Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária
Autor(a) principal: | |
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Data de Publicação: | 2020 |
Tipo de documento: | Tese |
Idioma: | por |
Título da fonte: | Biblioteca Digital de Teses e Dissertações da Uninove |
Texto Completo: | http://bibliotecatede.uninove.br/handle/tede/2767 |
Resumo: | Diabetic neuropathy (DN) is one of the main complications of Diabetes Mellitus (DM) and affects more than 50% of the individuals with this medical condition. This frequently overlooked complication compromises both the somatic and the autonomic nervous systems, and its prevalence rates vary according to the diagnostic criteria. Two of the main types of DN, Distal Symmetric Polyneuropathy (DSP) and Cardiovascular Autonomic Neuropathy (CAN), are among the diabetic complications with the greatest clinical repercussion, being responsible for high morbidity and mortality rates. The objective of this cross-sectional study was (1) to evaluate the 18 prevalence rates of DSP and of CAN in individuals with type 2 DM (T2D) followed in a primary care unit in the city of São Paulo and (2) to validate the equivalence of the performance of a nylon line to the performance of the Semmes-Weinstein monofilament in the assessment of foot ulcer risk. A total of 551 individuals with T2D (59.3% women, 65 [59–72] years old; diabetes duration of 10 [5–15] years; HbA1c of 7.2 [6.3–9.1] %; as median [interquartile interval]) were included. DSP was diagnosed by the sum of the Neuropathy symptoms score (NSS) and modified Neuropathy disability score (NDS) or presence of lower limb amputation. CAN was diagnosed by cardiovascular autonomic reflex tests (CARTs) combined with spectral analysis of the heart rate variability (HRV). The assessment of foot ulcer risk was performed with the two tools, the nylon line and the Semmes-Weinstein monofilament, in the three sites recommended by the Internacional Consensus on the Diabetic Foot and Practical Guidelines for the test with Semmes-Weinstein monofilament. The prevalence rate of DSP was 6.3% and the prevalence rate of foot ulcer risk as evaluated by Semmes-Weinstein monofilament was 14.3%. The prevalence rates of incipient and definitive CAN were 12.5% and 10%, respectively. The kappa coefficient of correlation between the nylon line and the Semmes-Weinstein monofilament was 0.94 (almost perfect). These findings suggest that the Semmes-Weinstein monofilament or even the nylon line may be more appropriate tools to diagnose DSP in the primary care setting in Brazil. |
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Giannella, Maria Lúcia Cardillo Corrêahttp://lattes.cnpq.br/5205676344593195Giannella, Maria Lucia Cardillo Corrêahttp://lattes.cnpq.br/5205676344593195Queiroz, Márcia Silvahttp://lattes.cnpq.br/1927869803694015Passarelli, Marisahttp://lattes.cnpq.br/7324507764759039Parisi, Maria Candida Ribeirohttp://lattes.cnpq.br/5855704434310397Nery, Márciahttp://lattes.cnpq.br/898357420031201http://lattes.cnpq.br/6970184024262667Matos, Mozânia Reis de2021-11-18T21:27:31Z2020-02-04Matos, Mozânia Reis de. Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária. 2020. 73 f. Tese( Programa de Mestrado em Medicina) - Universidade Nove de Julho, São Paulo.http://bibliotecatede.uninove.br/handle/tede/2767Diabetic neuropathy (DN) is one of the main complications of Diabetes Mellitus (DM) and affects more than 50% of the individuals with this medical condition. This frequently overlooked complication compromises both the somatic and the autonomic nervous systems, and its prevalence rates vary according to the diagnostic criteria. Two of the main types of DN, Distal Symmetric Polyneuropathy (DSP) and Cardiovascular Autonomic Neuropathy (CAN), are among the diabetic complications with the greatest clinical repercussion, being responsible for high morbidity and mortality rates. The objective of this cross-sectional study was (1) to evaluate the 18 prevalence rates of DSP and of