Avaliação do perfil metabólico dos pacientes transplantados do coração no Hospital de Messejana / Evaluation of the metabolic profile of heart transplant patients at the Hospital de Messejana

Objetivo: Este estudo visa avaliar o perfil metabólico de pacientes que foram submetidos a TxC em um centro de referência do estado do Ceará. Métodos: Trata-se de um estudo transversal, quantitativo, em que se avaliaram 110 pacientes receptores de TxC no Hospital de Messejana de Fortaleza, no período de 2011 a 2018, por meio de uma ficha clínica. Resultados: observou-se que a maioria dos pacientes era do gênero masculino (76,5%), e a média de idade foi de 46,26 ± 12,73 anos. Entre os pacientes, observou-se que previamente à cirurgia, 42,5% tinham histórico familiar de doença cardíaca, 40,1% estavam com sobrepeso e 15% eram diabéticos. A classe de medicação mais utilizada para as doenças de bases foram os diuréticos, inibidores da enzima conversora da angiotensina e bloqueadores de receptores da angiotensina. A principal etiologia que levou à necessidade do TxC foi a miocardiopatia isquêmica. Conclusões: Nesta amostra, a doença de base com maior prevalência que levou ao transplante foi a miocardiopatia isquêmica. A maioria dos pacientes apresentou rejeição ao enxerto em algum momento do período estudado. Todos os pacientes que apresentaram descompensação glicêmica fizeram uso de insulina.

Objective: This study aims to assess the metabolic profile of patients who underwent HT at a referral center in the state of Ceará. Methods: This is a cross-sectional, quantitative study, in which 110 patients receiving HT were evaluated at the Hospital de Messejana in Fortaleza, from 2011 to 2018, through a clinical form. Results: It was observed that the majority of patients were male (76.5%) and the mean age was 46.26 ± 12.73 years. Among the patients, it was observed that prior to surgery, 42.5% had a family history of heart disease, 40.1% were overweight, and 15% were diabetic. The most used class of medication for underlying diseases were diuretics, angiotensin-converting-enzyme inhibitors, and angiotensin receptor blockers. The main etiology leading to the need for HT was ischemic cardiomyopathy. Conclusions: In this sample, the most prevalent underlying disease leading to transplantation was ischemic cardiomyopathy. Most patients presented graft rejection at some point during the study period. All patients who presented glycemic decompensation used insulin.

Association between cardiovascular autonomic neuropathy and left ventricular hypertrophy in young patients with congenital generalized lipodystrophy.

BACKGROUND: Congenital generalized lipodystrophy (CGL) is a rare disorder characterized by the absence of subcutaneous adipose tissue, severe insulin resistance, diabetes mellitus, and cardiovascular complications, including cardiac autonomic neuropathy (CAN), left ventricular hypertrophy (LVH), and atherosclerosis. The present study aimed to access the association between CAN parameters and cardiovascular abnormalities in CGL patients. METHODS: A cross-sectional study was conducted with 10 CGL patients and 20 healthy controls matched for age, sex, BMI, and pubertal stage. We evaluated clinical, laboratory, and cardiovascular parameters-left ventricular mass index (LVMI), interventricular septum thickness (IVS), systolic and diastolic function determined by two-dimensional transthoracic echocardiography; carotid intimal media thickness (cIMT); and cQT interval. Heart rate variability (HRV) was evaluated by spectral analysis components-high frequency (HF), low frequency (LF), very low frequency (VLF), LF/HF ratio, and total amplitude spectrum (TAS)-and cardiovascular reflexes tests (postural hypotension test, respiratory, orthostatic and Valsalva coefficients). RESULTS: In CGL group, four patients (40%) had LVH and diastolic dysfunction. HF component (parasympathetic control) was lower in LVH patients. CGL patients presented higher values of cIMT and cQT interval than heathy subjects. Inverse association between LVMI and LF (p = 0.011), IVS and LF (p = 0.007), and cIMT and leptin (p < 0.001) were observed, even after adjustments by HOMA-IR, A1c, and blood pressure. In CGL group, there were associations between LMVI and HF component (IC95%: - 1.000; - 00.553), LVMI and TAS (IC95%: - 1.000; - 0.012), and IVS and HF component (IC95%: - 1.000; - 0.371). CONCLUSION: The association between increased LV mass and parameters of HRV provides possible speculations about the involvement of CAN in the pathophysiology of the cardiac complications, including LVH, in patients with CGL.

