues is rare. No effective strategy has been found yet. The incidence is estimated between 1 and 2.4% on insulin-treated patients. Reactions range from local signs to anaphylaxis. Individuals may be allergic to the insulin molecule itself or to pharmaceutical excipients such as protamine, zinc or metacresol. A defective injection technique (intradermal application) facilitates the development of such reactions. The underlying mechanisms of allergy may be type I (IgE-mediated), type III (IgGmediated immune complex) and type IV (T cell-mediated late-type hypersensitivity). Epidermal Langerhans cells carry a foreign antigen to T lymphocytes and perform a key role on the beggining of cutaneous immune responses and responses to chemical allergens found on the surface of the skin.
Case report: Patient 55 years old, fem, DM2 for 4 years, in the use of 2 sulfonylureas (SUs)at the same time and NPH insulin, came to our hospital. She denied allergies. SUs were suspended. Metformin was introduced and adjusted to be used with insulin. Ten days later she returned presenting erythema and pruritus at the site of insulin application, that had no improvement with antihistamine drugs nor taking off technique application error and there was an itchy maculopapular rash after 10 min around the injection spot, the same being observed after switching to another Insulin (Detemir). IgE antibody specific for insulin was positive. Insulin was suspended and started SGLT2 inhibitor together with DDP4 inhibitor, and submitted to desensitization protocol according to scheme Pföhler et al. In a new insulin test 3 months later, the skin reaction was again presented.
Discussion: The frequency of allergic reactions to insulin has decreased significantly since the introduction of the recombinant human form and it´s analogues. The hypersensitivity reactions are now generally due to the presence of various additives of pharmaceutical formulas. Treatments go from the use of antihistamines drugs to desensitization therapy. Systemic corticosteroids can be used as long as attention is paid to glycemic control. Changing Insulin could be effective because of little differences in amino acid sequences and their antigenicities. Initially, the patient presented with a good response to desensitization, although presented recurrence before the end of the protocol. The availability of oral treatments allowed the control without the use of insulin at this time.
Informed consent to publish had been obtained from the patient.
A18 Analysis of anthropometric parameters in patients with type 2 diabetes at a university hospital in Belém, PA
Aline da Silva Cota, Adrielle Aguiar de Carvalho, Elenilce Pereira de Carvalho, Fernanda Oliveira Serrão, Naiza Nayla Bandeira de Sá, Ana Beatriz Praia Ribeiro, Letícia Ribeiro das Chaves
UFPA, Pará, Brazil
Correspondence: Aline da Silva Cota
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A18
Introduction: Diabetes mellitus (DM) is considered a progressive metabolic disease. Several factors may contribute to the aggravation of this disease, such as overweight and visceral fat accumulation. It is well known that some visceral fat assessment methods could be complex and expensive. But, since waist circumference (WC) correlates directly with the amount of visceral fat, it can be used as a useful alternative method of measurement. Besides that, when WC results are compared to the body mass index (BMI) ones, a better evaluation of metabolic and cardiovascular risk is performed.
Objective: To analyze the nutritional status of diabetic patients by using anthropometric measurements.
Methods: A cross-sectional, quantitative and descriptive study was carried out with type 2 diabetic patients hospitalized in a university hospital, located in the city of Belém, State of Pará, Brazil, in a period of April to July 2016. Patients were asked about socioeconomic issues and were performed some anthropometric assessments (BMI and WC). Optimal WC cut-offs were 80 cm and 94 cm, in men and women. While for BMI the cut off used was 18.5 to less than 25 kg/m2. All the patients understood and accepted the Informed Consent Term (ICT).
Results: Fifty-five patients with type 2 DM were interviewed. Most of them were females (54.55%) with ages ranging from 32 to 78 years (mean: 61 ± 9.75 years). The mean time of diagnosis was 15 ± 10 years. Regarding the level of education, it was noted that most of the diabetic patients had only incomplete elementary schooling (81.81%). This might contributed to a low adherence to treatment. In the present study, it was found that the frequency of overweight (BMI ≥ 25 kg/m2) was high (41.8%), often resulting from a sedentary lifestyle and a high consumption of processed foods. Waist circumference analyzes showed an elevated risk of metabolic alterations in both women (93.33%) and men (52%), demonstrating the impact of this measurement on the occurrence and progression of diabetes.
Conclusion: Most of the patients had elevated WC and almost half had overweight. This condition of body fat accumulation in patients with type 2 DM is cause of concern, since it is a factor that impairs the metabolic control. This contributes to the appearance of chronic complications of diabetes. The role of nutritional therapy aims to introduce and sensitize the patient to having healthy living habits that provide a better quality of life.
A21 Analysis of the ophthalmoscopy examination in people with diabetes mellitus from a program of health promotion in the amazon
Jéssica Gomes da Silva, Francineide Pereira da Silva Pena, Rafael Pinto da Silva, Maria Silvia da Costa Silva, Sônia Silva Alves, Gabriela de Souza Amanajás, Jessica Monteiro Cunha, Ediene Stherfany Marques Vale, Adriane Stefanny Rocha Ribeiro, Danielle Cardoso Portilho, Amiraldo Dias Gama, Tallitha Barbosa da Luz, Emanuel de Jesus Vaz Bittencourt, Diego Quaresma Ferreira, Angel Tamna Souza de Souza
UNIFAP, Amapá, Brazil
Correspondence: Jéssica Gomes da Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A21
Introduction: Retinopathy is the third cause of blindness in adults in Brazil, and it is the major one among people of productive age (16–64 years). It is also one of the most common complications of Diabetes Mellitus (DM) being found after 20 years of DM analysis, 90% of diagnosis being type 1 and 50–80% type 2 and the growth of life expectancy of the patients is greatly increasing the incidences (Aragon, 2013).
Objective: Evaluate eye health of participants of a health promotion program for people with Diabetes Mellitus in the Amazon.
Method: Descriptive study of quantitative approach. The data gathering was made through analysis of fundoscopy results. Participation in the program was the inclusion criterion used for the development of the study. The study was approved by the Ethics and Research Committee (Comitê de Ética e Pesquisa) (CEP) of the Federal University of Amapá (Universidade Federal do Amapá), under Postal Code/CEP: 900.066/2015.
Results: Twenty-one (21) clinical examinations were analyzed, the majority of participants were female (76.1%); male (23.8%) (Table 1). Description of the results analysis: MACULA: brightness, 15 people (71.4%), low brightness, 2 people (9.5%) and no brightness 1 person (4.76%) and with no evaluation of the macula 2 people (9.5%). OPTIC DISC WITH CUPPING: 0.2 (19%), 0.3 (19%), 0.4 (23.8%), physiological (14.2%) and no result (23.8%). VESSELS: normal (61.9%), slight tortuous (4.7%), tortuous (4.7%), no vessel evaluation (23.8%). CONTOUR: preserved (42.8%), regular (19%), no result (38%). DIAGNOSES: Glaucoma, 1 person (4.7%), Cataract, 5 people (23.8%); Diabetic Retinopathy: mild, 1 person (4.7%), severe 1 person (4.7%); Hypertensive retinopathy, 1 person (4.7%), Asteroid Hyalitis, 1 person (4.7%); Pterygium 1 person (4.7%) (Table 2)
A25 Anti‐gad positive syndrome (stiff‐man): a 9‐years‐case report of treatment, evolution and a review
José Francisco de Camargo Carmello1, Acary Souza Bulle Oliveira2
1Hospital Alemão Osvaldo Cruz, São Paulo, Brazil; 2UNIFESP, São Paulo, Brazil
Correspondence: José Francisco de Camargo Carmello
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A25
Discussion: Stiff‐person (SPS) is a rare neurological disease (1:1,000,000–1:2,000,000 ihb/year) fistly described in 1956.Pubmed‐search as cognitive deficit + SPS = 10 articles, 5 case‐reports, one patient had all the AntiGAD‐stiff-person spectrum disorders described (SPSD).Epitopes recognized by SPSD‐anti‐GAD65 differ from T1D. It’s been described T‐lymphocyte‐infiltration in the medulla. In T1D‐LADA freq 1:10,000. In Central Nervous System (CNS), anti‐GAD65 blocks inhibitory GABAergic‐neurons. This deficit has been related to tetanus‐toxin‐sign, schizophrenia, and tetany of SPS, the agitation‐cognitive alteration of SPSD, confused as psychiatric. One article revises the treatment of SPS‐SPSD, maintaining the IV‐immunoglobulins (Dalakas MC validated A‐1‐double blind), stimulating‐GABA‐neurons: Benzodiazepines and Baclofen as an improved treatment. Two review the physiology of SPSD:in rats with infusion of antibodies from patients,and a case‐control‐study suggests cognitive loss in anti‐GAD65/non‐carriers, needing increased sample. Recently Dalakas MC`Trial doesn’t demonstrate statistical difference rituximab/placebo. We have already published another patient case study with lethal outcome without treatment and described this patient when the treatment was successful. Unfortunately, the patient had a cognitive loss without circulatory or immuno‐neurological disease only SPSD.
Final Comments: Our review confirm the best treatment for SPSD, despite this unexpected 9‐year‐evolution.
Informed consent to publish had been obtained from the patient.
A26 Assesment of food intake of patients with congenital generalized lipodystrophy in relation to the guidelines of brazilian diabetes society
Natasha Vasconcelos Albuquerque, Synara Cavalcante Lopes, Roberta Freitas Celedônio, Mônica de Oliveira Maia, Priscila Macêdo Fernandes, Lia Beatriz de Azevedo Souza Karbage, Izabella Tamira Galdino Farias Vasconcelos, Ana Paula Dias Rangel Montenegro, Virgínia Oliveira Fernandes, Renan Magalhães Montenegro Júnior
UFC, Ceará, Brazil
Correspondence: Natasha Vasconcelos Albuquerque
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A26
Background and Aims: Generalized Congenital Lipodystrophy (LGG) is a rare autosomal recessive disorder characterized by the difficulty of storing adipose tissue and metabolic abnormalities such as insulin resistance (IR), diabetes mellitus (DM), dyslipidemia and hyperphagia. The nutritional orientation in these patients contributes to the control of these comorbidities and represents one of the main treatment lines in force in Brazil. The aim of this work was to evaluate the dietary intake of patients with LGC at a center of reference in Ceará.
Metodology: A quantitative descriptive study performed at a hospital of reference in this disease in the state of Ceará, from November 2014 to February 2015. Eleven patients with a genetic diagnosis of LGC were evaluated. Food consumption was obtained through three 24-h recall (R24 h) collected on different days. The interviewers were trained and followed the automated multi-step method consisting of a five-step guided interview. The results of the R24 h analysis were grouped in means and standard deviation and compared to the values of energy, macronutrients and fibers recommended by the Brazilian Society of Diabetes (SBD).
Results: The mean age of the patients was 11.18 ± 9.26 years, ranging from 2 to 31 years. Eight patients were female. The average energy consumption was 1990.09 ± 483.09 kcal. There were inadequate intakes of protein, saturated fatty acids, total fat and fiber in 100% (11), 90.9% (10), 72.8% (8) and 45.6% (5) of the patients, respectively. While 90.9% (10), 90.9% (10) and 81.8% (9) of the subjects presented adequate intake of carbohydrates, polyunsaturated fatty acids and monounsaturated fatty acids, according to SBD recommendations, respectively.
Conclusions: The dietary intake of the patients was characterized by the inadequacy of proteins, saturated fatty acids, total fats and fibers. Considering the importance of nutritional management for the treatment of this group of patients, nutrient adjustment becomes essential.
A27 Assessment of emotional suffering and attitudes in relation to type 1 diabetes of users admitted in a public diabetes center in Belo Horizonte
Janice Sepúlveda Reis, Paula Lamego de Moura, Sônia Maria do Carmo Maulais, Karima Fernanda Rosa Simão Martins, Rodrigo Antônio Andrade Moura
IEP SANTA CASA BH, Bahia, Brazil
Correspondence: Janice Sepúlveda Reis
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A27
Background: The identification of the attitudes and emotional state of people with diabetes in relation to coping with the disease can facilitate more personalized interventions that help to obtain better results in self-management of the treatment.
Objective: To evaluate the level of emotional stress and attitudes towards diabetes in patients with type 1 diabetes (T1DM) admitted to a Reference Diabetes Center of the Unified Health System in Belo Horizonte, Minas Gerais.
Methods: This was a crosssectional study with evaluation of patients admitted from January 2015 to July 2017. Patients with cognitive limitations which impaired understanding of the instruments were excluded from the evaluation. Two instruments adapted and validated for Brazilian culture were applied: self-administered B-PAID for the measurement of emotional distress related to daily diabetes coping (a score above or equal to 40 points indicates a high level of emotional distress) and ATT-19, a self-administered questionnaire that assesses the attitude of the person with diabetes to the disease (above 70 points indicates a positive attitude towards the disease).
Results: Thirty-eight individuals with T1DM met the inclusion criteria. The median age was 34 years (10-79), with a diagnosis time of 8 years (1-26), female predominance (57.9%) and complete primary education (52.6%). Regarding instrument scores, the average score for B-PAID was 36.82 (1.25–80), which indicates a low stress index, with 39.4% of participants with a high diabetesrelated stress index (> 40 points). Regarding the sub-dimensions of B-PAID, it is observed that the predominance of stress responses was related to emotional, followed by feeding, treatment and social support (Table 1). In ATT-19, 73.6% of the people showed negative attitudes related to dealing with diabetes (score < 70), with an average score of 62.56 (36-81).
A30 Assessment of insulin resistance in patients with diabetes mellitus type 1 between 7 and 22 years old
Susane da Silva Reis, Isabela Rolim Adriano, Maria Cláudia Schmitt Lobe
Universidade Regional de Blumenau, Blumenau, Brazil
Correspondence: Susane da Silva Reis
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A30
Introduction: The prevalence of overweight and obesity seems to follow the worldwide trends of weight gain in type 1 diabetes mellitus (DM1), with obesity being the most common cause of insulin resistance (IR) in children and adolescents. In recent years, there has been an increase in the number of children and adolescents with a mixture of both types of diabetes, these being obese and/or presenting signs of insulin resistance and autoimmune markers for beta cells. Romualdo, Nóbrega and Escrivão, conducted a retrospective study with children and adolescents from 5 to 14 years of age. It was observed that those who were resistant to insulin had higher values of body mass index, waist circumference, triglycerides and HDL-C reduction. The possibility of a relationship between insulin resistance in young patients with DM1 has not yet been clarified and it is what this paper intends to verify as well as its relation with z-BMI score, insulin dose used by the patient and time of disease.
Methods: A quantitative cross-sectional study based on the retrospective analysis of medical records of the pediatric endocrinology clinic at the University Polyclinic was performed. Patients with a diagnosis of DM1, aged between 7 and 22, who signed the Free and Informed Consent Term were included. The following variables were evaluated: gender, chronological age (CA) at diagnosis, CA at the time of the test, weight and height at the exam and time of disease (TD). Laboratory tests: glycemia and fasting insulin, glycated hemoglobin (HbA1c), exogenous slow insulin dose and microalbuminuria value. IR was calculated using the Homeostasis Model Assessment-Insulin Resistance (HOMA-IR). Values of statistical significance were considered when p < 0.05. Data analysis was performed by Microsoft Excel 2013 and SPSS version 13. The study was approved by the Regional University of Blumenau Ethic’s Committee, approval number: 57640416.2.0000.5370.
Results: Thirty-five medical records were evaluated. Three patients did not have IR. The 32 patients with IR were 21 females (60%), with averages of CA at diagnosis: 6.07 years, CA at the examination: 13.38 years, TD: 7.3 years, HbA1c: 9.1% and 8 patients (22%) presented altered values of microalbuminuria. There was no correlation between HOMA-IR with z-BMI score, insulin dose and TD in this sample.
A31 Assessment of knowledge and the practice of insulin application in patients with type 1 diabetes mellitus
João Henrique Del Grandi Spontão, Martha Camillo Jordão, Daniele Iop de Oliveira Caldoncelli, Caio Villaça Carneiro, Camila Gagliardi Walter, Ariane Cantarella, Ravena Machado Massucatto, Thais Picelli Pescarolo, Alexandre Eduardo Franzin Vieira, Maria Teresa Verrone Quilici, Carla Sanchez Bergamin Rizzetto
PUC-SP, São Paulo, Brazil
Correspondence: João Henrique Del Grandi Spontão
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A31
Introduction: Good control of Type 1 Diabetes Mellitus (DM1) consists of several educational and psychosocial factors, emphasizing the knowledge and technique of insulin application. The lack of theoretical and practical knowledge about insulin application techniques may result in worsening glycemic control, resulting in possible acute and chronic complications of the disease.
Objective: To analyze the knowledge and practice of insulin application in patients with DM1.
Methods: This was a cross-sectional study, conducted in a clinic of Sorocaba–SP, from January to July, 2017, through a questionnaire, with questions about the technique of insulin application, degree of schooling, duration of illness and participation in education groups about DM1 and insulin application.
Results: Among the 75 DM1 patients evaluated, 60% were female, with a mean age of 28.4 ± 11.3 years, 1.4% of whom were not literate, 24.7% with elementary education, 54.8% with high school, 13.7% with higher education. Regarding disease time, 8% had up to 5 years of diagnosis, while 28% had 5 to 10 years and 64% had more than 10 years of illness. Regarding the time of outpatient follow‐up, 32.4% of the patients were followed for more than 10 years, 96% of whom reported receiving adequate guidelines from health professionals about insulin application techniques and 62.6% were regularly attending the education group in diabetes. It was found that 54.6% of the patients reused needles, mainly due to economic reasons. Only 12% of the patients had knowledge about lipodystrophy. When asked about skin fold, 70.6% performed it correctly; 93.3% of the patients reported site rotation, but when asked about the interval of days to return to the same site, 85.3% had intervals of less than 10 days and only 4% between 10 and 14 days. Most patients (58.6%) waited 10 s or longer to withdraw the needle after application.
Conclusion: After analyzing the questionnaires applied to DM1 patients, it was possible to conclude that regardless of the level of education, adequate knowledge about insulin application techniques and regular participation in the multidisciplinary group, adherence to diabetes education practices was not observed. These results showed the need for multi-professional commitment to institute educational strategies to face the challenges of lack of adherence.
A32 Assessment of knowledge, self-care, and attitudes of diabetes type 2 individuals enrolled in a health education program
Maria Isabella Luiz da Silva1, Alícia Siqueira Emerich2, Emylle Costa Bartuli1, Gyslaine de Oliveira Saez1, Caroline Fernandes-Santos1
1UFF, Sociedade União Beneficente Humanitária dos Operários, Rio de Janeiro, Brazil; 2UNESA, Sociedade União Beneficente Humanitária dos Operários, Rio de Janeiro, Brazil
Correspondence: Maria Isabella Luiz da Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A32
Introduction: There are several ways to improve the care of diabetic patients, such as the investment in new treatments and diets, support groups, global actions and health education.
Objective: Evaluate if a health education program changes the knowledge, self-care, and attitudes of subjects with type 2 diabetes attended by a philanthropic Institution in Nova Friburgo, RJ, Brazil.
Method: The study was approved by the Universidade Federal Fluminense Ethics Board (CAAE 51508915.0.0000.5626). Eleven participants with type 2 diabetes were followed up for 4 weeks. They attended health education lectures approaching diabetes physiopathology and complications and, glucose, cholesterol and triglycerides metabolism. A multiple choice questionnaire evaluated knowledge before and after lectures. Self-care and attitudes toward diabetes were assessed before and after lectures as well by the Summary of Diabetes Self-Care Activities questionnaire (SDSCA) and by the Diabetes Attitudes (ATT-19) questionnaire. Anthropometric measurements, random blood glucose and blood pressure (BP) were also evaluated before and after lectures. Data were analyzed by GraphPad Prism 6.0 and a P < 0.05 was considered significant.
Results: Data are presented as mean ± S.D. or percentage, and paired t-test assessed differences. The sample consisted of 11 participants, where 36.4% were male and 64.6% female with 58.5 ± 8.7 years old. Random blood glucose was 134.8 ± 44.8 mg/dL, systolic BP 124.8 ± 18.2 mmHg and diastolic BP 75.4 ± 8.8 mmHg before lectures, with no change after lectures. All anthropometric variables evaluated were not influenced by health education, but the waist-to-hip ratio showed a trend to decrease (0.96 ± 0.05 cm vs. 0.95 ± 0.04 cm, P = 0.08). Regarding knowledge, global questionnaire grade increased from 53.8 ± 23.3% to 65.1 ± 23.6% (P = 0.005), but the health education program did not improve the knowledge about glucose and cholesterol metabolism. Surprisingly, self-care score (SDSCA, 0-105 points) did not change after lectures (60.4 ± 18.1% before vs. 61.9 ± 13.7% after, P = 0.7) and diabetes attitude score (ATT-19, 19–95 points) decreased from 51.6 ± 10.5 to 45.9 ± 11.5 points after attending the lectures (P = 0.015).
Conclusion: Enrollment in a Health Education Program increased the knowledge of subjects with type 2 diabetes about their condition. However, lectures did not improve self-care, and their attitude toward their disease worsened. Informed consent to publish has been obtained from patients.
Martha Camillo Jordão, João Henrique Del Grandi Spontão, Daniele Iop de Oliveira Caldoncelli, Caio Villaça Carneiro, Camila Gagliardi Valter, Ariane Cantarella, Thais Picelli Pescarolo, Ravena Machado Massucatto, Alexandre Eduardo Franzin Vieira, Maria Teresa Verrone Quilici, Carla Sanchez Bergamin Rizzetto
PUC-SP, São Paulo, Brazil
Correspondence: Martha Camillo Jordão
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A33
Introduction: Type 1 Diabetes Mellitus (DM1) is a chronic disease that should receive intensive treatment aimed at preventing complications. Good glycemic control depends on patient adherence to therapy and multidisciplinary follow‐up.
Objective: To identify factors associated with the quality of glycemic control in DM1 patients.
Methods: A cross‐sectional study through medical records review, of 66 DM1 patients on insulin-based basal‐bolus regimen, on a regular follow‐up. Were avaluated: gender, age, degree of schooling, illness time, follow‐up time, body mass index (BMI), and frequency in the multidisciplinary diabetes education group (GMED) in relation to glycemic control by glycated hemoglobin (HbA1c). Patients were divided in two groups: best glycemic control with HbA1c less than or equal to 7.5% and poor glycemic control with HbA1c greater than 7.5%.
Results: Of the 66 patients, 22.7% were in the best control group: mean HbA1c was 6.6 ± 0.9%; 53.9% female, age 28.3 ± 6.5 years (6.6% between 15 and 20 years old). Illness time was 15.9 ± 8.6 years, 30.8% between 5 and 10 years, and 69.2% longer than 10 years. Regarding follow‐up time, 53.9% had less than 5 years and 46.1% regularly participated in the GMED. Half of this group was eutrophic and 16.7% obese. On the degree of schooling, 46.2% finished high school. In the poor control group, mean HbA1c was 9.8 ± 1.9%, 60% female; mean age 27.9 ± 12.6 years, with 35.3% being aged between 15 and 20 years. Illness time was 15.5 ± 9.8 years, 5% of patients had the disease for less than 5 years and 60% for more than 10 years. Regarding follow‐up time, 60% had more than 5 years and 55% were assiduous to GMED. Evaluating the BMI, 57.9% were eutrophic and 21.1% obese. And about degree of schooling, 50% finished high school. Comparing the variables, a difference was observed between the age of the two groups: 35.3% of the patients in the group of the poor control group vs. 6.7% of the best control group were aged between 15 and 20 years (p = 0.014).
Conclusion: Glycemic control did not correlate with disease time, outpatient follow-up, participation in the GMED and educational level. The group with the poor glycemic control presented a younger age group compared to the group with the best control. The results show the difficulty of identifying variables associated and the need for attention regarding the biopsychosocial factors involved in disease control.
A34 Association between dietary fatty acid composition and diabetes kidney disease: a systematic review a systematic review and meta-analysis of observational studies
Cristina Pavinatto, Igor de Oliveira, Maicon Falavigna, Themis Zelmanovitz
UFRGS, Rio Grande do Sul, Brazil
Correspondence: Cristina Pavinatto
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A34
Introduction: Some studies have shown the deleterious and beneficial effects of saturated fatty acids (SFA) and polyunsaturated fatty acids (PUFA), respectively on chronic kidney disease in patients with diabetes. However, so far these results have not been sufficient to establish a base of dietary recommendations for these nutrients specifically.
Objective: To make a systematic review of the observational studies that analyzed the association between the intake of SFA, monounsaturated FA (MUFA) and PUFA and diabetic kidney disease (DKD).
Methods: A systematic review and meta-analysis of observational studies published until February 2017 were performed, researching the following bases: PubMed, LILACS, Cochrane and EMBASE. Manual search in the cited references in previous review articles was also made. There was no restriction for language or period in the search strategy. Observational studies that evaluated the intake and serum composition of fatty acids and the presence of DKD in diabetic patients were included. The data were extracted independently and duplicated by two researches, including the year in which the studies were performed and published, their design, size, type of population and mean and standard deviation of the content in the diet or in the blood of SFA, MUFA and PUFA, or confidence intervals at the lowest and highest percentile.
Results: 4933 articles were found in a systematic and manual search. After the duplicates were removed, 4016 abstracts and titles were read by the reviewers, and 66 articles were selected for complete reading. Finally, seven articles were included in the systematic review and five were included in the meta-analysis. To analyze the dietary PUFA, two studies were evaluated (339 participants). The dietary PUFA were inversely associated with DKD (mean difference:—1.95% of energy [95% CI −3.57 to − 0.32]; P = 0.02 [I2 = 85.6%; P = 0.009]). Two studies (748 participants) were included to analyze the serum PUFA. An inverse association was also observed between the presence of DKD and the proportion of serum PUFA (mean difference:− 0.63% of total FA [95% CI − 0.85 to − 0.40], P = 0.0001 [I2 = 0%, P 0.368]). In order to analyze the MUFA in the diet, two studies were evaluated (339 participants). The MUFA presented an inverse, but not statistically significant association with the DKD (mean difference: − 0.69% of energy [95% CI − 1.50 to 0.12]; P = 0.09 [I2 = 0.0%; P = 0.4794]). Analyzing the dietary SFA, no association with DKD was observed.
Conclusion: In the present review, the lower intake of PUFA appears to be associated with the presence of DKD. However, the small number of studies and great heterogeneity among them are limiting factors for this conclusion. Further studies are needed to evaluate the association between the intake of fatty acids and their possible effects on kidney function in diabetic patients.
A35 Association between glycaemic control over a decade and the chronic complications of type 1 diabetes
Larissa Carolina Garcia Franco da Rosa, Joana Dantas Rodrigues Vezzani, Marcus Miranda, Debora Baptista Araújo, Lenita Zajdenverg, Melanie Rodacki
UFRJ, Rio de Janeiro, Brazil
Correspondence: Larissa Carolina Garcia Franco da Rosa
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A35
Introduction: It is not known any further study in Brazil that has evaluated the glycaemic control for a long period and microvascular complications, wich is well demonstrated in Caucasian population with findings from DCCT/EDIC. AIM: We have evaluated the association between the mean of HbA1c over 10 years (m-HbA1c) and glycaemic variability assessed by standard-deviation of HbA1c (SD-mHbA1c) with microvascular complications and it has been attempted to identify HbA1c patterns over time and their relation to complications.
Methodology: Patients with ≥ 10 years of T1D with medical appointments in 2014 at the Federal University of Rio de Janeiro and at least 7 yrs. of HbA1c mean (≥ 1 HbA1c measurement of certified NGSP methods/year) were selected. The Diabetic Retinopathy was evaluated by indirect fundoscopy, Albuminuria by a single urine sample (> 17 mg/L or 30 mg/g) or 24 h urine (30 mg/24 h), eGFR (calculated by CKD-EPI, considered reduced if < 60 mL/min/1.73m2) and Cardiac Autonomic Neuropathy (CAN), assessed by heart rate variability tests. The 10-year HbA1c graphics of all patients have been evaluated.
Results: The sample consisted of 172 patients with mean age and T1D duration of 28.7 and 18 years respectively. The frequency of DR, IUAE, eGFR < 60 mL/min/1.73m2 and CAN were respectively 12.6% (15/119), 18.9% (22/119), 6% (8/134) and 33.9% (20/59). The m-HbA1c was higher in patients with DR (9.8 ± 1.7% vs. 7.9 ± 1.2%; p = 0.001); Albuminuria (9 ± 1.6% vs. 7.9 ± 1.1%; p = 0.009); eGFR < 60 mL/min/1.73m2 (9.5 ± 1.8% vs. 8.3 ± 1.4%; p = 0.032) and CAN (9.3 ± 1.3% vs. 7.5 ± 1%; p = 0.001). SD-mHbA1c was associated with DR and CAN, being higher in these groups (1.6 ± 1.1% vs. 1 ± 0.6%; p = 0.011) and (1.3 ± 0.7% vs. 0.9 ± 0.6%; p = 0.026). Some HbA1c patterns were identified over time: (a) stable, (b) improvement, (c) worsening, (d) in “i”, (e) in “u”, (f) “2 peak” and (g) anarchic and 55% patients with Albuminuria presented anarchical pattern while most of patients without albuminuria exhibited a stable pattern (p = 0.005).
Thamires Yasmin Gomes de Souza, Lucia Henriques Alves da Silva, Rosane Kupfer
IEDE, Rio de Janeiro, Brazil
Correspondence: Thamires Yasmin Gomes de Souza
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A36
Case report: A 27-year-old male with a previous history of type 1 diabetes mellitus since the age of 19 and an irregular disease control in this period. He was diagnosed with celiac disease and diabetic distal polyneuropathy at the age of 27. At the same time, a dual energy X-ray absorptiometry (DXA) revealed femur Z-score of -5.09 and lumbar spine Z-score -3.62. Bisphosphonate and colecalciferol were promptly administered and combined to a gluten free diet. After 1 year, bisphosphonate was discontinued and the patient remains in regular medical care.
Discussion: The association between type 1 diabetes mellitus with autoimmune diseases such as celiac disease is not uncommon. It is well established that both diseases can lead to bone metabolism disfunction, which seems to be related to an imbalance of the immune system and not only due to a nutritional or endocrine disorder.
Conclusions: The association between type 1 diabetes mellitus with autoimmune diseases, such as Celiac Disease, seems to worse bone loss. It suggests a synergistic negative effect of hyperglycemia and autoimmunity on bone mineral density. Specific therapies to control this immunoregulatory imbalance and consequently bone reabsorption inhibition are still not available.
Informed consent to publish had been obtained from the patient.
A37 Association between nutritional status and dyslipidemia in children and adolescents with diabetes mellitus type 1 in a pediatric university hospital of Rio de Janeiro
Raquel Nascimento Chanca Silvério1, Elisa Maria de Aquino Lacerda1, Carolina Felizardo de Moraes da Silva1, Ana Isa Ramos de Lourenço1, Laura Maria Silva Porto1, Géssica Castor Fontes de Lima1, Júlia Maria Cabral Relvas Jacome Bertoldi1, Jorge Luiz Luescher2, Luiza Berganins Scancetti1, Fernanda Bispo dos Santos1, Roberta Ferreira Fortins1, Patrícia de Carvalho Padilha1
1UFRJ, Rio de Janeiro, Brazil; 2IPPMG/UFRJ, Rio de Janeiro, Brazil
Correspondence: Raquel Nascimento Chanca Silvério
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A37
Introduction: Children and adolescents with type 1 diabetes mellitus type 1 (DM1) have a higher prevalence of cardiovascular risk factors, among them dyslipidemia [1, 2].