CAN in individuals with type 2 DM (T2D) followed in a primary care unit in the city of São Paulo and (2) to validate the equivalence of the performance of a nylon line to the performance of the Semmes-Weinstein monofilament in the assessment of foot ulcer risk. A total of 551 individuals with T2D (59.3% women, 65 [59–72] years old; diabetes duration of 10 [5–15] years; HbA1c of 7.2 [6.3–9.1] %; as median [interquartile interval]) were included. DSP was diagnosed by the sum of the Neuropathy symptoms score (NSS) and modified Neuropathy disability score (NDS) or presence of lower limb amputation. CAN was diagnosed by cardiovascular autonomic reflex tests (CARTs) combined with spectral analysis of the heart rate variability (HRV). The assessment of foot ulcer risk was performed with the two tools, the nylon line and the Semmes-Weinstein monofilament, in the three sites recommended by the Internacional Consensus on the Diabetic Foot and Practical Guidelines for the test with Semmes-Weinstein monofilament. The prevalence rate of DSP was 6.3% and the prevalence rate of foot ulcer risk as evaluated by Semmes-Weinstein monofilament was 14.3%. The prevalence rates of incipient and definitive CAN were 12.5% and 10%, respectively. The kappa coefficient of correlation between the nylon line and the Semmes-Weinstein monofilament was 0.94 (almost perfect). These findings suggest that the Semmes-Weinstein monofilament or even the nylon line may be more appropriate tools to diagnose DSP in the primary care setting in Brazil.Entre as principais complicações do Diabetes Mellitus (DM) está a Neuropatia Diabética (ND), que atinge mais de 50% dos pacientes com diagnóstico de DM. A ND compromete tanto o sistema nervoso somático quanto o autonômico, e suas taxas de prevalência variam de acordo com os critérios de diagnóstico. Dois dos principais tipos de ND, a Polineuropatia Simétrica Distal (PSD) e a Neuropatia Autonômica Cardiovascular (NAC), estão entre as complicações de maior repercussão clínica do DM, sendo responsáveis por altos índices de 16 morbimortalidade. Os objetivos deste estudo transversal foram: (1) avaliar as prevalências de PSD e de NAC em indivíduos com DM tipo 2 (DM2) acompanhados em uma Unidade Básica de Saúde (UBS) da cidade de São Paulo, assim como os fatores de risco associados a essas complicações e (2) validar a equivalência do desempenho de um fio de nylon ao do monofilamento de Semmes-Weinstein na avaliação do pé de risco para Úlcera do Pé Diabético (UPD) na Atenção Primária a Saúde. Um total de 551 indivíduos com DM2 (59,3% mulheres, com idade de 65 [59–72] anos; duração do diabetes de 10 [5–15] anos; HbA1c de 7,2 [6,3–9,1] %; mediana [intervalo interquartílico]) foi incluído. O diagnóstico de PSD foi realizado pela soma do Neuropathy Symptoms Score (NSS) e do Neuropathy Disability Score (NDS) ou pela presença de amputação não traumática de membros inferiores. A NAC foi diagnosticada por testes do reflexo autonômico cardiovascular (Testes de Ewing) combinados com análise espectral da Variabilidade da Frequência Cardíaca (VFC). A comparação do desempenho do fio de nylon com o desempenho do monofilamento de Semmes-Weinstein foi realizada nos três sítios preconizados pelo Internacional Consensus on the Diabetic Foot and Practical Guidelines para o exame com o monofilamento. A prevalência de PSD foi de 6,3% e a prevalência de pé de risco para UPD pelo teste de monofilamento de Semmes-Weinstein foi de 14,3%. As prevalências de NAC incipiente e instalada foram de 12,5% e 10%, respectivamente. O coeficiente Kappa de concordância entre o fio de nylon e o monofilamento de Semmes-Weinstein foi de 0,94 (quase perfeito). Esses achados sugerem que o monofilamento de Semmes-Weinstein ou mesmo o fio de nylon podem ser ferramentas mais apropriadas para diagnosticar a PSD no contexto da APS no Brasil.Submitted by Nadir Basilio (nadirsb@uninove.br) on 2021-11-18T21:27:31Z No. of bitstreams: 1 Mozânia Reis.pdf: 1035561 bytes, checksum: