Ricardo M.R. Meirelles

Diabetes mellitus e depressão: uma revisão sistemática

The presence of depression in a patient with diabetes mellitus (DM) seems to be related to changes in the clinical course of the disease. The purpose of this study is to perform a systematic review on the association of DM and depression. A bibliographic search was performed using the MEDLINE and LILACS databases to identify relevant articles, published from 1990 to 2001, which evaluate this relationship. Information concerning prevalence, impact and treatment of depression in DM were analyzed. The prevalence of depression varied from 0 to 60.5%. The presence of depressive symptoms were associated with a poor glycemic control, an increase in the number and severity of clinical complications, a worse quality of life and impairment of social, educational and economic aspects related to DM. The treatment of depression is associated with an improvement in glycemic levels, which may contribute to a better control of several aspects related to DM.

Fitoestrogênios: posicionamento do Departamento de Endocrinologia Feminina da Sociedade Brasileira de Endocrinologia e Metabologia (SBEM)

To evaluate the benefit of phytoestrogens (PhE) in hormone replacement therapy of menopause (HRTM), the Department of Female Endocrinology of the Brazilian Society of Endocrinology and Metabolism convened a group of specialists to perform a bibliographic review. Only articles that met strict scientific methodological criteria were included. PhE exhibit both estrogenic and antiestrogenic actions, mainly on estrogen (E) receptors b, with much less estrogenic potency than estradiol. PhE content of vegetal sources varies, depending on cultivation, harvesting, storage and industrialization. Conversion of precursors to active phytohormones in the human body exhibits great individual variability. Most studies with PhE was done in vitro or in laboratory animals and could not always be extrapolated to humans. Some studies on the climateric syndrome suggest little improvement of hot flushes but not of vaginal dryness or mood instability. Regarding lipid metabolism, soy-rich food but not isolated isoflavones promotes reduction of total cholesterol, LDL-chol and triglyceride levels, but does not raise HDL-chol as E do, and promotes elevation of lipoprotein (a), which are reduced by E. Although some short-term studies suggest improvement of bone mineral density with isoflavones, no reduction in fracture rate is demonstrated. We conclude that there are no convincing evidences to support the use of PhE or soy-rich food as alternatives to HRTM.

Use of Optical Coherence Tomography (OCT) and Indirect Ophthalmoscopy in the Diagnosis of Macular Edema in Diabetic Patients

Objectives: To evaluate the use of Optical Coherence Tomography (OCT) in the diagnosis of macular edema (ME) in diabetic patients in comparison to indirect ophthalmoscopy (IO) and, in addition, to study the characteristics of these patients. Methods: 165 patients were randomly selected to join the study in 1998. Ophthalmological, clinical and laboratory examinations were performed for all these patients. Results: Diabetic retinopathy was identified in 143 eyes (44.7%) and ME in 58 (18.3% of the total and40.5% of the patients with retinopathy). 82.7% (48) of the eyes with ME could be diagnosed with OCT, against 62.0% (36) with IO. Haemoglobin A1c was the only variable that showed a significant association with ME, when compared to control (p < 0.05). Retinopathy was associated with the presence of nephropathy (p = 0.01) and neuropathy (p = 0.001), but ME was not (NS for both). 68% of patients without ME had a visual acuity of more than 50%. Conclusions: OCT is a new method that can help the evaluation of ME in diabetic patients. It can be used not only to diagnose the lesion, but also to follow up the patients during treatment. High levels of haemoglobin A1cmight be associated with the presence of ME. Diabetic complications (nephropathyand neuropathy) are associated with retinopathy but not with macular edema.

Menopausa e síndrome metabólica

The incidence of cardiovascular disease increases considerably after the menopause. One reason for the increased cardiovascular risk seems to be determined by metabolic syndrome, in which all components (visceral obesity, dyslipidemia, hypertension, and glucose metabolism disorder) are associated with higher incidence of coronary artery disease. After menopause, metabolic syndrome is more prevalent than in premenopausal women, and may plays an important role in the occurrence of myocardial infarction and other atherosclerotic and cardiovascular morbidities. Obesity, an essential component of the metabolic syndrome, is also associated with increased incidence of breast, endometrial, bowel, esophagus, and kidney cancer. The treatment of metabolic syndrome is based on the change in lifestyle and, when necessary, the use of medication directed to its components. In the presence of symptoms of the climacteric syndrome, hormonal therapy, when indicated, will also contribute to the improvement of the metabolic syndrome.