Early commitment of cardiovascular autonomic modulation in Brazilian patients with congenital generalized lipodystrophy.

BACKGROUND: Metabolic abnormalities in congenital generalized lipodystrophy (CGL) are associated with microvascular complications. However, the evaluation of different types of neuropathy in these patients, including the commitment of cardiovascular autonomic modulation, is scarce. The objective of the present study was to determine the prevalence of cardiovascular autonomic neuropathy (CAN) in patients with CGL compared with individuals with type 1 diabetes and healthy subjects. METHODS: Ten patients with CGL, 20 patients with type 1 diabetes and 20 healthy subjects were included in the study. Controls were paired 1:2 for age, gender, BMI and pubertal stage. Heart rate variability (HRV) was analyzed using cardiovascular autonomic reflex tests, including postural hypotension test, Valsalva (VAL), respiratory (E/I) and orthostatic (30/15) coefficients, and spectral analysis of the HRV, determining very low (VLF), low (LF) and high (HF) frequencies components. The diagnosis of CAN was defined as the presence of at least two altered tests. RESULTS: CAN was detected in 40% of the CGL patients, 5% in type 1 diabetes patients and was absent in healthy individuals (p < 0.05). We observed a significant reduction in the E/I, VLF, LF and HF in CGL cases vs. type 1 diabetes and healthy individuals and lower levels of 30/15 and VAL in CGL vs. healthy individuals. A significant positive correlation was observed between leptin and 30/15 coefficient (r = 0.396; p = 0.036) after adjusting for insulin resistance and triglycerides. Autonomic cardiovascular tests were associated with HbA1c, HOMA-IR, triglycerides and albumin/creatinine ratio in CGL cases. CONCLUSIONS: We observed a high prevalence of CAN in young patients with CGL, suggesting that insulin resistance, hypertriglyceridemia and hypoleptinemia, may have been involved in early CAN development. Additional studies are needed to evaluate the role of leptinemia in the physiopathogenesis of the condition.

Marcadores de risco cardiovascular em indivíduos com infarto do miocárdio precoce e em seus familiares de primeiro grau / Cardiovascular risk factors in patients with premature myocardial infarction and in their first-degree relatives

INTRODUÇÃO: O Infarto agudo do miocárdio (IAM) é infrequente em indivíduos jovens (<45 anos) e está associado à história familiar precoce de doença cardiovascular.OBJETIVO: O presente estudo descreveu o perfil sócio-demográfico e os fatores de risco cardiovascular de indivíduos com diagnóstico de IAM < 45 anos de idade e seus familiares de primeiro grau. Avaliou-se também a relação de parâmetros clínico-laboratoriais de acordo com a extensão angiográfica da doença arterial coronária (DAC) dos casos índices (doença uniarterial vs. multiarterial) e dos seus respectivos familiares.MÉTODOS: Estudo transversal realizado de novembro de 2010 a janeiro de 2015 em hospital terciário em Fortaleza, Ceará. Foram incluídos 103 casos índices e 166 familiares de primeiro grau que não apresentavam suspeita de hipercolesterolemia familiar. Estes foram comparados com 111 indivíduos assintomáticos e sem história familiar de DAC pareados para sexo e idade. Foram avaliados os parâmetros clínicos e laboratoriais dos 3 grupos. Os dados foram estudados por análises uni e multivariadas. RESULTADOS:O grupo casos apresentou maior prevalência de tabagismo (57,3 vs. 28,6%, p < 0,001), diabete melito tipo 2 - DM2 (43,4 vs. 19,5%, p < 0,001) e hipertensão arterial sistêmica - HAS (42,7 vs. 19%, p < 0,001) quando comparado aos familiares pareados para sexo e idade. Da mesma forma, os casos, quando comparados ao grupo controle, apresentaram, além destes fatores, concentrações mais elevadas de triglicerídeos (192 ± 75 vs. 140±74mg/dL, p < 0,001), menores concentrações de HDL-c (36 ± 12 vs. 48 ± 14mg/dL, p < 0,001) e uma maior prevalência de síndrome metabólica -SM (82,2 vs. 36%, p<0,001). Observou-se que 50,5% dos casos tinham acometimento multiarterial. Após análise multivariada, a HAS (p=0,030) e o DM2 (p=0,028) associaram-se de forma independente à DAC multiarterial. Quando comparados ao grupo controle, os familiares apresentaram maior prevalência de tabagismo...

