Débora Vieira Soares

Glucose Metabolism and Visceral Fat in GH Deficient Adults: Two Years of GH-Replacement

The aim of this study was to evaluate the effect of 24 months of growth hormone (GH) replacement on glucose metabolism and visceral fat in 17 adults with GH deficiency: 9 men and 8 women; age 40 ± 1.8 yr. [range 20–61] and body mass index 25 ± 0.8 Kg/m2.Glucose metabolism was evaluated by a standard oral glucose tolerance test (OGTT), by the homeostatic model assessment (HOMA) insulin resistance index and by the insulin sensitivity index (ISI)-composite derived from the OGTT. Visceral fat was evaluated by CT scan.Twenty-four months of GH replacement induced an increase in the prevalence of abnormal glucose tolerance, with significant progressive increment in 2h-OGTT insulin levels at 3, 12 and 24 months (p = 0.005). Plasma glucose levels and ISI-composite did not alter during the study. HOMA-IR index increased only in the group of patients (n = 8) who had abnormal OGTT at 24 months (p = 0.012). Visceral fat reduced at month 12 and remained decreased until the end of the study (p = 0.009).In conclusion, the present study suggests that adults with GH deficiency after twenty-four months of GH replacement developed abnormal glucose tolerance, probably due to an increase in insulin resistance, associated with higher insulin levels, despite favorable alterations in body composition.

Serum Leptin in Overt and Subclinical Hypothyroidism: Effect of Levothyroxine Treatment and Relationship to Menopausal Status and Body Composition

BACKGROUND The relationship between thyroid status, including subclinical hypothyroidism (SH) and serum leptin is controversial or uncertain. Therefore we evaluated serum leptin in SH and overt hypothyroidism (OH) and determined the effects of levothyroxine (LT(4)) replacement on serum leptin in these disorders. METHODS Serum leptin, thyrotropin (TSH), free thyroxine, insulin, glucose, and body composition parameters were compared in 55 SH, 20 OH, and 28 euthyroid (EU) pre- and postmenopausal women. In addition, the effect of LT(4) treatment on serum leptin in SH and OH was assessed. RESULTS The mean +/- SD (median) serum leptin concentrations in the OH and SH groups were higher than in the EU group (35.1 +/- 27.2 [33.0] and 36.6 +/- 21.9 [30.6] ng/mL, respectively, vs. 23.2 +/- 19.3 [17.9] ng/mL, p = 0.011), but the difference was only significant in postmenopausal women. The body mass index (BMI), fat mass index (FMI), and the homeostasis model assessment-insulin resistance (HOMA-IR) index values were not different among these groups. In premenopausal women there was no correlation between leptin, BMI, or FMI and serum TSH levels (r(s) = 0.009, p = 0.474; r(s) = 0.043, p = 0.367; r(s) = 0.092, p = 0.232). In the postmenopausal women, the partial correlation coefficient between TSH and leptin was present, even when controlling for BMI (r(s) = 0.297, p = 0.042) and FMI (r(s) = 0.275, p = 0.050). LT(4) treatment was associated with a reduction of serum leptin concentrations in the OH group (p = 0.008). In SH group there were no differences between LT(4) replacement or no treatment, since a fall in serum leptin levels was detected in both SH subgroups, despite a more pronounced fall with LT(4) use. Treatment of the SH and OH groups with LT(4) did not influence HOMA-IR index or body composition. CONCLUSIONS Serum leptin concentrations are elevated in postmenopausal women with SH or OH. A relationship between thyroid status and serum leptin is further supported by the fact that LT(4) treatment, to restore the EU status, reduced serum leptin levels in OH in the absence of significant effects on BMI. In women, hypothyroidism influences either leptin secretion or degradation and this effect is more pronounced in postmenopausal than in premenopausal women.

Aspectos diagnósticos e terapêuticos da síndrome de Sheehan

Sheehans syndrome is characterized by hypopituitarism that occurs as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage. Nowadays it is not usually seen in developed countries because of the improvements in obstetric care. However, in developing countries it is still frequent and probably one of the most common causes of hypopituitarism. Most patients usually present it months to years later, with a history of failure of postpartum lactation, failure to resume menses and other signs of panhypopituitarism. In mild forms of the disease, patients may remain undetected and do not receive treatment for many years. Early diagnosis and appropriate treatment are important to reduce the morbimortality of the patients with Sheehans syndrome. The aim of this review is to describe clinical, laboratorial and therapeutic aspects of Sheehans syndrome, including our experience in the replacement of recombinant GH in these patients.

