Flash glucose monitoring system in gestational diabetes: a study of accuracy and usability.

PURPOSE: Studies of flash glucose monitoring systems (FGMSs) in pregnancy are insufficient, especially in gestational diabetes (GD). Our aim was to evaluate Freestyle Libre's usability and accuracy (compared to self-monitoring of blood glucose [SMBG]) for GD patients in real-life conditions. METHODS: This is a prospective study with pregnant women diagnosed with GD (n = 24 for the usability analysis; n = 19 for the accuracy analysis). The study duration was up to 28 days (lifetime of two sensors). Participants executed a minimum of four daily FGMS readings obtained immediately after capillary SMBG. Analytical accuracy was assessed with mean absolute relative difference (MARD) and mean absolute difference (MAD); clinical accuracy was assessed with Surveillance Error Grid (SEG). Usability was evaluated with a user acceptability questionnaire. RESULTS: The mean pregestational BMI was 25.21 ± 5.15 kg/m2 (mean ± SD), the mean gestational age was 30.31 ± 2.02 weeks, and the mean glucose values were 76.63 ± 7.49 mg/dL. A total of 1339 SMBG-FGMS pairs of values were obtained. Analytical accuracy was good with an overall MARD of 14.07% and an in-target MARD of 13.79%. The number of SMBG-FMGS pairs for above-target values was low (122 of 1339) with an associated MARD of 17.95%. Clinical accuracy of the FGMS was demonstrated, with 94.4% of values in the no-risk or slight, lower risk zones of the SEG. FGMS accuracy was unaffected by pregestational BMI or gestational age. The user acceptability questionnaire showed high levels of satisfaction, with 95.8-100% preferring FGMS to SMBG. No unexpected or severe adverse effects occurred. CONCLUSION: FGMS showed good performance in GD regarding accuracy and usability. Larger studies are needed to corroborate our results, verify the analytical accuracy of above-target values as this glucose range might lead to initiation or adjustment of pharmacological therapy, and ultimately establish definitive recommendations regarding prescription of FGMS for GD patients.

Is elevated blood glucose at admission associated with poor outcomes in hospitalized COVID-19 patients?

Objective: Hyperglycemia has been suggested as a risk factor for poor outcomes in coronavirus disease 2019 (COVID-19). The aim of our work was to evaluate the association between blood glucose levels at admission (BGA) and disease outcomes in hospitalized COVID-19 patients. Subjects and methods: Retrospective study including all adult COVID-19 patients admitted to a Portuguese hospital from March to August 2020 with BGA measurement. Subjects were categorized into two groups: BGA < 140 mg/dL and ≥ 140 mg/dL. Statistical analysis was performed using SPSSv26® (significance defined as p < 0.05). Results: We included 202 patients: median age 74 (60-86) years; 43.1% female; 31.2% with diabetes. The median BGA was 130.5 (108-158) mg/dL. When compared to normoglycemic, patients with BGA ≥ 140 mg/dL were older (p = 0.013), more vaccinated for influenza (p = 0.025) and had more comorbidities (hypertension, heart failure and peripheral arterial disease, p < 0.05). The last group presented higher leucocyte and neutrophile count, higher procalcitonin and prothrombin time, and lower lymphocyte count. Concerning prognosis, BGA ≥ 140 mg/dL was associated with higher rates of mechanical ventilation requirement and intensive care unit admission (p < 0.001), shock (p = 0.011), in-hospital mortality (p = 0.022) and 30-day mortality (p = 0.037). Considering only non-diabetic patients (n = 139), those with hyperglycemia presented higher rates of severity indicators (polypnea, SatO2 ≤ 93% and PaO2/FiO2 ≤ 300) and an association with poor outcomes was also found, namely mechanical ventilation requirement and in-hospital/30-day mortality (p < 0.05). Conclusion: Hyperglycemia at admission was associated with poor outcomes in COVID-19 patients, even in those without known pre-existing diabetes. Glycemic testing should be recommended for all COVID-19 patients.