Objective: To evaluate the association between nutritional status and lipid profile of children and adolescents with DM1.
Method: This was a cross-sectional study carried out at the Diabetes Service of a Pediatric University Hospital of Rio de Janeiro from May 2016 to June 2017. The eligibility criteria were: age between 7 and 16 years, diagnosis of DM1 for at least 1 year and absence of other autoimmune diseases. The dependent variables were: total cholesterol, HDL, LDL, triglycerides and nutritional status, evaluated by body mass index by age (BMI/age). The independent variables were: age, family income, place of residence, sanitation conditions, parental level of education, diabetes diagnosis time, insulin regimen, dietary method used (traditional or carbohydrate counting method) and glycated hemoglobin (HbA1c). All variables were obtained by means of medical records. Statistical analysis included simple descriptive analysis (means and frequencies), Chi square test for comparison of categorical variables and ANOVA for comparison of means. The statistical program SPSS version 23.0 was used, and the significance level adopted was 5% (p < 0.05).
Results: A total of 105 patients with a mean age of 11.6 (± 2.9) years were included in the study, of which 47.6% (n = 50) were males. High levels of total cholesterol, LDL cholesterol and triglycerides were observed in 74.3% (n = 78), 42.9% (n = 45), 15.2% (n = 16), respectively. Approximately 12.4% (n = 13) had inadequate HDL values. The mean HbA1c was 8.27% (± 1.41). No significant differences were found in serum lipid averages in relation to the age of the child, time of diagnosis of DM1, insulin regimen and ethical diet method. There was an association between triglyceride levels and inadequate glycemic control (p = 0.032).
Conclusion: The results showed a high frequency of dyslipidemia, representing an important cardiovascular risk factor for this population. It is suggested the adoption of healthy eating habits and lifestyle practices regardless of anthropometric nutritional status, in order to prevent cardiovascular diseases.
American Diabetes Association. Standards of medical care in diabetes. The journal of clinical and applied research and education, 2017; 40(1):s1-114.
Bulut T, Demirel F, Metin A. The prevalence of dyslipidemia and associated factors in children and adolescents with type 1 diabetes. J Pediatr Endocrinol Metab. 2016; 30(2):181–7.
A38 Association between reduced vitamin d levels and glomerular filtration rate estimated by CKD-EPI equation and measured by a reference method
Angélica Dall‘Agnol, Eduardo Guimarães Camargo, Letícia Almeida Brondani, Sofia Michele Dick, Vítor da Agostim Cancelier, Sandra Pinho Silveiro
UFRGS, Rio Grande do Sul, Brazil
Correspondence: Angélica Dall‘Agnol
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A38
Introduction: Diabetes kidney disease (DKD) is the leading cause of end-stage renal disease and current treatment is not able to fully control disease progression. New therapeutic alternatives have been investigated and some evidence points to 25 (OH) vitamin D deficiency as a possible factor related to the onset and/or progression of DKD.
Objective: The objective of this study was to evaluate the relationship between 25 (OH) vitamin D levels and degree of renal damage in patients with type 2 DM.
Methods: Cross-sectional study, type 2 DM subjects. The glomerular filtration rate (GFR) was estimated by the Chronic Kidney Disease Epidemiology (CKDEPI) equation and measured by the 51Cr-EDTA technique. Urinary albumin excretion albumin (UAE) was assessed by immunoturbidimetry and 25 (OH) vitamin D by the chemiluminescence technique. ROC curve and multiple logistic regression were employed to evaluate the relationship between vitamin D levels and renal damage.
Results: A total of 87 individuals with type 2 DM with a mean age of 61 ± 10 years were included, of which 46 were female (53%), with DM duration of 12 ± 6 years and self-reported white ethnicity at 81%, GFR had to be ≥ 60 mL/min/1.73 m2. Figure 1 shows the vitamin D values according to GFR, both measured and estimated by equation, categorized in levels ≥ vs. < 90 mL/min/1.73 m2, demonstrating that using measured GFR, lower vitamin D values were found inthe lower GFR group. However, no difference was observed in vitamin D levelswhen GFR was calculated with the equation. Figure 2 shows ROC curves of the two methods of GFR, and again a relationship between reduced GFR and lower levels of vitamin D was only observed with measured GFR.
A39 Association between trans fatty acids from natural and industrial sources of diet and cardiovascular risk factors and endothelial function of patients with type 2 diabetes mellitus
Claudia Kirst, Ana Luiza Teixeira dos Santos, Tanara Weiss, Igor de Oliveira, Carolina Bassoto, Themis Zelmanovitz
UFRGS, Rio Grande do Sul, Brazil
Correspondence: Claudia Kirst
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A39
Introduction: In human nutrition the 3 main sources of trans fatty acids (TFA) are: transformation of polyunsaturated fatty acid (FA) in the rumen of animals, partial hydrogenation of vegetal oils and process of frying foods. Several studies investigate the difference of the impact that industrial TFA (I-TFA) and those from ruminants exert on cardiovascular disease (CVD), finding conflicting results. Considering the importance of the reversion of modifiable risk factors to prevent CVD in patients with type 2 DM, it is very important to study the association between the different sources of intake of TFA and CV risk factors and endothelial function in these patients.
Objective: To evaluate the relationship between the dietary TFA from ruminant (R-TFA) sources and industrial sources, with CV risk factor and endothelial function of patients with type 2 DM.
Methodology: Patients with type 2 DM followed in the Diabetes Outpatient Clinic at Hospital de Clinicas de Porto Alegre were evaluated. The clinical evaluation consisted of glycemic control, lipid profile, blood pressure and detection of chronic complications of DM. The endothelial function was determined by the Doppler study of the brachial artery to determine its diameter and the flow-mediated dilatation (FMD). The patients made 3-day weighed food records and the diet was calculated using the Nutribase Clinical Nutritional Manager software. A spreadsheet was constructed to calculate the TFA with data from the Brazilian Table of Food Composition (TACO - Tabela Brasileira de Composição dos Alimentos) and the American table (USDA). The anthropometric evaluation consisted of measures of weight, stature and abdominal circumference (AC).
Results: 186 patients were analyzed (44% men’s; mean age: 63 years and mean body mass index: 29.4 kg/m2). It was observed that the intake of R-TFA was associated with the AC of higher risk CV (dependent variable) [Risk Ratio: 2.45 (95% CI 1.11—5.38); P = 0.026], adjusted for sex and age. Also, the intake of R-TFA was associated with the greater diameter of the brachial artery [Risk Ratio: 1.93 (95% CI 1.01—3.69); P = 0.047], adjusted for age, hypertension and AC. No association was found between the I-TFA sources and the CV risk factors and parameters of endothelial function.
Conclusion: The present study suggests that the greater consumption of R-TFA sources in patients with type 2 DM is related to the greater AC and worse endothelial function.
Larissa Pessoa Vila Nova1, Rafael Augusto Batista de Medeiros2, Marinaldo Freire Lustosa2, Camila Lima Chagas2, Regina de Deus Lira Benevides2
1UPE, Pernambuco, Brazil; 2UFPE, Pernambuco, Brazil
Correspondence: Larissa Pessoa Vila Nova
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A40
Introduction: In Brazil, the nutritional transition presents a simultaneous aggravation of two opposing issues: a nutritional deficiency (anemia) and a typical condition of overeating, obesity. Few studies have evaluated this epidemiological paradox in the prevalence of diabetes mellitus and other chronic diseases.
Objective: Evaluate the association of anemia in obese, diabetic and cardiomyopathy patients.
Methods: A retrospective cross-sectional study was carried out to verify the admission data of overweight, diabetic and cardiac patients hospitalized at a cardiology reference center in Pernambuco. Overweight was considered according to the World Health Organization criteria (WHO, 1995) for adults (IMC ≥ 25 kg/m2) and from the cut-off point established for the elderly (BMI > 27 kg/m2) by Lipschitiz in 1994. Anemia was considered when serum haemoglobin results were < 13 m/dl for men and < 12 mg/dl for women. The study was approved by the Ethics and Research Committee of the University of Pernambuco hospital under the protocol number 656.800/2014. Statistical analyzes were performed in the software SPSS, v. 13.0, adopting statistical significance when p < 0.05.
Results: From the sixty patients evaluated, the mean age was estimated at 60.7 (±10.5) years, and 53.4% were female. The prevalence of anemia in diabetic patients with overweight was 41%, similar in both sexes (p = 0.846) and in adults and elderly (p = 0.951).
Conclusions: The high prevalence of anemia in diabetic patients with overweight highlights the need for an investigation, monitoring and prevention of this condition, regardless the nutritional condition of the individual. In addition, it is important to study other issues related to diabetes that may contribute to anemia, favoring its prevention.
A41 Association of maternal outcomes in pregnant women with diabetes mellitus and users of the unified health system who had their deliveries in a university hospital of the south of Brazil
Clarice dos Santos Mottecy1, Júlia Mottecy Piovezan2, Raquel Montagner Rossi2, Patrícia Molz3, Samantha Bernardo Nascimento2, Aloma Jacobi Dalla Lana2, Thais de Oliveira Flores2, Daniel Prá3, Sílvia Isabel Rech Franke3
1HUSM/EBSERH—UFSM, Rio Grande do Sul, Brazil; 2UFSM, Rio Grande do Sul, Brazil; 3UNISC, Rio Grande do Sul, Brazil
Correspondence: Clarice dos Santos Mottecy
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A41
Background: Gestational Diabetes Mellitus (GDM) is the most prevalent metabolic change in pregnancy. The impact of their screening on maternal and perinatal morbidity and mortality for women treated in the Basic Health Care is questioned. The Ministry of Health (MH) recommends universal screening at the first prenatal visit through fasting glycemia (FG) and clinical risk factors for GDM. The prenatal diagnosis of GDM is fundamental and its approach improves the prognosis of gestation.
Objectives: To verify the association between GDM screening (according to what MH advocates) and the repercussions on maternal outcomes in women who underwent prenatal care in the basic health care in the central region of Rio Grande do Sul, and had their births at the University Hospital of Santa Maria-RS (HUSM).
Methods: This descriptive-transversal study evaluated 283 puerperal women who underwent their prenatal care in the basic health care system through an interview, analysis of medical records and the Pregnant Woman‘s Card, and had their deliveries in HUSM between January and April 2015. Informed consent to publish has been obtained from patients. The study was approved by University of Santa Cruz do Sul Institutution‘s Ethics Board, approval number 37290714700005343.
Results: Data collected were allocated to the Statistical Package for Social Sciences (SPSS) version 20.0, with a descriptive statistical analysis and a Chi square test with significance of 0.05. In this sample, 53% of women were overweight according the Body Mass Index (BMI), being the most observed risk factor for GDM. 27.9% of the puerperal women were overweight and 25.1% were obese. Among the puerperal women, 14.5% did not undergo GDM screening through FG. The prevalence of positive screening in this sample was 86.4%. The most frequent maternal outcomes were preterm labor (12.4%), maternal tocotraumatism and lacerations (5.3%), preeclampsia in various degrees (3.9%) and premature amniorrexis (2.1%). Placental abruption occurred in two cases. There was a significant association of pregnant women with positive screening only with preeclampsia outcome.
Conclusion: Many of the maternal and fetal outcomes are known to be preventable. For this, the identification of DMG through adequate screening and early control of its risk factors is essential in the application of prenatal care actions by the health team of the basic network in the region studied in order to minimize them.
Natalia Fenner Pena, Ariene Carmo Silva, Nayhara Castro Coury, Simone de Vasconcelos Generoso
UFMG, Minas Gerais, Brazil
Correspondence: Natalia Fenner Pena
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A42
Introduction: Phase Angle (PA) has been related to the integrity of cell membranes, as a good prognostic indicator, with the general health and nutritional status of the patients. The hyperglycemia can be triggered by adverse and characteristics of the hospital routine; the metabolic stress is one of the main causes. It has already been shown that hyperglycemia is a common outcome observed in hospitalized patients; capable of causing cellular glycotoxicity. In addition it is considered marker of poor prognosis for serious patients, both clinical and surgical.
Objective: To evaluate the prevalence of hyperglycemia and its association with PA in hospitalized surgical patients.
Methods: A prospective longitudinal study was performed at Clinical Hospital in Belo Horizonte, Brazil. Patients PA was calculated by electrical bioimpedance in three moments: before, postoperative and hospital discharge moments. Blood glucose was also collected before and postprandial capillary glycemia and the average values were considered. Results above 140 mg/dL were classified as hyperglycemia. To compare the glycemic averages, according to the categorization of the PA; the Ancova Test was used. For all analyzes a significance level of 5% was adopted.
Results: Fifty patients were analyzed, and 33.3% presented hyperglycemia. The mean glucose levels observed were 120 ± 33 mg/dL, 135 ± 37 mg/dL and 125 ± 37 mg/dL at the before, postoperative and hospital discharge moments, respectively. In the paired analysis, hyperglycemia was observed with significantly higher postoperative values (135.35 ± 37.57 mg/dL) in relation to hospital discharge (125.68 ± 37.21);(p = 0.031). There was a higher frequency of noninfectious complications among diabetic individuals (50.0% vs. 24.8%, p = 0.23). Ancova test showed a significant difference between the glycemic groups, according to the categorization of PA, and patients with nutritional risk showed higher blood glucose levels in relation to patients without nutritional risk: (133.11 ± 8.7 vs. 115, 99 ± 4.6 p = 0.089).
Conclusion: The importance of glycemic evaluation in hospitalized patients before and after surgical intervention is highlighted, in order to verify if there are significant alterations in relation to moments, outcomes and if this, and to date, this study was the first to evaluate the association between PA and hyperglycemia in the hospital. Future studies are necessary to verify the depth of this association.
Jacqueline Akemi Nishio Juhasz, Ieside Arruda Valadares Chamon, Ana Cristina Pithon Curi, Luis Fernando Aguiar de Paula Filho, Luis Mauricio Batalin Junior, Emanuelle Barbara Dias Tomaz, Alcinda Aranha Nigri, Fernando de Oliveira Barros
PUC-SP, São Paulo, Brazil
Correspondence: Jacqueline Akemi Nishio Juhasz
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A43
Case report: a 54-year-old female was admitted with a medical history of type 2 diabetes mellitus (T2D), hypertension, non-dialysis dependent chronic kidney disease, and lower extremity ulcers. For the treatment of the ulcers the patient underwent debridement and received antibiotics (ATB). Subsequently, the patient sought a hospital with chief complaint of dyspnea and was diagnosed with pneumonia (sic) and treated with use of ATB. Then, she presented with anasarca and fever. There was no leukocytosis probably due to the use of ATB. On the physical examination, mitral murmur was found. On the echocardiogram the patient showed mitral and tricuspid insufficiency and vegetation in the mitral valve, indicating infective endocarditis. At the time of admission, the patient presented pleural effusion, high serum urea levels (142 mg/dl), hyperglycemia (256 mg/dL of serum glucose), and low serum albumin levels (2.6 g/dL). After 6 days, the mitral valve was replaced by a bioprosthetic valve, and a tricuspid valve cerclage was performed. Postoperative blood transfusions were required. She went into cardiac arrest and a cardiopulmonary resuscitation was performed successfully. Ten day later she presented with arrhythmia, cardiopulmonary arrest, sepsis and then she died.
Discussion: Infective endocarditis is a microbial infection of the endocardial surface of the heart. It mainly affects heart valves, most commonly the mitral valve. Common etiologies are: use of injectable drugs, oral infection, long-term hemodialysis, and diabetes mellitus. The Duke Criteria was used for the diagnosis of infective endocarditis. In this case report we present a case of a patient with type 2 diabetes who evolved with an infective endocarditis. The patient’s uncontrolled glycemia led to worsening of endocarditis
Final comments: Adequate management of T2D can prevent complications such as lower extremity ulcers, consequently avoiding hematogenic dissemination and infective endocarditis. We must consider the previous antibiotic use when analyzing the patient‘s white blood cell count.
Informed consent to publish had been obtained from the patient.
Lucas Marassi Theodoro Sousa Oliveira, Dênia Amélia Novato Castelli Von Atzingen, João Victor Braga Mendes, Marcos Mesquita Filho, Adriana Rodrigues dos Anjos Mendonça
UNIVÁS Pouso Alegre-MG, Minas Gerais, Brazil
Correspondence: Lucas Marassi Theodoro Sousa Oliveira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A44
Diabetes mellitus is a public health problem which assails millions of people around the world, and its cause can have not only hereditary factors but also environmental. The biggest worry for the health system is in relation to the lack of control of the disease by the sufferers, what can lead to a big number of consequences that can be disabling or even fatal. An important fact of the chronic phase of the disease allied to the lack of control is the appearance of skin lesions, as ulcers, which can be a simple injured or cut and progress to skin cavities formation. For the treatment of these wounds it was proposed the analysis of these wound healing through the use of a gel made from the green banana skin per 10%. This study took place in NAEENF (Nursery Assistance and Teaching Center) in the city of Pouso Alegre-MG and it was composed by 30 patients who used the gel from the green banana skin per 10% for 1 month. The protocol was approved by the Ethics Comitee of UNIVÁS (Vale do Sapucaí University) with the CAAE 48017915.6.0000.5102 and the Approval Report number 1.575.890.The results were the complete healing in 9 patient s. The initial average of the wounds was 32.89 mm2 and it finished in the eighth collection representing 22.45 mm2. The average was 19.94 mm2 for 10.30 mm2. By making the central tendencies measures there was significance in the obtained general results of the whole group (p < 0.001). We can conclude that the gel made from the green banana skin per 10% has a healing action in chronic ulcers presented by patients with diabetes.
Aline Andrade de Lucena, Paula Seixas V. Dias da Silva, João Marcelo Sampaio Santana, Luana Machado Figuerêdo, Gabriel Oliveira do Carmo, Ana Cláudia Rebouças Ramalho
UFBA, Bahia, Brazil
Correspondence: Aline Andrade de Lucena
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A45
Introduction: The effects of dapaglifozin inducing glycosuria, reducing hyperglycemia optimizing weight control and declining of pressure level is already well known in patients with diabetes type 2, however there are still a few studies abouts its use in patients with diabetes mellitus type 1 (DM1). As the phenotype of patients with diabetes mellitus type 1 have been modified with 25% showing metabolic syndrome, becames necessary the use of supplementary therapies to insulin.
Purpose: Assess the potential benefits and adverse effects of Dapaglifozin in a population with DM1 followed in particular offices in Salvador/BA city.
Methods: Observational and retrospective study in which they were analysed the medical recordo f patients with DM1 who made use of this medication in dose of 10 mg/day through 3-6 months.
Results: Twelve patients with DM1 were assessed, 10 females with average rate of 37.5 years. The average weight was 68.3 kg and 65.3 kg before and after therapy with dapaglifozin respectively (p = 0.002). The average BMI decreased from 26.1 to 25.4 kg/m2 after treatment (p = 0.002). There was a significant decrease in glicated hemoglobina (HbA1c) after therapy with Dapaglifozin (p = 0.002). There was a tendency to decrease of total colesterol, LDL and triglycerides (p = 0.260). Systolic blood pressure (SBP) decreased from a median of 120 mmHg to a mediano f 115 mmHg befora and after therapy with Dapaglifozin respectively (p = 0.02). With regard to dyastolic blood pressure a decrease in median values were noticed, however without statistic relevance (p = 0.059). Correlation among the use of Dapaglifozin and decreasing of basal insulin was found (p = 0.012). Values of creatinina did not change after us of adjuvante therapy (p = 0.207). With regard to adverse effects, 8.3% of patients presented urinary tract infection (UTI), 33.3% pain or pruritus on genital region and 8.3% ketoacidosis.
Conclusion: The presente study describes the uso of dapaglifozin and its beneficial and adverse effects in a population with DM1. Statistic significant decrease of Hba1C, body weight and BMI, in addition to tendency of increasing lipid profile were observed. Other studies are needed to ratify possible benefits and safety of this class of medication in patients with DM1.
A46 Beneficial effects of recreational soccer training on health profile of untrained postmenopausal women with type 2 diabetes mellitus
Maysa Vieira de Sousa, Rosa Fukui, Maria Elizabeth Rossi da Silva
FMUSP, São Paulo, Brazil
Correspondence: Maysa Vieira de Sousa
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A46
Background and aims: Postmenopausal is linked to modifications in blood hormone level and a progressive decrease in physical activity contributing to changes in metabolism and overweight, leading to an inflammatory status. This aging process and Diabetes Mellitus are strongly correlated with many chronic diseases and in this context, women warrant special attention. Lifestyle changes may modulate these disturbances among postmenopausal women. Therefore, we aimed to investigate the impact of recreational soccer combined with a calorie restricted diet on metabolic and hormonal responses of untrained postmenopausal women with T2DM vs. diet alone.
Materials and methods: Twenty-one (n = 21) untrained postmenopausal women with T2DM aged 48-74 years were randomized into a soccer + diet group (SDG; n = 9) and a diet group (DG; n = 12). Training sessions were held for 40 min, 3 times per week for 12 weeks. Dual-energy X-ray, treadmill testing, and fasting blood samplings were performed before and post 12 weeks.
Conclusion: Soccer training improved lipids profile in postmenopausal women probably related to increased fat oxidation rate post-training due to the multiple intense actions, stimulating musculoskeletal and cardiovascular adaptations. Lower LH levels may be associated with reduced risk in the prevalence of breast cancer in postmenopausal women, suggesting a potential mechanism of the favorable effect produced by regular training and weight reduction on neoplastic prevention. Thus, recreational soccer training plus diet resulted in large benefits on health profile of T2DM, decreasing risk factors associated with cardiovascular disease and cancer better than diet alone.
Hugo dos Santos Silva Júnior, Lucas Gabriel de Siqueira, Paulo Henrique Lopes, Elenice dos Santos Paula, Mayara Dumont Cunha, Daniela Pereira De Castro, Fernando Gonçalves dos Santos, Marileila Marques Toledo, Gabriela de Araujo Nominato, Ana Paula Nogueira Nunes, Luciana de Freitas Campos, Edson da Silva
UFVJM, Minas Gerais, Brazil
Correspondence: Hugo dos Santos Silva Júnior
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A47
Background: Social media are spaces that favor interaction between people, irrespective of social level and geographical position. Blogs and social networks are examples of social media used daily by a large part of the population, including as a means of creating content that promotes connection between people with common interests.
Objective: The objective of this study was to report the experience with the first year use of the Blog Diabetes Diamantina as a diabetes education tool.
Materials and methods: The Blog Diabetes Diamantina (www.diabetesdiamantina.blogspot.com.br) was created in March 2016 and became active in May of the same year (Fig. 1). Publications covered content produced by students and university professors or, in some cases, were publications adapted of national and/or international organizations of diabetes. The Blog database was accessed monthly from its creation until July 8, 2017 for analysis. Posts have been sorted into 7 categories. Subsequently, the total number of publications, content visualizations and readers‘countries of origin were identified. The data were analyzed and described. Results Sixty publications in the Portuguese language were produced, including texts, videos and images (Fig. 2). The subjects were classified as: complications of diabetes (n = 9), nutrition (n = 6), therapeutics/clinical aspects (n = 12), cell biology (n = 3), obesity (= 4), exercise (n = 2) and education (n = 24). The Blog received 67,546 views by national and international readers until the month of July. Currently, in October 2017 the number increased to almost 70 thousand views (Figs. 1 and 4). The United States was the main country from origin of the readers, followed by Brazil, Portugal, the United Kingdom, Chile, Mexico, France, Argentina, Spain and Russia (Fig. 3). Some Blog posts have been shared on Fanpage Diabetes Diamantina, a social network of diabetes education that publishes in the Portuguese, English and Spanish languages, which possibly justifies the origin of international access to the Blog.
A48 Brazilian young-onset type 2 diabetes in comparison to type 1 diabetes in adults and type 2 diabetes
Renata Midori Hirosawa, Sergio Atala Dib
UNIFESP, São Paulo, Brazil
Correspondence: Renata Midori Hirosawa
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A48
Introduction: There is an increasing prevalence of young-onset diabetes, especially in developing areas. Also, there is increasing recognition that the phenotype of YT2DM is more severe than type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in older adults, with a lower response to metformin, a more rapid evolution for insulin dependence. Further, the youth may be more susceptible to the development of some complications. At the moment there are no data on YT2DM in Brazil.
Objective: To evaluate long-term clinical outcomes in a brazilian YT2DM group compared to T1DM and T2DM.
Patients and Methods: YT2DM was defined as age between 18 and 39 years at the diagnosis, T1DM and DM2 according to the criteria of the SBD and ADA. We abstracted clinical data from electronic medical, laboratory records.
Results: The age at diagnosis of YT2DM (n = 61), T1DM (n = 26) and T2DM (n = 39) groups were, respectively: 29.8 ± 5.1, 25.8 ± 6.0 and 50.5 ± 8.4 years. The duration of diabetes was 22.3 ± 12.1 years (YT2DM), 13.5 ± 7.5 (T1DM), 17.3 ± 6.4 (T2DM). The BMI of YT2DM, T1DM and T2DM was 31.9 ± 5.5, 23.7 ± 3.3 and 29 ± 4.8 kg/m2. HbA1c (%) was 9.1 ± 1.9 (YT2DM), 8.8 ± 1.5 (T1DM) and 8.8 ± 1.6 (T2DM). YT2DM compared to T1DM showed a higher percentage of retinopathy (55.7 vs 26.9%, p 0.018), nephropathy (55.7 vs 30.8%, p 0.019) and neuropathy (62.3 vs 19.2% p 0.0002). Cardiovascular events showed superiority trend in YT2DM group (27.9 vs 11.5% p = 0.09) compared to T1DM. The percentage of complications, either micro (retinopathy (55.7 s 51.3% p 0.68), nephropathy (55.7 vs 53.8%, p < 1.0), neuropathy (62.3 vs 51.3%, p < 0.21) as macro (27.9 vs 33%, p = 0.66) were not significant, when compared YT2DM to T2DM.
Conclusions: YT2DM compared to T1DM with a similar age of onset, duration of diabetes and similar glycemic control was more aggressive in relation to microangiopathy. In relation to T2DM, YT2DM was similar. Glycemic control and screening of microangiopathy should be intensified in YT2DM.
A49 Brittle diabetes in a patient with polyglandular autoimmune syndrome type 2 (schmidt’s syndrome), neurogenic bladder and psycho-familial distress: a case report
Fátima Salomão Machado, Levimar Rocha Araújo
HUCM, Minas Gerais, Brazil
Correspondence: Fátima Salomão Machado
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A49
Introduction: Brittle diabetes occurs in a small group of patients with type 1 diabetes and is characterized by a severe instability of glycaemic levels, with frequent and unpredictable episodes of hypo or hyperglycaemia. The individuals with brittle diabetes are predominately young women and they use twice as much insulin than usual. The causes of the instability are varied and the prevalence of psychosocial distress is high in these patients. The type 1 diabetes is one of the components of Schmidt’s syndrome, a rare autoimmune syndrome.
Objective: To report a case of brittle diabetes in a patient with Schmidt’s syndrome and neurogenic bladder, as well as psycho-familial distress.
Case report: R.A.S, 28 years old, woman, single, presented with a picture of urinary retention in 2002, which was then characterized as neurogenic bladder. She has always used catheterization procedure for bladder drainage thereafter. In the following months of the initial presentation, the patient had a ketoacidosis episode and was diagnosed with type 1 diabetes. From the beginning, the glycaemic levels control has proved to be extremely difficult, even after trying different types of high dose insulin. In addition, the patient was diagnosed with hyperthyroidism in 2013, and after treatment with radioactive iodine, she developed renal insufficiency. After 7 months of haemodialysis, her renal function was unexpectedly recovered. In 2015, she started using a pump for continuous subcutaneous insulin infusion, which contributed for the attenuation of glycaemic instability and improved her quality of life. In 2016, the patient developed adrenal insufficiency, which together with type 1 diabetes and thyroid dysfunction characterizes Schmidt’s syndrome. Regarding the psycho-familial distress, she has had traumas in her childhood, she lives by her own since she was 14 years old and she does not have any family support. The medicines used by this patient includes prednisone, levothyroxine and ultra-fast insulin. The patient is assisted by a multidisciplinary team.
Conclusion: Brittle diabetes is a severe condition that requires constant vigilance from the patient as well as from the professionals involved. In addition to the other endocrine dysfunctions that this patient presents, there is the poor family support and consequent negative psychological impact. This psycho-familial aspect possibly plays an important role in the genesis and maintenance of the glycaemic instability.
Informed consent to publish had been obtained from the patient.
A50 Bruns-garland and parsonage-turner syndrome as a differential diagnosis of diabetic neuropathy: 2 case reports
Julia Martins de Oliveira, Priscila Rodrigues Leite Oyama, Filipe Dias de Souza, Gustavo Ivani de Paula, Clícia Santos de Moura Fé, Sergio Atala Dib, Luiz Clemente de Souza Pereira Rolim
UNIFESP, São Paulo, Brazil
Correspondence: Julia Martins de Oliveira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A50
Case 1: A 45-year-old male with type 2 diabetes mellitus (T2DM) and 6 years of diabetes duration (DD) presented with a complaint of severe lumbar pain (Verbal Numeric Rating Scale ‚VNRS‚ 10 out of 10) since the last 2 months. The characteristics of pain were paroxysmal, with nocturnal worsening, and irradiated to the left thigh. One month after the pain, this was associated with quadriceps weakness, which was initially asymmetrical and progressing to bilateral. Three weeks later, the patient presented crural paraplegia and could not walk. Physical examination (PE) revealed severe quadriceps wasting and bilateral patellar areflexia. Electroneuromyography showed asymmetric polyneuropathy and axonal degeneration, suggestive of Bruns-Garland (BG) syndrome. Consequently, the patient was started with prednisone (60 mg/day). After 30 days, he recovered the quadriceps strength, improved the sleep pattern and returned to walking. The pain was successfully managed with the combination of pregabalin and duloxetine (VNRS of 4 out of 10).
Case 2: A 68-year-old male with T2DM and 7 years of DD presented with a six-month history of intense burning pain in his right shoulder (VNRS 8 out of 10), with irradiation to the entire arm. 15 days after began the symptoms, deltoid weakness was observed. On PE, there was a right deltoid atrophy; therefore, a Parsonage-Turner (PT) syndrome was diagnosed. Although the patient had had a good response to pain after 12 months (VNRS of 0 out of 10) with the combination of pregabalin and imipramine, he developed severe depression. Discussion: BG and PT are diabetic radiculoplexus neuropathies (DRN) and can develop serious complications as paraplegia, chronic pain, insomnia, and depression. By contrast with the more common diabetic polyneuropathy, DRN usually manifests as an intense and acute or subacute focal pain that progresses to muscle weakness. Since DRN is an immune-mediated condition, the use of corticoids or intravenous immune globulin has been used in patients with onset of symptoms in the preceding 30-60 days. Improvement of pain, muscle weakness, and quality of life (QOL) has been reported following corticoid immunosuppression.
