2023 UPDATE: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes.

BACKGROUND: The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020. METHODS: The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria. RESULTS AND CONCLUSIONS: All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.

Flash glucose monitoring system in special situations

ABSTRACT The management of diabetes mellitus (DM) requires maintaining glycemic control, and patients must keep their blood glucose levels close to the normal range to reduce the risk of microvascular complications and cardiovascular events. While glycated hemoglobin (A1C) is currently the primary measure for glucose management and a key marker for long-term complications, it does not provide information on acute glycemic excursions and overall glycemic variability. These limitations may even be higher in some special situations, thereby compromising A1C accuracy, especially when wider glycemic variability is expected and/or when the glycemic goal is more stringent. To attain adequate glycemic control, continuous glucose monitoring (CGM) is more useful than self-monitoring of blood glucose (SMBG), as it is more convenient and provides a greater amount of data. Flash Glucose Monitoring (isCGM /FGM) is a widely accepted option of CGM for measuring interstitial glucose levels in individuals with DM. However, its application under special conditions, such as pregnancy, patients on hemodialysis, patients with cirrhosis, during hospitalization in the intensive care unit and during physical exercise has not yet been fully validated. This review addresses some of these specific situations in which hypoglycemia should be avoided, or in pregnancy, where strict glycemic control is essential, and the application of isCGM/FGM could alleviate the shortcomings associated with poor glucose control or high glycemic variability, thereby contributing to high-quality care.

Cardiovascular safety of naltrexone and bupropion therapy: Systematic review and meta-analyses.

Despite being approved for clinical use, evidence of cardiovascular safety (CV) is lacking for treatment with bupropion, naltrexone, or their combination (B-N). The purpose of the study is to determine the relationship between these treatments and the risk of major cardiovascular adverse events (MACE). Phase 3 randomized clinical trials (RCT) evaluating bupropion, naltrexone, or B-N versus control with reported incidence of MACE. The meta-analysis included 12 RCTs, 69% for weight loss and 29% for smoking cessation, with 19,176 patients and 7354 patient-years who were randomized to an active treatment (bupropion [n = 2965] or B-N [n = 6980] or naltrexone [n = 249]) versus control (placebo [n = 6968] or nicotine patch [n = 2014]). The mean age was 54 ± 8 years (55% female), and the baseline BMI was 32 ± 5 kg/m2 . The additive network meta-analysis model for random effects showed no association between bupropion, B-N, or naltrexone and MACE (odds ratio [OR] = 0.90 [95%CI 0.65-1.25], p = 0.52; OR = 0.97 [95%CI 0.75-1.24], p = 0.79; OR = 1.08 [95%CI 0.71-1.63], p = 0.73, respectively; I2 = 0%, p = 0.86). Meta-regression analyses showed no significant association between MACE and potential confounders from RCT demographic disparities (p = 0.58). The statistical power (post hoc two-tailed) for non-inferiority was 91%, giving a strong probability of validity. Naltrexone, bupropion, or B-N is not associated with the incidence of MACE as compared with placebo.

Prevalência de sintomas de ansiedade e depressão em pacientes com diferentes graus de obesidade / Prevalence of anxiety and depression symptoms in patients with different degrees of obesity

Introdução: A obesidade apresenta elevada prevalência e está associada ao aumento da morbidade e mortalidade. Vários estudos já identificaram impacto negativo da adiposidade em sintomas psicológicos, porém ainda se investiga a relação de causalidade entre estas afecções. Objetivo: Determinar a prevalência de sintomas ansiosos e depressivos em pacientes com diferentes graus de obesidade. Métodos: Estudo observacional transversal realizado entre 2016 e 2019 por meio da aplicação do questionário Escala Hospitalar de Ansiedade e Depressão (HADS) em pacientes com obesidade. Resultados: Foram incluídos 47 pacientes no estudo. 14 pacientes com obesidade grau 1 (G1) , 14 pacientes com obesidade grau 2 (G2) e 19 pacientes com obesidade grau 3 (G3). Do total, 37 eram mulheres (78,7%), com média de idade 43±10 anos, 110,6±27,7 kg e índice de massa corporal de 41,8±9,3 kg/m². Entre os participantes, 17 (36,2%) tinham sintomas de ansiedade, sendo 6 (42,9%) do G1, 6 (42,9%) do G2 e 5 (26,3%) do G3, (p=0,511). 16 pacientes (34%) tiveram sintomas depressivos, correspondendo a 5 (35,7%) pacientes no G1, 4 (28,6%) no G2 e 7 (36,8%) no G3, (p=0,874). Uma moderada correlação entre HADS-A e HADS-D foi constatada (r=0,654) (p<0,001). Conclusão: Foram identificadas elevadas taxas de sintomas ansiosos e depressivos entre os pacientes avaliados, dados estes, superiores aos dados da população geral descrito na literatura. Entretanto, não foram identificadas diferenças entre os diferentes graus de obesidade quanto a prevalência de sintomas ansiosos ou depressivos.

