Genetic architecture of congenital hypogonadotropic hypogonadism: insights from analysis of a Portuguese cohort.

STUDY QUESTION: What is the contribution of genetic defects in Portuguese patients with congenital hypogonadotropic hypogonadism (CHH)? SUMMARY ANSWER: Approximately one-third of patients with CHH were found to have a genetic cause for their disorder, with causal pathogenic and likely pathogenic germline variants distributed among 10 different genes; cases of oligogenic inheritance were also included. WHAT IS KNOWN ALREADY: CHH is a rare and genetically heterogeneous disorder characterized by deficient production, secretion, or action of GnRH, LH, and FSH, resulting in delayed or absent puberty, and infertility. STUDY DESIGN SIZE DURATION: Genetic screening was performed on a cohort of 81 Portuguese patients with CHH (36 with Kallmann syndrome and 45 with normosmic hypogonadotropic hypogonadism) and 263 unaffected controls. PARTICIPANTS/MATERIALS SETTING METHODS: The genetic analysis was performed by whole-exome sequencing followed by the analysis of a virtual panel of 169 CHH-associated genes. The main outcome measures were non-synonymous rare sequence variants (population allele frequency <0.01) classified as pathogenic, likely pathogenic, and variants of uncertain significance (VUS). MAIN RESULTS AND THE ROLE OF CHANCE: A genetic cause was identified in 29.6% of patients. Causal pathogenic and likely pathogenic variants were distributed among 10 of the analysed genes. The most frequently implicated genes were GNRHR, FGFR1, ANOS1, and CHD7. Oligogenicity for pathogenic and likely pathogenic variants was observed in 6.2% of patients. VUS and oligogenicity for VUS variants were observed in 85.2% and 54.3% of patients, respectively, but were not significantly different from that observed in controls. LARGE SCALE DATA: N/A. LIMITATIONS REASONS FOR CAUTION: The identification of a large number of VUS presents challenges in interpretation and these may require reclassification as more evidence becomes available. Non-coding and copy number variants were not studied. Functional studies of the variants were not undertaken. WIDER IMPLICATIONS OF THE FINDINGS: This study highlights the genetic heterogeneity of CHH and identified several novel variants that expand the mutational spectrum of the disorder. A significant proportion of patients remained without a genetic diagnosis, suggesting the involvement of additional genetic, epigenetic, or environmental factors. The high frequency of VUS underscores the importance of cautious variant interpretation. These findings contribute to the understanding of the genetic architecture of CHH and emphasize the need for further studies to elucidate the underlying mechanisms and identify additional causes of CHH. STUDY FUNDING/COMPETING INTERESTS: This research was funded by the Portuguese Foundation for Science and Technology (grant numbers PTDC/SAU-GMG/098419/2008, UIDB/00709/2020, CEECINST/00016/2021/CP2828/CT0002, and 2020.04924.BD) and by Sidra Medicine-a member of the Qatar Foundation (grant number SDR400038). The authors declare no competing interests.

Diabetes and Stroke: Impact of Novel Therapies for the Treatment of Type 2 Diabetes Mellitus.

Type 2 diabetes mellitus (T2DM) is a significant risk factor for stroke. Nevertheless, the evidence supporting stringent glycemic control to reduce macrovascular complications, particularly stroke, is not as clear as for microvascular complications. Presently, risk reduction strategies are based on controlling multiple risk factors, including hypertension, dyslipidemia, glycemia, smoking, and weight. Since 2008, new pharmacological therapies for treating T2DM have been required to undergo trials to ensure their cardiovascular safety. Remarkably, several novel therapies have exhibited protective effects against the combined endpoint of major cardiovascular events. Evidence from these trials, with stroke as a secondary endpoint, along with real-world data, suggests potential benefits in stroke prevention, particularly with glucagon-like peptide 1 receptor agonists. Conversely, the data on sodium-glucose cotransporter type 2 inhibitors remains more controversial. Dipeptidyl peptidase 4 inhibitors appear neutral in stroke prevention. More recent pharmacological therapies still lack significant data on this particular outcome. This article provides a comprehensive review of the evidence on the most recent T2DM therapies for stroke prevention and their impact on clinical practice.