Conclusions: DRN is an overlooked condition that requires both a high level of suspicion and a careful clinical examination. An early diagnosis is essential to the success of immunotherapy, which can reverse this syndrome improving plegia, pain, insomnia, and quality of life of these patients.
Informed consent to publish had been obtained from the patient.
A51a Cardiovascular autonomic neuropathy (CAN) is frequent in type 2 diabetic patients with painful polyneuropathy, even inthe absence of known autonomic dysfunction or signs or symptoms of can
Maria Regina Calsolari1, Alisson Verissimo1, Pedro Weslley Rosario1, Luis Fernando Faria Oliveira2, Adriana Aparecida Bosco1
1Santa Casa de Belo Horizonte, Minas Gerais, Brazil; 2Fundacao Universidade Itauna, Minas Gerais, Brazil
Correspondence: Maria Regina Calsolari
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A51a
Background: The 10-g monofilament test is widely used in clinical practice for the detection of neuropathic impairment. Alterations in this test reflect the involvement of large fibers, which occurs late in DM. Neuropathic pain reflects the involvement of small fibers, which occurs early in diabetes mellitus (DM) . Cardiovascular autonomic neuropathy (CAN), which is a serious complication even if subclinical, also results from the involvement of small fibers . It is therefore possible that neuropathic pain is more related to the presence of CAN and the early stage of this condition.
Objective: This study evaluated the frequency of CAN in type 2 diabetic patients with painful polyneuropathy (PNP), but without known autonomic dysfunction, or signs or symptoms of CAN. Materials and Methods: Type 2 diabetic patients with PNP (based on signs and symptoms of neuropathic impairment), who reported no exercise intolerance and who had no known autonomic dysfunction (e.g., gastroparesis, neurogenic bladder) and no postural hypotension or resting tachycardia, were selected. Patients with conditions that can also cause neuropathy or interfere with the evaluation proposed were excluded. A control group without DM, which was similar in terms of sex, age and BMI, was studied. Tests evaluating heart rate variability (HRV) during deep breathing, Valsalva maneuvers and orthostatism, and spectral analysis of HRV (spectral amplitude in the three bands: very low-frequency, low-frequency, and high-frequency)  were performed.
Conclusion: In patients with DM2 and PNP, but without known autonomic dysfunction, or signs or symptoms of CAN, HRV tests detected subclinical CAN in 36.6%, with 100% specificity. Compliance with Ethical Standards The study was approved by the Research Ethics Committee of our institution. Informed consent was obtained from all individual participants included in the study.
Hoeijmakers JG, Faber CG, Lauria G, Merkies IS, Waxman SG. Small-fibre neuropathies—advances in diagnosis, pathophysiology and management. Nat Rev Neurol. 2012; 8:369-379.
Spallone V, Ziegler D, Freeman R, et al.; Toronto Consensus Panel on Diabetic Neuropathy. Cardiovascular autonomic neuropathy in diabetes: clinical impact, assessment, diagnosis, and management. Diabetes Metab Res Rev. 2011; 27:639-653.
A51b Cardiovascular autonomic neuropathy (CAN) may even be present in type 2 diabetic patients without sensorimotor polyneuropathy, known autonomic dysfunction, or signs or symptoms of can
Maria Regina Calsolari1, Alisson Verissimo1, Pedro Weslley Rosario1, Luis Fernando Faria Oliveira2, Adriana Aparecida Bosco1
1Santa Casa de Belo Horizonte, Minas Gerais, Brazil; 2Fundacao Universidade Itauna, Minas Gerais, Brazil
Correspondence: Maria Regina Calsolari
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A51b
Background: Symmetrical sensorimotor polyneuropathy (PN) is a known complication of diabetes mellitus (DM). Cardiovascular autonomic neuropathy (CAN) is another possible complication of the involvement of nerve fibers in DM. It is therefore reasonable to imagine the CAN is present in patients with PN.
Objective: This study evaluated the frequency of subclinical CAN in patients with DM2, but without PN, known autonomic dysfunction, or signs or symptoms of CAN.
Materials and methods: Type 2 diabetic patients without PN (based on signs and symptoms of neuropathic impairment), who reported no exercise intolerance and who had no known autonomic dysfunction (e.g., gastroparesis, neurogenic bladder) and no postural hypotension or resting tachycardia, were selected. Patients with conditions that can also cause neuropathy or interfere with the evaluation proposed were excluded. A control group without DM, which was similar in terms of sex, age and BMI, was studied. Tests evaluating heart rate variability (HRV) during deep breathing, Valsalva maneuvers and orthostatism, and spectral analysis of HRV (spectral amplitude in the three bands: very low-frequency, low-frequency, and high-frequency) [1, 2] were performed.
Results: Twenty-four patients (17 women and 7 men) aged ≥ 40 years (mean 63 years), with a mean BMI of 27 kg/m2 and diagnosed with DM2 at least 3 years ago (mean 9.5 years) were included. The mean value of the last HbA1c was 7%. Four patients (16.6%) had a diagnosis of CAN, which was incipient in 3 (≥ 2 altered tests [1, 2]) and definite in 1 (3 altered tests [1,2]). None of the subjects of the control group had any altered test (100% specificity).
Vinik et al. Circulation 2007;
Spallone et al. Diabetes Metab Res Rev. 2011. Compliance with Ethical Standards
A52 Cardiovascular risk assessment by coronary calcium score in brazilian subjects with GCK- and HNF1A-mody
Luciana F. Franco1, Renata P. Dotto2, Gilberto Szarf3, Sergio A. Dib1, Regina CS Moises1, Magnus Regious Dias-da-Silva2, Fernando M A Giuffrida4, Andre Fernandes Reis1
1Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, Brazil; 2Laboratório de Endocrinologia Molecular a Translacional,Universidade Federal de São Paulo, São Paulo, Brazil; 3Disciplina de Radiologia Universidade Federal de São Paulo, São Paulo, Brazil; 4Universidade do Estado da Bahia –UNEB, Bahia, Brazil
Correspondence: Luciana F. Franco
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A52
Introduction: Monogenic diabetes due to glucokinase (GCK-MODY) and hepatocyte nuclear factor-1 homeobox A (HNF1A-MODY) mutations are the most common forms of MODY. Little is known about cardiovascular (CV) risk profile of subjects with these forms of diabetes. Together with clinical and biochemical data and some scores as Framingham, coronary artery calcium (CAC) score has shown good predictive value for coronary artery disease (CAD).
Objectives: assess CV risk by CAC score in GCK-MODY (GCK) and HNF1A-MODY(HNF1A).
Methods: Ninety-one individuals without CAD have been assessed for CV risk factors by clinical and laboratory data using high-sensitivity C-reactive protein (hs-CRP), Framingham Risk Score, Metabolic Syndrome (IDF), and CAC score with multi-slice computed tomography (Agatston score). We considered CAC > 10U as marker of subclinical atherosclerosis: 27 individuals with GCK-MODY(GCK) from 15 families and 8 individuals with HNF1A-MODY(HNF1A) from 4 families, 24 with type 2 diabetes (T2D), and 28 normoglycemic controls (C) (age-BMI-matched spouses or non-affected relatives of MODY patients),statistics by ANOVA and Kruskal–Wallis, significance P < 0.05,
Results: See Table 1.
A53 Cardiovascular risk profile and reach of LDL targets in diabetic patients type 2 attended in the diabetes ambulatory
Michelle Gentile Cherit, Daniele Maieron, Cátia Cristina Silva Sousa Vergara Palma, Roselee Pozzan, Raquel De Carvalho Abi-Abib, João Erni Vidal Scarparo Sorio, Aneliza Arantes Zanette
UERJ, Rio de Janeiro, Brazil
Correspondence: Michelle Gentile Cherit
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A53
Introduction: Identifying asymptomatic patients with increased cardiovascular risk (CVR) is fundamental for the implementation of therapeutic strategies aiming to more rigid risk factor control goals.
Objectives: To evaluate the CVR profile and the achievement of LDLc targets in type 2 diabetic patients treated at diabetes outpatient clinic.
Methods: Cross-sectional study with electronic data collection of patients treated in July 2017 for the following variables: age, sex, duration of diabetes, total cholesterol, HDLc, HbA1C systolic BP,history of hypertension treatment, smoking, coronary artery disease, stoke, peripheral vascular disease, atrial fibrillation(AF) and statin use and doses. The Framingham calculator (Wilson 2008) was used to evaluate CVR in patients aged 30-74 years and without history of previous events. The consensus of the AACE 2017 was used as a reference to define the lipid goals according to the degree of risk. The percentage of patients that were within the proposed goal were evaluated. Data were described as mean ± SD (min–max) and frequencies.
Results: 127 patients were evaluated, of which 33 (26%) had previous history of at least one cardiovascular event. The mean age was 62.9 ± 10.9 (28-91) years, and the duration of diabetes was 16.5 ± 10.7 (1-56) years. The following frequencies were found for the evaluated variables: female 61.4%, hypertension 93.7%, AF 1.6%, smoking 9.4%. The CVR was calculated in 84 patients: 61.9% were classified as high risk, 29.8% as intermediate risk and 8.3% as low risk. The percentage of patients with established cardiovascular disease (CVD) who presented LDLc below 70 mg/dl, according to the goal, was only 39.4%. Among the patients without CVD, 55.3% presented LDL-c below 100 mg/dl according to the goal. Statin use was observed in 109 (85.8%) and none of the patients were using the maximum dose.
Conclusion: Although the patients ‘profile was high in CVR, the proportion with LDL-c outside the goals established by the AACE consensus was high, pointing to the need for improvement in statin therapy. The prescription of more potent statins and in higher doses is often hampered by the financial difficulties of the patients attended in public clinics.
Beatriz da Camara Fernandes, Lucio Henrique Rocha Vieira, Elisa Borges Schmidt, Daniel Luis Schueftan Gilban, Lívia Vianna Ferreira
HFB, Rio de Janeiro, Brazil
Correspondence: Beatriz da Camara Fernandes
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A54
Background: Being a rare form of presentation of Diabetes Mellitus type 1 (DM1), Mauriac Syndrome (MS) is characterized by the symptomatology of hepatomegaly, growth retardation and diabetes with poor metabolic control of long evolution. It is reversible with improved metabolic control of the patient.
Conclusions: The diagnosis of MS is clinical and should be early. The prognosis is reserved, although the treatment is the same as in the traditional forms of DM1. Hepatic growth is a sign of inadequate glycemic control, in the exclusion of other secondary causes. Adequate patient therapy accelerated the growth curve and pubertal development. MS is a rare complication of poorly controlled DM1, the attending physician should be attentive to perform differential diagnoses, and thus, be able to perform timely interventions.
Informed consent to publish has been obtained from the parent of this patient.
A55 Case report: cardiovascular autonomic neuropathy associated with type 1 diabetes—evolution after myocardial revascularization
Denise Linhares Pereira Gottsch, Raissa Pereira Fernandes, Ronan Araujo Garcia, Hermelinda C Pedrosa, Cejana de Souza Hamu Aguiar
Hospital Regional de Taguatinga, Distrito Federal, Brazil
Correspondence: Denise Linhares Pereira Gottsch
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A55
Case report: Female patient, 43 years old, DM1 for 35 years, compensated hypothyroidism, grade 1 central obesity, SOAS, former smoker (aged > 20 years), current treatment (CIIS) and OAD (metformin; iSGT2, offlabel), mean HbA1c 8.0%. MI positive Family history (father died at age of 44 years). Painful diabetic polyneuropathy (PDPN) screening was absent and Installed cardiac autonomic neuropathy (ICAN) presente with high heart rate (HR, 95 bpm). Beta-blocker and thioctic acid HR 600 mg were initiated and she was referred to a cardiologista. Angiotomography could not be performed due to bronchospasm and further catheterization showed severe lesion in anterior descending artery (AD) and pharmacological stent was implanted. Reevaluation 8 months later showed CAN change to Incipient rather than Installed and HR reduced to 75 bpm.
Discussion: CAN is a DM frequent complication and considered a cardiovascular risk marker due to its association with silent infarctions, arrhythmias, sudden death. CAN is evaluated through cardiovascular autonomic reflex tests (CARTS) and cardiac frequency spectral analysis (CARTS and HR; Ewing DJ, 1986), respectively. CAN: Absent (0-1 abnormal test: sensitivity 99%); Incipient (2 abnormal tests: specificity 98%); Installed (3 abnormal tests, specificity 99%); Severe (3 abnormal tests and systolic hypotension). CARTS are non-invasive, have high sensitivity, specificity, reproducibility, easy to perform (time 20-30 min) and are golden standard for CAN. Overt changes indicate 56% mortality in 5 years (Vinik A, 2007). Screening should be performed after 5 year duration of DM1 independently of clinical symptoms (rest tachycardia, syncope, palpitation or weakness). Patient has never been investigated either for CAN or coronary heart disease.
Final comments: CAN is a strong predictor of CVR, early diagnosis and treatment increase survival and quality of life. However, CARTS have not been performed into the endocrinological or cardiologic clinical routine. This poor approach contribute to subdiagnosis, higher risk of sudden death and may explain the lack of studies of CAN following myocardial revascularization.
Informed consent to publish had been obtained from the patient.
A56 Case report: painful diabetic polyneuropathy and cardiovascular autonomic neuropathy associated with type 1 diabetes—evolution after myocardial revascularization
Denise Linhares Pereira Gottsch, Ronan Araujo Garcia, Raissa Pereira Fernandes, Cejana de Souza Hamu Aguiar, Hermelinda C Pedrosa
Hospital Regional de Taguatinga, Distrito Federal, Brazil
Correspondence: Denise Linhares Pereira Gottsch
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A56
Case presentation: Female patient, 56 years old, DM1 since 10 years of age, no smoker. Current treatment: insuline glargine + ultra fast acting insulin. Screening: severe diabetic polyneuropathy (DPN) and installed cardiovascular autonomic neuropathy (CAN). Angiotomography and coronary artery calcium score (CAC): diffuse calcification in anterior descending artery (AD), circumflex, marginal and right coronary arteries without possibility of determining stenosis due to intensity of calcification. Immediate catheterization was performed as AD showed 70% occlusion requesting a drug-eluting stent implantation.
Discussion: DPN and CAN are frequently associated DM complications. CAN is considered a marker of cardiovascular risk (CVR) and it is associated with silent infarctions, arrhythmias, sudden death. DPN and CAN were evaluated by validated protocols (Abbot C, 2011; Gomes MB, 2012 and Ewing DJ, 1986): Neuropathy Disability Score (NDS), cardiovascular autonomic reflex tests (CARTS) and heart rate, respectively. Painful DPN presente (PDPN) if score of signs ≥ 3 and symptoms ≥ 5; CAN: Absent (0-1 abnormal test: sensitivity 99%); Incipient (2 abnormal tests: specificity 98%); Installed (3 abnormal tests, specificity 99%); Severe (3 abnormal tests and systolic hypotension). CARTS are non-invasive, have good sensitivity, specificity, reproducibility and are easily performed (20-30 min), thus are considered gold standard. Abnormalities indicate 56% mortality in 5 years (Vinik A, 2007) and screening must be performed after 5 years of DM1 diagnosis. Patient had never been investigated for CAN neither for coronary heart disease. Strong relationship between PDPN and CAN as a result of small nervous fiber (pain and autonomic innervation, Testfaye S, 2010). ACCORD STUDY (2010) showed that CAN + DPN were the greatest predictors of cardiovascular death; and DCCT/EDIC (2013) the association of DM duration, age at DM diagnosis and CVR alluding a “metabolic memory” effect which influenced the lower incidence. Finally, Vinik A and Ziegler D (2007) points out CAN as a vector of the CVR.
Conclusion: Coexistence of CAN + DPN increases CVR, but are still underdiagnosed and subtreated. CAC with our without scan is not routinely used to screen CVR. The presente case is a clear example of lack of proper approach 2 and reinforces the need of screening, early diagnosis and prompt treatment of cardiovascular complications among DM1 patients.
Informed consent to publish had been obtained from the patient.
Caio Villaça Carneiro1, Martha Camillo Jordão1, Rafael Buck Giorgi1, João Henrique Del Grandi Spontão1, Daniele Iop de Oliveira Caldoncelli1, Camila Gagliardi Walter1, Ravena Machado Massucatto1, Thaís Picelli Pescarolo1, Ariane Cantarella1, Alexandre Eduardo Franzin Vieira1, Maria Teresa Verrone Quilici1, Carla Sanchez Bergamin Rizetto1, Luiz Clemente2
1PUC-SP, São Paulo, Brazil; 2UNIFESP, São Paulo, Brazil
Correspondence: Caio Villaça Carneiro
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A57
Case presentation: A 24-year-old male, diagnosed with type 1 diabetes mellitus (DM1) for 12 years, presented progressive of walking difficulties 5 years ago, associated with dizziness, weakness, and tachycardia at rest with hypotension. The patient had a history of poor glycemic control, with no evidence of nephropathy, retinopathy, and serum potassium levels within normal limits. Neuropathy Disability Score (NDS) was carried out, presenting 10 out of 10 points, classified as severe impairment. Because of an extremely significant clinical condition, with no evidence of microvascular compromise, hyporeninemic hypoaldosteronism (HH) was investigated. He was submitted to the posture test, with aldosterone dosage and renin plasma activity, without a significant increase in his values. Subsequently, the patient was exposed to the exogenous ACTH test, with the administration of ACTH 250mcg intravenous and dosages of serum cortisol and aldosterone at times 0‘, 30‘, 60‘. There was an elevation of serum cortisol to levels above the limit of normality (18 mcg/dL), discarding primary adrenal insufficiency, and aldosterone levels at the lower limit of normal (attached tables). Even tests without confirmation, the use of fludrocortisone 0.2 mg/day was started as a therapeutic test. The patient progressed with an improvement of the blood pressure (BP) and dizziness.
Discussion: HH is an uncommon condition, often associated with DM1, and such diagnosis is considered a challenge to the endocrinologist. Pathophysiology is supported by two main factors: reduction of aldosterone and renin production, secondary to autonomic neuropathy of the juxtaglomerular cells. HH has the effect of reducing angiotensin II, leading to hydro electrolytic disorders such as hyperkalemia, as well as BP deregulation. Recent studies showing this association are scarce due to the difficulty in diagnosis and lack of knowledge of this complication.
A58 Changes in intestinal tlrs gene expression after 3 months of roux-en-y gastric bypass (RYGB) in type 2 diabetes mellitus (T2DM) obese patients
Beatriz de Azevedo Muner Ferreira, Danielle Cristina Fonseca, Raquel Susana Matos de Miranda Torrinhas, Natasha Mendonça Machado, Robson Kiyoshi Ishida, Marco Aurélio Santo, Eduardo Guimarães Hourneaux de Moura, Paulo Sakai, Ismael Francisco Mota Siqueira Guarda, Dan Linetzky Waitzberg, Priscila Sala1
FMUSP, São Paulo, Brazil
Correspondence: Beatriz de Azevedo Muner Ferreira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A58
Background: Toll-like receptors (TLRs) are immune receptors involved in inflammation and are mostly activated by fatty acids and endotoxins. TLRs are present in inflammatory states such as obesity and metabolic syndrome. TLR4 and TLR7 receptors, for example, have been associated with chronic inflammation, impaired immune function and type 1 and type 2 diabetes mellitus (T2DM), while TLR10 is an anti-inflammatory pattern recognition receptor. Following Roux-en-Y Gastric Bypass (RYGB), patients may present changes in intestinal TLRs gene expression, decreased inflammation, and rapid improvement in glycemic control.
Objective: Examine selected TLRs in intestinal tissue within 3 months after RYGB.
Methods: Intestinal biopsies (duodenum, jejunum and ileum) were obtained from 20 obese women with T2DM (age, 46.9 ± 6.2 years, body mass index [BMI], 46.5 ± 5.3 kg/m2) before and 3 months after RYGB (BMI, 38.2 ± 4.2 kg/m2), and submitted to transcriptomic analysis by microarray technique and RT-qPCR. Markers of glycemic homeostasis were measured in the blood. After 1 year of RYGB, patients were classified as responsive (R) and nonresponsive (NR) to total remission of type T2DM.
Results: Three months after RYGB, TLR-encoding gene expression had significantly reduced TLR4 and TLR7 in the jejunum of patients responsive to remission of T2DM (p < 0.05).
Conclusion: RYGB and weight loss induce change in intestinal expression of TLRs mainly in the jejunum of R group. Modulation of TLRs in the gastrointestinal tract could mediate mechanisms of attachment to remission of T2DM after RYGB.
A59 Characterization of care of patients with foot diabetic in a public ambulatory in Sao Paulo‘s interior
Sandra Maria Batista Grossi, Ligia Nogueira Manso de Oliveira, Nancy Bueno Figueiredo
AME BAURU, São Paulo, Brazil
Correspondence: Sandra Maria Batista Grossi
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A59
Introduction: Diabetic foot is considered a complication of diabetes mellitus and it is the major cause of lower limb amputations. Avoiding its appearance, there is a need for guidelines on preventive measures and self-care.
Objective: Performing the matriciament of patients ‘wounds with diabetic foot, propose therapeutic actions to treat the lesions and emphasize the importance of self-care and prevention of complications related to diabetic foot.
Methods: Data were collected from February 2016 to July 2017, through an evaluation form of wounds. This is a descriptive and quantitative study with a sample of 24 patients who were followed up in nursing consultations.
Results: Data revealed a prevalence of males, aged average 59, predominance of type 2 diabetes, with neuropathic etiology and mean disease duration of 16 years. It was verified that 30% of patients presented amputation, five had osteomyelitis and three had progressed to amputation. Regard to the use of shoes, it was observed the use of inappropriate footwear in all patients‘therapeutic for 71% of the cases. Among 24 patients, 79% participated in multidisciplinary guidance on foot care. 17% of patients are under treatment, 46% wound healing, 21% were against referral to the primary service and 17% were referred to tertiary service, due to the complexity of the lesion.
Conclusion: This study revealed the need for educational, mainly in relation to preventive measures and, therefore, required education and self-care in order to prevent complications. Nurses play a key role in the evaluation and prescription of dressing, guidance and injury prevention. A multi professional action may potentiate as guidelines and increase adherence to treatment.
A60 Circulating microparticles are associated with type 2 diabetes mellitus and correlate with fasting glucose levels
Kathryna Fontana Rodrigues1, Nathalia Teixeira Pietrani1, Adriana Aparecida Bosco2, Ana Paula Fernandes1, Fernanda Magalhães Freire Campos1, Karina Braga Gomes Borges1
1UFMG, Minas Gerais, Brazil; 2Instituto de Ensino e Pesquisa da Santa Casa, Minas Gerais, Brazil
Correspondence: Kathryna Fontana Rodrigues
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A60
Introduction: Type 2 diabetes mellitus (T2DM) is associated with a chronic and subclinical inflammatory state. Microparticles (MPs) are extracelular microvesicles released during apoptose and cellular activation. MPs express pro-coagulant and -inflammatory activities, contributing to endothelial dysfunction observed in T2DM.
Objective: This study aimed to evaluate the circulating MPs profile in T2DM patients and to correlate it with fasting glucose levels in this group.
Methods: Sixty-nine subjects were selected, of whom 39 patients with clinical and laboratorial diagnosis of T2DM and diabetic kidney disease, and 30 gender and body mass index -matched non-diabetic control. Circulating MPs from platelets (PMPs; CD41 +), leukocytes (LMPs; CD45 +), endothelial cells (EMPs; CD51/61 +), and that express tissue factor (TFMPs; CD142 +) were measured by flow cytometry. Fasting glucose levels were measured in serum samples, after 8 h of fasting, using a commercial kit by enzyme-colorimetric method. Statistical analysis were performed with SPSS (version 17.0) using Mann–Whitney and Spearman’s correlation tests. The data were presented as “median (interquartile range)”. A pvalue < 0.05 was considered statistically significant. This study was approved by Federal University of Minas Gerais Ethical Committee and an informed consent was obtained from the individuals.
Results: We observed higher total levels of circulating MPs in T2DM [153.40 (142.15) MPs/μL] than in control group [85.33 (76.08) MPs/μL; p < 0.0001]. Moreover, higher levels of circulating PMPs [T2DM 167.53 (206.73) MPs/μL; control 113.83 (97.05) MPs/μL], LMPs [T2DM 119.13 (86.27) MPs/μL; control 53.80 (44.42) MPs/μL], EMPs [T2DM 157.53 (131.53) MPs/μL; control 86.50 (71.65) MPs/μL], and TFMPs [T2DM 169.93 (213.47) MPs/μL; control 99.60 (87.53) MPs/μL] were observed in T2DM patients when compared with control subjects (p < 0.0001 for all). Considering all the subjects, fasting glucose levels showed a significant positive correlation with PMPs (r = 0.286, p = 0.017), LMPs (r = 0.549, p < 0.0001), EMPs (r = 0.462, p < 0.0001), and TFMPs (r = 0.343, p = 0.004) levels.
Conclusion: These results suggested that higher circulating MPs levels are associated with T2DM and they correlate with glycemic levels. Therefore, MPs are promising biomarkers for assessment of inflammatory and pro-coagulant status in T2DM patients with diabetic kidney disease.
A61 Clinical and epidemiological profile of patients with post-transplant diabetes mellitus of liver in a center of reference of the state of Ceará
Naiara Castelo Branco Dantas, Leticia de Sousa Guerin, Caio Viana Botelho, Luma Maria Tavares de Sousa, Marcelo Kervin Reis Frota, Manoela Montenegro Dias de Carvalho, Daniel Duarte Gadelha, Cyntia Ferreira Gomes Viana, Elodie Bomfim Hyppolito, José Huygens Parente Garcia, Karla Brandão Pereira, Gustavo Rêgo Coelho, Tarciso Daniel Santos Rocha, Virgínia de Oliveira Fernandes, Renan Magalhães Montenegro Junior
HUWC, Ceará, Brazil
Correspondence: Naiara Castelo Branco Dantas
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A61
Introdution: Liver transplantation is becoming one of the most important therapeutic options in the liver failuretreatment. One of the complications of the transplantation is the developing of post-transplant diabetes mellitus (PTDM), due to the presence of multiple risk factors such as the use of immunosuppressive agents that increase the risk of developing PTDM by 74%. PTDM is associated with adverse outcomes such as an increasing mortality, a reduction of graft survival, a risk of sepsis and microvascular complications when compared to patients without PTDM.
Objective: To evaluate the clinicalepidemiological profile of patients with PTDM and to identify the potential risk factors for PTDM present in this population.
Methods: A cross-sectional, retrospective and descriptive study that occurred in a Hospital in the State of Ceará, Brazil, a national reference in liver transplantation, with patients who were followed up in an specialized center in PTDM between 2009 and 2015. The data were collected from medical charts. Demographic and clinical features were collected, including an evaluation of comorbidities, body mass index (BMI), glycated hemoglobin (HbA1c) and immunosuppressive therapy.
Results: From 2009 to 2015, 868 patients underwent liver transplantation, 5.3% (46/868) had diabetes before the transplant. Of those 822 who were not diabetic before surgery, 8.2% (67/822) were diagnosed with PTDM. The average age at diagnosis was 58.63 ± 10.5 years old and 77.8% (n = 52) were men. Arterial hypertension was present in 41.8% (28/67), dyslipidemia in 6% (4/67) and overweight/obesity in 65.7% (n = 44/67). The glycated hemoglobin at diagnosis was 7.06 ± 2.3%. Family history of diabetes was positive in 29.8% (20/67). The immunosuppressive treatment were done with 2 to 3 drugs, mainly tacrolimus, prednisone and mycophenolate mofetil.
Discussion: The subjects who developed with PTDM presented risk factors such as mean age greater than 40 years, metabolic syndrome, overweight/obesity, and family history of diabetes. This could suggest that patients who will undergo liver transplantation and present these features should be followed more closely after surgery and should be encouraged to reduce modifiable risk factors prior to surgery, because of the increased risk of developing diabetes. This may be a strategy to prevent PTDM in this population and the adverse outcomes associated with this condition.
A62 Clinical and sociodemographic variables associated with chronic complications in diabetic patients type 2 during ambulatory follow-up
Laís de Oliveira Hernandes1, Tatiana Siqueira Capucci2, Mariana Accioly Carrazedo3, Wimbler Pires4, Jucelia Candido5, Josafá Fabricio dos Santos5, Joelma Aguilera Dias Magalhães5, Ricardo Emidio Navarrete de Toledo3,5
1Santa Casa de São José dos Campos, São Paulo, Brazil; 2Instituto Policlin de Ensino e Pesquisa, São José dos Campos, São Paulo, Brazil; 3Beneficência Portuguesa de São Paulo, São Paulo, Brazil; 4FMU (Faculdades Metropolitanas Unidas), São Paulo, Brazil; 5IEFAP/Uningá, Paraná, Brazil
Correspondence: Laís de Oliveira Hernandes
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A62
Introduction: Type 2 diabetes mellitus (DM2) is one of the main public health problems today, with alarming rates of morbidity and mortality. The production of information on the prevalence and sociodemographic variables associated with complications increases the knowledge about the health of people with DM2 and favors the formulation of feasible policies and strategies for the prevention and treatment of this condition.
Objectives: To evaluate the interrelationships between chronic complications and clinical and sociodemographic variables of patients with DM2.
Materials/Methods: A cross-sectional study between October and December/2016, based on the medical records of 278 DM2 patients followed up at the Endocrinology Outpatient Clinic. Forty-two patients were excluded from the analysis by incomplete data, totaling 236 patients. The following variables were analyzed: age, gender, weight, height, body mass index (BMI), presence or absence of systemic arterial hypertension (HAS), and the presence of chronic microvascular and macrovascular complications. The data were organized in Excel 2010® worksheet and a descriptive analysis was performed.
Results: Among Multiple linear regression analysis identified that DM2 correlated positively with age (96% with age > 40 years had DM2, r = 0.61, p < 0.01), sex (prevalence 64% (p < 0.01), BMI (100% of DM2 had BMI > 30 kg/m2) and presence of hypertension (84.87%). With regard to complications, 52.56% had some micro or macrovascular complications. There was a reciprocal relationship between hypertension and BMI (76.69% of hypertensive patients had BMI > 25 kg/m2, while 77.77% of hypertensive obese patients had hypertension).
Conclusion: Our results reinforce the main clinical and sociodemographic variables associated with the phenotype of the metabolic syndrome, which corroborate the development of DM2.
Acknowledgments: No funding was obtained from pharmaceutical companies to carry out this study. All authors were involved in the data collection and analysis. DISCLOSURE: The authors declare no conflict of interest.
A63 Clinical evaluation of methodology based on variability of cardiac frequency for early diagnosis of autonomic neuropathy in individuals with type 1 diabetes
Ana Paula Franco Pacheco, Simone Van de Sande Lee, Jefferson Luiz Brum Marques, Cristina Schreiber Oliveira
UFSC, Santa Catarina, Brazil
Correspondence: Ana Paula Franco Pacheco
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A63
Background: Autonomic neuropathy (AN) is a serious diabetes complication, which affects the autonomic nervous system. This system has the function of controlling the autonomous body’s organs, it is sensitive to changes caused by the lack of control of type 1 diabetes mellitus (T1DM) and can cause cardiovascular autonomic neuropathy (CAN). One way to detect AN is by examining the heart rate variability (HRV) that corresponds to fluctuations in the intervals between consecutive heartbeats, using signal processing techniques.