Carotid intima-media thickness as a marker of cardiovascular risk in patients with subclinical hypothyroidism

Subclinical hypothyroidism (SH) has been associated with an increased risk for coronary disease. Carotid intima-media thickness (IMT), as assessed by ultrasonography, is a precise marker of atherosclerotic changes and can be used as an endpoint for cardiovascular events. Aims of this study were to determine carotid IMT in a group of patients with SH and its possible association with an increase in cardiovascular risk. There were no significant differences in mean carotid IMT between patients and controls. Results of both groups were, respectively: common carotid arteries, 0.573 +/- 0.070 mm and 0.576 +/- 0.068 mm (p= 0.904); carotid bifurcation, 0.602 +/- 0.079 mm and 0.617 +/- 0.102 mm (p= 0.714). Similar results were obtained when analyzing subgroups with serum TSH < or > 8 mIU/L and with positive or negative titers of TPOAb. The mean carotid IMT in these subgroups were: TSH 4-8 mIU/L: 0.579 +/- 0.070 mm and 0.586 +/- 0.063 mm; TSH > 8 mIU/L: 0.569 +/- 0.073 mm and 0.616 +/- 0.091 mm; TPOAb+: 0.585 +/- 0.070 mm and 0.621 +/- 0.085 mm; TPOAb-: 0.554 +/- 0.072 mm and 0.571 +/- 0.066 mm. No differences in the lipid profile and in the apoprotein B and lipoprotein (a) levels between the groups were found. These findings suggest that mild SH with no related metabolic changes is not associated with an increase in cardiovascular risk, as assessed by carotid IMT.

Comparison of two dose regimens of growth hormone (GH) with different target IGF-1 levels on glucose metabolism, lipid profile, cardiovascular function and anthropometric parameters in gh-deficient adults.

OBJECTIVE To compare the effects of two regimens of GH therapy with different target IGF-1 levels on anthropometric parameters, glucose metabolism, lipid profile and cardiac function in adults with GH deficiency (GHD). PATIENTS AND METHODS Retrospective analysis of 14 GHD adults from Clementino Fraga Filho University Hospital, Rio de Janeiro, Brazil, who were treated with a GH regimen aimed at maintaining serum IGF-1 levels between the median and upper reference limit (high dose group - HDGH) and 18 GHD adults from Federal University Hospital, Curitiba, Brazil, who received a fixed GH dose of 0.2mg/day in the first year of treatment, followed by titration to maintain serum IGF-1 levels between the median and lower reference limit (low dose group - LDGH). All patients were followed for 2 years with analysis of anthropometric parameters, serum levels of IGF-1, glucose, insulin, HOMA-IR, lipid profile, and transthoracic echocardiography. RESULTS Changes on weight, BMI and waist circumference were similar between the two groups. Insulin levels increased and HOMA-IR worsened in the LDGH group at 1year and improved thereafter. Total cholesterol and triglycerides did not change with therapy. LDL cholesterol reduced in both groups, while HDL-cholesterol significantly increased only in the HDGH group (p=0.007 vs LDGH). No significant variations on echocardiographic parameters were observed. CONCLUSION The HDGH and LDGH regimens resulted in similar changes on anthropometric, echocardiographic, glucose and lipid parameters in GHD adults, except for increase in HDL cholesterol that was only observed in the HDGH regimen.

Disfunção hepática aguda em paciente com hipertireoidismo e hepatite por vírus B: recuperação após plasmaférese e tireoidectomia - relato de caso

Acute Hepatic Failure in a patient with Hyperthyroidism and Virus B Hepatitis: Recovery after plasmapheresis and Thyroidectomy – a Case Report.