bc2ba1b82a3757e323ea8a624fa2e884 (MD5)Made available in DSpace on 2021-11-18T21:27:31Z (GMT). No. of bitstreams: 1 Mozânia Reis.pdf: 1035561 bytes, checksum: bc2ba1b82a3757e323ea8a624fa2e884 (MD5) Previous issue date: 2020-02-04application/pdfporUniversidade Nove de JulhoPrograma de Mestrado em MedicinaUNINOVEBrasilSaúdeneuropatia diabéticapolineuropatia simétrica distalneuropatia autonômica cardiovascularpé diabéticoatenção primária à saúdediabetic neuropathydistal symmetric polyneuropathycardiovascular autonomic neuropathydiabetic footprimary careCIENCIAS DA SAUDEPrevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primáriaDistal symmetric and cardiovascular autonomic neuropathy in brazilian individuals with type 2 diabetes mellitus followed in a primary health careinfo:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/doctoralThesis8765449414823306929600info:eu-repo/semantics/openAccessreponame:Biblioteca Digital de Teses e Dissertações da Uninoveinstname:Universidade Nove de Julho (UNINOVE)instacron:UNINOVEORIGINALMozânia Reis.pdfMozânia Reis.pdfapplication/pdf1035561http://localhost:8080/tede/bitstream/tede/2767/2/Moz%C3%A2nia+Reis.pdfbc2ba1b82a3757e323ea8a624fa2e884MD52LICENSElicense.txtlicense.txttext/plain; charset=utf-82165http://localhost:8080/tede/bitstream/tede/2767/1/license.txtbd3efa91386c1718a7f26a329fdcb468MD51tede/27672022-06-03 16:49:34.158oai:localhost: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Biblioteca Digital de Teses e Dissertaçõeshttp://bibliotecatede.uninove.br/PRIhttp://bibliotecatede.uninove.br/oai/requestbibliotecatede@uninove.br||bibliotecatede@uninove.bropendoar:2022-06-03T19:49:34Biblioteca Digital de Teses e Dissertações da Uninove - Universidade Nove de Julho (UNINOVE)false |
dc.title.por.fl_str_mv |
Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária |
dc.title.alternative.eng.fl_str_mv |
Distal symmetric and cardiovascular autonomic neuropathy in brazilian individuals with type 2 diabetes mellitus followed in a primary health care |
title |
Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária |
spellingShingle |
Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária Matos, Mozânia Reis de neuropatia diabética polineuropatia simétrica distal neuropatia autonômica cardiovascular pé diabético atenção primária à saúde diabetic neuropathy distal symmetric polyneuropathy cardiovascular autonomic neuropathy diabetic foot primary care CIENCIAS DA SAUDE |
title_short |
Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária |
title_full |
Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária |
title_fullStr |
Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária |
title_full_unstemmed |
Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária |
title_sort |
Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária |
author |
Matos, Mozânia Reis de |
author_facet |
Matos, Mozânia Reis de |
author_role |
author |
dc.contributor.advisor1.fl_str_mv |
Giannella, Maria Lúcia Cardillo Corrêa |
dc.contributor.advisor1Lattes.fl_str_mv |
http://lattes.cnpq.br/5205676344593195 |
dc.contributor.referee1.fl_str_mv |
Giannella, Maria Lucia Cardillo Corrêa |
dc.contributor.referee1Lattes.fl_str_mv |
http://lattes.cnpq.br/5205676344593195 |
dc.contributor.referee2.fl_str_mv |
Queiroz, Márcia Silva |
dc.contributor.referee2Lattes.fl_str_mv |
http://lattes.cnpq.br/1927869803694015 |
dc.contributor.referee3.fl_str_mv |
Passarelli, Marisa |
dc.contributor.referee3Lattes.fl_str_mv |
http://lattes.cnpq.br/7324507764759039 |
dc.contributor.referee4.fl_str_mv |
Parisi, Maria Candida Ribeiro |
dc.contributor.referee4Lattes.fl_str_mv |
http://lattes.cnpq.br/5855704434310397 |
dc.contributor.referee5.fl_str_mv |
Nery, Márcia |
dc.contributor.referee5Lattes.fl_str_mv |
http://lattes.cnpq.br/898357420031201 |
dc.contributor.authorLattes.fl_str_mv |
http://lattes.cnpq.br/6970184024262667 |
dc.contributor.author.fl_str_mv |
Matos, Mozânia Reis de |
contributor_str_mv |