Objectives: To evaluate the clinical utility of the method referred to diagnose CAN still in subclinical stage; evaluate its predictive validity as an indicator of prognosis; to determine which set of parameters and clinical characteristics best discriminates between stages of CAN; to evaluate influence on clinical status of individuals who participated in a structured education program (SEP).
Methods: In this cohort study, a spectral analysis of HRV was performed through a system that captures ECG signals, and this methodology was refined by comparison with conventional tests O’Brien and BRS for the detection of CAN in individuals with T1DM with different degrees (No CAN, Subclinical CAN and Established CAN). Analysis of clinical and physical examination of peripheral neuropathy (PN) and follow-up of individuals who participated in the SEP.
Results: The analysis of these results showed the efficacy of the methodology applied for the early detection of CAN, as well as to discriminate characteristics between the different stages, and determined parameters calculated to identify these groups of individuals. The sample size was 66; the mean age was 31.35 ± 9.97 years; The mean time of DM1 diagnosis was 16.03 ± 9.22 years; The mean HbA1c was 8.65% ± 1.94 or 71.05 mmol/mol ± 21.22; Of the total number of individuals, 25 (37.88%) had previously participated in SEP and 18 (27.27%) had a diagnosis of retinopathy. In the O‘Brien test, 16 (24.24%) individuals presented a diagnosis of subclinical CAN and 11 (16.67%) of established CAN, whereas by the HRV test, 35 (53.85%) were diagnosed with subclinical CAN and 12 (18.46%) with established CAN. The HRV parameters HF, LF, SD2, SDNN, RMSSD and TP showed a difference between groups and CSI values for subclinical CAN were higher than for individuals No CAN (p < 0.05). SEP participants maintained ideal HbA1c values.
A64 Clinical evolution of patients with type 1 diabetes mellitus followed in a secondary care reference center of Minas Gerais
Agma Leozina Viana Souza, Aleida Nazareth Soares, Alexandra Dias, Janice Sepulveda Reis, Tatiane Gea Horta
Instituto de Ensino e Pesquisa Santa Casa BH, Minas Gerais, Brazil
Correspondence: Agma Leozina Viana Souza
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A64
Background: Diabetes mellitus is a serious public health problem worldwide. Because it is a chronic condition of high prevalence, regular follow-up is important to prevent complications due to the disease.
Objective: To evaluate the clinical evolution of patients with type 1 diabetes mellitus (T1DM) attended in a secondary care reference center of Minas Gerais.
Methods: This is a longitudinal study with 174 people with T1DM followed up by a multidisciplinary team, all of them referred from primary care from 2010 to 2015. Clinical evolution was based on annual mean levels of glycated hemoglobin (A1c) and LDL cholesterol. Paired T-test and McNemar test were used for the annual comparisons of A1c and LDL-c. In every test a significance level of less than 5% was considered.
Results: The sample was constituted by a majority of men (55.1%), single (60.9%), self-referred as brown (47.1%), formal workers (47.1%), with full high school or college education (47.2%), income between 1 and 2 minimum wages (69.6%), average age of 34 ± 14 years old, having diabetes for 15.35 ± 10.3 years and 49.5% of people living in Belo Horizonte. All patients were undergoing intensive treatment of diabetes, with 10 patients (5.7%) in a continuous system of insulin infusion. Of those in multiple daily applications, the majority were in NPH use (61.5%), followed by glargine (32.8%), with 83.3% in ultrafast insulin use. Less than half of the study group, 87 subjects (47.1%), used statins. The study showed that 63.21% of patients (n = 110) started the accomplishment at the health service with A1c values above 8%, of which 47 (27.01%) were above 10%. At the end of the first year of follow-up, that percentage was reduced to 49.99%, with the higher reduction in the ones with A1c levels over 9% (Table 1). In this period, there was a significant reduction in the A1c means (9.01 ± 2.46 in 2010 and 8.2 ± 1.74 in 2011; p < 0.001), remaining unchanged in the following years, but with a concentration of patients in the category of 7–8%, below the national average. Regarding LDL-c, it was observed a significant reduction throughout the follow-up period (p < 0.005) (Table 2).
A65 Clinical impact of treatment intensification in patients with T2D uncontrolled with basal insulin
Erin Buysman1, Tao Fan2, Cori Blauer-Peterson1, Lesley-Ann Miller2
1Optum, INC., Eden Prairie, MN, USA; 2Sanofi US, INC., Bridgewater, NJ, USA
Correspondence: Erin Buysman
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A65
Despite the availability of several antidiabetes agents, treatment intensification (TI) may not be promptly implemented in cases of suboptimal glycemic control. This study compared clinical outcomes for patients (pts) with T2D uncontrolled after ≥ 6 months of treatment with basal insulin (BI) who underwent TI or no TI (NTI). TI included adding a GLP-1 receptor agonist (RA), bolus insulin or SGLT2 inhibitor, switching to premixed insulin or increasing BI dose. Data on eligible pts undergoing TI within 6 months of the first A1c ≥ 7.0% measure (index date) were collected from the Optum administrative claims database between January 1, 2009 and August 31, 2015. A1c change from the index date and hypoglycemia incidence were determined 12 months after TI (randomly selected date for the NTI cohort). Bivariate comparisons were made between the two cohorts. A total of 10.425/16,140 (65%) adults uncontrolled with BI underwent TI. Pts in the TI cohort were slightly younger than in the NTI cohort (61 vs. 62 years) and had higher index A1c (8.94% vs. 8.60%; P < 0.001). A greater A1c reduction (− 0.30% vs. − 0.04%; P < 0.001) and higher hypoglycemia rate (6.94% vs. 5.76%; P = 0.004) were seen for TI pts at follow-up. Pts adding a GLP-1 RA and bolus insulin showed greater A1c changes vs. those increasing BI dose (GLP-1 RA, − 0.62%; bolus insulin, − 0.61%; BI, − 0.23%; P ≤ 0.002 for both agents vs. BI), and severe hypoglycemia was less frequent with GLP-1 RA-containing vs. insulin-only regimens (GLP-1 RA, 0.43%; bolus insulin, 3.13%; BI, 2.52%; P < 0.05 for GLP-1 RA vs. insulin). Clinical inertia is still widespread in clinical practice. Timely TI improves A1c levels but is associated with more frequent hypoglycemia, primarily driven by basal-bolus insulin and BI titration. Injectable agents are more effective than BI dose increases for pts uncontrolled after ≥ 6 months on BI; GLP-1 RAs show the lowest hypoglycemia rate. Our data highlight a need for new and improved agents that effectively manage glycemia while reducing hypoglycemia risk. This is an ENCORE abstract previously presented at ADA2017. Funding and editorial support provided by Sanofi.
Leandro Arthur Diehl, Bárbara Jacob Vieira, Cláudio Augusto da Silva Júnior, Douglas Henrique Katayama de Souza, Emanuelle Roberto Trevisani
Universidade Estadual de Londrina (UEL), Paraná, Brazil
Correspondence: Leandro Arthur Diehl
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A66
Background: Only 24% of patients with diabetes mellitus (DM) present good glycemic control. This is partly due to clinical inertia (failure to adjust therapy when needed), especially related to insulin initiation.
Objective: To assess if playing a digital serious game for medical education on insulin therapy (InsuOnline) is associated with changes in the practice of primary care physicians (PCPs) related to insulin initiation.
Methods: A noncontrolled experimental study was performed with PCPs working in primary healthcare units (UBSs) in Londrina and Cambé (Paraná). All of them played InsuOnline. We identified the patients for whom those PCPs initiated insulin in their UBSs in 2 time points: up to 6 months before, and up to 6 months after playing the game. Then we collected from their charts: demographic data, time between the first indication for insulin and the first prescription of insulin, and glycemic control indicators. Data were stored and analyzed in Epi-Info 7. Research protocol was previously approved by an institutional review board and local health authorities.
Results: 23 PCPs were included (4 from Cambé and 19 from Londrina). They initiated insulin in 56 patients in the period (22 before, and 34 after the game; P = 0.09). Patients were most female (32/56), with mean age 59 ± 12. Mean duration of DM when insulin was initiated was 5.4 ± 5.3 years. Time between the first indication for insulin and the first prescription of insulin by the PCP was 70 days (median; IQ 0–393). When insulin was initiated, mean A1c was 10.2 ± 1.8% and mean plasma glucose was 268 ± 89 mg/dL. After insulin initiation, A1c and glucose decreased to 9 ± 1.5% and 193 ± 72 mg/dL, respectively; 59% of patients presented improved glycemic control after insulin initiation. No difference was found when the time points (before and after the game) were compared. The small sample and the lack of data in charts were limitations to this study. It is possible that additional interventions are required to improve the actual care of DM patients in primary health care.
Conclusion: There was a nonsignificant trend to more frequent insulin initiation by PCPs after playing the game InsuOnline.
A67 Clinical perspectives from the begin and edition longer-acting insulin programs: trial-level meta-analyses outcomes with either degludec (IDEG) or glargine 300 μ/ml (GLA-300) vs. glargine 100 μ/ml (GLA-100) in T2DM
Julio Rosenstock1, Robert A. Ritzel2, Soazig Chevalier3, Beverley Balkau4, Ronan Roussel5
1Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX, USA; 2Klinikum Schwabing, Städtisches Klinikum München GmbH, Munich, Germany; 3Sanofi, Paris, France; 4INSERM U1018, Center for Research in Epidemiology and Population Health, UPS-UVSQ, Villejuif, France; 5Assistance Publique Hôpitaux de Paris, Bichat Hospital, Paris, France
Correspondence: Julio Rosenstock
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A67
A68 Clinical profile of patients with diabetes mellitus and liver transplantation and results after a multidisciplinary team intervention
Cinthia Minatel Riguetto, Ticiane Gonçalez Bovi, Adriana Russo Fiore, Luciana Teixeira Lot, Elaine Cristina de Ataíde, Arnaldo Moura Neto, Ilka de Fátima Ferreira Santana Boin
Universidade Estadual de Campinas, São Paulo, Brazil
Correspondence: Cinthia Minatel Riguetto
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A68
Background and aims: Over the years, survival after liver transplantation (LT) has increased and metabolic complications are becoming more common, contributing to patients’ morbidity and mortality. The objectives of this study were to describe a population of patients with hepatic transplantation and diabetes mellitus (DM), evaluate the frequency of metabolic complications and assess the impact of a multidisciplinary team on DM management.
Materials and Methods: This was a retrospective study involving interview and medical record analysis of 46 consecutive patients followed at the Diabetes Mellitus and Liver Transplantation Unit of a tertiary university hospital, all evaluated by a multidisciplinary team. In twenty-nine of these patients anthropometric measures of nutritional status were evaluated including body mass index (BMI), triceps skinfold (TSF), arm circumference (AC), arm muscle circumference (AMC) and fat area (FA).
Results: Off all patients, 76.1% were men, with median age of 60 years old (IQR 56–65 years) and LT time of 5 years (0.6–9 years). The most frequent etiology of cirrhosis leading to LT was hepatitis C virus (69.6%), followed by alcohol abuse (19.6%). Hypertension, hypercholesterolemia, hypertriglyceridemia, alcoholism and smoking were present in 47.8, 34.8, 23.9, 34.8 and 30.4% of the patients, respectively. Regarding the evaluation of nutritional status, 11 patients (37.9%) were classified as overweight according to BMI (median 26.27 kg/m2) and 12 (41.2%) according to the TSF. Nineteen (66.5%), 21 (72.4%) and 13 (44.8%) patients were classified as eutrophic according to AC, AMC, and FA, respectively. The diagnosis of DM was made after LT in 65.2% of cases, with a median time of 1.5 years (0.5-5.5). The most frequent immunosuppressant in use were tacrolimus (71.1%) and mycophenolate (48.9%). The median HbA1c and weight before and after intervention of the multidisciplinary team were, respectively, 7.6% (5.7%–8.8%;) vs. 6.5% (5.7%–7.7%); p = 0.022 and 70.5 kg (64.7–82.0 kg) vs 71.6 kg (65.0–85.0 kg); p = 0.18.
Conclusions: There was a high frequency hepatitis C virus and users of tacrolimus in patients with DM. Hypertension and dyslipidemia are common in transplanted patients with DM. Intervention of the multidisciplinary team resulted in a significant improvement in HbA1c without significant weight gain. This study showed that a multidisciplinary team approach in the management of DM in LT patients is helpful.
A69 Clinical, demographic and laboratorial parameters in a population of type 1 diabetic patients with metabolic syndrome
Bianca Senger Vasconcelos Barros, Deborah Conte Santos, Marcela Haas Pizarro, Laura Gomes Nunes de Melo, Marilia Brito Gomes
UERJ, Rio de Janeiro, Brazil
Correspondence: Bianca Senger Vasconcelos Barros
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A69
Introduction: Obesity has become a concern worldwide, even in patients with type 1 diabetes. It has been associated with musculoskeletal disorders, cancer and metabolic syndrome (MS), which is known to enhance cardiovascular risk.
Objective: To investigate the prevalence of MS in a type 1 diabetic population and to determine which parameters are associated with this diagnosis.
Methods: We evaluated 1,760 patients from all geographical regions of Brazil, in this cross-sectional multicenter study. Patients were classified according to the International Diabetes Federation criteria for metabolic syndrome (MS).
Results: From a total of 1678 (95.3%) patients with complete data, 28.4% (n = 477) were classified as having MS. Mean age (35.3 ± 11.9 vs. 28.0 ± 11.4) and diabetes duration (18.7 ± 9.8 vs. 14.1 ± 8.8) were higher and use of metformin (25.4 vs. 7.1%), statin (34.4 vs. 16.7%), fibrate (1.7 vs. 0.4%) and renin-angiotensin system inhibitor (44.4 vs. 20.6%) was more frequent in patients with MS in comparison to those without MS (p < 0.05 for all the analysis). There was no difference between the two groups regarding HbA1c levels (8.9 ± 1.9 vs. 9.0 ± 2.2). Female gender was also more prevalent in the group with MS (68.6 vs 50.0%), as well as family history for type 2 diabetes (33.8 vs 21.9%) and obesity (29.6 vs. 21.2%), p < 0.001 for all the analysis. Patients with MS also showed significantly higher levels of ALT, AST, C-reactive protein and uric acid.
Conclusions: MS affects approximately one-third of patients with type 1 diabetes. Female patients, with higher disease duration, higher age, positive family history of type 2 diabetes and/or obesity should bring attention to the risk of MS. Patients with MS exhibit higher levels of ALT, AST, C-reactive protein and uric acid, which might be related to an increase cardiovascular risk and also to an increase risk of non-alcoholic liver disease. Further studies are necessary to determine which complications are more frequent in type 1 diabetic patients with MS and how these patients should be managed.
A70 Combination of behavioral strategies to improve adherence to oral antidiabetics: a randomized controlled trial
Danilo Donizetti Trevisan1, Flávia Helena Pereira2, Thaís Moreira São João1, Marilia Estêvam Cornélio1, Fernanda Freire Jannuzzi3, Roberta Cunha Matheus Rodrigues1, Maria Helena de Melo Lima1
1Universidade Estadual de Campinas, São Paulo, Brazil; 2Instituto Federal do Sul de Minas Gerais, Minas Gerais, Brazil; 3Colégio Técnico de Campinas, São Paulo, Brazil
Correspondence: Danilo Donizetti Trevisan
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A70
Background: Through psychosocial theories such as the Theory of Planned Behavior (TPB), it becomes possible to apply theoretical models with a view to improving the adherence of patients with T2DM to oral antidiabetics and, consequently, to improve glycemic control.
Aim: The aim of this study was to evaluate the effect of the combination of the intervention strategies “Action Planning” and “Coping Planning” on the medication adherence of oral antidiabetics among patients with T2DM.
Methods: A randomized clinical trial involving outpatients with T2DM attended in a primary service care in Brazil was conducted. At the baseline, participants were randomized into two groups (intervention—IG and control—CG) and were followed for a 15-week period. The IG received a combination of strategies to promote adherence to oral antidiabetics based on face-to-face meetings and telephone calls. The CG received usual care from the health service. Drug adherence behavior, Global Adherence assessment and Glycated hemoglobin (HbA1c) were evaluated as primary outcomes. Generalized estimating equations models were applied to compare groups throughout the follow-up.
Results: Of the 90 participants, 88 completed the follow-up (IG = 44, CG = 44). The regression analysis showed better scores for the adherence behavior (p = 0.028), global adherence (p < 0.0001) and percentage of adherence (p < 0.0001) for IG when compared to CG. At follow-up, it was evidenced that the chance of IG being more adherent corresponds to 18.31 times the CG chance (CI 95%: 4.58–73.10, p < 0.001).
Conclusion: The findings of the present study allow us to conclude that the combination of behavioral strategies was effective in improving drug adherence behavior, promoting compliance to oral antidiabetic drugs and reducing HbA1c levels. Keywords: Diabetes Mellitus, Type 2; Hypoglycemic Agents; Medication Adherence; Nursing; Clinical Trial Trial registration: Brazilian Registry of Clinical Trials (RBR-439f77). Consent to publish: Informed consent to publish has been obtained from this patient.
Ethics approval: The study was approved by the University of Campinas’ Ethics Board, approval number 1.278.099/2016, 1.408.883/2016 and 1.528.738/2016 and conducted according to the recommendations of the Declaration of Helsinki.
A71 Comparable glycemic control, greater weight loss, and lower hypoglycemia with once weekly dulaglutide versus insulin glargine, both combined with lispro, in type 2 diabetes and moderate to severe chronic kidney disease (AWARD-7)
Katherine R. Tuttle1, Mark C. Lakshmanan2, Jorge L. Gross3, Brian Rayner4, Robert S. Busch5, D. Bradley Woodward2, Alan G. Zimmermann2, Aline Rejane Muller Gerent2, Fady T. Botros2,
1Providence Health Care, University of Washington, Spokane, WA, USA; 2Eli Lilly and Company, Indianapolis, IN, USA; 3Centro de Pesquisas em Diabetes, Porto Alegre, Rio Grande do Sul Brazil; 4Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa; 5Albany Medical Center Division of Community Endocrinology, Albany, NY, USA
Correspondence: Katherine R. Tuttle
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A71
Introduction/objective: The objective was to demonstrate dulaglutide (DU) noninferiority for HbA1c change after 26 weeks.
Methods: This phase 3 study compared once weekly DU to titrated daily insulin glargine, both combined with insulin lispro, in people with type 2 diabetes (T2D) and chronic kidney disease (CKD) stages 3–4. Participants were randomized (1:1:1) to DU 1.5 mg or DU 0.75 mg or titrated insulin glargine.
Results: Baseline characteristics (N = 576) included: [mean ± SD] age 64.6 ± 8.6 years, HbA1c 8.6 ± 1.0%, eGFR 38.3 ± 12.8 mL/min/1.73m2, BMI 32.5 ± 5.2 kg/m2, daily insulin dose 58.2 ± 31.8 U. DU was non-inferior to insulin glargine for HbA1c change (table). Body weight decreased with DU, whereas it increased with insulin glargine. The hypoglycemia rate (≤ 70 mg/dL) was lower for DU 1.5 mg and 0.75 mg vs insulin glargine (5.5, 7.8 and 17.1 events/participant/year; p < 0.001). Nausea, vomiting and diarrhea were more common with DU 1.5 mg (19.8, 12.0, 15.6%) and DU 0.75 mg (11.1, 5.8, 13.7%) vs insulin glargine (2.6, 3.1, 3.1%).
Emmerson Cristyan Ferreira Dantas1, Jonathan Nícolas dos Santos Ribeiro2, Cláudio Barnabé dos Santos Cavalcanti1, Denise Maria Martins Vancea1
1UPE, Pernambuco, Brazil; 2UFPE, Pernambuco, Brazil
Correspondence: Emmerson Cristyan Ferreira Dantas
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A72
Introduction: Physical exercise has been advocated as a beneficial activity in the treatment of diabetes mellitus, improving glycemic control, contributing to weight loss and improving quality of life.
Objective: To compare different physical exercise intensities on capillary glycemia of type 2 diabetics.
Method: The study included 19 type 2 diabetics, of both sexes, with a mean age of 65 years. They were divided into two training groups according to intensity, moderate intensity training (n = 10) and high intensity training (n = 09). They performed the training three times a week in the morning, totaling 18 training sessions. The capillary glycemia was collected from diabetics before and after each training session, using glucoside. The training protocol was composed of aerobic and resistance training. For statistical analysis, the Wilcoxon test and the Kruscal-Wallis non-parametric test were used, adopting a significance level of p < 0.05.
Results: The frequency of diabetics in training was 65%. A significant decrease in glycemia in moderate intensity training (182.8 mg/dL ± 41.5 mg/dL vs. 139.2 mg/dL ± 47.2 mg/dL p = 0.00) was observed and in training (169.7 mg/dL ± 43.8 mg/dL vs. 129.2 mg/dL ± 38.9 mg/dL p = 0.00).
Conclusion: The training of different intensities, moderate and high intensity, were effective in reducing capillary glycemia of type 2 diabetics, but in the intergroup evaluation there was no significant difference. Keywords
A73 Comparative analysis between 2 studies conducted in a public health care center with 10-year interval regarding the selfblood glucose monitoring habits and level of understanding in a population of type 1 diabetic patients
Igor Torres Dias1, Cristina Figueiredo Sampaio Façanha2, Adriana Costa Forti3, João Augusto Lima Bisneto1, Gabriel Melo Ferraz Pessoa1, Joana Cysne Frota Vieira1, Gisele Ferreira Camara1, Isabele Moreno de Alencar1, Isabele Fontenele de Santiago Campos1, Kaik Brendon dos Santos Gomes1, Guilherme Leite Barboza Gonçalves1, Kenya Vitoria de Aguiar Queiroz1, George Sales de Arruda1
1Unichristus, Ceará, Brazil; 2Unichristus e Centro Integrado de Diabetes e Hipertensão do Estado do Ceará, Ceará; Brazil; 3Centro Integrado de Diabetes e Hipertensão do Estado do Ceará, Ceará, Brazil
Correspondence: Igor Torres Dias
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A73
Introduction: Self-monitoring blood glucose (SMBG) is essential for proper treatment of Type 1 Diabetes(DM1). It requires knowledge and skills to understand the tests results and make proper adjustments of the therapy. Therefore, educating the patient with diabetes to use the method has been a constant concern since the regulation of Federal Law No. 11.347, which conditioned patient education to the distribution of glucometers and supplies for the treatment of DM1. In 2007 we evaluated the ability of our patients to use SMBG and adjust the treatment, in order to direct educational actions. After 10 years of the program on a public health care setting, we evaluated another group of patients in our service.
Objectives: To compare the abilities of DM1 patient to use SMBG data to adjust their treatment at the beginning of the program and after 10 years of its implementation.
Methods: A comparative study between the data from the evaluation done in 2007 and 2017 at the same outpatient referral center about the knowledge of DM1 patients on SMBG. For statistical analysis EpiInfo version 3.5.2 was used.
Results: In 2006, we evaluated 108 DM1 patients, with a mean age of 16.6 years, 59% female, mean disease time of 6.6 years. In 2017: 95 DM1 patients, mean age: 17.03 years, 60.22% female, 40.22% with diabetes > 1 year and ≤ 5 years. In 2007 we observed that 41% monitored blood glucose 1x/day and only 11% ≥ 4×/day. Currently, 48.81% monitor ≥ 4×/day and only 2.38% 1×/day. Regarding the understanding of the test results, in 2007, 88.9% believed they knew the glycemic target, and of these 82.4% correctly answered the fasting value and 57.4% postprandial. In 2017, 91.4% answered to be aware of the glycemic target, of these, 80.0% correctly answered the fasting target and 47.37% the postprandial target. The test result was used to adjust treatment by 54.6% of the patients who monitored blood glucose levels in 2007, and currently only 65.22% of the users self-adjust the dose based on tests result.
Conclusion: We observed that in our current scenario, where the availability of supplies for SMBG is improving, our patients are monitoring more frequently throughout the day, and although we see improvement in patient skills on interpreting the test results, we still need to focus on the development of an educational program that promotes patient’s empowerment to obtain the full benefit of the procedure.
Mariana Carneiro da Silva1, Maiara Uchôa Fonseca2, Juliana Claro Peloso2, Gilson Fernandes Ruivo2, Rayssa Neves Salles de Carvalho1, Wanessa de Lourdes Pinto1, Camila Uchôa Fonseca2, André Luis Moreira Duarte1
1PUC Campinas, São Paulo, Brazil; 2Universidade de Taubaté, São Paulo; Bazil
Correspondence: Mariana Carneiro da Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A74
Introduction: Chronic kidney disease (CKD) consists of progressive and irreversible renal damage. According to the Brazilian Society of Nephrology, Diabetes Mellitus (MD) is the leading cause of kidney failure in the world. The best way to measure renal function is glomerular filtration rate (GFR). Currently, to calculate this, we use 24-h urine creatinine clearance (ClCr), and some formulas that estimate it: Cockcroft-Gault (CG), MDRD and CKDEPI.
Objectives: The main objective is to perform a comparative analysis between the formulas and the creatinine clearance in the diabetic population, in order to determine between the different groups the closest approach to creatinine clearance in the 24-h urine.
Methods: It represents a cross-sectional observational study using a population sample of 149 type 2 diabetic patients treated at the nephrology outpatient clinic during 2014 and 2015. Patients were stratified by sex, age, and insulin use. The data were analyzed statistically with the aid of the SPSS and Bioestat program. The parameters of the descriptive statistics were used, with the use of measures of central tendency and dispersion, besides the calculation of the relative frequency and the Kolmogorov–Smirnov test.
Results: Patients were stratified by demographic variables of race (black or non-black), sex and age, showing a white (95%), female (69%) and over 50 years (96.6%) prevalence. When the formulas of estimates of renal function compared to each other, we noticed that the CKD-EPI formula behaves statistically different from the others (p < 0.05), suggesting that it would be underestimating the value of the GFR. When considering classification by CKD stages, any of the methodologies can be used, although CKD-EPI has a particular pattern in relation to others, all of them have a significant correlation with CKr. No significant differences were found between the formulas and CrCl when compared to age, sex and insulin use or not.
A75 Comparison of cardiovascular risk calculators in type 2 diabetic patients attended in tertiary health unit
Bruna Nogueira Würdig, Bruna Duarte Berdun Silva, Luciana Müller Bagatini, Rebeca Bandeira de Melo Cavalcante, Bruna Braga Dias, Roselee Pozzan, Raquel de Carvalho Abi-Abib, Cátia Cristina Silva Sousa Vergara Palma
UERJ, Rio de Janeiro, Brazil
Correspondence: Bruna Nogueira Würdig
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A75
Introduction: Diabetes is often considered a “cardiovascular risk equivalent” despite representing a heterogeneous group of patients with different risks. In order to estimate cardiovascular risk (CVR), numerous formulas were developed differing to the population of origin, age group and the analyzed outcomes.
Objective: Compare the results of Framingham risk calculator (D‘Agostino, Circulation 2008) and ACC/AHA risk calculator(Circulation 2013) in type 2 diabetic patients.
Methodology: Cross-sectional study with data collection from electronic medical records: age, total cholesterol, HDL-c, systolic BP, treatment for hypertension, DM, smoking and history of coronary, cerebrovascular or peripheral arterial disease. Patients aged 40 to 74 attended in July 2017 were included. Those with coronary, cerebrovascular or peripheral vascular disease were excluded. Values above 20% in FRS and 7.5% in ACC/AHA were considered high risk. The percentage of agreement between the two calculators was evaluated.
Results: 82 patients, mean age 60.29 ± 7.6 years, mean DM duration of 14.9 ± 9.4 years, 64.6% female, 11% with smoking history and 92.7% with hypertension were evaluated. There were 52 (63.41%) patients classified as high risk by FRS and 67 (81.7%) by ACC/AHA. All those classified as high risk by FRS had the same classification by ACC/AHA. However, 14 out of 25 patients (56%) at moderate risk for FRS were classified as high risk by ACC/AHA, and 1 in 5 patients (20%) with low risk from FRS were at high risk by ACC/AHA.
Conclusion: Although the FRS, described by D‘Agostino 2008, assesses risk of more cardiovascular outcomes than the ACC/AHA 2013 calculator, the latter calculates more patients as being at high risk. There is disagreement mainly in the moderate risk groups of FRS, which may benefit from more intensive preventive measures or other risk assessment exams.
A76 Comparison of neuropathy disability score (NDS) with michigan neuropathy screening instrument (MNSI): peripheral polyneuropathy screening in grade II and III obese and diabetics patients
Lisiane Stefani Dias1, Otto Henrique Nienov1, Camila Perlin Ramos1, Fernanda Dapper Machado1, Emilian Rejane Marcon2, Daiane Rodrigues1, Helena Schmid1
1UFRGS, Rio Grande do Sul, Brazil; 2HCPA, Rio Grande do Sul, Brazil
Correspondence: Lisiane Stefani Dias
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A76
Introduction: In the DCCT/EDIC study cohort, the Michigan Neuropathy Screening Instrument (MNSI) was validated for screening of signs and symptoms of peripheral polyneuropathy (PNP) in diabetics’ patients, presenting a sensitivity and specificity of 61% and 79%, respectively, for a cutoff point of ≥ 2.5. Neuropathy Disability Score (NDS) has also been used in epidemiological studies to screening PNP in diabetic patients.
Objective: To evaluate PNP prevalence through MNSI and NDS instruments in grade II and III obese and diabetic patients, and to assess the sensitivity and specificity of NDS (cutoff point of ≥ 3) in relation to the gold standard MNSI.
Methods: A cross-sectional study was conducted in 291 patients with grade II and III obesity and 276 diabetic patients, where the prevalence of PNP was assessed by MNSI and NDS. For sensitivity and specificity evaluation, ROC curves were constructed.
Conclusion: For screening PNP, NDS shows acceptable performance when compared to the MNSI.
Izabel Cristina Ribeiro da Silva Saccomann, Melissa Aparecida Brandi Passaro, Flávia Pereti Schonfelder
PUC/SP, São Paulo, Brazil
Correspondence: Izabel Cristina Ribeiro da Silva Saccomann
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A77
Introduction: The appearance of complications in diabetic patients have worried some health professionals. Great part of this complications make the person unable to realize some common activities affecting the self-care and consequently his life quality.
Objective: Evaluate the competences for the self-care of patients with diabetics and the factors associated, and realize an educative action based on the shortfall self-care.
Method: Was realized an exploratory study of quantitative nature in 25 patients monitored in the Integral Attention to Adult Health Program from Family Health Unity, inside the São Paulo state. To collect the data was used the Identification of the Competence of the Diabetic for Self-care (ECDAC in Portuguese).
Result: In cognitive competence 51% of the patients presented shortfall of self-care in relation to knowledge about diabetes, signals and symptoms, and treatment. In physics and emotional competence, the patients didn’t show any shortfall. From this results realized an educative action based on the shortfall of self-care in the cognitive competence. Has some increase in the scores of the subscales cognitive competence with significant difference (p < 0.001), indicating the decrease of the shortfall of self-care in this competence.
