Carolina Castro Porto Silva Janovsky

Sleep characteristics in type 1 diabetes and associations with glycemic control: systematic review and meta-analysis

OBJECTIVES The association between inadequate sleep and type 2 diabetes has garnered much attention, but little is known about sleep and type 1 diabetes (T1D). Our objectives were to conduct a systematic review and meta-analysis comparing sleep in persons with and without T1D, and to explore relationships between sleep and glycemic control in T1D. METHODS Studies were identified from Medline and Scopus. Studies reporting measures of sleep in T1D patients and controls, and/or associations between sleep and glycemic control, were selected. RESULTS A total of 22 studies were eligible for the meta-analysis. Children with T1D had shorter sleep duration (mean difference [MD] = -26.4 minutes; 95% confidence interval [CI] = -35.4, -17.7) than controls. Adults with T1D reported poorer sleep quality (MD in standardized sleep quality score = 0.51; 95% CI = 0.33, 0.70), with higher scores reflecting worse sleep quality) than controls, but there was no difference in self-reported sleep duration. Adults with TID who reported sleeping >6 hours had lower hemoglobin A1c (HbA1c) levels than those sleeping ≤6 hours (MD = -0.24%; 95% CI = -0.47, -0.02), and participants reporting good sleep quality had lower HbA1c than those with poor sleep quality (MD = -0.19%; 95% CI = -0.30, -0.08). The estimated prevalence of obstructive sleep apnea (OSA) in adults with TID was 51.9% (95% CI = 31.2, 72.6). Patients with moderate-to-severe OSA had a trend toward higher HbA1c (MD = 0.39%, 95% CI = -0.08, 0.87). CONCLUSION T1D was associated with poorer sleep and high prevalence of OSA. Poor sleep quality, shorter sleep duration, and OSA were associated with suboptimal glycemic control in T1D patients.

Cardiovascular Autonomic Neuropathy Contributes to Sleep Apnea in Young and Lean Type 1 Diabetes Mellitus Patients

Knowledge about association between sleep apnea and cardiovascular autonomic neuropathy (CAN) in type 1 diabetes mellitus (T1DM) might give some insight into the pathogenesis of this condition in these patients. In obese patients, excessive central adiposity, including a large neck circumference, can contribute to obstructive sleep apnea (OSA). Its presence in non-obese patients, however, indicates that it could be correlated with autonomic neuropathy. The aim of this study was to compare the prevalence of OSA in young and lean T1DM patients with and without CAN. We studied 20 adult, non-obese, T1DM patients who were divided into two groups according to the results of the cardiovascular autonomic reflex tests (CARTs). These two groups (9 with CAN and 11 without CAN) were compared to a control group of 22 healthy individuals, who were matched by age and BMI. A polysomnography was performed and sleep was analyzed. The CAN+ group had a significantly higher prevalence of sleep apnea compared to the other groups (67% CAN+; 23% CAN−; 4.5% controls: CAN+ vs. Control; p = 0.006 and CAN+ vs. CAN−; p = 0.02). The CAN− group had higher sleep efficiency compared to the CAN+ group, demonstrating impaired sleep architecture in diabetics with this chronic complication. In conclusion, OSA may be related to the presence of CAN in young and lean T1DM patients. It could contribute to worse the prognosis and reducing the quality of life of these patients without specific treatment of these conditions.

Parathyroid carcinoma and hungry bone syndrome

We hereby report two patients with parathyroid carcinoma presenting extremely high calcium and PTH levels, severe bone disease, and palpable neck mass at diagnosis. They both underwent parathyroidectomy, and one of them evolved to lung metastasis. Important hypocalcemia was observed after surgery in both: after parathyroidectomy in one patient, and only after surgical removal of the metastasis in the other. Both required intravenous calcium replacement, thus revealing hungry bone syndrome (HBS). HBS usually reflects rapid mineralization after correction of hyperparathyroidism. The more severe the bone disease before surgery, the more prone the patient is to HBS after surgery. Despite being an unfavorable outcome, HBS state suggests that surgical removal of hypersecretory parathyroid tissue was accomplished. In this study, HBS was observed in both patients, who presented severe bone disease prior to surgery. HBS would be expected post-operatively in successful parathyroid carcinoma removal.

An unusual association between acute ischaemic stroke and cerebral venous thrombosis with thyrotoxic state.