Introduction: Obesity has high prevalence and is associated with increased morbidity and mortality. Several studies have already identified negative impact of adiposity on psychological symptoms, but the causal relationship between these conditions is still investigated. Objective: To determine the prevalence of anxious and depressive symptoms in patients with different degrees of obesity. Methods: Cross-sectional observational study conducted between 2016 and 2019 by applying the questionnaire Hospital Anxiety and Depression Scale (HADS) in obese patients. Results: 47 patients were included in the study. 14 patients with grade 1 obesity (G1), 14 patients with grade 2 obesity (G2) and 19 patients with grade 3 obesity (G3). Of the total, 37 were women (78.7%), with a mean age of 43 ± 10 years, 110.6 ± 27.7 kg and body mass index of 41.8 ± 9.3 kg / m². Among the participants, 17 (36.2%) had anxiety symptoms, being 6 (42.9%) from G1, 6 (42.9%) from G2 and 5 (26.3%) from G3, (p = 0.511). 16 patients (34%) had depressive symptoms, corresponding to 5 (35.7%) patients in G1, 4 (28.6%) in G2 and 7 (36.8%) in G3, (p = 0.874). A moderate correlation between HADS-A and HADS-D was found (r = 0.654) (p <0.001). Conclusion: High rates of anxious and depressive symptoms were identified among the patients evaluated, which is higher than the general population data described in the literature. However, no differences were identified between the different degrees of obesity regarding the prevalence of anxious or depressive symptoms.

Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus.

BACKGROUND: In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM. METHODS: MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria. RESULTS AND CONCLUSIONS: In non-pregnant adults, the recommended HbA1c target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA1c is 6.5-7.5%. When HbA1c is 7.5-9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-1RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA1c remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction (< 40%) and glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2, metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30-60 mL/min/1.73 m2 or eGFR 30-90 mL/min/1.73 m2 with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP-1RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.

Bariatric surgery-induced weight loss in patients with and without type 2 diabetes mellitus.

Surgical treatment of obesity leads to weight loss and metabolic improvement, but it is unclear if the response differs between patients with and without type 2 diabetes. Retrospective cohort study comparing weight loss and metabolic outcomes between patients with and without type 2 diabetes, matched for body mass index (BMI), gender and age, 12 months after Roux-en-Y gastric bypass. Forty-eight patients with type 2 diabetes (D) and 48 without type 2 diabetes (ND) were evaluated, 87.5% female, mean age 42.2 ± 0.9 years. The mean baseline weight and BMI of the D and ND groups were, respectively, 120.3 ± 21.6 vs 123.7 ± 20.8 kg (P = .45) and 47.2 ± 7.5 vs 47.2 ± 6.9 kg/m2 (P = .70). After 12 months, there was no significant difference in weight (40.4 ± 16.9 vs 44.1 ± 12.2 kg, P = .28) and BMI (15.8 ± 6.5 vs 16.9 ± 4.5 kg/m2 , P = .26) variation between groups. The parameters that presented significant variation were (D vs ND): fasting blood glucose (41.6 ± 43.0 vs 12.7 ± 17.2 mg/dL, P < .01), HbA1c (1.8 ± 1.6 vs 0.6 ± 0.7%; P < .01), triglycerides (91.1 ± 100.4 vs 54.2 ± 43.8 mg/dL; P = .04), low-density lipoprotein (27.2 ± 41.5 vs 37.5 ± 24.2 mg/dL; P < .01) and gamma glutamyl transferase (46.5 ± 55.3 vs 17.7 ± 11.9 UI/L; P = .04). Weight loss 12 months after a gastric bypass was similar in patients with and without type 2 diabetes, the greater metabolic benefits appearing in patients with type 2 diabetes as they had more pronounced changes at baseline.