The consequences of the new European reclassification of non-invasive brain stimulation devices and the medical device regulations pose an existential threat to research and treatment: An invited opinion paper.

A significant amount of European basic and clinical neuroscience research includes the use of transcranial magnetic stimulation (TMS) and low intensity transcranial electrical stimulation (tES), mainly transcranial direct current stimulation (tDCS). Two recent changes in the EU regulations, the introduction of the Medical Device Regulation (MDR) (2017/745) and the Annex XVI have caused significant problems and confusions in the brain stimulation field. The negative consequences of the MDR for non-invasive brain stimulation (NIBS) have been largely overlooked and until today, have not been consequently addressed by National Competent Authorities, local ethical committees, politicians and by the scientific communities. In addition, a rushed bureaucratic decision led to seemingly wrong classification of NIBS products without an intended medical purpose into the same risk group III as invasive stimulators. Overregulation is detrimental for any research and for future developments, therefore researchers, clinicians, industry, patient representatives and an ethicist were invited to contribute to this document with the aim of starting a constructive dialogue and enacting positive changes in the regulatory environment.

Acute venous thromboembolism plasma and red blood cell metabolomic profiling reveals potential new early diagnostic biomarkers: observational clinical study.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of cardiovascular mortality. The diagnosis of acute VTE is based on complex imaging exams due to the lack of biomarkers. Recent multi-omics based research has contributed to the development of novel biomarkers in cardiovascular diseases. Our aim was to determine whether patients with acute VTE have differences in the metabolomic profile compared to non-acute VTE. METHODS: This observational trial included 62 patients with clinical suspicion of acute deep vein thrombosis or pulmonary embolism, admitted to the emergency room. There were 50 patients diagnosed with acute VTE and 12 with non-acute VTE conditions and no significant differences were found between the two groups for clinical and demographic characteristics. Metabolomics assays identified and quantified a final number of 91 metabolites in plasma and 55 metabolites in red blood cells (RBCs). Plasma from acute VTE patients expressed tendency to a specific metabolomic signature, with univariate analyses revealing 23 significantly different molecules between acute VTE patients and controls (p < 0.05). The most relevant metabolic pathway with the strongest impact on the acute VTE phenotype was D-glutamine and D-glutamate (p = 0.001, false discovery rate = 0.06). RBCs revealed a specific metabolomic signature in patients with a confirmed diagnosis of DVT or PE that distinguished them from other acutely diseased patients, represented by 20 significantly higher metabolites and four lower metabolites. Three of those metabolites revealed high performant ROC curves, including adenosine 3',5'-diphosphate (AUC 0.983), glutathione (AUC 0.923), and adenine (AUC 0.91). Overall, the metabolic pathway most impacting to the differences observed in the RBCs was the purine metabolism (p = 0.000354, false discovery rate = 0.68). CONCLUSIONS: Our findings show that metabolite differences exist between acute VTE and nonacute VTE patients admitted to the ER in the early phases. Three potential biomarkers obtained from RBCs showed high performance for acute VTE diagnosis. Further studies should investigate accessible laboratory methods for the future daily practice usefulness of these metabolites for the early diagnosis of acute VTE in the ER.

Age-dependent NMDA receptor function is regulated by the amyloid precursor protein.

