Arnaldo Moura Neto

Abnormalities of Thyroid Hormone Metabolism during Systemic Illness: The Low T3 Syndrome in Different Clinical Settings

Thyroid hormone abnormalities are common in critically ill patients. For over three decades, a mild form of these abnormalities has been described in patients with several diseases under outpatient care. These alterations in thyroid hormone economy are a part of the nonthyroidal illness and keep an important relationship with prognosis in most cases. The main feature of this syndrome is a fall in free triiodothyronine (T3) levels with normal thyrotropin (TSH). Free thyroxin (T4) and reverse T3 levels vary according to the underlying disease. The importance of recognizing this condition in such patients is evident to physicians practicing in a variety of specialties, especially general medicine, to avoid misdiagnosing the much more common primary thyroid dysfunctions and indicating treatments that are often not beneficial. This review focuses on the most common chronic diseases already known to present with alterations in serum thyroid hormone levels. A short review of the common pathophysiology of the nonthyroidal illness is followed by the clinical and laboratorial presentation in each condition. Finally, a clinical case vignette and a brief summary on the evidence about treatment of the nonthyroidal illness and on the future research topics to be addressed are presented.

Panhypopituitarism Without GH Replacement: About Insulin Sensitivity, CRP Levels, and Metabolic Syndrome

A complete deficiency of anterior pituitary hormones from several etiologies characterizes Panhypopituitarism (PH). Despite advances in treatment, patients with PH maintain high rates of morbidity and mortality, a reason to investigate some insulin sensitivity, metabolic and inflammatory parameters that could be related to the increase of these indicators. This was a cross-sectional study comprising 41 PH patients under hormonal replacement, except for growth hormone, and 37 individuals in a control group (CG) with similar age, gender and body mass index (BMI). We assessed clinical data as age, sex, BMI, waist circumference, waist/hip ratio (WHR), history of hypertension, diabetes mellitus and dyslipidemia as well as fasting glycaemia, insulin, HOMA-IR, HbA1c, high-sensitivity CRP (hs-CRP), and lipid profile. PH patients presents lower values of glycaemia, insulin, HOMA-IR (0.88 vs 2.1) and WHR, but higher levels of hs-CRP (0.38 vs 0.16mg/dl) when compared with the CG. Although the occurrence of dyslipidemia was higher in patients with PH, the frequency of metabolic syndrome was similar between the groups. In multivariate linear regression analysis, the PH group independently predicted lower HOMA-IR and WHR values. In conclusion, this study demonstrated that patients with PH without GH replacement have lower HOMA-IR and WHR values and higher levels of hs-CRP than a CG paired by age, gender and BMI. The diagnosis of dyslipidemia was more frequent in patients with PH, but the occurrence of MS was similar to CG. Further studies are needed to confirm our findings and to better understand the metabolic characteristics of patients with PH.

The relationship between quality of life, cognition, and thyroid status in Graves’ disease

SummaryPurposeTo assess quality of life (QoL) and cognitive function among Graves’ disease (GD) patients with different thyroid status, with and without ophthalmopathy.MethodsThis is a cross-sectional clinic-based study involving 154 patients with GD (81.27% were female, mean age 45.6 ± SD 11.2 years) and 54 (35.06%) had ophthalmopathy. Data were collected after an informed consent from all patients was obtained. All patients completed the 36-Item Short Form Health Survey and Mini-Mental State Examination. Patients with ophthalmopathy also completed the Graves’ Orbitopathy Quality of Life Questionnaire.ResultsPatients with hyperthyroidism presented a greater impairment in QoL when compared to euthyroidism group. A lower score in physical role functioning was found in both subgroups with active disease (hyperthyroidism and euthyroidism using thionamides). A lower score was also seen in visual function, only in patients with hyperthyroidism, without difference in appearance. No difference was found in cognition between patients. Younger ages at diagnosis, male sex, euthyroidism and absence of ophthalmopathy were factors associated with better QoL, as well as a shorter disease duration was associated with better recall, attention and calculation.ConclusionsAn impairment in QoL among patients with active GD was evidenced, even in those receiving thionamides and in euthyroidism. Ophthalmopathy was a factor associated with a poor QoL and no clear evidence of cognitive impairment was demonstrated.