Lazer, política e sociedade: as contribuições da SEJEL para os feirantes do Ver-o-Peso / Leisure, politics and society: the contributions of the fairground SEJEL for O-Ver-Weight

O presente estudo objetiva analisar as contribuições políticas das práticas sociais do lazer promovidas pela Secretaria Municipal de Esporte, Juventude e Lazer (SEJEL) para os feirantes do Ver-o-Peso (2018 a 2019) privilegiando o lazer no cotidiano dos feirantes enquanto direito social. Questões norteadoras: Existe alguma contribuição política pela SEJEL que garanta o Lazer enquanto direito Social em prol dos feirantes do Ver-o-Peso. Se existe? Como existe? Problema ­Como contribuir para as políticas da SEJEL que garanta o Lazer enquanto direito social, em prol dos feirantes do Ver-o-Peso? Metodologia: pesquisa documental qualitativa, enfoque materialismo dialético, método dialético, coleta de dados: jornal, vídeo, blog da SEJEL, leis, projeto de lazer da prefeitura para os feirantes. Resultado: as políticas da SEJEL estão enquadradas com um significado recreativo, havendo necessidade da efetivação de políticas públicas de lazer consolidadas com os feirantes para a compreensão enquanto direito social, e, também por parte dos governantes quando o mesmo está sendo vivido e entendido pelas vias do senso comum somente como descanso, entretenimento e mercadoria. A promoção social do lazer pode estar atrelada a um serviço muitas vezes de forma limitada e alienante de convívio social.

Objective: to analyze the contributions of the social practices of leisure promoted by the municipal Sport, Youth andSport (SEJEL) to the vendors of the Ver-o-Peso (2018 to 2019) for the quality and style of life of them, as well as for that leisure becomes privileged in everyday merchants and practice as a social right of citizenship under the foundations of public policies of leisure. Methodology: qualitative desk research, focus dialectical materialism, dialectical method, data collection, newspaper, video, blog SEJEL, laws, leisure project of city hall to the fairground. Result: The public policies of social practices of leisure SEJEL (2008 to 2012) is framed with a recreational significance, requiring the execution of public policy leisure consolidated with the vendors to understand as a social right, and also by the rulers when it is lived and understood by way of common sense only as entertainment and merchandise. The social promotion of leisure can be linked to a service often quite limited and alienating.

Is elevated blood glucose at admission associated with poor outcomes in hospitalized COVID-19 patients?

ABSTRACT Objective: Hyperglycemia has been suggested as a risk factor for poor outcomes in coronavirus disease 2019 (COVID-19). The aim of our work was to evaluate the association between blood glucose levels at admission (BGA) and disease outcomes in hospitalized COVID-19 patients. Subjects and methods: Retrospective study including all adult COVID-19 patients admitted to a Portuguese hospital from March to August 2020 with BGA measurement. Subjects were categorized into two groups: BGA < 140 mg/dL and ≥ 140 mg/dL. Statistical analysis was performed using SPSSv26® (significance defined as p < 0.05). Results: We included 202 patients: median age 74 (60-86) years; 43.1% female; 31.2% with diabetes. The median BGA was 130.5 (108-158) mg/dL. When compared to normoglycemic, patients with BGA ≥ 140 mg/dL were older (p = 0.013), more vaccinated for influenza (p = 0.025) and had more comorbidities (hypertension, heart failure and peripheral arterial disease, p < 0.05). The last group presented higher leucocyte and neutrophile count, higher procalcitonin and prothrombin time, and lower lymphocyte count. Concerning prognosis, BGA ≥ 140 mg/dL was associated with higher rates of mechanical ventilation requirement and intensive care unit admission (p < 0.001), shock (p = 0.011), in-hospital mortality (p = 0.022) and 30-day mortality (p = 0.037). Considering only non-diabetic patients (n = 139), those with hyperglycemia presented higher rates of severity indicators (polypnea, SatO2 ≤ 93% and PaO2/FiO2 ≤ 300) and an association with poor outcomes was also found, namely mechanical ventilation requirement and in-hospital/30-day mortality (p < 0.05). Conclusion: Hyperglycemia at admission was associated with poor outcomes in COVID-19 patients, even in those without known pre-existing diabetes. Glycemic testing should be recommended for all COVID-19 patients.

Pheochromocytoma: A Case Report.