Avaliação do efeito da sibutramina sobre a saciedade por escala visual analógica em adolescentes obesos

Inicialmente empregadas para mensuracao de sintomas algicos, as escalas visuais analogicas (EVAs) podem ser tambem um instrumento util para avaliacao da saciedade. O agente antiobesidade sibutramina, ao contrario dos anorexigenos, parece exercer seu efeito de reducao de ingestao alimentar principalmente por estimulo da saciedade. Com o objetivo de avaliar o efeito da sibutramina sobre a saciedade, utilizamos uma EVA em adolescentes obesos que participaram de um estudo duplo-cego randomizado, comparando sibutramina 10mg com placebo. Cada paciente recebeu 13 escalas para serem preenchidas em intervalos de uma hora, num unico dia, das 9 as 21h. Uma dieta com deficit de 500kcal diarias foi dividida em 3 refeicoes, com horarios previamente estipulados: 9:30h, 12:30h, 18:30h. A partir da pontuacao obtida em cada uma das escalas, construiu-se um grafico de linha representativo da pontuacao media de saciedade ao longo do dia. Comparando-se a area sob a curva dos 2 grupos, encontramos 4.609 ± 1.309 para o grupo tratado com sibutramina e 4.141 ± 1.432 para o grupo placebo (p= NS). Desta forma, a sibutramina nao parece apresentar efeito sobre a saciedade de adolescentes obesos, pelo menos quando avaliado atraves de uma EVA.

Relation between insulin resistance and hematological parameters in a Brazilian sample

It has already been demonstrated that insulin resistance (IR) is associated with the stimulation of erythroid progenitors and with increased levels of inflammation markers. Therefore, IR should also be associated with increased red blood cell (RBC) and white blood cell (WBC) count. The aim of this study is to demonstrate that IR is independently associated with altered hematological parameters in a Brazilian sample. We analyzed laboratorial exams from 925 subjects. All data on hematological parameters, insulin resistance (Homeostasis Model Assessment [HOMA]) and lipid levels were included in the analysis. Demographic information included age and gender. HOMA correlated positively with RBC (r= 0.17, p< 0.001), plasma hemoglobin concentrations (r= 0.14, p< 0.001), hematocrit value (r= 0.15, p< 0.001) and WBC (r= 0.17, p< 0.01). Subjects in the upper quartile of IR had higher levels of plasma glucose, fasting insulin, triglycerides, hematocrit, hemoglobin, RBC and WBC count than those in the lower quartile. In conclusion, IR seems to be associated with alterations in several hematological parameters. These hematological alterations may be considered an indirect feature of the IR syndrome.

Diabetes e doenças auto-imunes: prevalência de doença celíaca em crianças e adolescentes portadores de diabetes melito tipo 1

OBJECTIVE: Determinate the prevalence of celiac disease in children and adolescents with type 1 diabetes mellitus (DM1) in attendance in Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE). METHODS: Blood samples were analyzed in 120 children and adolescents with DM1 from IEDE Diabetes Clinic for the IgA antitissue-transglutaminase antibody and dosage of the seric IgA. Those with positive serology were guided for upper endoscopy with small-bowel biopsy to confirm the celiac disease. RESULTS: The antibody was positive in 3 of the 120 patients. The small-bowel biopsy was confirmatory in all of the positive patients, leading to a prevalence of celiac disease of 2.5% in the studied group. CONCLUSIONS: The prevalence of celiac disease is increased in children and adolescents with DM1 when compared with normality. As most are asymptomatic, it is recommended periodical screening of celiac disease in children with DM1.

Terapia hormonal da menopausa: posicionamento do Departamento de Endocrinologia Feminina e Andrologia da SBEM em 2004.