Presença de auto-anticorpos não-tireóide-específicos no soro de pacientes com hipotireoidismo auto-imune

Autoantibodies against nonthyroid-specific components were detected in sera of patients with autoimmune thyroid disease. In this study we investigated the presence of the antinuclear antibody (ANA), antismooth muscle antibody (anti-SM) and antimitochondrial antibody (anti-Mc) in the sera of patients with autoimmune hypothyroidism comparing them to a control group. We studied 70 patients with autoimmune hypothyroidism (Hashimotos or atrophic thyroiditis) and 70 healthy controls (subjects without autoimmune and thyroid diseases ), all female, mean age 50.2 (+ 15.9) and 49.6 years (+ 14.4), respectively. ANA was detected by Inno-LIA™ ANA (Innogenetics, Belgium) in 26% of the patients with autoimmune hypothyroidism and in 14% of the controls; this difference was not statistically significant (p = 0.09). There were no differences between disease duration or age between the groups whether ANA was positive or not. Antibodies anti-Mc and anti-SM were not detected in any analyzed sample. In conclusion, patients with autoimmune hypothyroidism did not have greater incidence of autoantibodies against nonthyroid-specific components than healthy controls. Nevertheless, we emphasize that the association between autoimmune thyroid disease and other autoimmune diseases is undeniable and therefore regular assessments are recommended.

Avaliação do Metabolismo Glicídico e da Gordura Visceral em Adultos Deficientes de Hormônio de Crescimento

Growth hormone deficiency (GHD) syndrome in adults and the resulting increased cardiovascular risk have been extensively studied in recent years. To evaluate body composition abnormalities and insulin resistance in GHD adults, we studied 27 patients using abdominal CT, considering glucose and insulin responses during an oral glucose tolerance test (OGTT) and the Homeostasis Model Assessment (HOMA). The group of patients was compared to a control group of 27 healthy individuals matched by age, gender and body mass index. GHD patients showed increase in the amount of visceral adipose tissue (p= 0.008). The frequency of abnormalities indicated by OGTT was similar to that found within the control group. Fasting and after-oral glucose load plasma glucose and insulin levels were similar to those identified within the control group (p>0.05). The areas under the glucose and insulin curves were also similar (p>0.05) and there were no differences in the insulin sensitivity measured by HOMA (p= 0.989). There was a strong positive correlation between increased visceral adipose tissue with after-oral glucose load plasma glucose (r= 0.58; p= 0.001) and insulin (r= 0.72; p= 0.001) levels and the areas under the glucose (r= 0.40; p= 0.040) and insulin (r= 0.71; p= 0.001) curves on the patient group, but not within the control group (r 0.05). In conclusion, it was not observed any significant difference in glucose metabolism, despite the increased amount of visceral fat found in GHD patients.

INOVAÇÃO DE PROCESSOS - UM ESTUDO COMPARATIVO SOBRE SUA IMPLEMENTAÇÃO

Num ambiente globalizado de intensa competicao e de mudancas constantes e complexas, caracterizadas por exigencias cada vez maiores em termos de rapidez, qualidade, baixo custo, flexibilidade e satisfacao do cliente, o sucesso de uma organizacao reside na sua capacidade de responder adequadamente a essas exigencias, atraves de inovacoes continuas em seus produtos, processos e servicos. Neste contexto, este trabalho analisa as premissas, as motivacoes e os impactos causados pela Inovacao de Processos, nas organizacoes que utilizaram esta estrategia como forma de obter um diferencial competitivo no mercado. Para alcancar os objetivos pretendidos, apresenta-se uma revisao bibliografica sobre o tema e em seguida comparam-se os resultados depreendidos de alguns estudos de casos.

High-Dose Intravenous Pulse Therapy with Methylprednisolone and Orbital Irradiation in Graves’ Ophthalmopathy

Pulse therapy with steroids has been advocated as an effective therapy for Graves’ ophthalmopathy, followed or not by external radiotherapy, if more than one course fails or when side effects are not tolerated. Nineteen patients with Graves’ ophthalmopathy were treated with methylprednisolone IV pulses and a maintenance oral prednisone dose between pulses. Ten patients subsequently were sub-mitted to orbital radiotherapy because of recurrence of inflammatory signs and symptoms. Eight patients exhibited significant improvement after pulse therapy, and seven patients had a lesser response; inflammation showed significant regression in most patients, and proptosis improved in eight. Radiotherapy resulted in slight improvement in three patients and significant improvement in the other four. Proptosis regressed partially in three patients and completely in two. Diplopia disappeared in one patient, and visual acuity improved in five. Our results with steroid pulse therapy are comparable with other series reported in the literature, while other results with radiotherapy are less favorable.