Testosterone therapy for women with low sexual desire: a position statement from the Brazilian Society of Endocrinology and Metabolism

ABSTRACT Objective To summarize current evidence regarding testosterone treatment for women with low sexual desire. Materials and methods The Female Endocrinology and Andrology Department of the Brazilian Society of Endocrinology and Metabolism invited nine experts to review the physiology of testosterone secretion and the use, misuse, and side effects of exogenous testosterone therapy in women, based on the available literature and guidelines and statements from international societies. Results Low sexual desire is a common complaint in clinical practice, especially in postmenopausal women, and may negatively interfere with quality of life. Testosterone seems to exert a positive effect on sexual desire in women with sexual dysfunction, despite a small magnitude of effect, a lack of long-term safety data, and insufficient evidence to make a broad recommendation for testosterone therapy. Furthermore, there are currently no testosterone formulations approved for women by the relevant regulatory agencies in the United States, Brazil, and most other countries, and testosterone formulations approved for men are not recommended for use by women. Conclusion Therefore, testosterone therapy might be considered if other strategies fail, but the risks and benefits must be discussed with the patient before prescription. Arch Endocrinol Metab. 2019;63(3):190-8

Effects of Bariatric Surgery in Male Obesity-Associated Hypogonadism.

INTRODUCTION: The prevalence of obesity has grown exponentially over the last several decades. Research has linked male obesity to changes in the gonadal axis, which can induce functional hypogonadism. Bariatric surgery provides sustained weight loss and metabolic improvement. This was a retrospective cohort study to evaluate the male gonadal axis and metabolic profiles of obese individuals during the bariatric pre- and post-operative periods while comparing them to a normal body mass index (BMI) group. METHODS: Twenty-nine obese men, who underwent bariatric surgery between 2012 and 2016 at the Federal University of Santa Catarina Hospital and a control group (CG) of 29 age-matched men with normal BMI, were analyzed. Bariatric pre- and 6-month post-operative data were compared with the CG. RESULTS: The study group (G1) presented an average age, weight, and BMI of 42.8 ± 9.5 years, 155.2 ± 25.8 kg, and 50.6 ± 7.1 kg/m2, respectively. The pre-operative total testosterone (TT) G1 values were different from the CG (229.5 ± 96.4 versus 461.5 ± 170.8 ng/dL, p < 0.01). Bariatric surgery promoted a statistically significant improvement in weight, TT, and metabolic profiles in surgical patients. CONCLUSION: Functional hypogonadism is prevalent in obese men, and we must be aware of this diagnosis. Although studies defining the best diagnostic parameters and indication of adequate hormone replacement therapy are lacking, an increase in TT levels during the first 6 months after bariatric surgery was identified in our study. Previous studies have shown that gonadal function can normalize after metabolic improvement.

Hypercalcemia and acute renal insufficiency following use of a veterinary supplement / Hipercalcemia e insuficiência renal aguda após uso de suplemento veterinário

Abstract A previously healthy 24 yo male presented with a two-month history of epigastric pain, nausea, vomiting, fatigue and malaise. He reported abuse of different substances, including an injectable veterinary vitamin compound, which contains high doses of vitamin A, D and E, and an oily vehicle that induces local edema and enhances muscle volume. Serum creatinine was 3.1 mg/dL, alanine transaminase 160 mg/dL, aspartate transaminase 11 mg/dL, total testosterone 23 ng/dL, 25-OH-vitamin D >150 ng/mL (toxicity >100), 1,25-OH-vitamin D 80 pg/mL, vitamin A 0.7 mg/dL, parathormone <3 pg/mL, total calcium 13.6 mg/dL, 24-hour urinary calcium 635 mg/24h (RV 42-353). A urinary tract ultrasound demonstrated signs of parenchymal nephropathy. The diagnosis was hypercalcemia and acute renal failure secondary to vitamin D intoxication. He was initially treated with intravenous hydration, furosemide and prednisone. On the fifth day of hospitalization a dose of pamidronate disodium was added. The patient evolved with serum calcium and renal function normalization. Thirty days later he presented normal clinical and laboratory tests, except 25-OH-vitamin D that was persistently increased (107 ng/mL), as it may take several months to normalize. This case report is a warning of the risks related to the use of veterinary substances for aesthetics purposes.

