Rafael Selbach Scheffel

Prevalência de complicações micro e macrovasculares e de seus fatores de risco em pacientes com diabetes melito do tipo 2 em atendimento ambulatorial

BACKGROUND: Type 2 diabetes (DM2) has been related to the development of macroangiopatic [coronary heart disease (CHD), peripheral vascular disease (PVD) and stroke] and microangiopatic [retinopathy, nephropathy, and distal sensory neuropathy (DSN)] complications. The aims of this study were to analyze prevalence of complications in DM2 patients and to estimate their associated risk factors. METHODS: Cross-sectional study, including 927 out patients with DM2 from three medical centers in Rio Grande do Sul: Hospital de Clinicas de Porto Alegre (n = 475), Grupo Hospitalar Conceicao (n = 229) and Hospital Sao Vicente de Paula (n = 223). Of the patients 42% were male, mean age was 59 ± 10 years and the median known duration of DM2 was 11 (5 - 43) years. Retinopathy was identified by direct fundoscopy; CHD by WHO questionnaire and/or abnormal ECG and/or perfusion abnormalities on myocardial scintigraphy; DSN by compatible symptoms and absent sensation on 10 g monofilament and/or tune fork; PVD by the presence of claudication and absent foot pulses; stroke by presence of sequels and history; and nephropathy by the urinary albumin excretion rate (>20 µg/min). Hypertension was defined by blood pressure (>140/90 mmHg) and/or use of antihypertensive drugs. Body mass index (BMI, kg/m2) and waist-to-hip ratio (WHR) were calculated. RESULTS: CHD was present in 36% and PVD in 33% of the patients. Among the microvascular, 37% had nephropathy (12% with macroalbuminuria); 48% retinopathy (15% proliferative retinopathy). DSN was present in 36%. Seventy three percent of the patients presented arterial hypertension. Cholesterol levels were >200 mg/dl in 64% and BMI > 30 kg/m2 in 36%. Twenty two percent of patients were smokers and 21% ex-smokers. CONCLUSION: Diabetic complications are frequent among out patients referring to general hospitals. Almost all patients presented at least one risk factor for cardiovascular disease, justifying the efforts for identification and adequate control.

Toxic Cardiomyopathy leading to fatal acute cardiac failure related to vandetanib: a case report with histopathological analysis

CONTEXT Medullary thyroid carcinoma (MTC) accounts for 3-4% of all malignant thyroid neoplasias. Vandetanib, a tyrosine kinase inhibitor (TKI) targeting vascular endothelial growth factor receptor 2, epidermal growth factor receptor, and RET, has been approved by the FDA for the treatment of locally advanced or metastatic MTC. The heart seems to be particularly susceptible to adverse effects associated with TKI therapy, and virtually all TKIs have been associated with cardiovascular events. CLINICAL PRESENTATION We report the case of a patient with metastatic MTC who was enrolled in the Phase III clinical study (NCT00410761) and presented a favorable response to vandetanib therapy, displaying marked decrease in the level of serologic tumor markers and shrinkage of metastatic lesions. After 14 months of therapy, the patient developed a fatal cardiac failure. Myocardial infarction was excluded by serial measurements of specific cardiac markers (serial troponin-T measurements varied from 0.037 to 0.042 ng/ml) and serologic tests for Chagas disease were negative. Postmortem examination of the heart revealed cardiomyocyte hypertrophy and marked myocyte degeneration in the subendocardial zones and papillary muscles of the myocardium. These pathological changes are similar to those observed in TKI-treated rats and are suggestive of drug-induced cardiotoxicity. CONCLUSION This case illustrates a previously unreported serious vandetanib-related adverse effect and highlights the need for close monitoring of patients under TKI therapy in order to identify early signs of congestive heart failure or myocardium damage.

Precipitating factors of diabetic ketoacidosis at a public hospital in a middle-income country.

AIMS To study precipitating factors of diabetic ketoacidosis (DKA) at a public hospital in a middle-income country. METHODS Eighty patients with type 1 diabetes who had an emergency hospitalization for DKA between January 2005 and March 2010 at a tertiary care teaching hospital in Southern Brazil were studied. Data were collected by reviewing medical records and telephone calls. Treatment non-adherence was defined as the precipitating factor if there was diet abuse or insulin therapy noncompliance without identifiable infection. RESULTS The mean age of patients was 26±13 years. The majority (91.5%) of the patients had unsatisfactory metabolic control before the hospitalization. The most common DKA precipitating factor was treatment non-adherence: 39% of cases when all patients were evaluated and 49% when only patients with previous type 1 diabetes diagnosis were analyzed. Comparison between patients with DKA precipitated by treatment non-adherence and by other causes showed that the former group had more episodes of previous DKA and more frequently reported insulin omission previous to DKA. CONCLUSIONS Treatment noncompliance is the leading precipitating factor of DKA in Southern Brazil. Further efforts to reduce the occurrence of DKA should focus on patients with prior reports and evidence of treatment non-adherence.

Cerebral syphilitic gumma in HIV-infected patients: case report and review.

Neurosyphilis presenting as a cerebral gumma is an uncommon event. To date there are seven cases of cerebral gumma reported in human immunodeficiency virus (HIV)-infected patients. We describe a HIV-infected patient with neurosyphilis presenting as an expanding central nervous system lesion and unremarkable cerebrospinal fluid analysis. This case report illustrates the clinical and therapeutic aspects of syphilitic gumma in HIV-infected patients.