N-methyl-D-aspartate receptors (NMDARs) are critical for the maturation and plasticity of glutamatergic synapses. In the hippocampus, NMDARs mainly contain GluN2A and/or GluN2B regulatory subunits. The amyloid precursor protein (APP) has emerged as a putative regulator of NMDARs, but the impact of this interaction to their function is largely unknown. By combining patch-clamp electrophysiology and molecular approaches, we unravel a dual mechanism by which APP controls GluN2B-NMDARs, depending on the life stage. We show that APP is highly abundant specifically at the postnatal postsynapse. It interacts with GluN2B-NMDARs, controlling its synaptic content and mediated currents, both in infant mice and primary neuronal cultures. Upon aging, the APP amyloidogenic-derived C-terminal fragments, rather than APP full-length, contribute to aberrant GluN2B-NMDAR currents. Accordingly, we found that the APP processing is increased upon aging, both in mice and human brain. Interfering with stability or production of the APP intracellular domain normalized the GluN2B-NMDARs currents. While the first mechanism might be essential for synaptic maturation during development, the latter could contribute to age-related synaptic impairments.

A Toolbox to Study Tissue Mechanics In Vivo and Ex Vivo.

During vertebrate embryogenesis, tissues interact and influence each other's development to shape an embryo. While communication by molecular components has been extensively explored, the role of mechanical interaction between tissues during embryogenesis is just starting to be revealed. Addressing mechanical involvement in morphogenesis has traditionally been challenging mainly due to the lack of proper tools to measure and modify mechanical environments of cells in vivo. We have recently used atomic force microscopy (AFM) to show that the migration of the Xenopus laevis cephalic neural crest cells is triggered by stiffening of the mesoderm, a tissue that neural crest cells use as a migratory substrate in vivo. Interestingly we showed that the activity of the planar cell polarity (PCP) pathway is required to mediate this novel mechanical interaction between two tissues. In this chapter, we share the toolbox that we developed to study the role of PCP signaling in mesoderm cell accumulation and stiffening (in vivo) as well as the impact of mesoderm stiffness in promoting neural crest cell polarity and migration (ex vivo). We believe that these tools can be of general use for investigators interested in addressing the role of mechanical inputs in vivo and ex vivo.

Control of backbone chemistry and chirality boost oligonucleotide splice switching activity.

Although recent regulatory approval of splice-switching oligonucleotides (SSOs) for the treatment of neuromuscular disease such as Duchenne muscular dystrophy has been an advance for the splice-switching field, current SSO chemistries have shown limited clinical benefit due to poor pharmacology. To overcome limitations of existing technologies, we engineered chimeric stereopure oligonucleotides with phosphorothioate (PS) and phosphoryl guanidine-containing (PN) backbones. We demonstrate that these chimeric stereopure oligonucleotides have markedly improved pharmacology and efficacy compared with PS-modified oligonucleotides, preventing premature death and improving median survival from 49 days to at least 280 days in a dystrophic mouse model with an aggressive phenotype. These data demonstrate that chemical optimization alone can profoundly impact oligonucleotide pharmacology and highlight the potential for continued innovation around the oligonucleotide backbone. More specifically, we conclude that chimeric stereopure oligonucleotides are a promising splice-switching modality with potential for the treatment of neuromuscular and other genetic diseases impacting difficult to reach tissues such as the skeletal muscle and heart.

The clinical spectrum of X-linked adrenoleukodystrophy: from Addison's-only in men to middle-age neurologic manifestations in women.

X-linked adrenoleukodystrophy (X-ALD) is caused by a mutation in the ABCD1 gene which encodes for a peroxisomal very long-chain fatty acid (VLCFA) transporter. Clinically, X-ALD can present a wide range of phenotypes, from slowly progressive myelopathy to rapid demyelination of brain white matter (cerebral X-ALD-CALD). Adrenocortical insufficiency (AI) occurs mainly in the pediatric age group, and it can be the first manifestation of the disease. Female carriers may also develop manifestations of myelopathy, but later in life. We present two cases of patients who show the heterogeneous clinical manifestations of X-ALD. Case 1 was a man with AI diagnosed at 6 years old and with the first manifestations of myelopathy at 44 years old, which led to the diagnosis of X-ALD. At 47 years, he developed rapidly progressive CALD. Case 2 was a woman with progressive spastic gait disturbance that started at 49 years old. The diagnosis of X-ALD was confirmed at 54 years old after the discovery of a family history of the disease. Mild progression of the neurologic manifestations was noted, but with no signs of AI nor CALD. She is currently 60 years old and under surveillance. We review the current knowledge on X-ALD as concerns its genetic and pathophysiological mechanisms, clinical presentations, diagnosis, treatment, and follow-up. This condition is a real diagnostic challenge. The early detection of AI and CALD, potentially life-threatening complications in men, is very difficult. The surveillance of these complications in female patients still raises controversy.