Arterial cerebral ischaemia has been described in different diseases of the thyroid. Likewise, cerebral venous thrombosis (CVT) has been reported in association with hyperthyroidism. However, the association of arterial and venous cerebral ischaemic events in patients with hyperthyroidism has not been previously described. We report the case of a patient with thyrotoxicosis who presented initially with an arterial ischaemic stroke complicated by a concomitant CVT, ultimately treated with decompressive craniectomy. Laboratory results revealed elevated factor VIII coagulant activity and a positive lupus anticoagulant IgG. In conclusion, CVT and arterial ischaemic events can happen concomitantly in patients with hyperthyroidism. Although there is insufficient evidence to prove that a hypercoagulability state in hyperthyroidism predisposes to cerebral ischaemia, the presence of antiphospholipid antibodies and other hypercoagulability studies should be performed in patients with thyrotoxicosis and ischaemic events.

A Prospective Study Showing an Excellent Response of Patients with Low-Risk Differentiated Thyroid Cancer Who Did Not Undergo Radioiodine Remnant Ablation after Total Thyroidectomy.

Objectives: To prospectively evaluate the outcome of patients with low-risk papillary thyroid carcinoma treated with total thyroidectomy (TT) who did not undergo radioiodine remnant ablation (RRA). Study Design: We prospectively followed up 57 patients; 3 months after TT, thyroglobulin (Tg) assessment and neck ultrasonography (US) were performed while patients were taking L-T4, presenting suppressed TSH. Six months after TT, patients underwent stimulated Tg testing and whole-body scan (WBS) after recombinant TSH (rhTSH). Then, 18 months after TT, the patients were evaluated by neck US and Tg under TSH between 0.5 and 2.0 mIU/ml. Two years after TT, we performed another rhTSH assessment, measuring Tg and making a WBS. The patients were then annually monitored with neck US and Tg measurement under TSH between 0.5 and 2.0 mIU/l for 36-84 months. Results: Neck US of all patients, 3 months after TT, presented no evidence of abnormal residual tissues or metastatic lymph nodes (negative neck US); at this time, the mean Tg level was 0.42 ng/ml. Six months after surgery, after rhTSH, the mean thyroid bed uptake was 1.82%, and Tg levels ranged from 0.10 to 22.30 ng/ml (mean, 2.89 ng/ml). The patients were followed up without any sign of recurrence (negative neck US and stable or decreasing Tg levels). During the ongoing follow-up, the Tg trend was stable or decreasing, independently of the initial suppressed or stimulated Tg level, or WBS uptake. Conclusions: In patients with low-risk differentiated thyroid cancer, who were operated by TT and who did not undergo RRA, an excellent response to treatment may be confirmed by annual neck US and Tg trend.

Gender Dysphoria in a 62-Year-Old Genetic Female With Congenital Adrenal Hyperplasia

We report a case of gender dysphoria (GD) in a 62-year-old genetic female patient, raising the pros and cons of performing corrective surgery later in life. This 46,XX DSD patient was registered and reared as a girl; CAH was diagnosed late in childhood. Poor adherence to treatment and lack of proper psychological management contributed to evident GD. Living for years as a male, the patient applied for a legitimate male identification document in his late 50s; thereafter, he requested a sex-reassignment surgery “to disguise his female body upon his death.” We informed the patient and family about surgery hazards, while analytical therapy allowed the group to evaluate the actual wish for surgery. When the wish was brought up, the role of death urged the group to rethink the course of treatment. During the process, it became clear that the patient’s desire for surgery, more than a wish for changing the genitalia, expressed an impulse related to issues of endorsement and acceptance of his male identity. This report raises interesting questions about sexuality in a social context and prompts the idea that sexuality is broader than sex itself, raising new questions on the psychological risks faced when considering a body change after years of living with a disorder of sex development.

Clinical utility of 18F-FDG PET/CT in the follow-up of a large cohort of patients with high-risk differentiated thyroid carcinoma

OBJECTIVE To evaluate the clinical utility of 18F-FDG PET/CT in patients with high-risk DTC. SUBJECTS AND METHODS Single-center retrospective study with 74 patients with high-risk differentiated thyroid cancer (DTC), classified in 4 groups. Group 1: patients with positive sTg or TgAb, subdivided in Group 1A: negative RxWBS and no foci of metastases identified at conventional image (n = 9); Group 1B: RxWBS not compatible with suspicious foci at conventional image or not proportional to sTg level (n = 13); Group 2: patients with histological findings of aggressive DTC variants (n = 21) and Group 3: patients with positive RxWBS (n = 31). RESULTS 18F-FDG PET/CT identified undifferentiated lesions and helped restage the disease in groups 1B and 2. The scan helped guide clinical judgment in 9/13 (69%) patients of group 1B, 10/21 (48%) patients of group 2 and 2/31 (6%) patients of group 3. There was no clinical benefit associated with group 1A. 18F-FDG PET/CT was associated with progressive disease. CONCLUSION 18F-FDG PET/CT is a useful tool in the follow-up of patients with high-risk DTC, mainly in the group of RxWBS not compatible with suspicious foci at conventional image or not proportional to sTg level and in those with aggressive DTC variants. Additionally, this study showed that 18F-FDG PET/CT was associated with progression and helped display undifferentiated lesions guiding clinical assessments regarding surgeries or expectant treatments.