Resumo Um paciente de 24 anos do sexo masculino, previamente hígido, apresentou-se com uma história de dois meses de dor epigástrica, náuseas, vômitos, fadiga e mal-estar. Ele relatava abuso de diferentes substâncias, incluindo um composto vitamínico veterinário injetável contendo altas doses de vitamina A, D e E, e um veículo oleoso que induz edema local com aumento de volume muscular. A creatinina sérica estava 3,1 mg/dL, alanina transaminase 160 mg/dL, aspartato transaminase 11 mg/dL, testosterona total 23 ng/dL, 25-OH-vitamina D > 150 ng/mL (toxicidade > 100), 1,25-OH-vitamina D 80 pg/mL, vitamina A 0,7 mg/dL, paratormônio < 3 pg/mL, cálcio total 13,6 mg/dL, cálcio urinário de 24h 635 mg/24h (VR 42-353). Uma ultrassonografia do trato urinário demonstrou sinais de nefropatia parenquimatosa. O diagnóstico foi hipercalcemia e insuficiência renal aguda secundária a intoxicação por vitamina D. Ele foi tratado inicialmente com hidratação intravenosa, furosemida e prednisona. No quinto dia de hospitalização uma dose de pamidronato dissódico foi adicionada. O paciente evoluiu com normalização do cálcio sérico e da função renal. Trinta dias depois ele apresentou testes clínicos e laboratoriais normais, exceto a 25-OH-vitamina D que estava persistentemente elevada (107 ng/mL), já que ela pode demorar vários meses para normalizar. Este relato de caso é um alerta aos riscos relacionados ao uso de substâncias veterinárias para fins estéticos.

Diretriz brasileira baseada em evidências sobre prevenção de doenças cardiovasculares em pacientes com diabetes: posicionamento da Sociedade Brasileira de Diabetes (SBD), da Sociedade Brasileira de Cardiologia (SBC) e da Sociedade Brasileira de Endocrinologia e Metabologia (SBEM) / Brazilian evidence-based guideline on cardiovascular disease prevention in patients with diabetes: positioning of the Brazilian Society of Diabetes (SBD), the Brazilian Society of Cardiology (SBC) and the Brazilian Society of Endocrinology and Metabology (SBEM)