Continuous Teriparatide Treatment in Chronic Hypoparathyroidism: A Case Report.

BACKGROUND Hypoparathyroidism remains the only hormone deficiency-related disorder with a standard treatment that is not based on replacing a missing hormone. Growing evidence supports the use of recombinant human parathyroid hormone (PTH), mostly with subcutaneous injections. More recently, some clinicians have administered teriparatide, a pharmaceutical form of PTH, through continuous delivery systems. CASE REPORT A 31-year-old woman was referred to our department for further evaluation of chronic severe hypocalcemia due to iatrogenic postsurgical hypoparathyroidism. Despite being chronically medicated with high doses of calcium, vitamin D, and subcutaneous teriparatide injections, she still reported symptoms of hypocalcemia on a daily basis and frequently needed treatment with intravenous calcium perfusions. During hospitalization, we ruled out treatment noncompliance and documented 6 episodes of severe hypocalcemia. Our team then decided to implement a continuous subcutaneous perfusion of teriparatide through an insulin pump. After optimizing the infusion rate, no more severe hypocalcemia episodes occurred. Four months after hospital discharge, it was possible to fully suspend oral supplementation therapy, and the patient's serum calcium level consistently remained within normal range. No other episodes of hypocalcemia occurred. CONCLUSIONS The only way to effectively restore long-term calcium homeostasis in our patient was to start a continuous subcutaneous infusion of teriparatide. There was no need to maintain calcium or vitamin D supplementation and we were able to halve the required daily dose of teriparatide. To our knowledge, this case represents one of the very few reports of successful treatment of hypoparathyroidism with a continuous perfusion of PTH.

Adult-onset autoimmune diabetes: comparative analysis of classical and latent presentation.

INTRODUCTION: Adult-onset autoimmune diabetes (AID) has two different phenotypes: classic type 1 diabetes mellitus (T1DM), with insulin requirement just after diagnosis, and latent autoimmune diabetes in adults (LADA). The purpose of this study is to characterize patients with AID followed on a tertiary centre, comparing classic T1DM and LADA. METHODS: We collected data from patients with diabetes and positive islet autoantibodies, aged 30 years old and over at diagnosis. Patients who started insulin in the first 6 months were classified as T1DM and patients with no insulin requirements in the first 6 months were classified as LADA. Data regarding clinical presentation, autoantibodies, A1C and C-peptide at diagnosis, pharmacologic treatment and complications were analysed. RESULTS: We included 92 patients, 46 with classic T1DM and 46 with LADA. The percentage of females was 50% in T1DM group and 52.1% in LADA group. The median age at diagnosis was 38 years (IQR-15) for T1DM and 42 years (IQR-15) for LADA (p = 0.057). The median time between diagnosis of diabetes and diagnosis of autoimmune aetiology was 0 months in T1DM group and 60 months in LADA group (p < 0.001). The mean BMI at diagnosis was 24.1 kg/m2 in T1DM group and 26.1 kg/m2 in LADA group (p = 0.042). In T1DM group, 67.4% of the patients had more than one positive autoantibody, comparing to 41.3% of LADA patients (p = 0.012). There was no statistical difference in what concerns to title of GAD autoantibodies, A1C and C-peptide at diagnosis of autoimmune aetiology. The presence of symptoms at diagnosis was associated with T1DM group (p < 0.001). The median daily insulin dose was 40 IU for T1DM (0.58 IU/kg) and 33.5 IU for LADA (0.57 IU/kg), with no statistical difference. LADA patients were more often under non-insulin antidiabetic drugs (p = 0.001). At 10 years follow up, 21.1% of T1DM patients and 63.3% of LADA patients had microvascular complications (p = 0.004). Diabetic nephropathy was present in 23.5% of T1DM patients and 53.3% of LADA patients (p = 0.047). At the last evaluation, 55.6% of T1DM and 82.6% of LADA patients had metabolic syndrome and this difference was independent of diabetes duration. CONCLUSION: Patients with classic T1DM presented more often with symptoms, lower BMI and higher number of autoantibodies, which may be related to a more aggressive autoimmune process. Patients with LADA developed more frequently microvascular complications for the same disease duration, namely diabetic nephropathy, and had more often metabolic syndrome.

