Isabel do Carmo

Vulnerability to stress, anxiety and depressive symptoms and metabolic control in Type 2 diabetes

BackgroundVulnerability to stress has been associated to distress, emotional distress symptoms and metabolic control in type 2 diabetes mellitus (T2DM) patients as well. Furthermore some conflicting results were noticed. We aimed to evaluate the effect over metabolic control in what concerns vulnerability to stress beyond depressive and anxiety symptoms.FindingsThis cross-sectional study assessed 273 T2DM patients with depressive and anxiety symptoms using the Hospital Anxiety Depression Scale (HADS) and the 23 Questions to assess Vulnerability to Stress (23QVS), along with demographic and clinical diabetes-related variables. Hierarchical logistic regression models were used to investigate predictors of poor glycemic control. The results showed an association of depressive symptoms (odds ratio = 1.12, 95%CI = 1.01-1.24, P = 0.030) with increased risk of poor glycemic control. Anxiety symptoms and vulnerability to stress on their own were not predictive of metabolic control, respectively (odds ratio = 0.92, 95%CI = 0.84-1.00, P = 0.187 and odds ratio = 0.98, 95%CI = 0.95-1.01, P = 0.282).ConclusionsOur data suggested that vulnerability to stress was not predictive of poor glycemic control in T2DM, but depressive symptoms were.

Changes in the salivary protein profile of morbidly obese women either previously subjected to bariatric surgery or not

Saliva is a non-invasive source of biomarkers useful in the study of physiological mechanisms. Moreover, this fluid has diverse functions, among which food perception and ingestion, making it particularly suitable for the study of obesity. The aims of this study were to assess changes in salivary proteome among morbidly obese women, with a view to provide information about mechanisms potentially related to the development of obesity, and to evaluate whether these changes persist after weight loss. Mixed saliva samples from morbidly obese women (N = 18) who had been either subjected (group O-BS) or not (group O) to bariatric surgery and women with normal weight (N = 14; group C) were compared for protein profiles, alpha-amylase abundance and enzymatic activity, and carbonic anhydrase (CA) VI abundance. Differences in salivary obese profiles were observed for 23 different spots. Zinc-alpha-2 glycoprotein-containing spots showed higher abundance in group O only, whereas cystatin S-containing spots presented higher abundance in the two groups of obese subjects. Most of the spots identified as salivary amylase were present at lower levels in group O-BS. With regard to the amylase enzymatic activity, increases were observed for group O and decreases for group O-BS. One interesting finding was the high correlation between levels of CA VI and body mass index in group O, which was not observed for groups O-BS or C. The differences between groups, mainly regarding salivary proteins involved in taste sensitivity and metabolism, point to the potential of using saliva in the study of obesity development.

Treatment Response in Type 2 Diabetes Patients with Major Depression

AIMS Major depression is more prevalent in patients with type 2 diabetes mellitus (T2DM) than in general population. Comparing psychotherapeutic and pharmacological treatment responses could help to inform the choice between available treatment options. METHOD Thirty-four patients with T2DM and major depression detected by using the Hospital Anxiety-Depression Scale (HADS), the Montgomery-Äsberg Depression Rating Scale (MADRS) and a structured interview (Mini-International Neuropsychiatric Interview) were randomized to undergo Interpersonal Psychotherapy (IPT) or treatment with sertraline in a 3-month acute intervention course in addition to a 3-month continuation format. Provided that the initial MADRS score was not reduced ≥25% at week 6, these early non-responding patients continued treatment in a sequential add-on combined format. Psychological adjustment to diabetes, attachment style, diabetes self-efficacy, quality of life and HbA1c were also evaluated along intervention. RESULTS Out of 22 early-responding patients (11 for each treatment type), 16 had clinically significant improvements (<50% initial MADRS score) at endpoint with 11 reaching remission (MADRS scores ≤8), and with no significant differences between IPT and sertraline. Within sequential add-on treatment, out of eight patients, only three of them achieved a clinically significant improvement and only one reached remission. CONCLUSIONS These preliminary results suggested that IPT may be an option to treat major depression in T2DM against medical care with sertraline. Early non-responding patients likely need alternative or longer treatment interventions. Limitations of this study relate to small sample and absence of a control group, which was difficult to implement due to ethical restrictions. KEY PRACTITIONER MESSAGE Findings suggest that Interpersonal Psychotherapy is a useful tool to treat major depression in type 2 diabetes patients. A significant number of type 2 diabetes patients with major depression do not achieve depression remission irrespective of the type of treatment. Further clinical research should focus on addictive effects of psychotherapy and psychopharmacology in the treatment of depressed patients with chronic somatic diseases.