Conclusion: The knowledge of the competence for the self-care of this population made possible the educational action that show yourself as effective, offering subsidies for the patient be the author of your own care. It’s believed that this study sensitized this population for like healthy habits that will contribute in the reduction of events considered preventable.
A78 Consistent outcomes across dose ranges with titratable lixilan, insulin glargine/lixisenatide fixed-ratio combination, in the lixilan-o trial
Robert R. Henry1, Bo Ahrén2, Melanie Davies3, Yujun Wu4, Yehuda Handelsman5, Elisabeth Souhami6, Elisabeth Niemoeller7, Julio Rosenstock8, Lixilan-O Trial Investigators
1UC San Diego and Veterans Affairs San Diego Healthcare System, Center for Metabolic Research, San Diego, CA, USA; 2Lund University, Lund, Sweden; 3Diabetes Research Centre, University of Leicester, Leicester, UK; 4Biostatistics and Programming, Sanofi-Aventis US, Bridgewater, NJ, USA; 5Metabolic Institute of America, Tarzana, CA, USA; 6Diabetes Division, Sanofi, Paris, France; 7Diabetes Division, Sanofi, Frankfurt, Germany; 8Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX, USA
Correspondence: Robert R. Henry
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A78
Arthur Sampaio Façanha, Filipe Lins Linhares de Sousa, João Augusto Lima Bisneto, Lara Justi Silva Nogueira, Leonardo Siqueira Albuquerque, Ana Kamila Paiva de Souza, Matheus Pontes Parente Travassos, Valeria Silva Bezerra, Sabrina Gomes Aguiar, Marcela Sobreira Kubrusly, Cristina Figueredo Sampaio Façanha
Unichristus, Ceará, Brazil
Correspondence: Arthur Sampaio Façanha
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A79
Introduction: Pregnancy in women with Diabetes Mellitus (DM) is becoming more frequent and proper planning of pregnancy is especially important in this group to prevent adverse maternal and fetal outcomes related to hyperglycemia in early pregnancy. The education of these patients in family planning is critical, but given the complexity of diabetes treatment, it is often neglected by the health staff. The choice of the proper contraceptive method (CM) for the patient with diabetes is not always simple, since some are related to increased risk of vascular complications and worsening metabolic control.
Objectives: To evaluate the knowledge and practices of DM patients of childbearing age on contraception.
Methods: This is a descriptive, cross-sectional study with the application of a structured questionnaire in 66 women with diabetes, of childbearing age attending an outpatient practice on a referral service in the public health care system in Ceará, Brazil. For statistical analysis EpiInfo version 3.5.2 was used.
Results: The sample was 66 women, with a mean age of 36.5 years, 48% did not complete high school and 68% referred a stable marital status. 63% had type 1 DM, average years of disease of 11.4. 26% were nulliparous, and 29.1% had a history of previous abortion. 71.2% of the patients already used some CM, 39% used oral contraception (OC), 16.6% condoms and 18% injectable or subdermal implants and 4% IUDs. Behavioral methods were used by one patient. Among OC patients, 72.3% were unaware about any interference of the method on glycemic control and as only 51% of them used the OC with medical prescription, 8.9% were guided by friends or relatives. Among the existing CMs, it was observed that 97.0% knew the Male Condom, OC: 89.4%, IUD-Cu: 81.8% and 77.3 tubal sterilization. Behavioral methods such as the rhythmic method were known by 69.7%, Coitus Interruptus: 39.4% Cervical mucus: 7.6% and Spermicide: 7.6% and Basal Temperature, 6.1%.
Conclusions: Data show that in a high-risk population where family planning is critical, the issue is poorly discussed during medical care, and half the diabetic women of that sample were using hormonal contraception without medical advice. This situation certainly contributes to the high unplanned pregnancy rate in women with Diabetes. We also observed that behavioral methods are little used by these patients.
A80 Correlation between adiponectin levels and homa-ir index in children and adolescents with overweight and obesity
Carlos Alberto Menezes, Paulo Roberto Santana de Melo, Gabriela Correia Matos de Oliveira, Luís Jesuíno de Oliveira Andrade
UESC, Bahia, Brazil
Correspondence: Carlos Alberto Menezes
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A80
Background: Adiponectin is a major adipokine with insulin-sensitizing function, being an important mediator of insulin resistance (IR).
Objective: The purpose of this study is to study the correlation between IR and adiponectin concentrations in overweight and obese children and adolescents.
Materials and methods: It is a cross-sectional study involving overweight and obese children and adolescents. Anthropometric indices and laboratory evaluation were performed, including insulin, glucose, adiponectin, and IR by HOMA-IR determination. The mean adiponectin was 3.53 ± 5.86 mcg/mL. The HOMA-IR was elevated in 33.3% of overweight and 58.8% of obese. Adiponectin levels were higher in 16.7% overweight compared to 5.9% of obese subjects. The correlation between HOMA-IR elevation and adiponectin levels was statistically significant (P 0.0001).
Conclusion: Levels lower of adiponectin may be a biomarker for the presence of IR in overweight and obese children and adolescents, and constitute another predictive factor for the metabolic syndrome.
A81 Correlation between leptin concentrations and insulin resistance by homa-ir in children and adolescents with overweight and obesity
Carlos Alberto Menezes, Paulo Roberto Santana de Melo, Gabriela Correia Matos de Oliveira, Luis Jesuíno de Oliveira Andrade
UESC, Bahia, Brazil
Correspondence: Carlos Alberto Menezes
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A81
Background: The leptin have as function main the regulation of energy balance as well as regulation of glucose homeostasis and insulin sensitivity.
Objective: The purpose of this study is to study the correlation between leptin concentrations and insulin resistance (IR) by HOMA-IR in children and adolescents with overweight and obesity.
Materials and methods: It is a cross-sectional study involving overweight and obese children and adolescents. Anthropometric indices and laboratory evaluation were performed, including insulin, glucose, leptin, and IR by HOMA-IR determination.
Results: Forty-one subjects participated of study, 25 men and 16 women, mean age 11.68 (6 to 17) years, 24 with overweight (58.5%) and 17 obese (41.5%), 23 with normal HOMAIR (56.1%) and 18 with high HOMA-IR (43.9%). The mean leptin was 26.06 ± 11.025 ng/mL (48.8% normal and 51.2% high). The HOMA-IR was elevated in 33.3% of overweight subjects and in 58.8% of obese subjects. The leptin was elevated in 58.3% of overweight subjects and in 41.8% of obese subjects. The correlation between HOMA-IR elevation and leptin levels was not statistically significant.
Conclusion: High concentrations of leptin and IR are present in children and adolescents with overweight and obesity. The presence of hyperleptinemia without hyperinsulinemia suggests a likely inherent genetic basis for increased leptin resistance.
A82 Correlation between neuropathic symptoms and sensitivity tests in the evaluation of diabetic neuropathy
Júlia Scaravelli Mario, Marília Klein Reis, Mari Cassol Ferreira
Unochapeco, Santa Catarina, Brazil
Correspondence: Júlia Scaravelli Mario
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A82
Introduction: Diabetic foot is a chronic complication of diabetes mellitus (DM) that may manifest as neuropathy, vasculopathy, osteoarticular involvement and infection. Neuropathy initially affects small nerve fibers, responsible for the thermic and pain sensitivity; later, the large nerve fibers are affected leading to changes in proprioception, vibration sensitivity and monofilament test. Nerve damage contributes to the development of lower limb areas with abnormal pressure favoring callosities, local trauma and consequently ulcer and amputation.
Objective: Evaluate the prevalence of neuropathic symptoms and clinical manifestations of peripheral neuropathy in DM patients in primary and secondary care.
Method: Cross-sectional analytic study evaluated 550 individuals with DM type 1 and 2, assisted in the public health service, 212 in primary and 338 in secondary care, with informed consent. The protocol applied was: Screening and early assessment of risk factors and prevention of diabetic foot. The study was approved by UNOCHAPECÓ’s Ethic Board, approval number 162/14.
Results: Samples evaluated showed that diabetes duration average was 11.2 ± 8.4 years; glycated hemoglobin (HbA1c) average was 8.7 ± 2.2%, and 74.6% of individuals had a value above 7%. It was found that 32% of the patients presented loss of protective sensitivity (LPS) and 24.9% showed peripheral arterial disease (PAD). The most prevalent clinical findings were dry skin, cracks or fissures (68.4%), callosities (36.5%) and nail mycosis (35.3%). Neuropathic symptoms (burning, tingling, fatigue or pain) were reported by 74.5% of the individuals; this finding correlated with the involvement of nerve fibers observed by clinical examination (p < 0.001). Patients with LPS had a longer duration of DM (p < 0.001), but individuals with suggestive manifestations of only small fibers damage had a shorter time of disease than those who also had large fibers affected (p < 0.001). Most of the individuals (53.1%) were classified as risk zero (without LPS ± PAD) although some showed neuropathic symptoms, 17.5% as risk 1 (LPS ± deformity), 18.5% as risk 2 (PAD ± LPS) and 10.9% as risk 3 (previous ulcer/amputation).
Conclusion: Data confirms that there was a high prevalence of loss of protective sensibility, but the presence of neuropathic symptoms was higher than the alteration in the sensitivity tests, which highlights the importance of verification of these symptoms as an early sign of diabetic neuropathy.
A83 Correlation of distal diabetic polyneuropathy signs and symptoms with balance and strength of type 2 diabetic patients under insulin therapy: pilot study
Camilla Rodrigues de Souza Silva, André dos Santos Costa, Diogo Arruda Martins de Lima, Tamires do Nascimento, Sandro Gonçalves de Lima, Jhonnatan Vasconcelos Pereira Santos, Paulo Daywson Lopes da Silva, César Augusto Melo de Souza, Sílvia Regina Arruda de Moraes
UFPE, Pernambuco, Brazil
Correspondence: Camilla Rodrigues de Souza Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A83
Introduction: the distal diabetic polyneuropathy (DDP) is one of the main complications of Diabetes mellitus type 2 (DM2) and it contributes to atrophy and muscular weakness, bone deformations, impairment of foot mechanics, resulting in balance deficits and increased risk of falls in this population.
Objective: correlate the DDP signs and symptoms scores with strength and balance of DM2 patients under insulin therapy.
Methods: transversal study, with 6 type 2 diabetic patients (3 women e 3 men; 59 ± 4,7 years; 68,1 ± 4,9 kg; 160.8 ± 5,4 cm; 21,8 ± 9,2 years of DM2 diagnostic) under insulin therapy and DDP diagnosed by the DDP diagnostic scale (DDPDS). The DDPDS provided the Neuropathy Symptom Score (NSS) and the Neuropathy Disability Score (NDS) of each individual. The balance and risk of falls assessment was performed by Biodex Balance System (BBS) (Biodex Balance System, New York, USA) before and after the training period, by means of the modalities: Fall Risk Test (using the general instability index for the assessment of risk of falls), Limits of Stability Test (using the general limits of stability index and test duration to assess dynamic stability) and Postural Stability Test (using the general instability index, the anterior/posterior stability index and medial/lateral stability index for the assessment of static stability). The strength evaluation was performed by the 1 repetition maximum tests (1-RM), using the bench press and leg press machines to assess upper limb and lower limb, respectively. After the Kolmogorov–Smirnov normality test, the Pearson correlation index was calculated to describe the relation between the DDP scores and the balance and strength findings.
Results: The NDS showed negative correlations with the lower limbs ( − 840; p = 0.03) and with the general limits of stability index ( − 933; p < 0.01), while the NSS showed negative correlation with test duration on the dynamic stability assessment ( − 864; p = 0.02). The balance, risk of falls and upper limb strength parameters did not show a significant correlation.
Conclusion: The increase of the signs caused by DDP are related to less lower limb strength and the increase of both signs and symptoms are related to with dynamic balance deficits of type 2 diabetic patients under insulin therapy.
Maurício Aguiar de Paula, Maria Helena Senger, Flávio Morgado
Pontifícia Universidade Católica de São Paulo, São Paulo, Brazil
Correspondence: Maurício Aguiar de Paula
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A84
Introduction: Diabetic retinopathy (DR) is related to inadequate metabolic and blood pressure control. Diabetics treated in primary care in Sorocaba and region are referral to Hospital Oftalmológico de Sorocaba (HOS) already in advanced stage of the DR, which requires ophthalmologic intervention. To perform these procedures, there is a need for clinical adjustment that occurs in the primary care, generating delay, low resolution and social, economic and individual losses.
Objectives: To offer a program of intensive clinical-educational adjustment to patients with DR attended at HOS; Evaluate changes in the level of understanding and metabolic control of this population; Evaluate the performance of the proposed procedures compared to a similar population that did not undergo the intervention; Analyze the costs of the alternative of clinicaleducational adjustment. Material and
Methods: The program had four weekly individual medical visits with educational support. The adjustments were based on the clinical evaluation and analysis of glycemic monitoring with seven measures of 3-day intercalated that preceded care. One group underwent clinical-educational intervention (n = 24) and for the other (n = 24) only the medical records were evaluated. The intervention group was evaluated before and after regarding knowledge about DM, adherence to treatment and attitudes in coping with the disease. The evolution of the ophthalmologic picture in the two groups was compared with the performance of the indicated procedures and costs involved in the activities of each clinical adjustment process: usual and proposed by the study. The activities of each clinical adjustment process were mapped, their unit costs defined and the alternatives compared using the cost-effectiveness method.
Results: A significant difference was observed in the intervention group with improved glycemic control, a higher rate of scheduled procedures (96 vs 48%, p = 0.00), shorter performance time (1.2 months vs 5 months), and Cost-effectiveness ratio. There was a significant increase in knowledge about the disease, adherence to treatment and improvement of the attitude towards the disease.
Discussion: Intensive clinical-educational adjustment program for advanced-stage DR patients offered in specialized service as an alternative to that currently practiced in primary care has a better cost-effectiveness, occurs in a shorter time and can minimize personal, social and institutional losses resulting from evolution of DR. Funding: There was no funding to the study. Sanofi provided editorial support through the hiring of a third part—Eurotrials.
Ethics approval: The project was submitted and approved by the Research Ethics Committee of Hospital Oftalmológico de Sorocaba/SP (CAAE 32784014.7.0000.0088) Consent to publish: Informed consent to publish has been obtained from these patients
A85 Cost-effectiveness of insulin glargine 300 units/ml (GLA-300) vs insulin degludec 100 units/ml (IDEG) in t2d
Daniel R. Murphy1, Xueting Yu1, Marie Fournier2, Timothy M. Klein1, Tao Fan3, Sinem Perk1, Ron Preblick3, Fang Liz Zhou3
1Medical Decision Modeling Inc., Indianapolis, IN, USA; 2Sanofi, Chilly-Mazarin, France; 3Sanofi, Bridgewater, NJ, USA
Correspondence: Daniel R. Murphy
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A85
Objective: A new generation of basal insulins has been developed in recent years to reduce hypoglycemic risk and provide steadier glycemic control in T2D. This study evaluated cost-effectiveness for two of these basal insulins, Gla-300 and IDeg, from a US payer perspective.
Methods: This modelling analysis simulated a cohort representing patients in the EDITION 2 and 3 trials using the IMS Core Diabetes Model with a time horizon of 50 years (lifetime) for 1,000,000 patients starting at 62 years old. Treatment efficacy parameters, measured as A1C reduction and hypoglycemia event (HE) rates, were estimated using a network meta-analysis: for Gla-300 vs IDeg, the A1C reduction over 24 weeks was 1.00 vs 0.98%; HE rates were estimated as 2.5 vs 4.0 severe HEs and 446 vs 555 non-severe HEs (NSHEs) per 100 patient years, respectively. The cost/unit of Gla-300 was set to $0.22 to maintain dose-adjusted price parity with insulin glargine using data from the EDITION trials. The cost/unit of IDeg was set to $0.296 from its US Wholesale Acquisition Cost. The treatment cost was $1,561 per SHE and $13.65 per NSHE (2015 $). Utilities to estimate quality-adjusted life years (QALYs) for multiple comorbidities were applied using the minimum utility approach. A disutility of -0.0118 was applied for SHE, and method of diminishing marginal disutility for NSHE.
Results: Compared with IDeg, Gla-300 provided a total cost reduction per patient of $8,998 ($162,288 vs $171,286) and a QALYs gain of 0.035 (7.677 vs 7.642) for lifetime in base-case analysis. One-way sensitivity analysis showed that 10% change in A1C, SHE/NSHE rates, and treatment costs did not change the incremental cost-effectiveness ratio (ICER) dominance for Gla-300. Probabilistic sensitivity analysis found that Gla-300 was less costly in 95.4% of cases and more effective in 60.1% of cases vs IDeg.
Conclusion: Gla-300 provides a dominant cost-effectiveness profile over IDeg, though real-world data needs to confirm this finding. This is an ENCORE abstract previously presented at ADA2017. Funding and editorial support provided by Sanofi.
A86 Critical evaluation of the food factor in a group of patients with type 1 diabetes of different age groups using continuous subcutaneous insulin infusion and inadequate glycemic control
Monica A L Gabbay1, VAnessa Montanari1, Carolina Sallorenzo1, Paula Pascali1, Maria Gabriela Cavicchioli1, Willian Komatsu1, Erika HernandesOliveira2, Vanessa Fujimoro Galves3, Paula Cristina Augusto Costa1, Tarcila Ferraz Campos1, Beatriz F Bernardo1, Marcio Alex Santos1, Priscila F Gonçalves Pecoli1, Sergio Atala Dib1
1unifesp, São Paulo, Brazil; 2meditronic, São Paulo, Brazil; 3Roche, São Paulo, Brazil
Correspondence: Monica A L Gabbay
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A86
Introduction: At present, insulin replacement with the continuous subcutaneous insulin infusion (CSII) is considered to be the therapeutic option closest to the physiological one for patients with type 1 diabetes (T1D) because it allows greater food flexibility and rapid corrections of hyperglycemia. However, a significant percentage of these patients remain outside the targets of good metabolic control (glycemia and lipids). One of the factors may be related to an inadequate distribution among the three main food groups.
Objective: Evaluate the intake of carbohydrate, proteins and fats in relation to the standard diet in a group of patients with T1D of different age groups using CSII and inadequate glycemic control.
Methods: 53 patients with T1D, using CSII, were divided into 3 groups (PPGpre-pubertal: < 9 years), (PG-pubertal: 10–18 years) and (AG-adult: 19–35 years), BMI (kg/m2), CSII use time (years), A1c (%), total cholesterol (TC) and fractions, triglycerides (TG), and the relative percentage of carbohydrates, in relation to the standard diet.
Results: A1c was similar between the 3 groups (PPG: 8.1 ± 0.5%, PG: 9.3 ± 1.3% and AG-8.2 ± 1.1%). Carbohydrate intake below recommended age showed an inverse relationship with age (PPG < 63%, PG < 93% and AG < 100% p = 0.00). However, the type of carbohydrate was inadequate, being above recommended in relation to processed juices at 100% (PPG), 66% (PG) and 25% (AG), fastfood at 21% (PPG), 46% (PG) and AG (66%) and in sweet 81% (PPG), 73% (PG) and 33% (AG). Protein (milk) intake was adequate in 80% (PPG) PG and 33% in AG, while fat intake was above 40% in the 3 groups studied. Alcohol was present in ¼ PG and 62% AG, but in an adequate amount. The values of CT and TG were adequate in the 3 groups.
Conclusion: Patients with T1D using CSII had a carbohydrate intake below the recommended level and with an inverse relationship to age, but with inadequate content. The amount of fat was above the expected and protein within the recommended. The study emphasizes the need for a better orientation of the type of carbohydrate and the amount of fat for T1D patients using CSII. These aspects should be considered during optimization of the results obtained with this high cost therapy for T1D patients.
James Ml, Green L, Amiel SA, Chourdhary P. Evaluation of the effect of carbohydrate intake on postprandial glucose in patients with type1 diabetes treated with insulin pumps. J Diab Sci Tech 2016:1-7.
Bruno Stephano Ferreira da Silva1, Gabriel Gomes Araujo1, Larissa Lopes da Cruz1, Thais Leal Silva1, Verônyca Gonçalves Paula1, Rafaianne Queiroz de Moraes Souza1, Maysa Rocha de Souza1, Débora Cristina Damasceno2, Gustavo Tadeu Volpato1
1UFMT, Mato Grosso, Brazil; 2UNESP, São Paulo, Brazil
Correspondence: Bruno Stephano Ferreira da Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A87
Introduction: During pregnancy, hyperglycemia can lead to maternal and fetal complications, leading to reproductive changes and fetal impairment. considered to treat diabetes and prevent its complications, and one of these alternatives is the use of medicinal plants, such as Curatella americana. However, there is no scientific evidence on the safety of the plant use during gestation and its effects on fetuses.
Objective: To evaluate the effects of treatment with Curatella americana during pregnancy on the fetuses of rats with hyperglycemia of mild intensity.
Method: Diabetes was induced in newborn female Wistar rats, at 24 h after birth, by subcutaneous injection of Streptozotocin at a single dose of 100 mg/kg. At 110 days of age (adulthood), oral glucose tolerance test (OGTT) was performed to confirm the mild diabetes model. After confirmation of the diabetes, the rats were mated and distributed into 4 experimental groups (n = 12 animals/group): Control: Non-diabetic rats treated with water; Control Treated: Non-diabetic rats treated with the plant; Diabetic: Diabetic rats treated with water; Diabetic Treated: Diabetic rats treated with the plant. The administration of the Curatella americana leaves aqueous extract, at dose of 300 mg/kg, was done daily, by gavage, throughout pregnancy. On the morning of the 21st day of pregnancy, the rats were anesthetized and the uterus was removed. Fetuses and placentas were weighed and fetuses were analyzed for the presence of external, skeletal and visceral anomalies.
Results: There was no difference among the experimental groups in the ossification sites, placental efficiency and in the frequencies of fetal abnormalities (external, skeletal and visceral). However, the Control Treated group present lower fetal and placental weight, with an increase of fetuses classified as small for pregnancy age.
Conclusion: Treatment with Curatella americana caused intrauterine growth restriction in nondiabetic animals at the dose tested, but this weight loss did not translate into changes in skeletal development and anomalies. Therefore, more studies are needed to prove the safety of the use of this plant for the fetus.
Nara Nóbrega Crispim Carvalho1, Rômulo Bagano Meneses2, Lucas Sampaio Lustosa Neves3, Mariana Oliveira do Amaral3, Maria Alayde Miranda de Oliveira Neta3, Vivianne Almeida da Nóbrega4, Felícia Nóbrega Crispim Ribeiro5, Patrícia Fontes da Costa Bagano6
1Universidade Federal da Paraíba-PB, Paraíba, Brazil; 2Hospital Geral Ernesto Simões Filho-CE, Ceará, Brazil; 3Faculdade de Ciências Médicas da Paraíba-PB, Paraíba, Brazil; 4Centro Universitário de João Pessoa-UNIPÊ-PB, Paraíba, Brazil; 5Hospital Regional de Patos Janduhy Carneiro-PB, Paraíba, Brazil; 6Hospital Português-CE, Ceará, Brazil
Correspondence: Nara Nóbrega Crispim Carvalho
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A88
Introduction: SGLT2 inhibitors are oral antidiabetic agents capable of altering independent cardiovascular risk factors, such as: blood glucose, blood pressure, weight, intrarenal hemodynamic and albuminuria.
Objective: To describe a clinical case in which the use of dapaglifozin (DAPA) was effective in inducing and maintaining weight loss over 3 years.
Case report: M.G.G.A, female, 65 years old, caucasian, married, sought an endocrinologist in 2014 due to the diagnosis of type 2 diabetes mellitus 3 years ago, she used glimeperide 4 mg/day and metformin (MTF) 1 g/day. She was hypertensive and dyslipidemic, already under treatment, and reported difficulty in losing and maintaining weight for several years. She denied physical activity (PA) practice for 1 month (before walking 3x/week) and in a 24-hour diet reminder there was an excess of simple carbohydrate (SC) intake and saturated fat (SF). The physical examination showed: arterial pressure (AP):130x80 mmHg, weight (W):78.6 kg, height:1.54 m, BMI:33.14 kg/m2 and abdominal circumference (AC):108 cm. The patient was oriented to change her lifestyle and it was also requested exams. After 1 month: fasting glycemia (FG):169 mg/dl, postprandial glycemia (PPG):145 mg/dl, Hb1Ac:7.1%, total cholesterol (TC):253 mg/dl, HDL:55 mg/dl, LDL:129 mg/dl, triglycerides (TG):156 mg/dl, 25-hydroxy vitamin D(25-OHD):23 ng/dl, creatinine:0.6 mg/dl, glomerular filtration rate (GFR): > 60 ml/min/1.73 m2 (MDRD), microalbuminuria, and the rest of the serum tests normal. At this time, due financial limitation, she was directed to maintain medications, prescribed vitamin D3 14,000 IU/week and stimulated lifestyle change (LC). She returned after 4 months with unchanged physical examination measures, HbA1c:7.8%, FG:166 mg/dl, PPG:163 mg/dl, being chosen to exchange oral antidiabetic regimen for DAPA 10 mg/day and MTF 1 g/day, with maintenance of the other guidelines for LC. After 9 months: W:69.9 kg, AC:98 cm, BMI:29.47 kg/m2, and she reduced the consumption of SC and SF, but maintained the sedentary lifestyle. Exams: Hb1Ac:7.0%, FG:118 mg/dl, PPG:152 mg/dl, TC:242 mg/dl, LDL: 139 mg/dl, TG:127 mg/dl and irregularly using rosuvastatin 10 mg, guided regular use of medications. During 3 years of follow-up, patient maintained controlled HbA1c (around 6.8%) and W:69 kg, but she still did not perform PA.
Conclusion: DAPA associated with MTF improved the glycemic levels, and it also helped in the weight loss and the weight maintenance of the pacient over these 3 years. Informed consent to publish has been obtained from this patient.
A89 Day-to-day variability of fasting self-measured plasma glucose (SMPG) correlates with risk of hypoglycemia in adults with type 1 (T1D) and type 2 diabetes (T2D)
Timothy S Bailey1, Anuj Bhargawa2, Hans de Vries3, Gregg Gevery4, Januz Gumprecht5, Wendy Lane6, Carol Wysham7, Athena Philis-Tsimikas8, Monica Palmanhani9, Bak Ba10, Nielsen E Rachmann10
1AMCR Institute, San Diego, CA, USA; 2Iowa Diabetes and Endocrinology Research Center, Des Moines, IA, USA; 3University of Amsterdam, Amsterdam, Netherlands; 4Albany Medical Center, Albany, NY, USA; 5Medical University of Silesia,Zabrze,Poland; 6Mountain Diabetes and Endocrine Center, Asheville, NC, USA; 7Rockwood Clinic, Spokane, WA, USA; 8Scripps Whittier Diabetes Institute, San Diego, CA, USA; 9Novo Nordisk, São Paulo, Brazil; 10Novo Nordisk, Bagsværd, Denmark
Correspondence: Timothy S Bailey
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A89
Background: The relationship between hypoglycemia and day-to-day variability of glycemic control has not been well established.
Aim: A post hoc analysis was performed correlating day-to-day variability of fasting SMPG with hypoglycemia in two double-blind, treat-to-target, crossover trials that compared insulin degludec once daily (OD) with insulin glargine U100 OD in adults with T1D (SWITCH 1, n = 501) or insulin-experienced adults with T2D (SWITCH 2, n = 721)
Methods: Available SMPG measurements were used to determine a weekly variance for each patient, using the log SMPG values to allow for relative comparisons. For each patient and treatment, the geometric mean of the weekly variance was calculated and these values were categorized into low, medium and high tertiles as a measure for day-to-day variability. The effect of having low or high variability compared with medium variability was analyzed in relation to overall symptomatic (severe or blood glucose [< 56 mg/dL] confirmed), nocturnal symptomatic (00:01–05:59), and severe (requiring third-party assistance and confirmed by a blinded adjudication committee) hypoglycemia.
Results: Day-to-day SMPG variability was a significant predictor for the risk of overall and nocturnal hypoglycemia in T1D and T2D, and severe hypoglycemia in T1D (Table).
Conclusion: Day-to-day glycemic variability relates to hypoglycemia risk.
Alessandra Muto, Fernanda Padua, Olga Simone Nebel First
Hospital Ipiranga, São Paulo, Brazil
Correspondence: Alessandra Muto
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A90
Dunnigan type partial lipodystrophy is a rare autosomal dominant disease. In its classic form, it is resulting from a heterozygous missense mutation in the LMNA gene, which encodes the nuclear protein called A/C lamina(1). Changes begin at puberty, with enlargement of the labia majora, chin and face, as well as disappearance of subcutaneous tissue in upper and lower limbs. Affected women are particularly predisposed to insulin resistance and its complications, including signs of polycystic ovary syndrome. Case report: 35-year-old female diabetic, hypertensive, diagnosed with Kobbeling Dunningan syndrome after the first gestation in 2001, began treatment with a plastic surgery team for changes in the classic fat distribution of her disease, with rhytidectomy and initiated follow-up in the team of endocrinology for diabetes control in the use of insulin therapy with poor glycemic control, after the initiation of DDP4 inhibitor initiated improvement of glycemic levels with maintenance of control.
Informed consent to publish had been obtained from the patient.
Rafael Pinto da Silva, Francineide Pereira da Silva Pena, Jessica Gomes da Silva, Jessica Monteiro Cunha, Sônia Silva Alves, Danielle Cardoso Portilho, Gabriela de Souza Amanajás, Tallitha Barbosa da Luz, Diego Quaresma Ferreira, Emanuel de Jesus Vaz Bittencourt, Amiraldo Dias Gama, Maria Silvia da Costa Silva, Adriane Stefanny Rocha Ribeiro
UNIFAP, Amapá, Brazil
Correspondence: Rafael Pinto da Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A91
João Batista Moreira, Eliene Sousa Muro, Ismael David de Oliveira Muro, Lidiane Aparecida Monteiro, Denise Hollanda Iunes, Érika de Cássia Lopes Chaves, Juliana Bassalobre Carvalho Borges
UNIFAL, Minas Gerais, Brazil
Correspondence: João Batista Moreira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A92
Introduction: Diabetes Mellitus is a challenge for Health, with a high potential for morbidity and mortality. Among its main complications is the diabetic foot, defined as a series of alterations that occur in the lower limbs, associated to the high amputation index, which affects the productivity and independence of the person. Proper examination of the feet is able to diagnose the problem early and prevent injuries and hospitalizations. However, the evaluation for prevention of diabetic foot is insipient and not fully incorporated in the health services. However, it is necessary to develop innovative tools that facilitate foot examination in order to save time and standardize evaluation.
Objective: To develop an application to evaluate the risk of diabetic foot, based on the Diabetic Foot Manual of the Brazilian Ministry of Health.
Methods: Methodological, descriptive, quantitative and multidisciplinary study that allowed the development of an application on the Android platform, with based on the evaluation of the feet of the person with Diabetes Mellitus advocated by the diabetic foot manual of the Ministry of Health. Java language was used for programming. For interaction between the researchers was used the Extreme Programming method that consisted of a cyclical process: select user stories; divide stories into tasks; plan release; develop/integrate/test; release version and evaluate the application, returning through the steps until it was suitable for foot evaluation.