Resumo Fundamentação: desde o primeiro posicionamento da Sociedade Brasileira de Diabetes (SBD) sobre diabetes e prevenção cardiovascular, em 2014,1 importantes estudos têm sido publicados na área de prevenção cardiovascular e tratamento do diabetes,2 os quais contribuíram para a evolução na prevenção primária e secundária nos pacientes com diabetes. Ferramentas de estratificação de risco mais precisas, novos fármacos hipolipemiantes e novos antidiabéticos com efeitos cardiovasculares e redução da mortalidade, são parte desta nova abordagem para os pacientes com diabetes. O reconhecimento de que o diabetes é uma doença heterogênea foi fundamental, sendo claramente demonstrado que nem todos os pacientes diabéticos pertencem a categorias de risco alto ou muito alto. Um porcentual elevado é composto por pacientes jovens, sem os fatores de risco clássicos, os quais podem ser classificados adequadamente em categorias de risco intermediário ou mesmo em baixo risco cardiovascular. O presente posicionamento revisa as melhores evidências atualmente disponíveis e propõe uma abordagem prática, baseada em risco, para o tratamento de pacientes com diabetes. Estruturação: perante este desafio e reconhecendo a natureza multifacetada da doença, a SBD uniu-se à Sociedade Brasileira de Cardiologia (SBC) e à Sociedade Brasileira de Endocrinologia e Metabolismo (SBEM), e formou um painel de especialistas, constituído por 28 cardiologistas e endocrinologistas, para revisar as melhores evidências disponíveis e elaborar uma diretriz contendo recomendações práticas para a estratificação de risco e prevenção da Doença Cardiovascular (DVC) no Diabetes Melito (DM). As principais inovações incluem: (1) considerações do impacto de novos hipolipemiantes e das novas medicações antidiabéticas no risco cardiovascular; (2) uma abordagem prática, baseada em fator de risco, para orientar o uso das estatinas, incluindo novas definições das metas da Lipoproteína de Baixa Densidade-colesterol (LDL-colesterol) e colesterol não Lipoproteína de Alta Densidade HDL; (3) uma abordagem baseada em evidências, para avaliar a isquemia miocárdica silenciosa (IMS) e a aterosclerose subclínica em pacientes com diabetes; (4) as abordagens mais atuais para o tratamento da hipertensão; e (5) recomendação de atualizações para o uso de terapia antiplaquetária. Esperamos que esta diretriz auxilie os médicos no cuidado dedicado aos pacientes com diabetes. Métodos: inicialmente, os membros do painel foram divididos em sete subcomitês para definirem os tópicos principais que necessitavam de uma posição atualizada das sociedades. Os membros do painel pesquisaram e buscaram no PubMed estudos clínicos randomizados e metanálises de estudos clínicos e estudos observacionais de boa qualidade, publicados entre 1997 e 2017, usando termos MeSH: [diabetes], [diabetes tipo 2], [doença cardiovascular], [estratificação de risco cardiovascular] [doença arterial coronária], [rastreamento], [isquemia silenciosa], [estatinas], [hipertensão], [ácido acetilsalicílico]. Estudos observacionais de baixa qualidade, metanálises com alta heterogeneidade e estudos transversais não foram incluídos, embora talvez tenham impactado no Nível de Evidência indicado. A opinião de especialistas foi usada quando os resultados das buscas não eram satisfatórios para um item específico. É importante salientar que este posicionamento não teve a intenção de incluir uma revisão sistemática rigorosa. Um manuscrito preliminar, destacando recomendações de graus e níveis de evidência (Quadro 1), foi esboçado. Este passo levou a várias discussões entre os membros dos subcomitês, que revisaram os achados e fizeram novas sugestões. O manuscrito foi, então, revisto pelo autor líder, encarregado da padronização do texto e da inclusão de pequenas alterações, sendo submetido à apreciação mais detalhada pelos membros dos comitês, buscando uma posição de consenso. Depois desta fase, o manuscrito foi enviado para a banca editorial e edição final, sendo encaminhado para publicação. Quadro 1 Graus de recomendações e níveis de evidências adotados nesta revisão Grau de recomendação Classe I A evidência é conclusiva ou, se não, existe consenso de que o procedimento ou tratamento é seguro e eficaz Classe II Há evidências contraditórias ou opiniões divergentes sobre segurança, eficácia, ou utilidade do tratamento ou procedimento Classe IIa As opiniões são favoráveis ao tratamento ou procedimento. A maioria dos especialistas aprova Classe IIb A eficácia é bem menos estabelecida, e as opiniões são divergentes Classe III Há evidências ou consenso de que o tratamento ou procedimento não é útil, eficaz, ou pode ser prejudicial Níveis de Evidência A Múltiplos estudos clínicos randomizados concordantes e bem elaborados ou metanálises robustas de estudos clínicos randomizados B Dados de metanálises menos robustas, um único estudo clínico randomizado ou estudos observacionais C Opinião dos especialistas

Níveis séricos de 25(OH)-vitamina D em pacientes com obesidade grau 2 e 3 / Serum 25(OH)-vitamin D levels in patients with grade 2 and 3 obesity

Introdução: Deficiência de vitamina D é reconhecida hoje como pandemia e fator de impacto no desenvolvimento de várias doenças, sendo recentemente relacionada à fisiopatologia da obesidade e da síndrome metabólica. Objetivos: Analisar os níveis séricos de vitamina D em pacientes obesos em avaliação pré-operatória para cirurgia bariátrica correlacionando-os com variáveis clínicas, laboratoriais e epidemiológicas. Métodos: Estudo observacional transversal, com 170 pacientes obesos grau 2 e 3 avaliados no ambulatório de cirurgia bariátrica do HU-UFSC em 2013. Foram coletados dados clínicos, epidemiológicos, antropométricos e laboratoriais. Resultados: A média de idade foi de 40 ± 10 anos, sendo a maioria do sexo feminino, caucasiana e habitante do litoral. O peso e o IMC médios foram 126,0 ± 24,2 kg e 48,0 ± 7,1 kg/m² respectivamente. As comorbidades mais prevalentes foram diabetes mellitus tipo 2 (24,7%) e hipertensão arterial sistêmica (55,3%). A média dos níveis de 25(OH)-vitamina D foi de 26,3 ± 8,4 ng/mL. Deficiência e insuficiência de vitamina D foram encontrados em 23,5 e 45,3% dos pacientes, respectivamente. Não houve correlação significativa entre os níveis de vitamina D e as demais variáveis estudadas, exceto o cálcio corrigido para a albumina. Conclusão: Os pacientes obesos em avaliação para cirurgia bariátrica neste serviço apresentam alta prevalência de deficiência/insuficiência de vitamina D. Estes níveis apresentaram correlação negativa estatisticamente significativa com o cálcio sérico corrigido, mas não com as demais variáveis estudadas.