The Prevalence of Disturbances of Eating Behaviour in a Portuguese Female University Population

This paper reports the results of a questionnaire constructed to identify the prevalence of bulimia nervosa (BN), binge eating and other manifestations of concern with body and shape and habits of consumption of alcohol, tobacco and illicit drugs among female university students in Lisbon. It was sent out to 1542 subjects and responses from 50.1 per cent were obtained. Among those students who responded, 55.1 per cent desired to lose weight, 25 per cent reported weight fluctuations in the previous year, 12 per cent were dieting at that moment and 48.8 per cent had been on a diet before. The prevalence of BN was 3 per cent and 13.2 per cent of subjects reported at least two binge eating episodes per week (binge-eaters). Bulimics and binge-eaters were heavier, wanted to lose more weight, had used diets before more frequently, and reported ponderal oscillations more frequently than controls. They also reported more frequent consumption of alcohol, tobacco and illicit drugs than controls, but this is not statistically significant.

The impact of migration on body weight: a review

A obesidade pode ser uma das caracteristicas mais alteraveis no processo de migracao. Pretendeu-se resumir a informacao sobre o impacto da migracao no indice de massa corporal (IMC). Realizou-se uma revisao sistematica da literatura de acordo com as diretrizes PRISMA, por meio de pesquisa eletronica (ultima atualizacao em agosto de 2014). Foram incluidos e avaliados qualitativamente 39 artigos. A associacao entre migracao e evolucao de IMC varia de acordo com o grupo etnico e paises de origem/acolhimento. Imigrantes hispânicos, europeus e africanos apresentam relacao consistente e positiva entre IMC e tempo de migracao. Os imigrantes asiaticos apresentam associacao positiva em menos da metade dos estudos. No geral, a qualidade dos estudos e fraca e ha necessidade de melhorar conceitos e metodos. Parece existir um efeito deteriorativo da migracao no IMC. Alteracoes nutricionais, de atividade fisica, fatores psicossociais e suscetibilidade genetica podem ser motivos subjacentes a incluir como variaveis moderadoras em estudos futuros.Immigrants may be more vulnerable to obesity as a result of the immigration process. The aim of this article is to summarize current knowledge about the impact of immigration on body mass index (BMI). A systematic review was performed in accordance with PRISMA guidelines through a database search of scientific articles (last updated in August 2014). Thirty-nine articles were included and assessed. Results varied according to ethnic background, country of origin and host country. A consistent positive association between BMI and time since immigration was found among Hispanic, European and African immigrants. Less than half of the studies observed a positive association among Asian immigrants. The quality of the majority of the studies assessed was poor, reflecting a need to improve methodology and concept definition. Immigration appears to have a deteriorative effect on BMI. Underlying causes may include changes in nutrition and physical activity, psychological and social factors, and genetic susceptibility and these aspects should be included as moderator variables in future studies.

The Relationship between Dehydroepiandrosterone (DHEA), Working Memory and Distraction – A Behavioral and Electrophysiological Approach

Dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulphate (DHEAS) have been reported to have memory enhancement effects in humans. A neuro-stimulatory action and an anti-cortisol mechanism of action may contribute to that relation. In order to study DHEA, DHEAS and cortisol relations to working memory and distraction, we recorded the electroencephalogram of 23 young women performing a discrimination (no working memory load) or 1-back (working memory load) task in an audio-visual oddball paradigm. We measured salivary DHEA, DHEAS and cortisol both before each task and at 30 and 60 min. Under working memory load, a higher baseline cortisol/DHEA ratio was related to higher distraction as indexed by an enhanced novelty P3. This suggests that cortisol may lead to increased distraction whereas DHEA may hinder distraction by leading to less processing of the distractor. An increased DHEA production with consecutive cognitive tasks was found and higher DHEA responses attributed to working memory load were related to enhanced working memory processing as indexed by an enhanced visual P300. Overall, the results suggest that in women DHEA may oppose cortisol effects reducing distraction and that a higher DHEA response may enhance working memory at the electrophysiological level.