Results: “Foot Care” application was developed with 19 main screens that contain icons for access to photos and help and videos that demonstrate the procedure of sensitivity and reflex tests. Screens are thus arranged: presentation screen with information about the application and instructions for use; screen with features of registration, data export and the list of people evaluated; screens of the assessment itself, which include the skin and attachment domains, sensitivity assessment, vascular assessment and evaluation of foot deformities. Finally, the screen that presents the risk classification of the diabetic foot; the change that suggested such a risk; the recommendations, the evaluation frequency and the behaviors that should be taken by the health professional.
Conclusion: It is concluded that the application made in this study is an innovative tool and is an important tool to prevent early diabetic foot.
Marcia Carolina Mazzaro1, Émelin Alves dos Santos1, Géssica Baptista de Melo2, Priscila Duarte Marques2, Laura Vilela Souza1, Jefferson Elias1, Bruna Campos da Silva1, Fabiana Martins de Paula2, Fernanda de Mello Malta2, Ronaldo César Borges Gryschek2
1UFG, Goiás, Brazil; 2USP, São Paulo, Brazil
Correspondence: Marcia Carolina Mazzaro
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A93
Introduction: Strongyloides stercoralis is an intestinal nematode that infects approximately 100 million people worldwide, mainly in tropical and subtropical regions. Most S. stercoralis carriers are asymptomatic or oligosymptomatic, which does not mean absence of pathogenic action. Extra-intestinal manifestations can lead to severe and life-threatening conditions, especially in immunocompromised patients. The medical literature has case reports of disseminated strongyloidiasis in diabetic patients, but no studies have determined the relationship between diabetes and strongyloidiasis.
Objective: The aim of this study was to evaluate the parasitological and molecular profile of strongyloidiasis in patients with type 2 diabetes mellitus (DM2) and to analyze their value in the detection of chronic asymptomatic infection in these patients.
Method: The study population were patients seen in the Diabetes Education and Control Program Jataí—GO and other non—diabetic individuals living in the city. A total of 149 individuals were collected from three fecal samples on alternate days, these were characterized in two groups: Group I (97) patients with DM2, Group II (52) individuals not carrying DM2. The fecal samples provided were submitted to parasitological methods of Hoffman, Rugai and agar plate culture, and subsequently, to molecular analysis by Polymerase Chain Reaction (PCR), and all positive samples were confirmed by DNA sequencing. Data were analyzed using Chi square and logistic regression tests.
Results: The overall positivity of S. stercoralis by parasitological techniques was 2.6% (4/149), and only one DM2 patient was positive for the infection. With PCR, the positivity was 16.1% (24/149), being 9.3% (9/97) in the group I, and 28.8% (15/52) in the group II. DM2 showed to be a protective factor for strongyloidiasis (OR 0.252 IC95% 0.101 a 0.628 p = 0.003). There was no agreement between the parasitological methods and PCR in the detection of S. stercoralis.
Conclusion: The PCR technique using primer species-specific for S. stercoralis showed a superior ability to detect infection in asymptomatic diabetic and non-diabetic patients.
Mônica Maurer Sost, Vanice Low Wagner, Anize von Frankenberg, Jussara Carnevale de Almeida
UFRGS, Rio Grande do Sul, Brazil
Correspondence: Mônica Maurer Sost
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A94
Several strategies can be used to obesity treatment by the multidisciplinary team: diet, physical activity, behavioral therapy, medications and surgery. The dietary adherence has been associated with weight loss, however determinants to weight loss in the individual approach of treatment with nutritionist are not clarified yet. To know these determinants can support the strategies adoption in clinical practice. In this way, the aim of this retrospective cohort is to evaluate the factor determinants to weight loss of outpatients with obesity follow by nutritionist. Obese outpatients who were follow out dietary counselling by registered nutritionist from the Endocrinology Division of HCPA, Porto Alegre-RS were select consecutively. All procedures involving patients were approved by the Hospital Ethics Committee (nº15.0138) according to Declaration of Helsinki. The protocol were five visits: anamnesis (clinical, lifestyle, and anthropometric evaluation); diet visit with delivered a prudent diet with calorie restriction; and three bimonthly visits (described as visit one, two and three) to dietary approaches. The dietary adherence was ranked (0-100%). Patients were grouped into those who achieved the goal of at least weight 3% loss from initial weight in 6 months (achieved the goal) and those who cannot achieved the weight loss goal and their characteristics were compared using appropriate tests. Poisson regression models were performed to evaluate the possible association between determinants and weight loss. One hundred and forty-seven patients were included and 47 patients (26%) achieved the weight loss goal [Δ weight—5.9(−21.5 to −2.3)kg]. A higher proportion of patients which achieved the goal also attended the visit one (83% vs. 66%, p = 0.040) and visit two (83% vs. 56%, p = 0.001) as compared to patients without weight loss. Dietary adherence was not different between groups, as well as the other characteristics (social,clinical and medications use). The attendance in the visit two was associated with more chance of weight loss when comparing with those who did not go to the visit: OR 4.44 (95% IC 1.6112.25); p = 0.004) after adjust to physical activity, drugs use and dietary adherence. In conclusion, the patients who achieved the weight goal were more assiduous than the other patients. The visit absence maybe a negative determinant to weight loss. The reasons for that need to be investigated.
A95 Development and cultural adequacy of a tool to evaluate the level of knowledge from users of continuous insulin infusion system (CIIS-Brazil)
Maria Eugênia Silva Hitchon1, Carla Ferraz de Oliveira Borges1, Débora Bohnen Guimarães1, Luciana Valadares Ferreira1, Adriana Silvina Pagano2, Ilka Afonso Reis2, Aleida Nazareth Soares1, Janice Sepúlveda Reis1
1Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte., Minas Gerais, Brazil; 2UFMG, Minas Gerais, Brazil
Correspondence: Maria Eugênia Silva Hitchon
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A95
Background: The Continuous Insulin Infusion System (CIIS) is increasingly being used in Brazil, with trained professionals actively involved in the initiation and monitoring of diabetes treatment. However, there are not any tools that have been adapted to measure the level of knowledge of diabetes patients using CIIS. The elaboration of reliable tools that make possible to measure effects of the teaching-andlearning process, before and after an intervention, can only be useful and able to present scientific results when those tools have valid psychometric qualities in order to not implicate the quality of acquired data.
Objective: To elaborate and to adequate culturally a tool to evaluate the knowledge from users of CIIS.
Methods: Methodological study, comprising two steps: 1) Elaboration of the tool, based on both national and international diabetes guidelines, followed by evaluation by a committee of experts, including endocrinologist, nutritionist, nurses and statistician, to generate the first version (V1); 2) V1 was sent via the e-surv platform to a committee of judges, comprising endocrinologists with experience in therapy, certified instructors employed by the companies that sell the CIIS in Brazil, and linguists from different regions of the country, who evaluated the tool for clarity and relevance. Based on this evaluation, the Content Validity Index (CVI) and the judges’ percentage score for the adequacy of the tool’s components were calculated, with changes which generate a second version (V2). After each of these phases, there was discussion of the Expert Committee to evaluate suggestions, to identify problems and pertinent changes.
Results: V1 of the tool was highly scored by the judges’ committee with respect to clarity and relevance, with a CVI of 0.97, from which V2 was generated, comprising 17 questions (Table 1).
Luiz Carlos Pereira Junior, Maytê Alves de Andrade Possamai, Thyara Becker, Fulvio Clemo Santos Thomazelli
NAD (Núcleo de Atenção em Diabetes da Prefeitura de Blumenau—SC), Santa Catarina, Brazil
Correspondence: Luiz Carlos Pereira Junior
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A96
Introduction: In the region of Blumenau, the prevalence of Diabetes Mellitus (DM) is approximately 25,000 people, of which 3,249 are insulinized and are enrolled in the program of distribution of inputs for the treatment of the disease by SUS. In 2012, the Coordination of the Adult Health Policy and the Management of the Health Department of the Municipality of Blumenau elaborated the implementation of a Diabetes Care Center (NAD).
Objective: To describe the actions performed by the NAD team, whose main objective is to provide specialized interdisciplinary care to people with decompensated DM.
Methodology: This is a descriptive study about the experience of professionals working at the Diabetes Care Center of the Municipality of Blumenau. The reporting period is from the year of its implementation to date.
Results: In the implementation of the NAD in 2012, the activities started with a team with a minimum structure, however, with the increase in the demand of patients, it was necessary to hire more professionals and the construction of a new headquarters, with a bigger physical structure. Today 2,688 users are already registered with NAD. A total of 320 consultations in endocrinology, 80 nutrition consultations, 60 consultations in psychology and 40 nursing consultations are carried out per month for foot evaluation, insulinization and acquisition of special footwear for free. To ensure psychological support, meetings of therapeutic groups are also held. Since its implementation, it has been established as an Assistence Teaching Unit and serves as a research field for scholarship recipients and health course volunteers, who work in the FURB PET-HEALTH GRADUASUS group. Online marriages in endocrinology and training for network professionals are conducted through an event entitled Debates Mellitus. In November, actions related to the Municipal Diabetes Prevention Week are carried out, among them: Seminars, background work, preventive actions in squares with capillary glycemia tests, and, finally, the “Blue Walk”.
Conclusions: We believe that through a policy of care the person with DM develops educational, preventive and diagnostic actions, that guarantees the free supply of medicines and supplies for self-control and that makes the user aware of their co-responsibility in the treatment through of Supported Self-Care, it is possible to minimize the complications of DM and improve the quality of life of users.
Erick Augusto Ferreira Coutinho, Giovana Mahamed Daher, Fernanda Vasconcelos de Carvalho
Conjunto Hospitalar do Mandaqui (CHM), São Paulo, Brazil
Correspondence: Erick Augusto Ferreira Coutinho
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A97
A 42-year-old male patient with obesity and hypertension was brought to the emergency department of Hospital Conjunto do Mandaqui in São Paulo with adinamy, weight loss, polyphagia, polydipsia and polyuria 3 weeks ago. On physical examination, the patient had sleepinees, dehydration (3 +/4 +), ketone breath, tachycardia 136 BPM, hypotension, 75 × 50 mmHg, oxygen saturation of 99% and respiratory rate of 20/min. The initial laboratory tests indicated high capillary blood glucose, leukocytosis of 18,400 (neutrophilia of 90%), haemoglobin level of 15.1 g/dl, hematocrit of 49.9%, urea of 173 creatinine of 3,36 sodium of 146 potassium of 5,1. The arterial gasometry showed a significant metabolic acidosis. The urinalysis was marked by glycosuria (2 +) and leukocyturia (176,000). The diagnosis of diabetic ketoacidosis was made, and the patient was treated with venous hydration and continuous intravenous insulin infusion. The patient showed a satisfactory response to treatment, with good control of the dehydration and blood pressure. An hyposodic and diabetic diet was introduced, and the patient showed an increase in appetite. Normal values of the C—4,6 peptide were obtained and indicated no pancreatic injury. Two consecutive tests were negative for the autoantibodies against GAD, islet cells, insulin and IA2. The pacient was discharged from the hospital with full insulin therapy. During the follow-up, the insulin dose was gradually reduced due to few episodes of hypoglycemia. After 2 months the patient had good glycemic control, and reported adequate lifestyle and dietary habits. metformin use XR 1500 mg/day establishing as most likely diagnosis flatbush diabetes. Flatbush diabetes is one of the several variations of the type 2 DM, and is also refered to as idiopathic type 2 DM and ketosis-prone type 2 DM. Here, a misleading diagnosis of DM 1 is common, due to the total autoimmune destruction of the T cell-mediated pancreatic beta cells, without antibodies associated with the type 1 DM. In DM flatbush, diabetic ketoacidosis, but in this case it is possible the weaning of insulin therapy and the drug adoption proposed for DM 2, in addition to the non-medicament measures, since it was observed that preservation and recovery of pancreatic function is possible. The case report aimed to raise awareness of this rare condition and avoid misdiagnosis and unecessary treatments.
Informed consent to publish had been obtained from the patient.
A98 Diabetes patients’ adherence who went through education group in a clinical program from a private institution in São Paulo
Marcela Alves Teixeira Furtado, Camila Yumi Senaga, Pedro Gabriel Melo Barros e Silva, Viviane Aparecida Fernandes, Valter Furlan
Amil-Total Care SP, São Paulo, Brazil
Correspondence: Marcela Alves Teixeira Furtado
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A98
Introdution: Diabetes Mellitus (DM) is a chronic, complex, not transmissible disease that requires continuous medical care and strategies to decrease multifactorial risks besides glycemic control; to improve patients’ treatment and prevent possible complications. From1980 s diabetes’ treatment has becoming even more complex with incorporation of new medications and technology within reach of patients being part of their daily lives. From the beginning of the diagnosis, patients and their relatives must get knowledge about the disease and develop necessary skills for patients’ self-care. It is called, education in diabetes. The process that develops these skills incorporates tools that reach results in each stage of the treatment. Therefore, education in diabetes is the main tool to guarantee patient’s self-care,leading them to self-control. The present study aims to describe the importance of promoting education for type 1 and type 2 diabetic patients for the purpose to promote treatment adherence and encourage self-monitoring.
Study population: Patients from Diabetes Clinical Program in a Private Outpatient Institution (POI) in São Paulo (TOTAL CARE) who passed through education in comparison to diabetic patients who did not pass through diabetes education (N = 1673). The average age is mainly between 41 and 80 years old, 50% both sexes; in the two groups, 50% with more than 20 years of diagnosis.
Methods: The Patients from Diabetes Clinical Program—Total Care (N = 2152) were evaluated regarding adherence to multi-professional intervention (nutrition, eye examination, foot examination, dentist consultation). Patients who were seen by the diabetes Educator were compared with those who did not pass through this developing process as a stage of their treatment.
Luana Aparecida de Lima Ramaldes de Oliveira1, Patricia Medici Dualib1, Mônica Andrade Lima Gabbay1, João Roberto Sá2, Sérgio Atala Dib2
1Unifesp, São Paulo, Brazil; 2Unifesp- Escola Paulista de Medicina, São Paulo, Brazil
Correspondence: Luana Aparecida de Lima Ramaldes de Oliveira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A99
Introduction: Until now it is known that diabetes presenting as ketoacidosis (DKA), in the absence of a detectable precipitating factor, may correspond to a heterogeneous group of pathologies, especially when it occurs in adults. Among these pathologies we have ketosis-prone diabetes (KPD), initially described by Banerji et al. 1994 in African Americans. KPD is a rare form of Diabetes Mellitus (DM) which presents with DKA and after initial glycemic compensation may evolve into insulin exogenous independence. In recent years, cases of KPD have been reported in Africa, Japan, Spain, China and Pakistan, suggesting a global distribution. In Brazil, there is only one case report in the literature.
Patients: Here we report a prospective study of 4 cases of Brazilian KPD. The diagnosis of KPD was based on the occurrence of spontaneous DKA after the age of 30 years in individuals with newly diagnosed DM and not classifiable according to the classic types. The data during the presentation and follow-up of the KPD are summarized in the table Discussion The patient diagnosis age during the 4th and 5th decade of life is compatible with the studies described in the literature. The mean BMI of the group was 31.23 kg/m2, comparable to previous studies (28.9 kg/m2 reported by Banerji, 37 kg/m2 by Umpierrez, 30.3 kg/m2 by Maldonado). The presence of family history of DM2 was 80% higher than that seen by other groups (Chihaoui (56%), Banerji (67%) and Mauvais Jarvis (67.6%). Significant recovery of beta cell function and time of insulin dependence in the group was reported to be close to 1 year, consistent with studies reporting a period of 1 to 2 years.
A100 Diabetes without borders: insertion of digital media into diabetes education actions developed within the state of Minas Gerais
Elenice dos Santos Paula1, Mayara Dumont Cunha1, Daniela Pereira De Castro1, Fernando Gonçalves dos Santos1, Gabriela de Araujo Nominato1, Hugo dos Santos Silva Júnior1, Lucas Gabriel de Siqueira1, Paulo Henrique Lopes1, Marileila Marques Toledo1, Jéssica Samara Oliveira Tolomeu2, Juliana Sales Rodrigues Costa1, Grayce Kelly Cristina Costa dos Santos1, Érica Cristina Santos Rodrigues1, Ana Cláudia Chaves1, Franciele Angelo de Deus1, Eduardo Augusto Barbosa Figueiredo1, Noêmia de Fátima Silva Lopes3, Luciana de Freitas Campos1, Milena Campos Silva1, Lorena Kelly Babetto Amaral1, Edson da Silva1
1UFVJM, Minas Gerais, Brazil; 2Secretaria Municipal de Saúde de Diamantina, Minas Gerais, Brazil; 3UNIMONTES, Minas Gerais, Brazil
Correspondence: Elenice dos Santos Paula
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A100
Background: Diabetes Mellitus (DM) is a chronic disease with increasing worldwide prevalence. Therefore, it is relevant to use digital media resources in diabetes education, especially to educate people living in the interior regions of the country, in which patients deal with limitations of access to health services
Objective: In this study, our aim was to report the insertion of digital media in diabetes education actions developed in a project of University extension.
Results: Our search identified a total of 128 unpublished radio programs that were produced and broadcast, reaching about 100,000 people from Diamantina and 10 other municipalities in the region. The FDD received more than 1,500 likes/followers and its publications reached 375,647 views in Brazil and in 44 other countries (Figs. 1 to 4). Diabetes Diamantina on SoundCloud shared 25 podcasts, which were reproduced online 1,196 times, and received 37 likes. The Diabetes Diamantina Blog hosted 42 posts about DM, with weekly frequency and the total of 49,040 views by people from Brazil and other 9 countries. In addition, 25 educational games were developed from the texts used in the radio programs.
Conclusion: The University extension actions of the project have been a high social relevance, given the scope of the sharing of educational content and the use of digital media. There was an admirable contribution to the academic formation and greater integration among those involved in this proposal for online diabetes education. The authors are grateful to the CNPq, FAPEMIG, Rádio 99.7 FM and UFVJM for the support.
A101 Diabetes mellitus evolution in two brothers with berardinelli-seip congenital lipodystrophy (BSCL), one R
Enzo Loandos Oliveira, Luiz Brandão Dantas Costa Junior, Thays Marchi, Thiago Almeida Gomes Moura, Aline Andrade de Lucena, Gabriel Oliveira do Carmo, Gisele de Sá Mascarenhas, Luana Machado Figueredo, Leila Maria Batista Araújo
HUPES/UFBA, Bahia, Brazil
Correspondence: Enzo Loandos Oliveira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A101
Case presentation: Two brothers with neonatal diagnosis of Berardinelli-Seip Congenital Lipodystrophy (BSCL), born in Caculé-Bahia, without cases of diabetes or similar diseases in their family. Clinically, both present muscular hypertrophy and acromegaloid features. Case 1: MJFA, 17 years old, at 11 with hyperglycemia (fasting 108 mg/dL; HbA1C 6.4%), moderate hepatic steatosis and hypertriglyceridemia between 200 and 350 mg/dL. Serum leptin 1 ng/mL (reference range: 2–18). In july 2017, in use of Metformin 1.5 g, Fenofibrate 160 mg and Losartan 50 mg/day, with HbA1C 7.6% and triglyceride level of 453 mg/dL. Case 2: LJFA, 16 years old, at 10 with hyperglycemia (fasting 73 mg/dL; HbA1C 7%), left ventricle hypertrophy detected by echocardiography and hepatomegaly. Leptin 1.3 ng/mL. In 2016, HbA1C 7.8%, in use of Metformin 2 g/day, pioglitazone and vitamins E, A and D supplementation. 2017 Fibroscan revealed Hepatic Fibrosis F3. In april 2017, HbA1C 6.1% and triglyceride level 151 mg/dL. By that time, Metreleptin was initiated at a 5 mg/day dose (0.07 mg/kg/day) and Metformin was maintained. After 3 months, the patient has HbA1C 5%, triglyceride level 70 mg/dL, TGO 42 U/L and TGP 32 U/L.
Discussion: BSCL is characterized by the absence of functional adipocytes and leptin diminution. Major clinical criteria for diagnosis are: lipoatrophy (trunk, limbs and face), acromegaloid features, hepatomegaly, hypertriglyceridemia and insulin resistance. Minor criteria are: hypertrophic cardiomyopathy, psychomotor retardation, hirsutism, precocious puberty in women, bone cysts and phlebomegaly. Diagnosis is established in an individual with 3 major criteria or 2 major plus 2 or more minor criteria, and/or by detection of biallelic pathogenic variants in genes BSCL-2 and/or AGPAT-2. In the presented cases, diagnosis was established solely by clinical criteria. After 60 years of BSCL’s first description and of unsuccessful management with general use drugs, metreleptin, a recombinant leptin analog, emerged with significant impact on metabolic parameters of BSCL, notably on insulin resistance and type 2 diabetes mellitus, lipid profile and liver enzymes, as noted here in the comparison between the two brothers, one in use of Metreleptin, and the other not.
Final comments: Metreleptin has been shown as pivotal in improving diabetes mellitus status in BSCL patients, and therefore it is necessary to spread its use by this population. Informed consent to publish has been obtained from these patients.
Luiz Fellipe Carvalho Viola, Lariana Stefanello, Marcela Junqueira, Diego Rocha, Paloma Nehab Hess, Rosane Kupfer, Carolina Martins Corcino
Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, Brazil
Correspondence: Luiz Fellipe Carvalho Viola
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A102
Case report: We present a case of a 63-year old, female patient, who had been diagnosed with Type 2 Diabetes Mellitus (T2DM) 20 years ago, poorly controlled, as well as chronic kidney disease stage V. Patient has been undergoing hemodialysis for 3 years already listed for renal transplantation, with a history of diabetic retinopathy submitted to extensive photocoagulation, and also had a long-standing diagnosis of hypertension. She was referred to an endocrinology center with a seven-month complaint of profuse sweating, extending from the neck to the scalp. It was triggered by chewing any kind of food and lasting up to 20 min after ingestion without associated symptoms. She had initially been treated for Panic Disorder in another department. After evaluation and exclusion of other diagnoses (medication use, trauma, or facial surgery) as well as exclusion of another kind of diabetic neuropathy, such as sensitive or cardiac autonomic neuropathy, the hypothesis of diabetic gustatory sweating (DGS) was established. A starch-iodine test was performed, which was positive, revealing an extensive area of sweating after eating a small amount of food. In the absence of contraindications, systemic treatment with oxybutynin was proposed due to the size of sweating area and involvement of the scalp. Patient experienced an excellent response as early as week 1 of medication use, with mild side effect of xerostomia; lower intensity sweating only occurred with the ingestion of large amount of food.
Discussion: DGS is considered a type of diabetic autonomic neuropathy, usually associated with other diabetic neuropathies and/or diabetic nephropathy. It is characterized by the appearance of sweating during and/or shortly after a meal, and its intensity depends on the amount of food ingested. It usually affects the upper thorax and face and may be accompanied by erythema. DGS seems to be underdiagnosed because of different intensities of symptoms and also due to the fact that it may not be a patient’s primary complaint nor a physician’s question. It is observed, however, that patients affected by DGS have worse quality of life. Therapeutic options include oral anticholinergics (oxybutynin, glycopyrrolate, scopolamine), alpha-blockers (clonidine), topical agents (glycopyrrolate), or botulinum toxin application. The onset of treatment improves the quality of life and decreases the intensity and frequency of sweating.
Conclusion: Even though underdiagnosed, diabetic gustatory sweating is a common condition among patients with long-term T2DM, which treatment provides an extensive improvement in the quality of life of those patients. Informed consent to publish the case report has been obtained from this patient.
Jacqueline Akemi Nishio Juhasz, Ieside Arruda Valadares Chamon, Ana Cristina Pithon Curi, Alcinda Aranha Nigri, Luis Fernando Aguiar de Paula Filho, Luis Mauricio Batalin Junior, Emanuelle Barbara Dias Tomaz
PUC-SP, São Paulo, Brazil
Correspondence: Jacqueline Akemi Nishio Juhasz
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A103
Case report: A 12-year-old female, previously diagnosed with type 1 diabetes mellitus, on regular insulin use, presented with lowered level of consciousness and increasing abdominal pain which first started a week before. The patient was then referred to Hospital de Mairinque. At the admission the patient presented hyperglycemia (capillary blood glucose = 453 mg/dL), metabolic acidosis (pH 7.01) and hypokalemia (potassium = 3.4 mEq/L). It was performed administration of intravenous (IV) saline solution containing 4U of regular insulin. Subsequently, administration of saline solution with insulin 0.1 U/g/h and replacement of HCO3 were performed. She was intubated due to a decrease in the level of consciousness and bronchoaspiration. The patient was transferred to Conjunto Hospitalar de Sorocaba presenting leukocytosis (20,100/mm3). She was diagnosed with urinary tract infection (UTI) by Candida sp, and then admitted to the pediatric intensive care unit (PICU). The patient remained in the PICU for 14 days and had difficulty maintaining hydroelectrolytic and glycemic control, then she evolved with severe dehydration, acute renal failure and septic shock.
Discussion: Diabetic ketoacidosis (DKA) is characterized by dehydration, abdominal pain, Kussmaul breathing (a deep and labored breathing pattern), lowered level of consciousness, hyperglycemia (glycemia > 250 mg/dL), metabolic acidosis (arterial pH < 7.3 or plasma bicarbonate (HCO3) < 15 mEq/dL), ketosis and ketonuria. Common DKA complications are hydroelectrolytic disorders and cerebral edema (mainly in pediatric cases). In this case report we present a case of a patient with type 1 DM who presented a non-specific UTI with atypical symptoms which usually occur in children who evolved with diabetic ketocidadose. We emphasize the importance of the discussion of the case about the non-specific symptoms of UTI in children presenting with a complication which was diabetic ketoacidosis.
Final comments: It’s possible that UTI promoted increase in proinflammatory cytokines, these may cause insulin resistance which decreases the use of glucose, increases lipolysis and, consequently, increases fatty acids in plasma. The oxidation of fatty acids leads to the production of ketone bodies in the liver. The case presented several complications caused by difficulties in maintaining hydroelectrolytic and glycemic control, resulting in shock, long period of hospitalization and great risk to life.
Informed consent to publish had been obtained from the patient.
Danielle Cardoso Portilho, Francineide Pereira da Silva Pena, Jessica Gomes da Silva, Rafael Pinto da Silva, Jessica Monteiro Cunha, Sônia Silva Alves, Gabriela de Souza Amanajás, Adriane Stefanny Rocha Ribeiro, Diego Quaresma Ferreira, Ediene Sterfany Marques Vale, Amiraldo Dias Gama, Tallitha Barbosa da Luz, Emanuel de Jesus Vaz Bittencourt, Maria Silvia da Costa Silva, Angel Tamna Souza de Souza
UNIFAP, Macapá, Brazil
Correspondence: Danielle Cardoso Portilho
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A104
Background: Diabetes Mellitus (DM) is considered a worldwide public health problem. It is estimated that there are 415 million adults with DM by 2015 and this number is estimated to increase to 642 million by 2040 (IDF, 2015). Diabetic retinopathy (RD) is one of the main complications related to DM and the main cause of blindness in people aged 20-74 years (KLEIN; KLEIN, 2000). Thus, the duration of diabetes and glycemic control are respectively the two most important factors related to the development and severity of RD (DSBM, 2016).
Objective: To evaluate the RD rate of people participating in a health promotion program for people with Diabetes Mellitus (GPSDM).
Method: A cross-sectional and descriptive study developed with 16 members of the Group of Health Promotion of People with Diabetes Mellitus (Grupo de Promoção da Saúde de pessoas com Diabetes Mellitus) (GPSDM) of the Federal University of Amapá (Universidade Federal do Amapá) (UNIFAP). The study was approved by the Ethics and Research Committee (Comitê de Ética e Pesquisa) (CEP) from UNIFAP, with Postal Code/CEP number: 39488114.6.0000.0003.
Results: Demographic and socio-economic background information: female gender predominance (56.2%), average age 58.5 (SD ± 11.7) years. CLI laboratory profile: 100% present Type 2 DM, of these, 7 (41.1%) carry the disease less than 5 years, 6 (37.5%), 5 to 10 years and 3 (18.7%) over 10 years; Hypertension is 68.7%, average Systolic Blood Pressure (SBP): 128.1 (DP ± 13.7)mmHg and Diastolic: 76.8 (DP ± 7.04)mmHg and HbA1c average 6.8% (PD ± 1.8) (Table 1).
Dyrlanne Marcia Lopes Bastos 1, Wildlay Dos Reis Lima 2, Emanuelle Lopes Vieira Marques3, Ana Cristina de Araújo Bezerra2, Paola Cole Brugnera4, Isadora de Farias Pereira2
1Universidade De Brasília, Brasília, Brazil; 2Hospital De Base De Brasília, Brasília, Brazil; 3Hospital Regional Da Asa Norte, Brasília, Brazil; 4Hospital Da Criança De Brasília, Brasília, Brazil
Correspondence: Dyrlanne Marcia Lopes Bastos
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A105
Case report: Patient, 1 years and 2 months, Diabetes Mellitus Type 1 (DM1) diagnosed at the age of 11 months. In this case the child presented polydipsia, polyuria, vomiting and dyspnea. It was hospitalized in the ICU dehydrated in diabetic ketoacidosis. The examinations have shown metabolic acidosis with an 825 mg/dl glycemia index. In the etiological investigation, the decarboxylase antibody of the glutamic acid (anti-GAD) and the antiisland were positive. The patient has used the glargine and the ultrafast insulin, but has evolved with a huge glycemic variability. This way, he has started the therapy with the continuous infusion of insulin system and has improved the glycemic control.
Discussion: The Diabetes diagnosis in children younger than 1 year old must include the pancreas malformation and auto immune diabetes, specially during the 6 first months. Between 6 months and 1 year, the auto immune DM1 is more common. The treatment with insulin in this age group leads to hypoglycemia risks. The continuous infusion of insulin system permits a glycemic control with less glycemic variability and glycemia reduction.
Final considerations: The Diabetes and its diagnosis in children younger than 1 year old is a challenge. The continuous infusion of insulin system permits a glycemic control with less glycemic variability.
Informed consent to publish had been obtained from the patient.
A106 Differences in sedentary behavior measured by triaxial accelerometry between type 1 and type 2 diabetes patients
Bruno Pereira de Moura1, Bruna Priscila Colombo2, Marília de Brito Gomes1
1Programa de Pós-graduação em Ciências Médica–UERJ, Rio de Janeiro, Brazil; 2Residência em Medicina de Família e Comunidade–SMS Rio de Janeiro, Rio de Janeiro, Brazil
Correspondence: Bruno Pereira de Moura
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A106
Introduction: Sedentary behavior (SB) is defined as behavior that generates low energy expenditure (1.0-1.5 MET) in a sitting or reclining position during the waking time. SB has been the new focus for research in the field of “physical activity for health”. Therefore, it is necessary to establish a better understanding about SB profile among patients with type 1 (DM1) and type 2 (DM2) diabetes.
Objective: To compare SB between DM1 and DM2 groups.