Diabetes and cardiovascular disease: from evidence to clinical practice – position statement 2014 of Brazilian Diabetes Society

There is a very well known correlation between diabetes and cardiovascular disease but many health care professionals are just concerned with glycemic control, ignoring the paramount importance of controlling other risk factors involved in the pathogenesis of serious cardiovascular diseases. This Position Statement from the Brazilian Diabetes Society was developed to promote increased awareness in relation to six crucial topics dealing with diabetes and cardiovascular disease: Glicemic Control, Cardiovascular Risk Stratification and Screening Coronary Artery Disease, Treatment of Dyslipidemia, Hypertension, Antiplatelet Therapy and Myocardial Revascularization. The issue of what would be the best algorithm for the use of statins in diabetic patients received a special attention and a new Brazilian algorithm was developed by our editorial committee. This document contains 38 recommendations which were classified by their levels of evidence (A, B, C and D). The Editorial Committee included 22 specialists with recognized expertise in diabetes and cardiology.

Consenso brasileiro para o diagnóstico e tratamento do hipertireoidismo: recomendações do Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia

Universidade Federal do Rio Grande do Sul (UFRGS) Hospital de Clinicas de Porto Alegre Servico de Endocrinologia

Invasive fungal infections in endogenous Cushing’s syndrome

Cushings syndrome is a condition characterized by elevated cortisol levels that can result from either augmented endogenous production or exogenous administration of corticosteroids. The predisposition to fungal infections among patients with hypercortisolemia has been noted since Cushings original description of the disease. We describe here a patient with endogenous Cushings syndrome secondary to an adrenocortical carcinoma, who developed concomitant disseminated cryptococcosis and candidiasis in the course of his disease.

Consumptive hypothyroidism : case report of hepatic hemangioendotheliomas successfully treated with vincristine and systematic review of the syndrome

Objectives: To provide a comprehensive description of consumptive hypothyroidism syndrome (CHS), a severe form of hypothyroidism that occurs due to the high expression levels of thyroid hormone inactivation enzyme type 3 deiodinase (D3) in tumors. Study Design: Case report and systematic review. Results: A 7-month-old girl with a diagnosis of massive hepatic hemangioendotheliomas was treated with high doses of thyroid hormones and tumor-directed chemotherapy with vincristine. The tumor displayed excellent response, and euthyroid status was regained. A systematic review on the databases PubMed/Medline and Embase was performed, using the term “Consumptive AND “Hypothyroidism.” From the 33 selected references, we extracted 42 case reports of CHS: 36 children and 6 adults. The laboratory profile at diagnosis displayed high TSH and low T4 and T3 serum levels. The serum reverse T3 and D3 activity levels were high in all patients tested. In children, 97% had vascular tumors, whereas in adults 33% were vascular tumors, 33% fibrous tumors, and 33% gastrointestinal stromal tumors. The conservative treatment was predominant in children, while in adults all cases were treated with surgery. Death occurred in 16% of children and 33% of adults. Conclusions: CHS is a rare form of hypothyroidism that occurs in children and adults, usually linked to hepatic vascular tumors. The condition is associated with high lethality. Prompt diagnosis, followed by high-dose thyroid hormone replacement and tumor-directed therapy are the keys to optimize outcomes.

Left Atrial Metastases of Poorly Differentiated Thyroid Carcinoma Diagnosed by Echocardiography and Magnetic Resonance Imaging—Case Report and Review of Literature

Intracardiac metastases of thyroid carcinoma are a rare event. Their incidence is low in large autopsy series, and antemortem diagnosis is even less common. We present the case of a woman with advanced poorly differentiated thyroid carcinoma who had extensive intracardiac metastases. This case highlights the usefulness of echocardiography and magnetic resonance imaging in the diagnosis and differential diagnosis of cardiac metastases. (Echocardiography 2012;29:E30‐E33)

The prevalence of chronic diabetic complications and metabolic syndrome is not associated with maternal type 2 diabetes

The maternal history of type 2 diabetes mellitus (DM) has been reported more frequently in patients with type 2 DM than paternal history. The aim of the present study was to determine if there was an association between maternal history of DM and the presence of chronic complications or metabolic syndrome (MetS) in patients with type 2 DM. A cross-sectional study was conducted with 1455 patients with type 2 DM. All outpatients with type 2 diabetes attending the endocrine clinics who fulfilled the eligibility criteria were included. Familial history of DM was determined with a questionnaire. Diabetic complications were assessed using standard procedures. The definition of MetS used was that of the World Health Organization and the National Cholesterol Education Programs Adult Treatment Panel III report criteria. Maternal history of DM was present in 469 (32.3%), absent in 713 (49.1%) and unknown in 273 patients (18.7%). Paternal history of DM was positive in 255 (17.6%), negative in 927 (63.8%) and unknown in 235 patients (16.1%). The frequency of microvascular chronic complications in patients with and without a positive maternal history of DM was similar: diabetic nephropathy (51.5 vs 52.5%), diabetic retinopathy (46.0 vs 41.7%), and diabetic sensory neuropathy (31.0 vs 37.1%). The prevalence of macrovascular chronic complications and MetS was also similar. Patients with type 2 DM were more likely to have a maternal than a paternal history of DM, although maternal history of DM was not associated with an increased prevalence of chronic complications or MetS.