A rat model of enhanced glycation mimics cardiac phenotypic components of human type 2 diabetes : A translational study using MRI.

BACKGROUND: The success of translational research depends on how well animal models mimic the pathophysiology of the human phenotype, and on the identification of disease mechanisms such as enhanced glycation. METHODS: Here, we studied cardiac MRI and metabolic phenotypes in human type 2 diabetes (N = 106; 55 patients+51 controls) and animal models with distinct levels of fat diet and end glycation products, to model the role of these factors in the cardiac phenotype. We included four groups of rats, designed to evaluate the role of lipid load and glucotoxicity in cardiac function and to correlate these with the cardiac phenotype observed in humans. We also aimed to assess into which extent phenotypes were related to specific risk factors. RESULTS: Stroke Volume (SV) and Peak Filling Rate (PFR) measures were similarly discriminative both in humans and animal models, particularly when enhanced glycation was present. Factorial analysis showed that reduction of multidimensionality into common main explanatory factors, in humans and animals, revealed components that equally explained the variance of cardiac phenotypes (87.62% and 83.75%, respectively). One of the components included, both in humans and animals, SV, PFR and peak ejection rate (PER). The other components included in both humans and animals are the following: ESV (end systolic volume), left ventricular mass (LVM) and ejection fraction (EF). These components were useful for between group discrimination. CONCLUSIONS: We conclude that animal models of enhanced glycation and human type 2 diabetes share a striking similarity of cardiac phenotypic components and relation with metabolic changes, independently of fact content in the diet, which reinforces the role of glucose dysmetabolism in left ventricular dysfunction and provides a potentially useful approach for translational research in diabetes, in particular when testing new therapies early on during the natural history of this condition.

Cultural Adaptation and Validation of the Portuguese Version of the CANHELP Lite Bereavement Questionnaire.

BACKGROUND: Satisfaction with care is an important outcome measure in end-of-life care. Validated instruments are necessary to evaluate and disseminate interventions that improve satisfaction with care at the end of life, contributing to improving the quality of care offered at the end of life to the Portuguese population. The purpose of this study was to perform a cross-cultural adaptation and psychometric analysis of the Portuguese version of the CANHELP Lite Bereavement Questionnaire. METHODS: Methodological research with an analytical approach that includes translation, semantic, and cultural adaptation. RESULTS: The Portuguese version comprised 24 items. A panel of experts and bereaved family members found it acceptable and that it had face and content validity. A total of 269 caregivers across several care settings in the northern region of Portugal were recruited for further testing. The internal consistency analysis of the adapted instrument resulted in a global alpha value of 0.950. The correlation between the adapted CANHELP questionnaire and a global rating of satisfaction was of 0.886 (p < 0.001). CONCLUSIONS: The instrument has good psychometric properties. It was reliable and valid in assessing caregivers' satisfaction with end-of-life care and can be used in both clinical and research settings.

Maturity-Onset Diabetes of the Young (MODY) in Portugal: Novel GCK, HNFA1 and HNFA4 Mutations.