Giannella, Maria Lúcia Cardillo Corrêa Giannella, Maria Lucia Cardillo Corrêa Queiroz, Márcia Silva Passarelli, Marisa Parisi, Maria Candida Ribeiro Nery, Márcia |
dc.subject.por.fl_str_mv |
neuropatia diabética polineuropatia simétrica distal neuropatia autonômica cardiovascular pé diabético atenção primária à saúde |
topic |
neuropatia diabética polineuropatia simétrica distal neuropatia autonômica cardiovascular pé diabético atenção primária à saúde diabetic neuropathy distal symmetric polyneuropathy cardiovascular autonomic neuropathy diabetic foot primary care CIENCIAS DA SAUDE |
dc.subject.eng.fl_str_mv |
diabetic neuropathy distal symmetric polyneuropathy cardiovascular autonomic neuropathy diabetic foot primary care |
dc.subject.cnpq.fl_str_mv |
CIENCIAS DA SAUDE |
description |
Diabetic neuropathy (DN) is one of the main complications of Diabetes Mellitus (DM) and affects more than 50% of the individuals with this medical condition. This frequently overlooked complication compromises both the somatic and the autonomic nervous systems, and its prevalence rates vary according to the diagnostic criteria. Two of the main types of DN, Distal Symmetric Polyneuropathy (DSP) and Cardiovascular Autonomic Neuropathy (CAN), are among the diabetic complications with the greatest clinical repercussion, being responsible for high morbidity and mortality rates. The objective of this cross-sectional study was (1) to evaluate the 18 prevalence rates of DSP and of CAN in individuals with type 2 DM (T2D) followed in a primary care unit in the city of São Paulo and (2) to validate the equivalence of the performance of a nylon line to the performance of the Semmes-Weinstein monofilament in the assessment of foot ulcer risk. A total of 551 individuals with T2D (59.3% women, 65 [59–72] years old; diabetes duration of 10 [5–15] years; HbA1c of 7.2 [6.3–9.1] %; as median [interquartile interval]) were included. DSP was diagnosed by the sum of the Neuropathy symptoms score (NSS) and modified Neuropathy disability score (NDS) or presence of lower limb amputation. CAN was diagnosed by cardiovascular autonomic reflex tests (CARTs) combined with spectral analysis of the heart rate variability (HRV). The assessment of foot ulcer risk was performed with the two tools, the nylon line and the Semmes-Weinstein monofilament, in the three sites recommended by the Internacional Consensus on the Diabetic Foot and Practical Guidelines for the test with Semmes-Weinstein monofilament. The prevalence rate of DSP was 6.3% and the prevalence rate of foot ulcer risk as evaluated by Semmes-Weinstein monofilament was 14.3%. The prevalence rates of incipient and definitive CAN were 12.5% and 10%, respectively. The kappa coefficient of correlation between the nylon line and the Semmes-Weinstein monofilament was 0.94 (almost perfect). These findings suggest that the Semmes-Weinstein monofilament or even the nylon line may be more appropriate tools to diagnose DSP in the primary care setting in Brazil. |
publishDate |
2020 |
dc.date.issued.fl_str_mv |
2020-02-04 |
dc.date.accessioned.fl_str_mv |
2021-11-18T21:27:31Z |
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Matos, Mozânia Reis de. Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária. 2020. 73 f. Tese( Programa de Mestrado em Medicina) - Universidade Nove de Julho, São Paulo. |
dc.identifier.uri.fl_str_mv |
http://bibliotecatede.uninove.br/handle/tede/2767 |
identifier_str_mv |
Matos, Mozânia Reis de. Prevalência de polineuropatia simétrica distal e de neuropatia autonômica cardiovascular em indivíduos com diabetes mellitus tipo 2 acompanhados em um serviço de atenção primária. 2020. 73 f. Tese( Programa de Mestrado em Medicina) - Universidade Nove de Julho, São Paulo. |
url |
http://bibliotecatede.uninove.br/handle/tede/2767 |
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UNINOVE |
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Brasil |
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Saúde |
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