BACKGROUND: The acute myocardial infarction (AMI) is uncommon in young individuals ( < 45 years), and is associated with premature family history of cardiovascular disease. OBJECTIVE: This study described the socio-demographic and cardiovascular risk factors of both subjects with AMI < 45 years of age and their first-degree relatives. The association of clinical and laboratory parameters with the angiographic extension of coronary artery disease (CAD) of index cases (single-vessel vs. multivessel disease) and in their respective relatives was also evaluated. METHODS: Cross-sectional study conducted from November 2010 to January 2015 in a tertiary hospital in Fortaleza, Ceara. One hundred and three index cases and 166 first-degree relatives without suspicion of familial hypercholesterolemia were included. These were compared with 111 asymptomatic individuals without family history of CAD matched for sex and age. Clinical and laboratory parameters of the 3 groups were evaluated. Associations were tested by univariate and multivariate analysis. RESULTS: AMI cases presented a higher prevalence of smoking (57.3% vs. 28.6%, p < 0.001), type 2 diabetes mellitus -DM2 (43.4 vs. 19.5%, p < 0.001), and hypertension (42.7 vs. 19%, p < 0.001) when compared to relatives matched for sex and age. Likewise cases, when compared to controls showed in addition higher triglycerides (192 ± 75mg/dL vs. 140 ± 74mg/dL, p < 0.001), lower HDL-C (36 ± 12mg/dL vs. 48±14mg/dL, p < 0.001), and a greater prevalence of the metabolic syndrome-MS (82.2% vs. 36%, p < 0.001). Multivessel disease was found in 50.5% of cases. After multivariate analysis, hypertension (p=0.030), and DM2 (p=0.028) were independently associated with multivessel disease. First-degree relatives showed a greater prevalence of smoking (29.5% vs. 6.3%, p < 0.001), DM2 (19.9% vs. 1.8%, p < 0.001), pre-diabetes (40.4 % vs. 27%, p < 0.024) and MS (64.7% vs. 36%, p < 0.001), when compared to controls. Lower HDL...

Monostotic Langerhans' cell histiocytosis in a child with central diabetes insipidus.

Langerhans'cell histiocytosis (LCH) comprises a rare group of reticuloendothelial system disorders that can produce focal or systemic manifestations. Diabetes insipidus is considered to be an important indicator of serious underlying diseases in children, including LCH. We report the case of a young patient with monostotic LCH confined to the mandibular ramus, who was diagnosed with the disease after presenting symptoms of central diabetes insipidus and was satisfactorily treated with multi-agent chemotherapy. Additionally, we discuss the clinical, radiographic, histological and immunohistochemical findings, as well as the multidisciplinary approach of this important disease, which should receive attention by dental practitioners, especially when it occurs in children.