Association between Thyroid-Stimulating Hormone Levels and Non-Alcoholic Fatty Liver Disease Is Not Independent from Metabolic Syndrome Criteria

Introduction: Thyroid hormones are involved in the regulation of body composition, lipid metabolism, and insulin resistance. Thus, it is possible that they might play a role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). However, the role of thyroid function on NAFLD is not well defined. In this study, we evaluated the relationship between thyroid-stimulating hormone (TSH) levels, within the reference range, and presence of NAFLD in asymptomatic individuals. Study Design: We included all individuals evaluated at a preventive clinic of the Hospital Israelita Albert Einstein, between 2014 and 2015. The prevalence of NAFLD (analyzed by abdominal ultrasound), according to TSH quartiles, within the reference range, was determined. The association between TSH quartiles and NAFLD was analyzed by logistic regression adjusted for possible confounders. Results: We evaluated 10,539 individuals (73% male, age 43.4 ± 9.4 years). The prevalence of NAFLD was 34, 38, 38, and 39% in the first to the fourth TSH quartiles (0.46–1.44, 1.45–1.97, 1.98–2.68, and 2.69–4.68 mUI/L, respectively, p for trend < 0.001). At univariate analysis, higher TSH levels were associated with the diagnosis of NAFLD. When data were adjusted for the metabolic syndrome characteristics (waist circumference, HDL-cholesterol and triglycerides levels, presence of diabetes, and systemic arterial hypertension), the association was no longer significant. Conclusions: Although the TSH variability within the reference range is associated with NAFLD in univariable models, once adjusted for metabolic syndrome factors no significant association is noted.

Bethesda Classification and Cytohistological Correlation of Thyroid Nodules in a Brazilian Thyroid Disease Center

Background: The Bethesda System has been used to classify thyroid cytology in 6 categories besides presenting malignancy rates and respective approaches. Reference centers have validated its use by comparing its proposed malignancy rates with those in in their populations. However, to the best of our knowledge, there has been no corresponding study in Brazil. Objectives: To evaluate the performance of the Bethesda classification in a Brazilian thyroid reference center and correlate the results with cytohistological reports in patients referred to surgery. Methods: Data records from 980 fine-needle aspiration (FNA) results were retrospectively analyzed, and, in patients who underwent surgery, the results were correlated with the cytohistological findings. Results: 980 FNAs and 585 patients were evaluated. The incidence of each cytological category was: 11% nondiagnostic (ND), 59.6% benign, 7.1% (atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS), 8.5% follicular neoplasm or suspicious for follicular neoplasm (FN/SFN), 5.1% suspicious for malignancy (SM), and 8.3% malignant. The surgery rate was 41.8% (245/585). The malignancy rate in each category was: 6% benign, 12% AUS/FLUS, 20.8% FN/SFN, 72.5% SM, and 97.3% malignant. For ND nodules, the malignancy rate was 25.7% (66.6% multifocal and papillary microcarcinomas), a higher rate than in the literature. In this category, surgery was performed in multinodular goiters presenting with another nodule > 3.0 cm and/or with an FN/SFN, SM, or malignant cytological result. Conclusion: The Bethesda System can be applied to the Brazilian population, since the frequency and malignancy rates of each category were similar to those described by its classification. It is noteworthy that a higher risk of malignancy was observed in the ND cytological category.

Impact of self-reported fasting duration on lipid profile variability, cardiovascular risk stratification and metabolic syndrome diagnosis

OBJECTIVE We sought to investigate the impact of self-reported fasting duration times on the lipid profile results and its impact on the cardiovascular risk stratification and metabolic syndrome diagnosis. SUBJECTS AND METHODS We analyzed data from all consecutive individuals evaluated in a comprehensive health examination at the Hospital Israelita Albert Einstein from January to December 2015. We divided these patients in three groups, according to the fasting duration recalled (< 8h, 8-12h and > 12h). We calculated the global cardiovascular risk and diagnosed metabolic syndrome according to the current criteria and estimated their change according to fasting duration. RESULTS A total of 12,196 (42.3 ± 9.2 years-old, 30.2% females) patients were evaluated. The distribution of cardiovascular risk was not different among groups defined by fasting duration in both men and women (p = 0.547 for women and p = 0.329 for men). Similarly, the prevalence of metabolic syndrome was not influenced by the fasting duration (p = 0.431 for women and p = 0.166 for men). CONCLUSION Self-reported fasting duration had no significant impact on the lipid profile results, including triglyceride levels. Consequently, no changes on the cardiovascular risk stratification using the Framingham risk score nor changes on the prevalence of metabolic syndrome were noted.