Background: Vitamin D deficiency nowadays is recognized as a pandemic and important factor for development of a variety of diseases. It has been recently related to the physiopathology of obesity and metabolic syndrome. Objectives: To analyze serum levels of vitamin D in obese patients on preoperative evaluation for bariatric surgery and correlate them to clinical, laboratory and epidemiological variables. Methods: Cross-sectional observational study, including 170 patients with grade 2 and 3 obesity evaluated at the obesity outpatient clinic of the University Hospital (HU-UFSC) in 2013. Clinical, epidemiological, anthropometric and laboratory data were collected. Results: Mean age was 40 ± 10 years, the majority was females, Caucasian and living on the coast. Average weight and BMI were 126.0 ± 24.2 kg e 48.0 ± 7.1 kg/m² respectively. The most prevalent comorbidities were type 2 diabetes mellitus (24.7%) and hypertension (55.3%). Mean serum level of 25(OH)-vitamin D was 26.3 ± 8.4 ng/mL. Vitamin D deficiency and insufficiency were found in 23.5 and 45.3% of patients, respectively. There was no significant correlation between serum vitamin D levels and variables analyzed in this study, except albumin-corrected serum calcium. Conclusion: Obese patients evaluated for bariatric surgery in this service present a high prevalence of vitamin D deficiency/insufficiency. These levels were significantly negatively correlated with albumin-corrected serum calcium, but not with the other studied variables.

Mitochondrial Respiration Chain Enzymatic Activities in the Human Brain: Methodological Implications for Tissue Sampling and Storage.

Mitochondrial respiratory chain complexes enzymatic (MRCCE) activities were successfully evaluated in frozen brain samples. Epilepsy surgery offers an ethical opportunity to study human brain tissue surgically removed to treat drug resistant epilepsies. Epilepsy surgeries are done with hemodynamic and laboratory parameters to maintain physiology, but there are no studies analyzing the association among these parameters and MRCCE activities in the human brain tissue. We determined the intra-operative parameters independently associated with MRCCE activities in middle temporal neocortex (Cx), amygdala (AMY) and head of hippocampus (HIP) samples of patients (n = 23) who underwent temporal lobectomy using multiple linear regressions. MRCCE activities in Cx, AMY and HIP are differentially associated to trans-operative mean arterial blood pressure, O2 saturation, hemoglobin, and anesthesia duration to time of tissue sampling. The time-course between the last seizure occurrence and tissue sampling as well as the sample storage to biochemical assessments were also associated with enzyme activities. Linear regression models including these variables explain 13-17 % of MRCCE activities and show a moderate to strong effect (r = 0.37-0.82). Intraoperative hemodynamic and laboratory parameters as well as the time from last seizure to tissue sampling and storage time are associated with MRCCE activities in human samples from the Cx, AMYG and HIP. Careful control of these parameters is required to minimize confounding biases in studies using human brain samples collected from elective neurosurgery.

Escores de neuropatia periférica em diabéticos / Peripheral neuropathy scores in diabetic

