Nova abordagem para o tratamento da diabetes: da glicemia à doença cardiovascular

Diabetes, a metabolic disease with vascular consequences due to accelerated atherosclerosis, is one of the 21st century's most prevalent chronic diseases. Characterized by inability to produce or use insulin, leading to hyperglycemia and insulin deficiency, diabetes causes a variety of microvascular (such as retinopathy and kidney disease) and macrovascular complications (including myocardial infarction and stroke) which reduce the quality of life and life expectancy of individuals with diabetes.We describe the close relationship between diabetes, cardiovascular risk factors, and cardiovascular disease, and examine multifactorial approaches to diabetes treatment, including reducing cardiovascular risk in individuals with type 2 diabetes. Finally, we analyze new prospects for the treatment of type 2 diabetes, resulting from the development of novel antidiabetic drugs.The aim of this review is that the clinician should assume the crucial role of guiding individuals with diabetes in the control of their disease, in order to improve their quality of life and prognosis. In view of the currently available evidence, the emergence of new glucose‐reducing therapies with proven cardiovascular benefit means that the best therapeutic strategy for diabetes must go beyond reducing hyperglycemia and aim to reduce cardiovascular risk.     

Effect of lifestyle on blood pressure in patients under antihypertensive medication: An analysis from the Portuguese Health Examination Survey

Introduction and ObjectivesHypertension is one of the main risk factors for disability and death from cardiovascular disease. Current guidelines include initiatives to control blood pressure in hypertensive patients that focus on lifestyle changes. The main objective of this study was to analyze the association between lifestyle and blood pressure in patients under antihypertensive medication.MethodsData collected in the Portuguese National Health Examination Survey (INSEF) were analyzed. Individuals who met INSEF inclusion criteria and reported being under antihypertensive medication in the two weeks prior to the questionnaire were studied. Lifestyle variables (alcohol consumption, smoking, added salt intake, fruit and vegetable consumption, and physical activity) were assessed by questionnaire, and systolic and diastolic blood pressure were measured by physical examination. Associations between lifestyle factors and blood pressure, stratified by gender and adjusted for sociodemographic variables and obesity, were estimated through a multiple linear regression model.ResultsAlcohol consumption (beta=6.31, p=0.007) and smoking (beta=4.72, p=0.018) were positively associated with systolic blood pressure in men. Added salt intake, fruit and vegetable consumption, and physical activity were not associated with blood pressure in men. In women, no association was observed for any behavioral variable.ConclusionsThese conclusions highlight the need in the population under antihypertensive medication, particularly in men, to focus on the fight against high systolic blood pressure in the two modifiable and preventable behaviors of smoking and alcohol consumption.     

Identification of a critical isthmus in complex macroreentrant atrial tachycardia using Ripple mapping in a patient with surgically repaired Ebstein's anomaly

Ripple mapping is a novel, three-dimensional, electroanatomic mapping tool that displays each electrogram at its corresponding 3-dimensional coordinate as a dynamic moving bar, which changes in length according to the electrogram voltage-time relationship. We present the case of a 43-year-old male patient with surgically repaired Ebstein's anomaly who previously underwent two unsuccessful ablation procedures for right atrial flutter (cavotricuspid isthmus and intercaval lines). Ripple mapping was decisive, enabling the arrhythmia mechanism to be appropriately recognized, and a distinction to be made between critical areas of the circuit and delayed activated bystander regions.     

Anti-platelet effects of Curcuma oil in experimental models of myocardial ischemia-reperfusion and thrombosis