Clinical predictors of cardiac autonomic neuropathy in patients with type 1 diabetes

Results CAN was diagnosed in 39 (38.2%) patients. No statistically significant differences were found in age (34.87±9.71 vs. 33.90±11.74 yrs.; p=0.467), age at diagnosis (15.10±9.16 vs. 17.38±11.29 yrs.; p=0.495) and HbA1c (9.26%±2.04 vs. 8.84%±2.07; p=0.144) between groups. Hypertension and dyslipidemia were seen more frequently in patients with CAN (61.5 vs. 19%; p≤0.001 and 51.3 vs. 22.2%; p=0.002, respectively). Patients with CAN had higher total cholesterol (p=0.009) and triglycerides (p=0.004). Patients with CAN complained more often of post-prandial sweating

Somogyi effect as the most common cause of fasting hyperglycemia in T1D patients

Materials and methods We analyzed the glycemic profile measured by 72h-CGMS in 85 patients with T1D (29 female), resulting in 255 overnight periods. We assessed the nocturnal glycemic profile and the accuracy of the CGMS sensor per night. Fasting hyperglycemia was categorized into dawn phenomenon when there was no nocturnal hypoglycemia followed by a minimum 10mg/dL rise plasma between 4: 00h-7: 00h; Somogyi effect when nocturnal hypoglycemia (< 70mg/dL) between 0: 00h-3: 00h was followed by morning hyperglycemia and poor glycemic control when there was sustained overnight hyperglycemia. Clinical data (age, diabetes duration, insulin regime, and HbA1c values) were obtained by chart review and compared to the different causes of fasting hyperglycemia.

Diabetic and non-diabetic patients in the intensive care unit: morbidity and mortality

Materials and methods Between January and December 2013, 97 patients were studied (diabetics and non-diabetics). We analyzed gender, age, total hospitalization days, number of exams (echocardiography, x-ray, computed tomography, magnetic resonance imaging), number of prescribed antibiotics, invasive procedures (dialysis catheter, nasogastric tube, hemodialysis, surgery intervention) and outcome: death, discharged to the ward or home.

Risk factors for ulceration and amputation in patients with diabetic foot at risk: results form a tertiary care center

Background Ulceration and amputation are severe complications of diabetes, leading to great morbidity and mortality. Of all lower limb amputations, about 50% are performed in these patients (1). In their lifetime, diabetics have a chance as high as 25% to develop a foot ulcer (2). After an amputation, mortality rates ranges from 13% to 40% at 1 year, 35% to 65% at 3 yrs., and 39% to 80% at 5 yrs. (3). The aim of this study was to assess the main risk factors of ulceration and amputation in patients with type 1 and type 2 diabetes.

CSII treatment as an option in high-risk pregnant patients with type 1 diabetes.

Background Studies highlight that continuous subcutaneous insulin infusion (CSII) during pregnancy leads to better glycemic control and lower glycated hemoglobin (HbA1c) without an increase in hypoglycemic episodes or diabetic ketoacidosis. Poor glycemic control can lead to birth defects, miscarriages, growth abnormalities and stillbirth. However, how to obtain better gestational outcomes is still debatable.

Evaluation of the insulin administration technique in a tertiary hospital

Background Optimizing glycemic control is important to minimize the risk of macro and microvascular complications in diabetes. Therefore, it is important that patients under insulin treatment know the correct technique for insulin self-administration to ensure proper management. Objective Assess whether patients with longstanding diabetes followed in a tertiary hospital know how to correct selfadminister their insulin.

Charcot osteoarthropathy in conservative treatment: clinical and functional results

Background Charcot neuro-osteoarthropathy (CA) is a rare complication of neuropathy that affects patients who have lost protective sensation, has multiple etiologies and diabetes mellitus is the most prevalent. The CA is progressive degeneration of the affected joints and it is known that, in situations where there is not an adequate intervention, can install the complete destruction of the affected joints, as well as irreversible deformations, which lead to the development of ulcers and high index of amputation. In the consolidation phase, surgical treatment is usually indicated; however, the procedure is not always possible due to clinical limitations of patients, or even surgical difficulty itself. The suropodalic orthosis adapted to the patient may present as an alternative therapy.