OBJETIVO: Diabetes mellitus é uma doença crônica prevalente, associada a inúmeras complicações. A neuropatia periférica diabética é a mais comum, acometendo 50% dos diabéticos, mas muitas vezes não é diagnosticada. Por cursar com insensibilidade distal e alterações arquiteturais dos pés, predispõe a úlceras, podendo culminar no pé diabético com risco de amputação. O diabetes mellitus é responsável por 70% das amputações de membros, que poderiam ser prevenidas com o diagnóstico precoce da neuropatia periférica diabética. Sugere-se avaliar o grau de neuropatia em diabéticos por meio de escores, visando homogeneizar o diagnóstico, quantificar a prevalência e promover medidas preventivas. MÉTODOS: Realizou-se entrevista, exame físico e coleta de dados de diabéticos atendidos ambulatorialmente, para pontuação e qualificação no Escore de Sintomas Neuropáticos e no Escore de Comprometimento Neuropático, validados na língua portuguesa para avaliar neuropatia periférica diabética, além de análise das características clínicas e epidemiológicas associadas. RESULTADOS: Foram incluídos 116 pacientes, constatando-se neuropatia periférica diabética em 31,9%. Houve correlação significativa de neuropatia periférica diabética coma idade dos pacientes, mas não com as demais variáveis clínicas e laboratoriais. Os pacientes avaliados apresentaram médias de idade de 55±15 anos e tempo de diabetes de 14,8±10,9 anos, sendo predominantemente caucasianos, mulheres e portadores de diabetes mellitus tipo 2. Eram hipertensos 67,2% e 42,2%, obesos. CONCLUSÃO: A prevalência encontrada corrobora a literatura, embora poucos estudos tenham utilizado critérios similares para diagnosticar neuropatia periférica diabética. Empregando os escores padronizados, de baixo custo e fácil aplicação possibilitamos o diagnóstico precoce e embasado dessa entidade, sendo possível, com isso, reduzir a prevalência de graves complicações do pé diabético e disseminar informações a respeito.

OBJECTIVE: Diabetes mellitus is a prevalent chronic disease, associated with numerous complications. Diabetic peripheral neuropathy is the most common, affecting 50% of diabetics, although is often not diagnosed. Presenting with distal numbness and architectural alterations of the feet, it predisposes ulcers and may culminate in diabetic foot at risk for amputation. Diabetes mellitus is responsible for 70% of limb amputations, which could be prevented with early diagnosis of diabetic peripheral neuropathy. This study aims to evaluate the degree of neuropathy in diabetics through validated scores, in order to standardize the diagnosis, quantify the prevalence and promote preventive actions. METHODS: We performed an interview, physical examination and data collection of diabetic outpatients, for rating in the Neuropathy Symptom Score and the Neuropathy Disability Score, validated in Portuguese, to assess diabetic peripheral neuropathy, in addition to analysis of clinical and epidemiological associated characteristics. RESULTS: We included 116 patients and diabetic peripheral neuropathy was found in 31.9%. There was significant correlation diabetic peripheral neuropathy with age, but not with other clinical and laboratory variables. The mean age was 55±15 years, diabetes duration was 14.8±10.9 years and patients were predominantly Caucasian, women and had type 2 diabetes mellitus. Of the patients, 67.2 % were hypertensive and 42.2% obese. CONCLUSION: The prevalence found is supported by previous data, although few studies have used similar criteria to diagnose diabetic peripheral neuropathy. Employing the standard scores, of low cost and easy implementation, we enable early and accurate diagnosis of this condition, allowing to reduce the prevalence of severe diabetic foot complications and spread information about it.

Validity and screening properties of three depression rating scales in a prospective sample of patients with severe traumatic brain injury

Objective: To evaluate the validity and utility of the Hamilton Rating Scale for Depression (HAM-D), Beck Depression Inventory (BDI), and Hospital Anxiety and Depression Scale (HADS) as screening tools for depression after severe traumatic brain injury (TBI). Methods: Forty-six consecutive survivors of severe TBI were evaluated at a median of 15 months after injury. Receiver operating characteristic (ROC) analysis was performed using HAM-D, BDI, and HADS as predictors, and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) as gold standard. Results: The area under the curve (AUC) for HAM-D was 0.89, and the optimal cutoff point was 7 (sensitivity 92.9%, specificity 78.1%); for the BDI, the AUC was 0.946 and the optimal cutoff point was 14 (sensitivity 92.3%, specificity 96.7%); for the HADS, the AUC was 0.947 and the optimal cutoff point was 9 (sensitivity 100%, specificity 80.7%); and for the HADS depression subscale, the AUC was 0.937 and the optimal cutoff point was 6 (sensitivity 92.9%, specificity 83.9%). There were no statistically significant differences among the AUCs. Conclusion: Our findings support a high validity and utility for the HAM-D, BDI, and HADS as screening tools for depression in patients with severe TBI, without major changes in standard cutoff points. .