Distúrbios metabólicos em doenças infecciosas emergentes e negligenciadas / Metabolic disorders in emerging and neglected infectious diseases

A substituição gradual e progressiva das doenças infecciosas e parasitárias pelas doenças crônico-degenerativas como causas de morbidade e mortalidade, caracterizando o processo de transição epidemiológica, não tem sido observada em várias populações, em especial em países subdesenvolvidos ou em desenvolvimento, verificando-se, na realidade, uma sobre-posição desses perfis (transição incompleta). Além do aumento da prevalência de distúrbios metabólicos, várias doenças infecciosas permanecem endêmicas em diversas regiões, como é o caso da hanseníase, da tuberculose, da leishmaniose, das hepatites virais, entre outras, assim como condições emergentes nas últimas décadas, como a infecção pelo HIV/Aids. Nesse contexto, nos últimos anos tem sido dada uma maior atenção para a ocorrência de distúrbios metabólicos, principalmente a partir da observação de elevada incidência dessas anormalidades associadas à infecção pelo HIV/Aids e à sua terapia com as drogas antirretrovirais. Nesta revisão são abordados aspectos clínico-epidemiológicos dos distúrbios metabólicos reportados em algumas enfermidades infectoparasitárias de relevância mundial e local (no Brasil), assim como possíveis mecanismos e fatores envolvidos nessas associações.

The gradual and progressive replacement of infectious and parasitic by chronic diseases as causes of morbidity and mortality, characterizing the process of epidemiological transition hasn't been observed in various populations, especially in underdeveloped or developing countries characterizing a superposition of these profiles (incomplete transition). Besides the increased prevalence of metabolic disorders, various infectious diseases remain endemic in several regions, such as leprosy, tuberculosis, leishmaniasis, viral hepatitis, among others, as well as emerging diseases in recent decades, as HIV infection/Aids. In this context, more attention has been given to the occurrence of metabolic disturbances in the recent years, mainly from the observation of a high incidence of metabolic disorders associated with HIV infection/Aids, and its therapy with antiretroviral drugs. This review addresses clinical and epidemiological aspects of metabolic disturbances reported in some infectious and parasitic diseases with worldwide and local (Brazil) relevance, as well as possible mechanisms and factors involved in these associations.

[Metabolic disorders in emerging and neglected infectious diseases]. / Distúrbios metabólicos em doenças infecciosas emergentes e negligenciadas.

The gradual and progressive replacement of infectious and parasitic by chronic diseases as causes of morbidity and mortality, characterizing the process of epidemiological transition hasn't been observed in various populations, especially in underdeveloped or developing countries characterizing a superposition of these profiles (incomplete transition). Besides the increased prevalence of metabolic disorders, various infectious diseases remain endemic in several regions, such as leprosy, tuberculosis, leishmaniasis, viral hepatitis, among others, as well as emerging diseases in recent decades, as HIV infection/Aids. In this context, more attention has been given to the occurrence of metabolic disturbances in the recent years, mainly from the observation of a high incidence of metabolic disorders associated with HIV infection/Aids, and its therapy with antiretroviral drugs. This review addresses clinical and epidemiological aspects of metabolic disturbances reported in some infectious and parasitic diseases with worldwide and local (Brazil) relevance, as well as possible mechanisms and factors involved in these associations.

Disfunção do eixo gonadotrófico em homens com infecção pelo HIV/Aids: [revisão] / Gonadotrophic axis dysfunction in men with HIV-infection/Aids: [review]

A disfunção do eixo gonadotrófico é frequentemente observada em pacientes infectados pelo HIV. A patogênese é multifatorial e está relacionada à duração da infecção pelo HIV, aos efeitos citopáticos diretos do vírus, ao uso de drogas gonadotóxicas, às infecções oportunistas, às neoplasias, à desnutrição, entre outros fatores. Em homens, a redução dos níveis de testosterona está associada à perda de massa e de força muscular, à redução da densidade mineral óssea, à lipodistrofia, à depressão, à astenia, à fadiga e à disfunção sexual. Em pacientes infectados pelo HIV com hipogonadismo, inúmeros estudos têm comprovado os efeitos benéficos da reposição de testosterona sobre o perfil metabólico e a distribuição da gordura corporal, com aumento da massa corporal magra, além de promover melhora da qualidade de vida, reduzir a perda de massa óssea e reduzir os índices de depressão. Assim, esta revisão teve como objetivo trazer uma breve atualização sobre o presente tema, abordando dados epidemiológicos, mecanismos fisiopatológicos e estratégias terapêuticas para as principais anormalidades do eixo gonadotrófico masculino associadas à infecção pelo HIV e ao seu tratamento.