Method: This is a cross-sectional study in which 100 patients DM1 and 150 DM2 were evaluated; > 19 years, both genders and at least 1 year of diabetes diagnosis. Patients with severe cardiovascular disease or functional disability were excluded. The study was approved by the local Ethics Committee. SB was measured by tri-axial accelerometers fixed with an elastic belt on the right side of the hip for 7 consecutive days, except in activities in the water or during nighttime sleep. Data were recorded at 60-s intervals and analyzed using ActiLife software version 6.13.3. Wear time validation was defined according to the following criteria: (A) 1 day was considered valid if it had at least 600 min (10 h) of use, without excessive counts (> 20,000 counts.min-1); (B) Only data that had at least 1 valid day was included in the analysis. SB was considered as time spent in activities ≤ 200 counts min−1 of vector magnitude. Data were standardized for 17 h of use. Comparisons of means between groups DM1 and DM2 were performed using t-test for independent samples through IBM SPSS software, version 24. Data are showed as mean ± SD.
Results: DM1 group: 59% were women; Age (y): 37.07 ± 12.12; Diagnostic time (y): 17.21 ± 10.25; BMI (Kg.m-2): 25.14 ± 4.78; Waking time (h): 16.80 ± 1.44; A1C (%): 8.70 ± 1.96; SB (min): 533.72 ± 103.15. DM2 group: 60.7% were women; Age: 57.54 ± 9.27; Diagnostic time: 13.14 ± 7.88; BMI: 29.97 ± 5.41; Waking time: 16.34 ± 1.47; A1C: 8.21 ± 1.68; SB: 495.02 ± 115.04. When comparing the groups, all variables above showed statistical significance (p < 0.05). However, despite presenting statistically different BMI, both are still classified as overweight/pre-obese. DM1 group presented more SB than DM2 group (p = .007). DM1 were 38.69 min (7.25%) more sedentay than DM2 group.
A107 Dipeptidyl peptidase-4 inhibitors, pancreatic cancer and acute pancreatitis: a meta-analysis with trial sequential analysis
Lana C Pinto, Dimitris V Rados, Sabrina S Barkan, Cristiane B Leitão, Jorge L Gross
UFRGS, Rio Grande do Sul, Brazil
Correspondence: Lana C Pinto
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A107
Background: The use of dipeptidyl peptidase-4 (DPP-4) inhibitors may be associated with increased risk for pancreatic cancer and acute pancreatitis. Recent meta-analyses have reported conflicting findings. Therefore, we performed a meta-analysis to assess the risk of both pancreatic cancer and acute pancreatitis associated with the use of DPP-4 inhibitors. In addition, we investigate if the number of patients included in the trials was enough to establish definitive conclusions.
Methods: PubMed, EMBASE, Cochrane Library, and clinicaltrials.org were reviewed up to February 2017. We included randomized controlled trials, lasting 24 weeks or more, that compared DPP-4 inhibitors versus placebo or other antihyperglycemic agents. We also performed trial sequential analysis (TSA) to estimate if meta-analysis was powered for firm conclusions and a metarregression using duration of trial as a covariate to access if it interfered in the results found.
Results: A total of 59,404 patients were included. There was no relationship between the use of DPP-4 inhibitors and pancreatic cancer (Peto odds ratio 0.65; 95% CI 0.35–1.21), and the optimal sample size was reached to determine a number needed to harm (NNH) of 1000 patients. DPP-4 inhibitors were associated with increased risk for acute pancreatitis (Peto odds ratio 1.72; 95% CI 1.18–2.53), with a large NNH (one case for 1066 patients treated). Trial duration had no impact on the incidence of both outcomes.
Larissa Pessoa Vila Nova1, Camila Lima Chagas2, Marinaldo Freire Lustosa2, Rafael Augusto Batista de Medeiros2, Regina de Deus Lira Benevides2
1UPE, Recife, Brazil; 2UFPE, Recife, Brazil
Correspondence: Larissa Pessoa Vila Nova
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A108
Introduction: The Body Mass Index (BMI) is a widely-applied method of diagnosing the nutritional status in clinic analyses, differentiating individuals in underweight, eutrophic, overweight or obese. However, the literature has demonstrated that those considered underweight or eutrophic are not always with the adequate percentage of body fat. Considering that the accumulation of fat in the abdominal region is considered a risk factor for endocrine, metabolic and cardiovascular diseases, even if BMI is within the limits of normality, it is essential to evaluate body composition in order to reduce the risk of new coronary incidents in diabetic individuals, who are already considered high-risk cardiovascular patients.
Objective: Identify the presence of inadequate body fat distribution in eutrophic diabetic individuals.
Methods: A retrospective study of data from patients hospitalized at a cardiology hospital during the period of 2010 to 2014 was carried out. Diabetic patients under 21 years old and of both sexes were included. Healthy BMI ranged between 18.5 and 24.9 kg/m2 for adults (WHO, 1997) and 22–26.9 kg/m2 for the elderly (Lipschitiz, 1994). The variables taken into consideration were: gender, age, BMI and Abdominal Circumference (AC). Body fat distribution was assessed by CA (≥ 88 cm for women and ≥ 102 cm for men). The study was approved by the Ethics and Research Committee (protocol number 346,129/2013) of the Universidade de Pernambuco hospital. The data were analyzed in the SPSS software, v. 13.0, adopting a significant value of p < 0.05.
Results: From 49 patients with mean age of 66.4 ± 9.2 years with homogeneous distribution between genders, the prevalence of poor body fat distribution in eutrophic diabetic patients was 40.8%. It was found higher in females (p < 0.001) and similar in adults and elderly (p = 0.301).
Conclusions: Eutrophic diabetic patients exhibited an inadequate distribution of body fat, especially women, indicating that BMI should not be adopted as an isolated assessment resource. Abdominal obesity should be evaluated in diabetics since it represents an additional risk factor for cardiovascular diseases.
Fabiane Maria Costa, Antonio Carlos Frias, Célia Aparecida Paulino
Universidade Anhanguera de São Paulo (UNIAN-SP); São Paulo; Brazil
Correspondence: Fabiane Maria Costa
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A109
Background: Aging can support a multiplicity of diseases that lead to polypharmacy and drug interactions, increasing health risks among elderly adults, including those with balance disorders and their associated comorbidities.
Objective: The aim of the study was to analyze drug interactions in elderly people with vestibular diseases and their consequences on glycemia.
Materials and methods: A retrospective study was carried out involving 131 elderly patients with a medical diagnosis of vestibular disease, at the research laboratory of a private university in São Paulo, Brazil. The study was approved by the Institution‘s Research Ethics Committee, approval number CAAE 24995713.6.0000.5493. We collected sociodemographic, clinical, and pharmacological data. The identification and classification of drugs were made according to the Anatomical, Therapeutic and Chemical Classification System (ATC code); analysis of drug interactions and their consequences were carried out using specialized software. A significance level of 5% was used for association analysis.
Results: There was a prevalence of women (86%) in the study population, and mean age was 70.5 years. Dizziness was the most frequent vestibular complaint (97%). There was concomitant use of 3–5 drugs (45%) and 6 or more drugs (27%). The most prevalent drugs were for treatment of cardiovascular (29%), nervous (23%), and digestive system disorders and metabolism disorders (14%), among others. Of the total, 71 elderly patients (54%) had some type of drug interaction, especially women and those aged 65–70 years (32%). The most frequent consequences of these interactions included hyperglycemia (13%) owing to a reduced insulin effect, and increased hyperglycemic effect of thiazides, and hypoglycemia (11%) due to an increased hypoglycemic effect, and increased risk of hypoglycemia. The Chi square test showed a significant association between concomitant use of 6 or more drugs and hyperglycemia (p < 0.001). There was no association of these consequences with the most common vestibular symptoms (dizziness, body imbalance, and tinnitus) or the occurrence of falls (p > 0.05).
Conclusions: Polypharmacy increases drug interactions and the use of 6 or more drugs may result in hyperglycemia, a serious condition associated with vestibular disorders. It is important to monitor insulin therapy and thiazide diuretics to avoid this therapeutic consequence. Glycemic control is relevant in the treatment of vestibular disorders and contributes to the control of body balance in elderly patients with vestibular complaints.
Luciana Catunda Gomes de Menezes 1, Yara Lanne Santiago Galdino2, Nádya dos Santos Moura3, Denizielle de Jesus Moreira Moura1, Eline Saraiva Silveira Araujo2, Sherida Karanini Paz de Oliveira4
1Faculdade da Grande Fortaleza-Fametro, Fortaleza, Brazil; 2Prefeitura Municipal de Fortaleza, Fortaleza, Brazil; 3Universidade Federal do Piauí, Piauí, Brazil; 4Universidade Estadual do Ceará-UECE, Ceará, Brazil
Correspondence: Luciana Catunda Gomes de Menezes
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A110
Introduction: Among the chronic complications of diabetes mellitus (DM), there is the diabetic foot. This condition requires great investment of care and permanent educational interventions that can contribute to reduce this complication. In Nursing, there are different technologies that promote the emancipation of the people involved in the care process. In the classification of technologies highlighted in this study the construction of an educational technology, the primer type.
Objective: To describe the process of building an educational booklet on self-care to the diabetic foot.
Method: Methodological approach, in which the steps are followed: the content and type of technology selection to be built, imaging, typesetting and composition of the layout. Among the selected and addressed care in the booklet, the highlights: daily foot inspection to detect early minor trauma, care such as washing and drying the feet, particularly the interdigital spaces to avoid injury, hydration of the feet to prevent drying of the skin with moisturizer use, cutting the toenails with clippers and nail scissors with rounded tip, and others. The ethical and legal aspects of research involving human beings were respected in accordance with Resolution 466/2012 and the project was approved by the Ethics Committee of the State University of Ceará (UECE) under Opinion No. 728464/2014.
Results: The work resulted in the production of the final version of the booklet, which was entitled “Healthy Foot‘s Foot Well Care”. The construction process of the booklet was based from the items of the Accession Questionnaire Self Care Patients with Diabetic Feet (QPED) Silva (2014).
Conclusion: The feature is facilitator for the improvement of knowledge and self-care practices with diabetic foot.
A111 Educational strategies on insulin therapy for young people with diabetes mellitus: systematic review
Rebecca Ortiz La Banca1, Mariana Bueno1, Taine Costa1, Valéria de Cássia Sparapani2, Lucila Castanheira Nascimento1
1Universidade de São Paulo, São Paulo, Brazil; 2Universidade Federal de Santa Catarina, Santa Catarin, Brazil
Correspondence: Rebecca Ortiz La Banca
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A111
Introduction: Brazil is the third country with the highest number of Type 1 Diabetes (T1D) new cases per year in young people. Treatment requires the development of skills and knowledge for self-care. Among behaviors that are expected, taking medication is challenging, since insulin therapy is a highly complex subject and requires an adequate educational approach according to age group.
Objective: To identify evidence from the literature about educational strategies on insulin therapy targeted at young people with T1D.
Method: A systematic review was led in October 2016. Searches were conducted at Medline via PubMed, EMBASE, CINAHL, LILACS and ERIC databases. MeSH terms used were Insulin/therapeutic use, Patient Education as Topic, Diabetes Mellitus Type 1, Child, Infant, Adolescent and other keywords. Primary studies on educational strategies for insulin therapy targeted to young people with T1D were included. Studies regarding insulin pump therapy were excluded.
Results: 226 references were identified of which 12 met the inclusion criteria. Studies were published between 1991 and 2013. Educational strategies aimed at young people (from 8 to 24 years old) were described. These strategies were implemented in a large variety of.
Methods: One-on-one sessions, in groups, by telephone, by a text messages, through role play and diabetes camps. Studies did not focus solely on insulin therapy education, but rather on general aspects of diabetes education. Positive results were described regarding quality of life, reduction of hypoglycemia episodes and number of hospitalizations. No significant results were described in terms of the improvement of metabolic control.
Conclusions: The development of educational strategies for young people with T1D is needed. Educational strategies should be tailored by using appropriate language, and focusing specifically on insulin therapy and its complexity. The development of interventions to promote self-care behaviors related to insulin therapy contributes with teaching guidelines to young people with T1D, with promoting adherence to drug therapy, and with improving metabolic control.
A112 Alpha-linolenic acid supplementation effects on endoplasmic reticulum stress in visceral adipose tissue from morbid obese patients
Mariana Pinto Chaves, Maria Cristina Foss-Freitas
Universidade de Sao Paulo-HCRP-USP, São Paulo, Brazil
Correspondence: Mariana Pinto Chaves
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A112
Alpha-linolenic acid supplementation effects on endoplasmic reticulum stress in visceral adipose tissue from morbid obese patients. 2017. Tese (Doutorado)—Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, 2017. Currently, obesity is considered a worldwide epidemic. It is associated with chronic inflammation and stress activation of the endoplasmic reticulum (ERE), related to the pathogenesis of various diseases such as type 2 diabetes mellitus, cardiovascular diseases, cancer, hypertension, among others. In this context, studies are needed to find alternatives that improve the inflammatory process. Several studies in humans and animals have already demonstrated the anti-inflammatory properties of omega-3 fatty acid. The objective of our study was to evaluate the effects of alpha-linolenic acid (ALA) supplementation on the metabolism and stress of the endoplasmic reticulum in obese patients. A prospective, randomized, placebo-controlled, double-blind study was conducted. In total, 52 patients were randomized to supplementation with 3 g/day of ALA or placebo, 27 individuals from the omega-3/ALA group and 25 from the control group. Lipid, glycidic and inflammatory profile were evaluated before and after supplementation. Visceral adipose tissue (TAV) was collected during bariatric surgery after supplementation. The fatty acid profile incorporated in the TAV was evaluated by gas chromatography. Genes were evaluated by real-time PCR. There was no change in serum levels of IL-6 (p = 0.2201), TNF-α (0.7703) and CRP (p = 0.57) after supplementation with ALA, but we observed a decrease in serum Leptin levels (P = 0.0154) and IP-10 (p = 0.0410), inflammatory cytokines, and increase in IL-4 (p = 0.0211), anti-inflammatory cytokine. Significant incorporation of ALA (p = 0.0002), EPA (p < 0.0001) and DHA (p = 0.0005) into the TAV was observed. Molecular evaluation showed an increase in the gene expression of XBP1 (p = 0.0013), sXBP1 (p < 0.0001), EIF2-α (p = 0.0063), GADD34 (p = 0.0117) and CCT4 chaperone (p = 0.0001), decrease in the gene expression of leptin (p = 0.0410) and ATF-6 (p = 0.0305) and a tendency to decrease the gene expression of CHOP. We can conclude that ALA can modulate ERE through the IRE1/XBP, PERK and ATF-6 pathways, leading to increased chaperones (CCT4), which may demonstrate a therapeutic potential of ALA in obese patients.
A113 Effect of dapagliflozin in energetic and glycemic homeostasis in the brain and hypothalamic functionality in humans
Leticia da Silva Pires1, Ana Carolina Junqueira Vasques1, Andrea Tura2, Brunno de Campos1, Licio Augusto Velloso1, Bruno Geloneze1
1UNICAMP, São Paulo, Brazil; 2CNR Institute of Neuroscience, Padova, Italy
Correspondence: Leticia da Silva Pires
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A113
Background: In type 2 diabetes mellitus, sodium-glucose co-transporter inhibitors type 2 (iSGLT-2) reduce the renal glucose reabsorption threshold, resulting in glycosuria, lower glycotoxicity and insulin resistance, improved beta-cell function, loss of body weight and consequent improvement of glycemic control. Glucose is the main source of energy for the brain and, in the hypothalamus where the mechanisms of hunger and satiety are regulated, the expression of SGLTs may be important in the detection of glucose and a possible therapeutic target for obesity. So, the aim of this study was to evaluate the effect of SGLT-2 inhibitor (dapagliflozin) on glycemic and energetic homeostasis and the hypothalamic functionality of healthy people.
Methods: Twenty healthy and non-diabetic women (19–37 years old) were evaluated at baseline and 7 days after dapagliflozin (10 mg/day), maintaining their regular lifestyle. Body mass index (BMI), sagittal abdominal diameter, body composition by electrical bioimpedance and energy expenditure of resting and oxidation of energetic substrates in fasting by indirect calorimetry were analyzed. Functional magnetic resonance imaging detected the activation of brain areas against the stimulation of glucose and dapagliflozin. From the oral glucose tolerance test (TTOG), insulin sensitivity, hepatic insulin extraction and beta-cell function were assessed by mathematical modeling. Moreover, glucose, insulin, peptide C, glucacon, glycated hemoglobin, adiponectin and free fatty acids were measured.
Results: After the intervention, there was no reduction in BMI (21.7 ± 2.0 vs. 21.5 ± 2.0 kg/m2, p = 0.05), sagittal abdominal diameter (15.1 ± 1.1 vs. 14, (p = 0.05) and fat percentage (28.4 ± 6.3 vs. 27.6 ± 4.0%, p = 0.46). Calorimetry did not identify significant changes in energy expenditure and respiratory quotient. There was a reduction in glycemia (75 ± 7 vs. 71 ± 7 mg/dL, p = 0.02), a trend to reduce insulinemia (5.7 ± 3.6 vs. 3.9 ± 3.5 mU/mL, p = 0.05) and increased adiponectin levels (3.2 ± 1.4 vs. 5.7 ± 3.3 μg/mL, p = 0.02) and free fatty acids (0.6 ± 0.2 vs. 0.3 mmol/L, p = 0.02). In TTOG, after intervention, there was better efficiency in the glycemic curve decay (p = 0.028) without accompanied changes in the curves of insulin, peptide C and glucagon. Also, there was an increase in insulin sensitivity index with oral glucose-OGIS (p = 0.048), reduction of beta-cell sensitivity to glucose, greater efficiency in the first phase of insulin secretion and reduction in the rate of insulin secretion to a glycemia of 90 mg/dL. Functional magnetic resonance imaging examined correlation and connectivity among the hypothalamus and other brain regions, such as insula and primary gustatory cortex, suggesting that the use of dapagliflozin may alter these connections.
Conclusions: The intervention with dapaglifozin in healthy women did not alter energetic homeostasis and provided a set of metabolic adaptations to maintain normal glycemic levels and to prevent hypoglycemia against the glycosuric effect of the drug. The use of dapagliflozin may alter the connections among the hypothalamus and specific regions of the brain, which are related to food intake. Thus, dapagliflozin can act similarly to glucose and play a possible role in hunger control.
A114 Effect of insulin on renal maximum glucose transport capacity in healthy volunteers and patients with type 2 diabetes
Ricardo Pereira Moreira1, Marta Seghiere2, Brenno D. Astiarraga2, Aglecio L Souza1, Valeria B Chueire1, Anna Solini2, Ele Ferrannini3, Elza Muscelli1
1Unicamp, São Paulo, Brazil; 2University of Pisa, Pisa, Italy; 3CNR Institute of Clinical Physiology, Pisa, Italy
Correspondence: Ricardo Pereira Moreira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A114
Background: Most studies, though not all, indicate that the maximum glucose transport capacity of the proximal tubule (TmG) is increased in patients with type 2 diabetes (T2D). Furthermore, one study from 1951 suggested that insulinization may reduce TmG. In contrast, in human embryonic kidney 293T cells insulin increases the activity of transfected human SGLT2. To assess these issues de novo, we examined the effect of physiological hyperinsulinaemia on TmG and urinary glucose excretion (UGE) in healthy subjects (NGT) and T2D patients under steady-state conditions of plasma glucose and insulin concentrations. Subjects and.
Methods: 13 T2D (7F/6 M; 54 ± 6 years, mean ± SD; BMI = 29.5 ± 5.0 kg/m2; HbA1c = 7.6 ± 0.6%) and 12 NGT (6F/6 M; 36 ± 10 years; 24.2 ± 3.0 kg/m2) received a IV 7-h constant somatostatin (400 µg/h) and a variable glucose infusion to achieve steady-state glycaemias of ~ 22 mmol/L in 1 h and to maintain this level for the next 3 h (CT period). Then, a constant insulin infusion (1 mU min−1 kg−1) was started and maintained for additional 3 h (INS period) while clamping glycaemia at CT levels with the use of an ad hoc algorithm. Urines were collected separately for the two study periods for the measurement of glucose and creatinine.
Results: Plasma glucose plateaus were similar across group and study periods. Exogenous glucose infusion rate (GIR) was similar in T2D and NGT during the CT period (26 ± 12 vs 36 ± 16 µmol kg MM−1 min−1; p = ns); during the INS period, GIR rose much higher in NGT than T2D (157 ± 46 vs 71 ± 47 µmol kg MM−1 min−1, p < 0.0001). Creatinine clearance was similar between groups and study periods. During the CT period, UGE was significantly lower in T2D than in NGT (490 vs 690  µmol min−1, median and [IQR], p = 0.03) whereas fractional glucose excretion (FEG) tendede to change (17 ± 6 and 20 ± 5%, respectively; p = 0.0502). During the INS period, both UGE and FEG rose above CT levels in NGT (to 770  µmol min−1 and 24 ± 3%, respectively, p < 0.005 for both vs CT), whereas UGE tended to change in T2D (530 µmol min−1; p = 0.0546) and FEG was unchanged (17 ± 7%, p = ns). In the pooled data of T2D and NGT participants, FEG was positively associated with GIR during the INS period (Rho = 0.462, p = 0.0008).
Conclusions: Acute physiological hyperinsulinaemia during steady-state hyperglycaemia increases urinary glucose excretion in NGT subjects. This insulin effect is impaired in patients with type 2 diabetes, and may be related to insulin resistance.
Letícia da Silva Pires, Thiago Matos Ferreira de Araújo, Daniela Soares Razolli, Albina de Fatima Silva Ramalho, Ana Carolina Junqueira Vasques, Lício Augusto Velloso, Bruno Geloneze Neto
UNICAMP, São Paulo, Brazil
Correspondence: Letícia da Silva Pires
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A115
Background: The balance between eating behavior and energy expenditure is coordinate by specialized neurons in hypothalamic nuclei. In the arcuate nucleus, NPY/AgRP and POMC/CART neurons respond to peripheral signals regarding energetic status. Variations in blood glucose levels generate a hypothalamic response that is still poorly understood, however the transporters GLUT and SGLT play an important role in this process. The sodium-glucose co-transporter type 2 (SGLT-2) is expressed in the kidney and brain and its inhibition leads to glycosuria and caloric loss concomitantly with a decrease in body weight and an apparent increase in food intake. Thus the aims of this study were to evaluate (i) the effect of SGLT-2 inhibition by dapagliflozin in the hypothalamus of mice; (ii) the potential effect of dapagliflozin on body weight, food intake and glycemic homeostasis; (iii) to characterize the hypothalamic expression of neurotransmitters involved on the regulation of food intake and energy expenditure.
Methods: C57BL/6 mice received vehicle or dapagliflozin (1, 5 or 10 mg/kg) by gavage once a day for 2 weeks. Body weight and food intake were evaluated at treatment times 0, 7 and 14 days. At the end of the treatment, glucose tolerance was evaluated by ipGTT as well as epididymal adipose tissue weight and neurotransmitters by immunofluorescence.
Results: SGLT-2 is expressed in the arcuate nucleus and colocalizes with POMC and NPY neurons. The treatment with dapagliflozin did not alter food intake significantly, although there was a decrease in body weight gain (mean = 0.56 ± 1.1 g, p < 0.05) and a trend to reduce epididymal adipose mass (mean = 0.15 ± 0.02 g, p = 0.13). There was increased glycosuria (mean = 307.2 mg/dL, min = 30 mg/dL, max = 1221 mg/dL, p < 0.05), improved fasting glycemia (mean = 165.6 ± 28.8 mg/dL, p < 0.05) and reduction in the area under glucose curve during the glucose tolerance test (mean = 28,078 ± 5623.5 arbitrary units, p < 0.05).
Conclusions: SGLT-2 is expressed in the hypothalamic arcuate nuclei and colocalizes with neurons that control energetic homeostases. The treatment with dapagliflozin for 2 weeks improved fasting glycemia and glucose tolerance, promoted glycosuria and reduced body weight gain without altering food intake. Understanding the mechanisms involved in body weight control promoted by dapagliflozin could guide strategies to enhance weight loss in obesity concomitantly with diabetes treatment.
Giovanni Faccina Brolo, Fernanda Augustini Rigon, Marisa Helena Cesar Coral, Simone van de Sande-Lee, Alexandre Hohl, Marcelo Fernando Ronsoni, Beatriz Marquardt Leite, Manuella de Lucca Michels, Priscila Nobre Dantas Mattje, Camila Sartor Spivakoski
UFSC, Santa Catarina, Brazil
Correspondence: Giovanni Faccina Brolo
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A116
Functional hypogonadism in obese male patients is considerably higher if compared with the general population, fact that is widely reported in literature. One of the ways to study this condition is to analyze gonadal hormonal changes after the weight loss resulting from bariatric surgery, being this approach employed in this study. The present work comprises a longitudinal and observational investigation of 27 men, aged between 30 and 64 years, body mass index (BMI) greater than 35, that underwent to bariatric surgery (Roux-en-Y gastric bypass and the sleeve gastrectomy). The clinical data were recorded, for all subjects, before and after 6 months of the surgical procedures. After 6 months of the surgery, a substantial weight loss from 158.5 ± 25.8 to 119.4 ± 20.8 kg (p < 0.0001 for both) was verified. The BMI and total testosterone (TT) level ranged from 51.9 ± 6.6 to 39.2 ± 5.6 (p < 0.0001) and 225.5 ± 96.9 ng/dl to 394.4 ± 160.9 ng/dl (p < 0.001), respectively. The hypogonadism (TT ≤ 300 ng/dl), verified in 85% of the subjects before the surgery, persisted in only 26% of these patients after 6 months. There were no statistical differences in hypogonadism neither between the two surgical techniques, nor between the patient groups with and without diabetes. The results point out that the weight loss induced by bariatric surgery leads to an important recovery of the gonadal function in a significant number of male patients.
A117 Effect on the reproductive performance of Curatella americana treatment during the pregnancy of rats with mild diabetes
Bruno Stephano Ferreira da Silva1, Gabriel Gomes Araujo1, Larissa Lopes da Cruz1, Thais Leal Silva1, Verônyca Gonçalves Paula1, Rafaianne Queiroz de Moraes Souza1, Cristielly Maria Barros Barbosa1, Kleber Eduardo de Campos1, Débora Cristina Damasceno2, Gustavo Tadeu Volpato1
1UFMT, Mato Grosso, Brazil; 2UNESP, São Paulo, Brazil
Correspondence: Bruno Stephano Ferreira da Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A117
Introduction: During pregnancy, hyperglycemia can lead to maternal and fetal complications, causing reproductive changes. Alternatives are considered to treat diabetes and prevent its complications, and one of these alternatives is the use of medicinal plants, such as Curatella americana. However, there is no scientific evidence on the safety of this plant effect during gestation.
Objective: To evaluate the effects of the aqueous extract of Curatella americana in the reproductive performance of pregnant rats with mild intensity hyperglycemia.
Methods: Diabetes was induced in newborn female Wistar rats, at 24 h after birth, by subcutaneous injection of Streptozotocin at a single dose of 100 mg/kg. At 110 days of age (adulthood), oral glucose tolerance test (OGTT) was performed to confirm the mild diabetes model. After confirmation of the diabetes, the rats were mated and distributed into 4 experimental groups (n = 12 animals/group): Control: Non-diabetic rats treated with water; Control Treated: Nondiabetic rats treated with the plant; Diabetic: Diabetic rats treated with water; Diabetic Treated: Diabetic rats treated with the plant. The administration of the Curatella americana leaves aqueous extract, at dose of 300 mg/kg, was done daily, by gavage, throughout pregnancy. The maternal weight was verified at the beginning and end of pregnancy. On the morning of the 21st day of pregnancy, the rats were anesthetized and the uterus was removed. Pre- and post-implantation loss rates were calculated.
Results: Both diabetic groups exhibited higher pre-implantation loss rates and lower maternal weight gain. The treatment with the plant change no others reproductive parameters.
Conclusion: The reproductive alterations showed in the present study were caused by hyperglycemia, and treatment with Curatella americana did not cause any maternal impairment at this dose.
A118 Effectiveness of gestational diabetes mellitus screening in the central region of Rio Grande do Sul
Clarice dos Santos Mottecy1, Júlia Mottecy Piovezan2, Raquel Montagner Rossi2, Patricia Molz3, Julia Thies Baladão2, Kátia Biasuz Trevisan1, Laura Hélen Mercado Vargas2, Sílvia Isabel Rech Franke3
1HUSM/EBSERH - UFSM, Rio Grande do Sul, Brazil; 2UFSM, Rio Grande do Sul, Brazil; 3UNISC, Rio Grande do Sul, Brazil
Correspondence: Clarice dos Santos Mottecy
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A118
Background: One of the most observed pathologies in pregnancy is Diabetes Mellitus (DM). When Gestational Diabetes Mellitus (GDM) is not identified and treated can lead to complications during gestation and/or delivery, besides woman with GDM may develop Type 2 DM in the future, and their children can become obese and have DM as adults. In Brazil, according to the Ministry of Health (MH), the screening should be universal with assessment of risk factors and fasting glycemia (FG) at the first prenatal visit, ideally in the first trimester. If negative, FG should be repeated in the second trimester. If positive, oral glucose tolerance test (OGTT) should be requested. The cut-off point of normal glycemia in pregnancy of 4.72 mmol/L was standardized by a Brazilian multicenter study using parameters from the World Health Organization with sensitivity of 94%.
Objective: The aim of this study was to evaluate the effectiveness of GDM screening according to the MH guideline, using FG criteria in postpartum women in the public health care who had their deliveries at the University Hospital of Santa Maria-RS.
Methods: In a cross-sectional study, postpartum women over 18 years of age who underwent prenatal care at the health units and had the pregnant woman‘s card at the time of the interview were included. Data were collected through interviews, analysis of the pregnant women’s card and evaluation of medical charts between January and April of 2015. Informed consent to publish has been obtained from patients. The study was approved by University of Santa Cruz do Sul Institutution‘s Ethics Board, approval number 37290714700005343.
Results: Of the total of 283 postpartum women studied 85.5% performed a FG, 14.5% did not perform the test. Negative screening was observed in 74.8% of postpartum women, while 25.2% had positive test. Of the postpartum women with negative screening, only 50.3% continued research. Of the women with positive screening who should progress in the investigation performing the OGTT, only 37.7% did it.
Conclusion: In this group was observed that GDM screening process, through FG was not performed effectively in 59.7% of the women, as recommended by MH. Therefore, it is necessary to identify the factors responsible for ineffectiveness and promote awareness and training of the health team in the basic care to improve the screening and diagnosis of this pathology, aiming to reduce maternal–fetal morbidity and mortality and its future consequences.
Benno D Astiarraga1, Elza Muscelli2, Stefania Camastra1, Ricardo Pereira Moreira2, Valéria B Chueire2, Simona Baldi1, Andrea Tura3, Andrea Mari3, Ele Ferrannini4
1University of Pisa, Pisa, Italy; 2Unicamp, São Paulo, Brazil; 3CNR Institute of Neurosciences, Padua, Italy; 4CNR Institute of Clinical Physiology, Pisa, Italy
Correspondence: Benno D Astiarraga
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A119
Background: Plasma nonesterified fatty acids (NEFA) are an important source of energy during fasting and postprandial periods but their excess could have an inhibitory effect on insulin secretion (IS). Information on in vivo effects of NEFA on incretin-stimulated IS is lacking.