Maturity-onset diabetes of the young (MODY) is a frequently misdiagnosed type of diabetes, which is characterized by early onset, autosomal dominant inheritance, and absence of insulin dependence. The most frequent subtypes are due to mutations of the GCK (MODY 2), HNF1A (MODY 3), and HNF4A (MODY 1) genes. We undertook the first multicenter genetic study of MODY in the Portuguese population. The GCK, HNF1A, and HNF4A genes were sequenced in 46 unrelated patients that had at least two of the three classical clinical criteria for MODY (age at diagnosis, family history, and clinical presentation). The functional consequences of the mutations were predicted by bioinformatics analysis. Mutations were identified in 23 (50%) families. Twelve families had mutations in the GCK gene, eight in the HNF1A gene, and three in the HNF4A gene. These included seven novel mutations (GCK c.494T>C, GCK c.563C>G, HNF1A c.1623G>A, HNF1A c.1729C>G, HNF4A c.68delG, HNF4A c.422G>C, HNF4A c.602A>C). Mutation-positive patients were younger at the time of diagnosis when compared to mutation-negative patients (14.3 vs. 23.0 years, p = 0.011). This study further expands the spectrum of known mutations associated with MODY, and may contribute to a better understanding of this type of diabetes and a more personalized clinical management of affected individuals.

The Amyloid Precursor Protein C-Terminal Domain Alters CA1 Neuron Firing, Modifying Hippocampus Oscillations and Impairing Spatial Memory Encoding.

There is a growing consensus that Alzheimer's disease (AD) involves failure of the homeostatic machinery, which underlies the firing stability of neural circuits. What are the culprits leading to neuron firing instability? The amyloid precursor protein (APP) is central to AD pathogenesis, and we recently showed that its intracellular domain (AICD) could modify synaptic signal integration. We now hypothesize that AICD modifies neuron firing activity, thus contributing to the disruption of memory processes. Using cellular, electrophysiological, and behavioral techniques, we show that pathological AICD levels weaken CA1 neuron firing activity through a gene-transcription-dependent mechanism. Furthermore, increased AICD production in hippocampal neurons modifies oscillatory activity, specifically in the γ-frequency range, and disrupts spatial memory task. Collectively, our data suggest that AICD pathological levels, observed in AD mouse models and in human patients, might contribute to progressive neuron homeostatic failure, driving the shift from normal aging to AD.

Thoracic spine metastasis presenting 18 years after complete resection of a phaeochromocytoma.

Phaeochromocytomas are rare neuroendocrine tumours (NET) with malignant behaviour in about 10% of cases. The median time from the diagnosis of primary tumour and bone metastasis is 3.4 years. We report a case of a 66-year-old woman presenting with a hypertensive crisis and back pain. She has a history of a phaeochromocytoma completely resected 18 years before. MRI showed a neoplastic mass on the 10th thoracic vertebra (T10), with fracture and spinal cord compression. The CT-guided biopsy was consistent with metastasis of a NET. Therefore, she was treated with phenoxybenzamine and external beam radiotherapy. However, clinical (dorsal pain) and biochemical (ie, elevated chromogranin A) signs suggested persistent disease and the patient was treated with iodine-131 metaiodobenzylguanidine and T10 kyphoplasty. After 8 years, she remains clinically stable. This case demonstrates that phaeochromocytomas may reveal malignant behaviour several years after diagnosis, and therefore patients should be maintained under long term surveillance.

Interleukin-6 Producing Pheochromocytoma: A Rare Cause of Systemic Inflammatory Response Syndrome.

Systemic inflammatory response syndrome (SIRS) can be a rare manifestation of pheochromocytoma, since this adrenal tumor may produce cytokines and other hormones or neuropeptides besides catecholamines. We report the case of a 53-year-old female patient with a pheochromocytoma that presented with fever and weight loss of 5% in one month along with normocytic anemia, thrombocytosis, leukocytosis, and elevated C-reactive protein. In this setting, interleukin-6 (IL-6) was requested and was elevated [26.7ng/L (<7.0)]. She also presented biochemical evidence of ACTH-independent cortisol production without overt Cushing syndrome. After adrenalectomy, the inflammatory syndrome resolved and all biochemical parameters normalized, including IL-6 and ACTH. To our knowledge, this is the first case report of IL6-producing pheochromocytoma along with autonomous cortisol production.