Graves' Disease and Massive Thymic Hyperplasia

Graves’ disease is an autoimmune thyroid condition in which autoantibodies against the thyrotropin (TSH) receptor stimulate the autonomous production of thyroxine and triiodothyronine. It is characterized by diffuse goiter and thyrotoxicosis and may be accompanied by an infiltrative orbitopathy and dermatopathy. A seldom-recognized feature of this disease is thymic hyperplasia. We would like to highlight this association and consider the pitfalls that can occur when this is encountered by describing a patient with Graves’ disease and massive thymus hyperplasia. A 22-year-old woman presented with Graves’ disease. Serum biochemistry revealed TSH receptor autoantibodies (TRAbs) 178 U=L (normal range: <10 U=L; RIA TRAK-assay [Brahms, patterns MRC LATS-B 65=22 and TSAb Who 90=672), TSH <0.01 mU=mL (0.35–5.5 mU=mL), free thyroxine 4.37 ng=dL (0.89–1.8 ng=dL), and free triiodothyronine 19.41 pg=mL (2.3–4.2 pg=mL). TSH, free triiodothyronine, and free thyroxine levels were determined by a chemiluminescent assay (ADVIA Centaur; Bayer). The patient had marked Graves’ ophthalmopathy and an incidentally discovered anterior mediastinal mass (8 5 cm) with no invasive characteristics on magnetic resonance imaging (Fig. 1a, b). She was started on treatment with methimazole. There was marked improvement of her thyrotoxic state and concomitant reduction in the size of her thymus (Fig. 2a, b). The patient was treated with total thyroidectomy. Ten months after surgery, the thymic mass regressed to its normal involutionated size at this age—total reduction of 80% (Fig. 3a, b). Thymic hyperplasia is a common and reversible feature in Graves’ disease (1). There are no consistent data between thymic hyperplasia and other hyperthyroid states. It has been suggested that one-third of patients with Graves’ disease have microscopic abnormalities in the thymus (2). In most cases, however, thymic enlargement is minimal. Indeed, massive enlargement of the thymus has been reported only infrequently in Graves’ disease (1,3). The pathophysiology of thymic hyperplasia in this setting has not been fully determined. However, the fact that treatment of the hyperthyroid state in Graves’ disease with concomitant decrease in TRAbs leads to regression of the dimensions of the thymus suggests that thymic hyperplasia is more likely to be the result of Graves’ disease (4). Actually, Murakami et al. postulated that both an indirect action of the lowering of thyroid hormone levels and the lowering of TRAbs could induce reduction in the thymus size. It seems that antithyroid drugs, besides causing a blockade of thyroid hormone synthesis, can also have an immunosuppressive effect, namely, reducing TRAbs levels. The same authors have demonstrated the presence of TSH receptor in nonneoplastic thymic tissue, suggesting that this receptor may serve as an autoantigen (5). Their findings support the concept that TRAbs in Graves’ disease stimulate that thymic receptor causing thymus enlargement as they induce goiter in Graves’ disease.

Prevalence of Anorexia Nervosa: a Portuguese Population Study

There has been no epidemiological study done on Anorexia Nervosa (AN) in the Portuguese population of Continental Portugal. In the economical, social and cultural areas, this country is in a transitional situation. A population of 2422 girls from the Lisbon and Tagus Valley area was studied through a questionnaire that included the criteria definition of AN and other issues concerning the changing pattern of cultural image and eating behaviour. We found 0.4 per cent of AN, 12.6 per cent of subclinical illness and 7 per cent with only body image disturbance. The total population included 38 per cent that wished to be thinner, 49 per cent that felt they had a fat body part and 51.5 per cent that had a ‘horror of being heavier’. The results confirm the hypothesis that Portugal is in a transitional situation.

Cancer screening in Portugal: sex differences in prevalence, awareness of organized programmes and perception of benefits and adverse effects

Cancer screening has contributed to downward trends in cancer mortality, but is also associated with adverse effects, which highlights the importance of promoting the participation based on informed decisions.

Rare and severe complications of congenital adrenal hyperplasia due to 21-hydroxylase deficiency: a case report

IntroductionWe report the case of a patient with classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency who presented with unusual anatomical and biochemical features, namely massively enlarged adrenal glands, adrenogenital rest tissue and an unexpected endocrine profile. The contribution of the adrenocortical cells in the adrenals and testicles was determined by a cosyntropin stimulation test before and after adrenalectomy. To the best of our knowledge this is the first report of such a case in the literature.Case presentationA 35-year-old Caucasian man was admitted to the emergency room with an Addisonian crisis. He had been diagnosed with congenital adrenal hyperplasia in the neonatal period. He acknowledged poor adherence to treatment and irregular medical assistance. Physical examination revealed marked cutaneous and gingival hyperpigmentation, hypotension, and hard nodules in the upper pole of both testicles. Blood analysis showed mild anemia and hyponatremia and no evidence of acute infection. Endocrine evaluation showed very low cortisol levels, low dehydroepiandrosterone-sulfate and elevated corticotropin, 11-deoxycortisol and delta-4-androstenedione. The concentration of 17-hydroxyprogesterone was 20,400ng/dL. After the cosyntropin stimulation test the pattern was similar and there was no significant increase in cortisol or 17-hydroxyprogesterone. The abdominal computed tomography scan revealed grossly enlarged and heterogeneous adrenal glands (left, 12cm; and right, six cm). A bilateral adrenalectomy was performed and pathologic examination revealed adrenal myelolipomas with nodular cortical hyperplasia. The sonogram showed bilateral heterogeneous masses on the upper pole of both testes which corresponded to the nodular hyperplasia of adrenal rest tissues. The genetic study revealed compound heterozigoty (mutations R124H and R356W), suggestive of a phenotypically moderate disease. We performed a cosyntropin stimulation test after adrenalectomy. The steroidogenic profile displayed the same unusual features, indicating an important contribution from the adrenogenital cells.ConclusionThis case illustrates that congenital adrenal hyperplasia due to 21-hydroxylase deficiency can progress to severe acute and chronic complications. The masses in the patient’s adrenal glands and testicles resulted from chronically elevated adrenocorticotropic hormone and growth of adrenocortical cells. The basal and stimulated steroid profile, before and after adrenalectomy, revealed an unexpected pattern, suggesting significant contribution of the testicular adrenal cells to the steroidogenesis.