Hormonal Therapy of Menopause: 2004 Position of the Department of Female Endocrinology and Andrology of the Brazilian Society of Endocrinology and Metabolism. After randomized clinical trials produced impact and questions at the medical community on menopause hormonal therapy (MHT), the Depar- tment of Female Endocrinology and Andrology of the Brazilian Society of Endocrinology convened a group of specialists to produce an informative, critical and position paper, offering guidelines for those who practice or are called to express their opinion on menopause therapy. MHT is indicat- ed for relief of vasomotor symptoms, maintenance of vaginal trophism, bone mass and collagen preservation, sexual and general well-being. Studies on primary cardiovascular prevention are not conclusive, and thus insufficient to indicate or not MHT for this purpose. Schemes and forms of association should de individualized. Whenever possible, one should use 17-beta estradiol, associated to natural progesterone or its derivatives in women with an intact uterus, at the lowest effective doses. Duration of therapy depends on its aims, and should be periodically re-evaluated through an individual indication/contra-indication balance. Orientation toward a healthier lifestyle, with smoking cessation, adequate calcium intake and a low fat diet, together with regular physical activity is funda- mental during menopause.

Desvendando os mistérios da mulher (pelo menos os endócrinos)

317 O DE ENDOCRINOLOGIA FEMININA da SBEM teve, até hoje, três presidentes, todos do Rio de Janeiro, onde esta área da especialidade mais se desenvolveu. Para isso contribuiu, provavelmente, o Ambulatório de Endocrinologia Feminina do Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), criado em 1980, durante a gestão de Luiz Cesar Póvoa. O nome do ambulatório foi idealizado de modo a sugerir uma abrangência maior do que “Endocrinologia Ginecológica”, incluindo as diversas influências de hormônios não pertencentes ao eixo hipotálamo-hipófise-ovário sobre o sistema reprodutor e as ações dos hormônios desse sistema sobre outras estruturas que não as diretamente ligadas à reprodução, aos caracteres sexuais secundários femininos e à sexualidade. editorial Desvendando os Mistérios da Mulher (pelo Menos os Endócrinos)

A obesidade estaria relacionada ao aumento do volume das adrenais

Varios estudos sugerem que existe uma hiperatividade do eixo hipotalamo-hipofisario-adrenal (HHA) na obesidade, com maior acumulo de gordura na regiao abdominal. Estes trabalhos demonstram que, apos injecoes de hormonio liberador de corticotropina (CRF) ou hormonio adrenocorticotrofico (ACTH) e ainda atraves de testes de stress, os niveis de cortisol estao aumentados em comparacao com pacientes com deposicao periferica de gordura. Alem do mais, alguns estudos mostram que em pacientes deprimidos, onde a hiperatividade do HHA e uma alteracao endocrina importante e conhecida, o volume das adrenais esta aumentado quando comparado com normais. Para investigar se o teor de gordura visceral de alguma maneira se relaciona com o volume das adrenais, 52 mulheres com idade entre 19 e 54 anos, com diferentes indices de corpulencia, foram estudadas atraves de medidas antropometricas como peso, indice de massa corporal (IMC), cintura e relacao cintura-quadril (RCQ). As areas de gordura visceral (GV) e subcutânea (GSC), alem do volume das adrenais, foram medidas atraves da tomografia computadorizada. Houve uma correlacao extremamente significativa entre as medidas de distribuicao de gordura (RCQ e cintura) e a GV, sendo que a RCQ nao se correlacionou com a GSC. O somatorio do volume das adrenais mostrou uma correlacao positiva e significativa com a RCQ (r = 0,272, p = 0,02) e uma correlacao positiva, mas no limite da significância com a GV (r = 0,228, p = 0,05), nao mostrando qualquer correlacao com a GSC. Alem disso, o somatorio do volume das adrenais foi maior naquelas com GV ³ 120 cm2 quando comparado com pacientes com area de GV < 120 cm2 (p = 0,05). Portanto, o estudo sugere que o deposito de GV parece inter-relacionar-se com a hiperatividade do HHA, aqui estimada anatomicamente atraves do volume das adrenais, glândula alvo deste eixo.