[The Impact of Prolonged Use of Continuous Subcutaneous Insulin Infusion in the Control of Type-1 Diabetes]. / Impacto do Uso Prolongado da Terapêutica Subcutânea Contínua com Insulina no Controlo da Diabetes Mellitus Tipo 1.

INTRODUCTION: The use of continuous subcutaneous insulin infusion therapy in type 1 diabetes mellitus has increased due to its benefits on glycemic control and on the lifestyle flexibility. The aim of this study was to assess the impact of continuous subcutaneous insulin infusion therapy on glycemic control, body mass index, total daily dose of insulin and complications associated with this therapy, during 20 years of experience in Centro Hospitalar e Universitário de Coimbra. MATERIAL AND METHODS: This retrospective study included patients with type 1 diabetes mellitus who started continuous subcutaneous insulin infusion therapy up until 2005, followed at Centro Hospitalar e Universitário de Coimbra. Glycated hemoglobin A1c, body mass index, total daily dose of insulin and acute complications associated with continuous subcutaneous insulin infusion therapy were evaluated immediately prior to initiation of continuous subcutaneous insulin infusion therapy with follow-up at six months, one year, five, 10, 15 and 20 years. The frequency of acute complications associated with this type of therapy was also evaluated. RESULTS: This study included 20 patients (seven males, 13 females) with mean disease duration up to the start of continuous subcutaneous insulin infusion therapy of 16.1 ± 7.9 years, mean age of onset of continuous subcutaneous insulin infusion therapy of 31.1 ± 8.4 years and follow-up during 13.2 ± 2.3 years. The reasons for initiating pump therapy were: inadequate metabolic control in 15 patients, history of asymptomatic or severe hypoglycemia in four patients, and pregnancy/pregnancy planning in one patient. The previous median of glycated hemoglobin A1c was 9.3% (6.5 - 16.0) and, at six months, decreased to the minimum value of 7.2% (5.3 - 9.8); p < 0.0125. The reduction of glycated hemoglobin A1c remained statistically significant in the first 10 years of follow-up. There was a statistically significant difference in the body mass index variation at 10 years with continuous subcutaneous insulin infusion therapy compared to previous body mass index; 24.7 kg/m2 (18.9 - 31.8) vs 25,5 kg/m2 (18.9 - 38.9), p <0.0125. Daily insulin requirements were reduced from 56.5 U (32.0 - 94.0) to 43.8 U (33.0 - 64.0) (p < 0.0125) at six months and no statistical differences were found in the remaining follow-up. There were two severe episodes of hypoglycemia (incidence 0.0095/patient/year), five episodes of diabetic ketoacidosis (0.0238/patient/year) and no infections at the site of catheter insertion. DISCUSSION: This study shows that continuous subcutaneous insulin infusion therapy improved glycemic control, especially during the first 10 years of follow-up and allowed a significant decrease in total daily dose of insulin in the first six months. The rate of acute complications was low. CONCLUSION: Treatment with continuous subcutaneous insulin infusion therapy seems effective in achieving metabolic control in selected patients with type 1 diabetes mellitus.