Gonadotrophic axis dysfunction is commonly observed in HIV-infected patients. The pathogenesis is multifactorial and related to duration of HIV infection, direct cytopathic effects of viruses, use of drugs, opportunistic infections, malignancies, and malnutrition, among other factors. In men, reduced levels of testosterone is associated with loss of muscle mass and strength, decreased bone mineral density, lipodystrophy, depression, asthenia, fatigue and sexual dysfunction. In HIV-infected patients with hypogonadism, numerous studies have shown the beneficial effects of testosterone replacement on the metabolic profile and distribution of body fat, with increased body mass weight, and promote better quality of life, reduce the bone mass loss and the rates of depression. Thus, this review aimed to present a brief update of epidemiologic data, pathophysiology aspects and treatment strategies for the major abnormalities of male gonadotrophic axis associated with HIV infection and its treatment.

[Gonadotrophic axis dysfunction in men with HIV-infection/aids]. / Disfunção do eixo gonadotrófico em homens com infecção pelo HIV/Aids.

Gonadotrophic axis dysfunction is commonly observed in HIV-infected patients. The pathogenesis is multifactorial and related to duration of HIV infection, direct cytopathic effects of viruses, use of drugs, opportunistic infections, malignancies, and malnutrition, among other factors. In men, reduced levels of testosterone is associated with loss of muscle mass and strength, decreased bone mineral density, lipodystrophy, depression, asthenia, fatigue and sexual dysfunction. In HIV-infected patients with hypogonadism, numerous studies have shown the beneficial effects of testosterone replacement on the metabolic profile and distribution of body fat, with increased body mass weight, and promote better quality of life, reduce the bone mass loss and the rates of depression. Thus, this review aimed to present a brief update of epidemiologic data, pathophysiology aspects and treatment strategies for the major abnormalities of male gonadotrophic axis associated with HIV infection and its treatment.

E449X mutation in the thyroid hormone receptor β associated with autoimmune thyroid disease and severe neuropsychomotor involvement / Mutação E449X no receptor β do hormônio tireoidiano associada com doença tireoidiana auto-imune e retardo neuropscicomotor grave

OBJECTIVE: To report the clinical and molecular aspects of a patient with a diagnosis of Resistance to Thyroid Hormone (RTH) harboring the E449X mutation associated with autoimmune thyroid disease and severe neuropsychomotor retardation. METHODS: We present a case report including clinical and laboratory findings, and molecular analysis of a Brazilian patient with RTH. RESULTS: A 23-year old male presented hyperactivity disorder, attention deficit, delayed neuropsychomotor development, and goiter. Since the age of 1 year and 8 months, his mother had sought medical care for her son for the investigation of delayed neuropsychomotor development associated with irritability, aggressiveness, recurrent headache, profuse sudoresis, intermittent diarrhea, polyphagia, goiter, and low weight. Laboratory tests revealed normal TSH, increased T3, T4, antithyroglobulin and antimicrosomal antibody titers. Increasing doses of levothyroxine were prescribed, reaching 200 µg/day, without significant changes in his clinical-laboratory picture. Increasing doses of tiratricol were introduced, with a clear clinical improvement of aggressiveness, hyperactivity, tremor of the extremities, and greater weight gain. Molecular study revealed a nonsense mutation in exon 10, in which a substitution of a guanine to tyrosine in nucleotide 1345 (codon 449) generates the stop codon TAA, confirming the diagnosis of RTH. CONCLUSION: This patient has severe neuropsychomotor retardation not observed in a single previous report with the same mutation. This may reflect the lack of a genotype-phenotype correlation in affected cases with this syndrome, suggesting that genetic variability of factors other than β receptor of thyroid hormone (TRβ) might modulate the phenotype of RTH.