Aim: Assess the effects of acute hyperlipidaemia on incretin-stimulated IS in healthy subjects (HS).
Methods: 10 HS, 34 ± 3 years, BMI 24 ± 2 kg/m2 were studied in 2 sets of experiments. First, each subject received a 75-g oral glucose tolerance test (CT-OGTT) and, a week later, an isoglycaemic intravenous glucose infusion (CT-IIGT) matching glycaemic profile from CT-OGTT. Both tests were repeated during a 20% Intralipid infusion (60 mL/h) plus a primed continuous heparin infusion started 2 h before either test (L-OGTT and L-IIGT). The dynamics of IS were assessed by mathematical model of glucose and C-peptide responses.
Main parameters: insulin secretion rate (ISR); glucose sensitivity (ßGS—the mean slope of the IS/plasma glucose dose–response curve); glucose-induced potentiation (PGLU), a time-dependent modulation of the dose–response during IIGI; incretin-induced potentiation (PINCR), which quantifies the time-course of the incretin effect, IE. The IE was also indexed as the oral-to-IV ratio of IS. Results NEFA rose from 0.19 ± 0.03 to 3.55 ± 0.53 mmol/L on the L-OGTT, and from 0.23 ± 0.03 to 3.77 ± 0.45 mmol/L on the L-IIGT (p ˂ 0.005 for both). Plasma triglycerides increased from 0.7 ± 0.1 to 3.2 ± 0.6 mmol/L on L-OGTT and from 0.6 ± 0.1 to 3.2 ± 0.5 mmol/l on L-IIGT (p ˂ 0.005 for both). While lipid infusion raised glycemia only marginally (p = ns), it increased total ISR from 61  to 78  nmol m−2, median [IQR] on the OGTT (p = 0.005), and from 29  to 57  nmol m−2 on the IIGT (p = 0.02). While neither ßGS nor PGLU was significantly affected (p = ns), PINCR decreased from 1.6 [1.1] to 1.3 [0.2] units, p = 0.05. Moreover, during Intralipid infusion IE was significantly decreased between 0 and 90 min (p = 0.001). The time-courses of GLP-1 and GIP did not change significantly, while the plasma ghrelin response to the OGTT declined from 12.3 ± 2.6 to 8.2 ± 1.2 ng/mL, p = 0.005. Lipid infusion also induced mild insulin resistance during the OGTT (as the oral insulin sensitivity index [OGIS] decreased from 402 ± 22 to 355 ± 28 mL min−1 m−2 p = 0.05).
Conclusion: An acute increment in plasma lipids stimulates total insulin secretion but selectively impairs incretin-stimulated insulin secretion.
A120 Effects of Bisphenol-A consumption on insulin secretion in ovariectomized female mice fed with hyperlipidic diet
Kênia Moreno de Oliveira, Letícia de Souza Figueiredo, Vanessa Kiil Rios, Juliana do Nascimento da Silva, Helene Nara Henriques Blanc, Rosane Aparecida Ribeiro
UFRJ, Rio de Janeiro, Brazil
Correspondence: Kênia Moreno de Oliveira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A120
Introduction: Bisphenol-A (BPA) is used as a raw material in the production of everyday utensils, but there is evidence that it may have estrogenic, antiestrogenic and antiandrogenic actions related to increased adiposity and type 2 diabetes.
Objective: The effects of BPA on the development of obesity and glucose homeostasis in ovariectomized (OVX) and high fat diet (HFD) female mice.
Methods: Female Swiss mice with 80–100 days of life were OVX, after 2 weeks females in anestrous were distributed in the control groups (CTL): fed with normolipid diet and water containing 0.01% ethanol (vehicle); BPA control (CBPA): normolipid diet and water containing 0.01% ethanol and 1 μg/mL BPA; HFD: diet containing 36 g% fat and vehicle; and (HBPA): HFD and BPA. After 3 months, glucose tolerance test (GTT) and islet isolation for insulin secretion were performed (CEUA UFRJ-Macaé: MAC035 approval). Data were analyzed for the distribution of normality (Shapiro–Wilk), followed by analysis of variances: parametric (ANOVA followed by Newman–Keuls) or non-parametric (Kruskal–Wallis followed by Dunns; P < 0.05).
Results: HFD females had higher body weight (BW, 57.3 ± 2.3 g) when compared to female CTL (47.8 ± 1.8 g). The HBPA group had higher CP (63.4 ± 2.1 g) when compared to HFD. During the GTT, HFD females presented hyperglycemia at 15 and 30 min of the test (444 ± 13 and 453 ± 23 mg/dL) in relation to CTL (332 ± 19 and 361 ± 24 mg/dL, respectively). HBPA female presented hyperglycemia similar to the HFD group (427 ± 17 and 450 ± 22 mg/dL) at 15 and 30 min of GTT. AUC area in GTT was higher in HFD females (33,049 ± 2931 mg/dL min−1) than in CTL females (21,658 ± 1910 mg/dL min−1). However, HBPA females had AUC area in GTT (32,409 ± 1992 mg/dL min−1) similar to HFD and CTL. Insulin secretion in response to 2.8 and 22.2 mM glucose did not differ between HFD islets (1.2 ± 0.14 and 4.0 ± 0.7 ng/islet h) and CTL (0.88 ± 0.1 and 2.0 ± 0.3 ng/islet h). However, islets isolated from HFD females secreted more insulin compared to 11.1 mM glucose (1.0 ± 0.3 ng/ilhota h) relative to CTL islets (0.5 ± 0.2 ng/islet h). Females consuming BPA and HFD hypersecreted insulin in response to 2.8 and 11.1 mM glucose (1.8 ± 0.2 and 1.0 ± 0.3 ng/islet h).
Conclusion: Data to date demonstrate that the HFD diet causes glucose intolerance, when associated with BPA, elevates BW and generates impaired insulin secretion.
A121 Effects of educational strategy on sleep hygiene and light exposure on sleep quality, emotional stress and glycemic control in type 2 diabetes mellitus: randomized controlled trial
Flávia Helena Pereira1, Danilo Donizetti Trevisan2, Daniela Santos Lourenço3, Maria Helena de Melo Lima2
1Instituto Federal do Sul de Minas Gerais, Minas Gerais, Brazil; 2Universidade Estadual de Campinas, São Paulo, Brazil; 3Universidade Federal de Alfenas, Minas Gerais, Brazi
Correspondence: Flávia Helena Pereira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A121
Background: The relationship between type 2 diabetes mellitus (DM2) and sleep is already established and studies indicate that this relationship is bidirectional. Measures to improve sleep quality may reduce the emotional stress related to diabetes and consequently improve glycemic control.
Aim: To evaluate the effects of educational strategy of sleep hygiene and light exposure on sleep quality, emotional stress and glycemic control in people with T2DM.
Methods: Randomized Controlled Trial (RCT), unicego, involving 91 participants with DM2, attended in primary care service, in a municipality in the south of Minas Gerais, Brazil. Participants were randomized into two groups: intervention (IG), who received the educational strategy of sleep hygiene and exposure to light and control (CG), who received guidance on foot care and were followed for a period of 3 months. Both groups received face-to face counseling at 1-month intervals and telephone reinforcements each week, with the exception of the last month. The variables related to sociodemographic and clinical characterization, sleep quality, diabetes-related distress (DRD) and glycated hemoglobin (HbA1c) were performed at the baseline and at the 3rd month of follow-up. The primary endpoint was the assessment of sleep quality observed after 3 months of follow-up. The Consolidated Statement of Reporting Trials (CONSORT) was followed for randomization, masking, group tracking and data analysis. Linear mixed effects models were used to compare the variables over time and the linear regression model to correlate the variables with the primary outcome. The level of significance was set at 5%. Ethics Approval: The study was approved by the University of Campinas’ Ethics Board, approval number 1.183.930/2015 and conducted according to the recommendations of the Declaration of Helsinki.
Results: Comparison over time, between groups, showed that IG presented better sleep quality (mean of 5.02 versus 6.30 points, p = 0.0272). For the IG, over time, there was an improvement in sleep quality (p < 0.0001) and in the mean of DRD score (p = 0.0001). Through a linear regression model, it was observed that the variables of DRD, gender and type of group had influence, with significant statistical difference on sleep quality. Being male and showing improvement in DRD levels contributed significantly to sleep quality improvement (p = 0.0314 and p = 0.0202, respectively). In relation to the groups, belonging to the IG contributes to the improvement of sleep quality (p = 0.0024).
Conclusion: This study demonstrated that measures of sleep hygiene and exposure to light have a positive effect on the improvement of sleep quality, emotional stress and glycemic control in individuals with T2DM.
A122 Effects of nurse telesupport on transition between specialized and primary care in diabetic patients
Ana Marina da Silva Moreira1, Camila Bergonsi de Farias2, Roberta Marobin1, Dimitris Varvaki Rados1, Sabrina Coelli2, Bárbara Luiza Bernardi2, Thizá Massaia Londero1, Livia Almeida Faller2, Laura Ferraz dos Santos2, Ana Maria Matzenbacher2, Natan Katz2, Erno Harzheim2, Sandra Pinho Silveiro2
1HCPA, Rio Grande do Sul, Brazil; 2UFRGS, Rio Grande do Sul, Brazil
Correspondence: Ana Marina da Silva Moreira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A122
Introduction: The prevalence of diabetes mellitus type 2 (T2DM) is increasing and the primary health care (PHC) plays an important role in its management. In an attempt to improve the training of PHC team, the National Telehealth Program was created. One of the aims of this program is to stimulate the transition of care, increasing the safety of outpatient discharge from specialized services.
Objectives: To evaluate the effectiveness of a telehealth strategy in T2DM patients who were discharged from a tertiary hospital outpatient clinic.
Methods: Randomized clinical trial open-label (randomization 1:1). Were included T2DM patients on treatment at Endocrinology Service of Hospital de Clínicas de Porto Alegre, with glycated hemoglobin (HbA1c) < 8% and indication of discharge. The exclusion criteria were: glomerular filtration rate < 30 mL/min, symptomatic ischemic heart disease, severe peripheral and autonomic neuropathy. Both groups were discharged and were followed-up in PHC. The intervention group received phone-calls for education in T2DM by a trained nurse every 3 months and a free phone number (0800) for resolution of any doubt. The control group received calls without intervention. After 1 year of follow-up, both groups returned for clinic evaluation.
Results: To date, 145 patients were included in the study (target 150), with 2 follow-up losses. The sample consisted of 62.3% women, 67.2% white, with median age of 65.3 ± 11.2 years-old, BMI 31.1 ± 7.4, with a DM duration of 15.4 ± 10.8 years. Medium HbA1c (%) at discharge was 7.01 ± 0.68, fasting glucose (mg/dl) was 127.37 ± 42.33 and creatinine (mg/dl) was 0.91 ± 0.29, without differences between groups at baseline. To date, 67 patients were evaluated after 1 year. There were no differences between groups (control and intervention, respectively) in terms of HbA1c (7.6% × 6.9%, p = 0.16), systolic blood pressure (129 mmHg × 129 mmHg, p = 0, 85), diastolic blood pressure (77 mmHg × 75 mmHg, p = 0.35) and total cholesterol (161 mg/dL × 160 mg/dL, p = 0.48).
Conclusions: In a preliminary analysis of the data, after 1 year of follow up, the patients maintained a good glycemic control, with no differences between the groups. These findings need to be confirmed in the final analysis of the study.
A123 Effects of physical exercise on adiponectin transduction signal in hypothalamus of obese animals
Rafael Calais Gaspar1, Vitor Rosetto Muñoz1, Guilherme Pedron Formigari1, Barbara Moreira Crisol1, Gabriel Keine Kuga1, Susana Castelo Branco Ramos Nakandakari1, José Diego Botezelli1, Luciene Lenhare1, Adelino S.R. da Silva2, Dennys Esper Cintra1, Leandro Pereira de Moura1, Eduardo Rochete Ropelle1, José Rodrigo Pauli1
1UNICAMP, São Paulo, Brazil; 2USP, São Paulo, Brazil
Correspondence: Rafael Calais Gaspar
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A123
Introduction: Physical exercise is one of the main interventions capable of modulating energy homeostasis, but little is known about the relationship between physical exercise and adiponectin in the energy balance of regulatory mechanisms.
Objective: Verify the acute physical exercise effect on the adiponectin signaling pathway modulation in the hypothalamus of obese mice and its action on energetic homeostasis.
Methods: Swiss mice, 6 weeks old, were divided into 3 groups exposed to different diets: CTL-standard diet; OBS-hyperlipidic diet; OBEX-hyperlipidic diet and submitted to the protocol of acute physical exercise (3 sessions of 45 min at treadmill with break of 15 min between each session). Serum adiponectin, glucose tolerance, food intake and energy expenditure were analyzed. For the molecular analyzes, the animals received stimulation of intraperitoneal leptin. Signaling pathway of leptin proteins, adiponectin and PI3K-Akt in the hypothalamus and UCP1 in brown adipose tissue were analyzed.
Conclusion: Physical exercise is able to increase the protein content of APPL1 in the hypothalamus of obese mice, increase energy expenditure and reduce food intake.
Cristiane Correia da Silva1, Jonathan Nícolas dos Santos Ribeiro2, Cláudio Barnabé dos Santos Cavalcanti1, Denise Maria Martins Vancea2
1UPE, Recife, Brazil; 2UPE/UFPE, Recife, Brazil
Correspondence: Cristiane Correia da Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A124
Introduction: Collagen is the main protein responsible for resistance to flexibility, and in connective tissue disorders of glucose metabolism in the diabetic can produce a superglicolization of specific collagens, thus reducing levels of flexibility.
Objective: To verify the effects of regular physical exercise on the flexibility levels of type 2 diabetics.
Method: Characterized as a quasi-experimental study. The sample was non-probabilistic; 11 female subjects with type 2 diabetes, with a mean age of 66.5 ± 1.6 years, participated in the study. The training protocol was composed of resistance and aerobic training, the flexibility assessment was performed before and after the intervention that lasted 6 weeks. To assess flexibility, a Tera Flex 1.8 digital flexometer was used by Tera Science. For the comparison of the means of the variables, a variance analysis was used with repeated measures, and multiple comparisons using Fisher‘s least significant difference method and Wilcoxon‘s nonparametric test. For all tests a significance level was adopted p < 0.05.
Results: There was an increase from 87.7 ± 12.5 to 102.4 ± 14.6 (p = 0.003), in the thoracic joint amplitude of the diabetics evaluated.
Conclusion: The training protocol used in this study showed a significant increase in the levels of flexibilities of type 2 diabetics, of this sample.
A125 Effects of resistance training on signs and symptoms of distal diabetic polyneuropathy in type 2 diabetic patients: pilot study
Camilla Rodrigues de Souza Silva, André dos Santos Costa, Tamires do Nascimento, Diogo Arruda Martins de Lima, Sandro Gonçalves de Lima, Jhonnatan Vasconcelos Pereira Santos, Paulo Daywson Lopes da Silva, César Augusto Melo de Souza, Sílvia Regina Arruda de Moraes
UFPE, Pernambuco, Brazil
Correspondence: Camilla Rodrigues de Souza Silva
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A125
Introduction: The distal peripheral polyneuropathy (DPP) is one of the main Diabetes complications and physical exercise can be an alternative to minimize the signs and symptoms.
Objective: Assessment of resistance training effects on signs and symptoms of DPP on type 2 diabetic patients.
Methods: Randomized controlled trial with 10 diabetic patients (7 women and 3 men 58.8 ± 3.8 years; 71.9 ± 9.1 kg; 158 ± 5.5 cm; 15.6 ± 10.6 years of DM2 diagnostic) with DDP diagnosed by the DDP diagnostic scale (DDPDS). They were randomized in two groups, the control group (n = 4) received education sessions about diabetes, and the exercise group (n = 6) besides the education sessions, followed a moderate exercise training for upper and lower limbs 3 times a week, during 12 weeks. The DDPDS provided the Neuropathy Symptom Score (NSS) and the Neuropathy Disability Score (NDS) of each individual. The tactile sensibility was evaluated with the Semmes–Weinstein monofilament (10 g). After the Kolmogorov–Smirnov normality test, the pared t test was used for intragroup comparisons. For the intergroup comparison, the t test was used for independent samples both on pre and post intervention phases.
Results: The results showed significant improvements on the NDS, on both intragroup comparison of the exercise group (p < 0.01) and intergroup comparison on the post-intervention moment. The other parameters assessed did not show significant difference.
Conclusion: The resistance training was effective on the improvement of the Neuropathy Disability Score of type 2 diabetic patients with distal diabetic polyneuropathy.
Vânia Naomi Hirakata1, Maria Lúcia da Rocha Oppermann2, Janine Alessi3, Daniela Wiegand1, Angela Jacob Reichelt1
1Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; 2Hospital de Clínicas de Porto Alegre, FAMED UFRGS, Porto Alegre, Brazil; 3FAMED UFRGS, Porto Alegre, Brazil
Correspondence: Vânia Naomi Hirakata
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A126
Introduction: Pregestational diabetes is associated with adverse outcomes for the mother and the newborn. This may further depend on the epoch women were treated, due to changes in standards of care and maternal clinical characteristics. Our objective was to study characteristics of pregnant diabetic women across two periods of time.
Methods: We evaluated 220 women, 85 with type 1 diabetes (DM) and 135 with type 2 DM, attended at a specialized prenatal care. Clinical characteristics as weight, body mass index (BMI), preeclampsia, cesarean section and newborn outcomes were evaluated. Epoch of care was stratified in two periods: from 2005 until 2010 (period 1) and after 2010 (period 2). Analyses were performed applying the Student‘s t test and the Chi square test in SPSS version18.
Results: Type 1 DM was more frequent in period 1 (56.5% vs. 43.5%), but was surpassed by type 2 DM in period 2 (63.0% vs 37.0%) (p = 0.005). The Figure presents the number of patients with type 1 and type 2 diabetes taking prenatal care at each year. Previous macrosomia (8.2% vs. 20.5%, p = 0.011) and previous preeclampsia (PE) (9.2% vs 21.3%; p = 0.015), as well as pregestational BMI ≥ 25 kg/m2 (59.1% vs 78%, p = 0.003) were more frequent in period 2. There was a trend to a lower diagnosis of PE (37.0% vs 24.8%; p = 0.055) in the second period. We stratified data of the two periods according to type of diabetes: in women with type 2 diabetes, previous PE and macrosomia were more frequent and ρfamily history of diabetes, less frequent, in the second period. Conversely, women with type 1 diabetes presented higher pre-pregnancy weight and higher A1c test in the second period.
A127 Effects of the physical training in different intensities on the balance of elderly with type 2 diabetes
Rodrigo dos Santos Rodrigues Alves1, Jonathan Nícolas dos Santos Ribeiro2, Cláudio Barnabé dos Santos Cavalcanti1, Denise Maria Martins Vancea3
1UPE, Pernambuco, Brazil; 2UFPE, Pernambuco, Brazil; 3UPE e UFPE, Pernambuco, Brazil
Correspondence: Rodrigo dos Santos Rodrigues Alves
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A127
Introduction: In diabetes mellitus, changes in skeletal muscle, associated with age muscle mass loss, contribute to a decrease of muscle strength, balance and control.
Objective: To investigate the effects of physical training after 3 months of intervention in the balance of elderly with type 2 diabetes.
Method: Characterized as quase-experimental. Twenty-four elderly with type 2 diabetes were enrolled in a supervised physical exercise program. Two groups of moderate intensity (n = 11) and high intensity (n = 13) were organized. The physical training protocol was composed of aerobic and strength training. The strength group was divided into moderate intensity of 20–25 repetitions and high intensity of 8–15 repetitions, both with 1′ interval. The aerobic group, which used the treadmill, used the protocol with 10′ in the moderate intensity, scale 13 on the Subjective Effort Perception, and 5′ for high intensity, in the scale 15. For balance evaluation we used the sit and stand test. Multiple comparisons were made using Fisher‘s least significant difference method. Nonparametric Kruscal-Wallis test was also performed and a significance level of p < 0.05 was used for all tests.
Results: There was an improvement in the balance at moderate intensity (pre 4.9 ± 2.0 versus post 6.2 ± 2.2 p = 0.04) and at high intensity (pre 3.7 ± 2.6 vs. post 5.0 ± 2.6 p = 0.03).
Conclusion: The physical training used in this study was effective in improving the balance of elderly with type 2 diabetes.
A128 Efficacy and safety across the final dose ranges in patients with T2DM receiving insulin glargine/lixisenatide fixed-ratio combination in the LixiLan-L trial
Robert Ritzel1, Josep Vidal2, Vanita R. Aroda3, Yujun Wu4, Elisabeth Souhami5, Elisabeth Niemoeller6, Robert R. Henry7, Lixilan-L Trial Investigators
1Klinikum Schwabing, Städtisches Klinikum München GmbH, Munich, Germany; 2Department of Endocrinology and Nutrition, Hospital Clinic of Barcelona, Barcelona; Spain; 3Medstar Health Research Institute, Hyattsville, MD, USA; 4Biostatistics and Programming, Sanofi-Aventis US, Bridgewater, NJ, USA; 5Diabetes Division, Sanofi, Paris, France; 6Diabetes Division, Sanofi, Frankfurt, Germany; 7UC San Diego and Section of Diabetes, Endocrinology, and Metabolism, Veterans AWairs San Diego Healthcare System, Center for Metabolic Research, San Diego, CA, USA
Correspondence: Robert Ritzel
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A128
A129 Efficacy and safety of insulin degludec/liraglutide (IDegLira) vs basal–bolus (BB) therapy in patients with type 2 diabetes (T2D): dual VII trial
Billings LK1, Gouet D2, Oviedo A3, Rodbard H4, Tentolouris N5, Grøn R6, Halladin N6, Jodar E7, Fonseca MIH6
1NorthShore University Health System, Evanston, Illinois, USA; 2La Rochelle Hospital, Aunis, France; 3Santojanni Hospital and Cenudiab, Bueno Aires, Argentina; 4Endocrine and Metabolic Consultants, Rockville, MD, USA; 5National and Kapodistrian University of Athens, Athens, Greece; 6Novo Nordisk, Bagsværd, Denmark; 7University Hospital Quiron Salud, Madrid, Spain
Correspondence: Billings LK
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A129
Introduction: The efficacy and safety of insulin degludec/liraglutide (IDegLira) has been demonstrated in patients with type 2 diabetes uncontrolled on several treatments.
Objective: To demonstrate non-inferiority of Ideglira in A1c reduction from baseline as compared to basal-bolus insulin therapy.
Methods: 26-week open-label trial comparing Ideglira with Basal-bolus insulin therapy in type 2 diabetes.
Results: 506 patients (pts) with T2D uncontrolled on metformin and 20–50 units (U) of insulin glargine U100 (IGlar) were randomized 1:1 to IDegLira or BB therapy (IGlar + insulin aspart up to 4 times a day). Mean A1C decreased from 8.2% at baseline to 6.7% at end of trial in both arms; non-inferiority (by < 0.3%) for IDegLira was confirmed (p < 0.0001; Table). A similar proportion of pts achieved A1C targets with IDegLira vs BB (66.0% vs 67.0% for < 7%/49.6% vs 44.6% for ≤ 6.5% respectively). Total daily insulin dose was lower for IDegLira (40.4 U) vs BB (84.1 U) (p < 0.0001). Body weight decreased with IDegLira and increased with BB (p < 0.0001); the rate of hypoglycemic episodes (HEs) was lower with IDegLira vs BB (p < 0.0001). More pts achieved a triple composite endpoint (A1C < 7% with no HE in the last 12 weeks and no weight gain) with IDegLira vs BB (38.2% vs 6.4%; odds ratio 10.39 [5.76; 18.75] p < 0.0001). Mean pre- to postprandial plasma glucose increment decreased more with BB vs IDegLira (p = 0.0032). SF-36 (mental component summary) and TRIM-D (total scores) improved more with IDegLira vs BB (p = 0.0074 and p < 0.0001 respectively). Adverse event rates were similar.
A130 Efficacy of group education for carbohydrate counting in a public diabetes center in Belo Horizonte
Alessandra de Cássia Lovato, Débora Bohnen Guimarães, Marina Moreno Wardi, Stephanie Araújo Oliveira Rezende, Luciana Valadares Ferreira, Juliana Bohnen Guimarães, Janice Sepúlveda Reis
Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, Minas Gerais, Brazil
Correspondence: Alessandra de Cássia Lovato
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A130
Background: Carbohydrate counting (CC) is considered the nutritional therapy of choice for patients with type 1 diabetes (T1DM), since it allows greater food flexibility and adjustment of insulin treatment as intake. However, it is a strategy little used in the public health service because there are very few specialized team, resources and appointments times for the correct training of the therapy. Since 1970, teaching people in groups has been an effective intervention for diabetes education.
Objective: To evaluate the efficacy of nutritional education groups for the treatment of CC in patients with T1DM from a public referral service in Belo Horizonte, Minas Gerais, Brazil.
Methods: Forty-one adult patients underwent to a group nutritional education program with 3 meetings: 1st healthy eating and introduction to the CC; 2nd CC for extra snacks or substitutions; 3rd full CC (at all meals with food amount required). The evolution to this stage was made based on an evaluation of the 24-h food recall, with quantification of carbohydrate grams by nutritionists, and insulin/carbohydrate ratio prescribed by endocrinologists. In addition, this evolution was the patients’ free choice because they felt or not safe. A fourth meeting was held for patients with doubts about the progression to full CC. A 3-day food record with the quantification of carbohydrate grams per meal, together with glycemic control, was requested after beginning the therapy. The study was approved by Institution’s Ethics Board, approval number 1.064.985 and written consent was obtained from all participants.
Results: The sample consisted of 66% women, ages 39.8 ± 16.4 years old, with incomplete elementary school and complete high school education (24.4 and 36.6%, respectively). 49% of the patients evolved for the full carbohydrate counting treatment (3rd meeting), with observation in 51% of the participants not learning the therapy, or of their own choice in not counting the carbohydrates daily, maintaining fixed dose of food amount. Lower schooling (r2 = 0.34, p < 0.001) and advanced age (r2 = 0.45, p < 0.001) showed a positive correlation with non-evolution for full therapy, being independent of gender (p 0.91).
Conclusion: The carbohydrate counting groups were effective for patients with T1DM of a public service, with optimization of time and greater involvement of patients in the discussions. However, low schooling and older age are barriers to the broader choice of therapy.
A131 Elaboration and cultural adequacy of the adhesion test to healthy diet in carbohydrate counting (TAHC)
Sheyla Geralda Cordeiro Ferreira1, Débora Bohnen Guimarães2, Alessandra de Cássia Lovato2, Marina Moreno Wardi2, Heloísa de Carvalho Torres3, Adriana Silvina Pagano3, Ilka Afonso Reis3, Janice Sepúlveda Reis4
1IEP-Instituto de Pesquisa da Santa Casa de Belo Horizonte, Minas Gerais, Brazil; 2IEP - Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, Minas Gerais, Brazil; 3UFMG-Universidade Federal de Minas Gerais, Minas Gerais, Brazil; 4Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, Minas Gerais, Brazil
Correspondence: Sheyla Geralda Cordeiro Ferreira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A131
Background: Carbohydrate counting are indicated for patients with type 1 diabetes mellitus as an effective strategy in optimizing food intake and should be inserted in the context of healthy eating. There is a lack of instruments adapted to the Brazilian population to evaluate the adherence to healthy eating by patients who use this nutritional therapy.
Objective: To elaborate and adapt culturally the instrument of evaluation of adherence to healthy diet in carbohydrate counting (TAHC).
Methods: Methodological study, including three steps: First: Preparation of the instrument, based on national and international guidelines for diabetes and nutrition, followed by the evaluation of a committee of experts, composed of endocrinologists, nutritionists, linguists, and statisticians-Version 1 (V1). Second: The V1 was sent, via an e-survey platform, to the judges committee of nutritionists and endocrinologists experienced in carbohydrate counting, where the clarity and relevance of the questions were evaluated for each item of the instrument. Based on this evaluation, the Content Validity Index (IVC) and the percentage of acceptance of the judges were calculated in relation to the adequacy of the evaluated items, with changes generating the version (V2). Third (pre-test); With the participation of 20 individuals with type 1 diabetes with more than 12 years of age, with changes and adaptations generating version 3 (V3). After each phase described, an interdisciplinary meeting was held by researchers and the committee of experts evaluated the suggestions. At all stages, the methodology followed the recommendations established in the literature and for each problem identified, improvements were suggested, and changes were made.
Results: The V1 of the instrument presented a good agreement among the Judges Committee, with a valid content index of 0.954, being considered appropriate the value ≥ 0.78 for new instruments (Table 1).
Andressa Martins Oliveira, Renata Moraes Fagundes Costa, Camila Vicente Santos, Paloma Nehab Hess, Rosane Kupfer
Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, Brazil
Correspondence: Andressa Martins Oliveira
Journal of Diabetology & Metabolic Syndrome 2018, 10(Supp 1):A132
M.C.F., a 56 year-old female, diagnosed with type 2 diabetes (T2DM) at 22 years old, using insulin for 22 years. Eight years ago, she started to present frequent episodes of symptomatic hypoglycemia, preferably in fasting periods. There was no cessation of the episodes even with the suspension of all insulin and antidiabetic drugs, which lead to an investigation with a prolonged fasting test (Table 1). The test confirmed endogenous hyperinsulinism (EH). Endoscopic ultrasound and abdominal magnetic resonance imaging showed no masses. She was then submitted to a selective arterial calcium stimulation test (SACST), whose results excluded insulinoma. Acarbose was prescribed 2 years ago, with no improvement. Verapamil (80 mg/day) was initiated along with dietary changes, with good response.
Discussion: In the presence of hypoglycemia and serum levels of nonsuppressed insulin/C-peptide, rare causes such as pancreatic beta (β) cell disease and autoimmune hypoglycemia should be excluded. EH is confirmed by the prolonged fasting test through the findings: glycemia < 55 mg/dL with symptoms, associated with insulinemia ≥ 3 IU/mL, peptide C ≥ 0.60 ng/mL, proinsulin ≥ 5 pmol/L. In adults, the main cause is insulinoma, but when a mass is not identified, the diagnosis of non-insulinoma pancreatogenic hypoglycemia syndrome (NIPHS) should be considered. NIPHS is a hyperfunctional pancreatic disorder characterized by the diffuse involvement of islets with nesidioblastosis. Its incidence in patients with previous T2DM is rare, with only 4 cases being documented. In these cases, T2DM can be reversed by dysfunctioning hypertrophic β cells, which is a reactive process to the destruction of β cells or existing functional failure in diabetic patients, leading to hypoglycemia and confirmed by the prolonged fasting test. The diagnosis is established by exclusion of insulinoma and histopathological and immunohistochemical findings in the pancreas. Patients with EH with inconclusive noninvasive imaging are candidates to perform SACST, which is important for the therapeutic definition. Treatment consists of dietary changes, medications and, in refractory cases, surgery. Surgical extension should be evaluated to avoid recurrence of hypoglycemia and, at the same time, the risk of exocrine and endocrine complications.