Introdução: O uso da terapêutica com perfusão subcutânea contínua de insulina na diabetes mellitus tipo 1 é cada vez mais frequente devido aos seus efeitos benéficos no controlo glicémico e na flexibilidade do estilo de vida. Constituiu objetivo deste estudo avaliar o impacto da terapêutica com perfusão subcutânea contínua de insulina no controlo glicémico, índice de massa corporal, dose diária total de insulina e complicações desta modalidade terapêutica durante vinte anos de experiência no Centro Hospitalar e Universitário de Coimbra. Material e Métodos: Estudo retrospetivo que inclui doentes com diabetes mellitus tipo 1 seguidos no Centro Hospitalar e Universitário de Coimbra, que iniciaram terapêutica com perfusão subcutânea contínua de insulina até 2005 e com pelo menos 10 anos de tratamento com terapêutica com perfusão subcutânea contínua de insulina. Avaliou-se a hemoglobina glicada A1c, o índice de massa corporal e a dose diária total de insulina imediatamente antes e seis meses, um ano, cinco, 10, 15 e 20 anos após terapêutica com perfusão subcutânea contínua de insulina a partir dos registos médicos. Avaliou-se ainda a frequência de complicações agudas associadas a este tipo de terapêutica. Resultados: Obtiveram-se dados de 20 doentes (sete homens; 13 mulheres) com duração média de doença até início da terapêutica com perfusão subcutânea contínua de insulina de 16,1 ± 7,9 anos, idade média de início de terapêutica com perfusão subcutânea contínua de insulina de 31,1 ± 8,4 anos e seguimento durante 13,2 ± 2,3 anos. As indicações para colocação de bomba foram: inadequado controlo metabólico em 15 doentes, história de hipoglicemias assintomáticas ou severas em quatro doentes, e gravidez/planeamento de gravidez em um doente. A mediana de hemoglobina glicada A1c prévia foi 9,3% (6,5 - 16,0) tendo diminuído aos seis meses para o valor mínimo de 7,2% (5,3 - 9,8); p < 0,0125. A redução da hemoglobina glicada A1c manteve-se estatisticamente significativa nos primeiros 10 anos de seguimento. Verificou-se uma diferença estatisticamente significativa na variação do índice de massa corporal após 10 anos de seguimento comparativamente com o valor prévio à terapêutica com perfusão subcutânea contínua de insulina; 24,7kg/m2 (18,9 - 31,8) vs 25,5 kg/m2 (18,9 - 38,9), p < 0,0125. As necessidades diárias de insulina foram reduzidas de 56,5 U (32,0 - 94,0) para 43,8 U (33,0 - 64,0) (p < 0,0125) nos primeiros seis meses e não se encontraram diferenças estatísticas no restante seguimento relativamente às necessidades prévias à terapêutica com perfusão subcutânea contínua de insulina. Verificaram-se duas hipoglicemias severas (incidência 0,0095/doente/ano), cinco cetoacidoses diabéticas (0,0238/doente/ano) e nenhuma infeção no local de inserção do cateter. Discussão: Este estudo demonstrou a eficácia da terapêutica com perfusão subcutânea contínua de insulina, que está associada a uma diminuição significativa da hemoglobina glicada A1c sustentada durante 10 anos e a uma redução da dose diária total de insulina, significativa nos primeiros seis meses. A taxa de complicações agudas foi baixa. Conclusão: A evidência sugere que a terapêutica com perfusão subcutânea contínua de insulina é efetivamente vantajosa no controlo metabólico em doentes com diabetes mellitus tipo 1 selecionados.

Verbal emotional expressiveness in women with eating disorders: recalling autobiographical memories.

PURPOSE: This study aimed to study autobiographical memories in women with eating disorders regarding emotional verbal expression, according to age. Our hypotheses are threefold: due to the emotional avoidance that occurs in women with eating disorders, in the younger ages, it was hypothesized that younger participants with anorexia and bulimia nervosa will present a lower number of emotional expressions in the descriptions of their memories than women without eating disorders; that older participants with anorexia and bulimia nervosa will present a greater number of negative verbal expressions in the reports of their memories than women without eating disorders, given the development of negative bias that occurs with age in women with eating disorders; and that women with eating disorders will use more words in a description of their sad memories than women without eating disorders because of the existence of negative bias. METHODS: With a sample of 90 women and combining age and the presence or absence of eating disorders, we formed four groups. The task that they had to perform was to recall a sad and a happy life event. RESULTS: The younger women used more words than the older women to describe their memories, and women with eating disorders used more words in their descriptions of the sad memories. However, there were no differences in terms of the number of positive and negative expressions. CONCLUSIONS: Women with eating disorders exhibit higher levels of cognitive reappraisal and thus use more positive expressions and fewer negative expressions. LEVEL OF EVIDENCE: Level V, Descriptive study.