OBJETIVOS: Descrever aspectos clínicos e moleculares de um paciente com resistência ao hormônio tireoidiano (RHT) portador da mutação E449X associada a doença tireoideana auto-imune e retardo neuropscicomotor grave. MÉTODOS: Relatamos um caso incluindo achados clínicos, laboratoriais e análise molecular de um paciente brasileiro com RHT. RESULTADOS: Paciente masculino, 23 anos de idade, apresentou-se com distúrbio de hiperatividade, déficit de atenção, retardo no desenvolvimento neuropsicomotor e bócio. Desde 1 ano e 8 meses de idade, sua mãe procurou assistência médica para investigação do retardo do desenvolvimento neuropsicomotor associado com irritabilidade, agressividade, cefaléia recorrente, sudorese profusa, diarréia intermitente, polifagia, bócio e perda de peso. Avaliação laboratorial evidenciou TSH normal e aumento do T3, T4 e anticorpos antimicrossomal e antitireoglobulina. Doses crescentes de levotiroxina foram prescritas, máximo de 200 µg/dia, sem significativas alterações em seu quadro clínico-laboratorial. Doses crescentes de tiratricol foram introduzidas com melhora clínica evidente da agressividade, da hiperatividade, do tremor de extremidades e maior ganho de peso. O estudo molecular revelou uma mutação nonsense no éxon 10, no qual a substituição da guanina pela tirosina no nucleotídeo 1345 (códon 449) gerou um stop códon TAA, confirmando o diagnóstico da RHT. CONCLUSÃO: Este paciente tem um grave retardo neuropiscomotor não observado em um relato único anterior com a mesma mutação. Isto pode refletir a falta de relação genotipo-fenótipo nos casos afetados com esta síndrome sugerindo que a variabilidade genética de outros fatores, além do receptor do hormônio tireoidiano (HT), possa modular o fenótipo da RHT.

E449X mutation in the thyroid hormone receptor beta associated with autoimmune thyroid disease and severe neuropsychomotor involvement.

OBJECTIVE: To report the clinical and molecular aspects of a patient with a diagnosis of Resistance to Thyroid Hormone (RTH) harboring the E449X mutation associated with autoimmune thyroid disease and severe neuropsychomotor retardation. METHODS: We present a case report including clinical and laboratory findings, and molecular analysis of a Brazilian patient with RTH. RESULTS: A 23-year old male presented hyperactivity disorder, attention deficit, delayed neuropsychomotor development, and goiter. Since the age of 1 year and 8 months, his mother had sought medical care for her son for the investigation of delayed neuropsychomotor development associated with irritability, aggressiveness, recurrent headache, profuse sudoresis, intermittent diarrhea, polyphagia, goiter, and low weight. Laboratory tests revealed normal TSH, increased T3, T4, antithyroglobulin and antimicrosomal antibody titers. Increasing doses of levothyroxine were prescribed, reaching 200 microg/day, without significant changes in his clinical-laboratory picture. Increasing doses of tiratricol were introduced, with a clear clinical improvement of aggressiveness, hyperactivity, tremor of the extremities, and greater weight gain. Molecular study revealed a nonsense mutation in exon 10, in which a substitution of a guanine to tyrosine in nucleotide 1345 (codon 449) generates the stop codon TAA, confirming the diagnosis of RTH. CONCLUSION: This patient has severe neuropsychomotor retardation not observed in a single previous report with the same mutation. This may reflect the lack of a genotype-phenotype correlation in affected cases with this syndrome, suggesting that genetic variability of factors other than beta receptor of thyroid hormone (TRbeta) might modulate the phenotype of RTH.