Extensive research on the mechanism of action and medicinal importance of curcumin obtained from turmeric (Curcuma longa) has unfolded its potential therapeutic value against many chronic ailments. Curcuma oil (C.oil), the highly lipophilic component from Curcuma longa has been documented for its neuroprotective efficacy against rat cerebral ischemia-reperfusion injury; however its effect on myocardial reperfusion injury remains unexplored. In the present study, effect of C.oil (500 mg/kg, po) was evaluated against myocardial ischemia-reperfusion induced injury in the rat model. C.oil failed to confer protection against cardiac injury, however significant reversal of ADP induced platelet aggregation (p < 0.05) was evident in the same animals. Moreover, collagen and thrombin induced platelet aggregation (p < 0.001) as well as tyrosine phosphorylation of various proteins in activated platelets was also suppressed. C.oil also offered significant protection against collagen-epinephrine induced thromboembolism in mice as well as augmented total time to occlusion against FeCl₃ induced arterial thrombosis in rats. C.oil however had no effect on coagulation parameters (TT, PT and aPTT) and exerted a mild effect on the bleeding time. Bioavailability of C.oil, as assessed by monitoring ar-turmerone, α,β-turmerone and curlone, was 13%, 11% and 7% respectively, indicating high systemic exposure. Moreover, longer mean residence time (MRT) of ar-turmerone (13.2 h), α,β-turmerone (11.6 h) and Curlone (14.0 h) and plasma elimination half lives in the range of 5.5 to 7.2 h correlated with single 500 mg/kg dose regimen of C.oil. In the present study, C.oil thus seems to be an efficacious and safe anti-platelet agent which was protective against intravascular thrombosis.     

Cost-utility analysis of genetic polymorphism universal screening in colorectal cancer prevention by detection of high-risk individuals

BackgroundIn the past 15 years numerous studies have been published on the involvement of low-penetrance susceptibility genes on the risk for developing colorectal cancer (CRC).AimTo perform an economic analysis of blood genetic testing in CRC screening in a population-based nationwide setting using polymorphisms in prostaglandin E₂ pathway genes as proof of concept.MethodsA cost-utility analysis was performed from a societal perspective in Portugal comparing two strategies: blood genetic testing by the age of 40 versus no genetic screening under different assumptions of the cost of genetic testing (€10 and €30) and expected risk (1.5 to 5-fold). The adopted threshold was set at €44,870 (USD 50,000). The primary outcome was the incremental cost-effectiveness ratio (ICER) for a base case scenario.ResultsPolymorphism genotyping provided cost-utility only under the assumption of a 5-fold increased risk in the general population, providing ICERs of €44,356 and €30,389 for €30 and €10 tests, respectively.ConclusionBlood genetic screening for colorectal cancer has cost-utility only under specific assumptions of increased CRC risk and conservative cost estimates. Future studies should focus on defining genetic profiles because single-gene approaches are very unlikely to be cost-effective considering their modest predictive value.     

Predictive models of mortality and hospital readmission of patients with decompensated liver cirrhosis

IntroductionComplications of cirrhosis are one the major causes of hospital admission associated with high morbimortality rates and social and economic charges.The aims of this study were to evaluate hospital readmission and mortality rates and predictive factors for hospital readmission and mortality.MethodsPatients with decompensated cirrhosis admitted to our institution between 2008–2014 were retrospectively analyzed.ResultsIncluded 427 admissions from 177 patients with cirrhosis with mean age of 59.0 ± 12.3 years. The major cause was alcoholic-related liver disease and the median duration of admission was 9.0 days (IQR 6.0–14.0).During the follow-up period,there were 250 readmissions from 95 patients, with a median of 58 (IQR27-134) days for readmission, representing 58.5% of the total number of admissions.The 180-day mortality rate was 35.0%.In the multivariate analysis, ascites, smoking and MELD Na were associated with 180-day mortality. Creatinine, albumin, esophageal variceal bleeding, previous variceal banding, lactulose, rifaximin and proton pump inhibitors use were independently associated with need of readmission. Based on regression analysis, two models were calculated to predict 180-day mortality (AUROC 0.74 (0.682?0.794)) and need for readmission(AUROC 0.821 (0.781?0.861)), p < 0.001.ConclusionThe readmission rate and mortality of cirrhotic patients are still very high and it is a priority to determine preventable risk factors to improve patient outcome.Two models were created to predict 180-day mortality(AUROC 0.74) and need for readmission(AUROC 0.821), that could guide the management of the patients at the time of admission.