Personality changes and return to work after severe traumatic brain injury: a prospective study

Objective: To evaluate predictors of non-return to work (nRTW) among social, demographic, clinical, and psychiatric variables after severe traumatic brain injury (TBI) in a cohort of Brazilian patients. Methods: Prospective study. Forty-three community-dwelling individuals treated at a Level I trauma center at the time of TBI were evaluated 18 months after trauma. Measures included DSM-IV-TR criteria for personality changes after TBI and Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to assess psychiatric diagnosis. Hospitalization variables included Glasgow Coma Scale scores, pupil examination findings, associated limb trauma, Marshall computed tomography classification, and blood glucose levels. Results: After multiple logistic regression analysis, only the diagnosis of personality changes was found to be independently associated with nRTW, with an adjusted odds ratio of 10.92 (p = 0.02, 95% confidence interval 1.41-84.28). Conclusions: In this study, personality changes were an independent predictor of nRTW after severe TBI. Ways to predict risk factors associated with personality changes after severe brain injury could aid in identification of early and effective interventions that might ease the burden associated with this condition. .

Hirsutism: diagnosis and treatment.

Hirsutism is defined as excessive terminal hair growth in androgen-dependent areas of the body in women, which grows in a typical male distribution pattern. Hirsutism is a common clinical problem in women, and the treatment depends on the cause. The condition is often associated with a loss of self-esteem. Hirsutism reflects the interaction between circulating androgen concentrations, local androgen concentrations, and the sensitivity of the hair follicle to androgens. Polycystic ovary syndrome and idiopathic hirsutism are the most common causes of the condition. A woman's history and, physical examination are particularly important in evaluating excess hair growth. The vast majority of women with hirsutism have the idiopathic variety, and the diagnosis is made by exclusion. Serum testosterone level>200 ng/dL is highly suggestive of adrenal or ovarian tumor. Treatment of hirsutism should be based on the degree of excess hair growth presented by the patient and in the pathophysiology of the disorder. Treatment includes lifestyle therapies, androgen suppression, peripheral androgen blockage, and cosmetic treatments. The current review discusses definition, pathogenesis, physiopathology, differential diagnosis, diagnostic strategies, and treatment.

Effects of endocrine disruptors in the development of the female reproductive tract.

Environmental agencies have identified a growing number of environmental contaminants that have endocrine disrupting activity, and these can become a major public health problem. It is suggested that endocrine disruptors could account for the higher-than-expected increase in the prevalence of some non-communicable diseases, such as obesity, diabetes, thyroid diseases, and some cancers. Several endocrine Disrupting Chemicals (EDCs), such as pesticides, bisphenol A, phthalates, dioxins, and phytoestrogens, can interact with the female reproductive system and lead to endocrine disruption. Initially, it was assumed that EDCs exert their effects by binding to hormone receptors and transcription factors, but it is currently known that they may also alter the expression of enzymes involved in the synthesis or catabolism of steroids. Biomonitoring studies have identified these compounds in adults, children, pregnant women, and fetuses. Among the diseases of the female reproductive tract associated with EDCs exposure are the following: precocious puberty, polycystic ovary syndrome, and premature ovarian failure. The different populations of the world are exposed to a great number of chemicals through different routes of infection; despite the various available studies, there is still much doubt regarding the additive effect of a mixture of EDCs with similar mechanisms of action.

Validity and screening properties of three depression rating scales in a prospective sample of patients with severe traumatic brain injury.

OBJECTIVE: To evaluate the validity and utility of the Hamilton Rating Scale for Depression (HAM-D), Beck Depression Inventory (BDI), and Hospital Anxiety and Depression Scale (HADS) as screening tools for depression after severe traumatic brain injury (TBI). METHODS: Forty-six consecutive survivors of severe TBI were evaluated at a median of 15 months after injury. Receiver operating characteristic (ROC) analysis was performed using HAM-D, BDI, and HADS as predictors, and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) as gold standard. RESULTS: The area under the curve (AUC) for HAM-D was 0.89, and the optimal cutoff point was 7 (sensitivity 92.9%, specificity 78.1%); for the BDI, the AUC was 0.946 and the optimal cutoff point was 14 (sensitivity 92.3%, specificity 96.7%); for the HADS, the AUC was 0.947 and the optimal cutoff point was 9 (sensitivity 100%, specificity 80.7%); and for the HADS depression subscale, the AUC was 0.937 and the optimal cutoff point was 6 (sensitivity 92.9%, specificity 83.9%). There were no statistically significant differences among the AUCs. CONCLUSION: Our findings support a high validity and utility for the HAM-D, BDI, and HADS as screening tools for depression in patients with severe TBI, without major changes in standard cutoff points.