Pheochromocytomas are rare tumors located in the adrenal medulla, that derives from the chromaffin cells and produce catecholamines. They are an uncommon cause of hypertension, and only 50% of the patients present symptoms compatible with this pathology. Here we describe the case of a 70-year-old woman with a history of anxiety, hypertension and palpitation, who had an unspecified nodule in the right adrenal gland. Laboratory studies revealed an elevated urinary metanephrines secretion. A diagnosis of pheochromocytoma was made and an adrenalectomy was performed. Our aim is to highlight the diagnosis of this rare tumor and how its early management can prevent morbidity and mortality.

The role of neck ultrasound in the follow-up of low- and intermediate- risk papillary thyroid cancer

ABSTRACT Objective: The optimal time for a neck ultrasound (US) in the follow-up of papillary thyroid cancer (PTC) after the first year is undetermined. We aimed to verify the utility of routine neck US in the surveillance of patients diagnosed with low- and intermediate-risk PTC with no evidence of disease at the one-year assessment. Materials and methods: We conducted a retrospective longitudinal study of patients with low- and intermediate-risk PTC with normal neck US, unstimulated serum thyroglobulin (Tg) < 1 ng/mL and negative anti-Tg antibodies at the one-year follow-up. Patients were divided into group 1 [undetectable Tg (<0.20 ng/mL)] and group 2 [detectable Tg but < 1 ng/mL]. The negative predictive value (NPV) of the one-year unstimulated Tg at the five-year and last follow-up visits was calculated. Results: We included n = 88 patients in group 1 and n = 8 patients in group 2. No patient from group 1 presented suspicious US findings at the five-year evaluation [NPV: 100.0% (95% confidence interval (CI): 95.5%-100.0%)], and at the last visit, only one patient had developed a lymph node classified as suspicious [NPV: 98.8% (95% CI: 93.2%-100.0%); mean follow-up: 6.7 years]. In group 2, two patients' USs presented suspicious findings at the five-year evaluation [NPV: 75.0% (95% CI: 34.9%-96.8%)]. At the last visit, only one patient persisted with suspicious findings in the US [NPV: 87.5% (95% CI: 47.4%-99.7%); mean follow-up: 6.5 years]. Conclusion: Low- and intermediate-risk PTC with an excellent response to treatment at the one-year assessment can be safely monitored with regular unstimulated Tg assessments. Conclusions should not be drawn for Tg levels between 0.20-0.99 ng/mL.

The role of neck ultrasound in the follow-up of low- and intermediate- risk papillary thyroid cancer.

Introduction: The optimal time for a neck ultrasound (US) in the follow-up of papillary thyroid cancer (PTC) after the first year is undetermined. We aimed to verify the utility of routine neck US in the surveillance of patients diagnosed with low- and intermediate-risk PTC with no evidence of disease at the one-year assessment. Subjects and methods: We conducted a retrospective longitudinal study of patients with low- and intermediate-risk PTC with normal neck US, unstimulated serum thyroglobulin (Tg) < 1 ng/mL and negative anti-Tg antibodies at the one-year follow-up. Patients were divided into group 1 [undetectable Tg (<0.20 ng/mL)] and group 2 [detectable Tg but < 1 ng/mL]. The negative predictive value (NPV) of the one-year unstimulated Tg at the five-year and last follow-up visits was calculated. Results: We included n = 88 patients in group 1 and n = 8 patients in group 2. No patient from group 1 presented suspicious US findings at the five-year evaluation [NPV: 100.0% (95% confidence interval (CI): 95.5%-100.0%)], and at the last visit, only one patient had developed a lymph node classified as suspicious [NPV: 98.8% (95% CI: 93.2%-100.0%); mean follow-up: 6.7 years]. In group 2, two patients' USs presented suspicious findings at the five-year evaluation [NPV: 75.0% (95% CI: 34.9%-96.8%)]. At the last visit, only one patient persisted with suspicious findings in the US [NPV: 87.5% (95% CI: 47.4%-99.7%); mean follow-up: 6.5 years]. Conclusion: Low- and intermediaterisk PTC with an excellent response to treatment at the one-year assessment can be safely monitored with regular unstimulated Tg assessments. Conclusions should not be drawn for Tg levels between 0.20-0.99 ng/mL.

Antimicrobial Resistance of Clinical and Commensal Escherichia coli Canine Isolates: Profile Characterization and Comparison of Antimicrobial Susceptibility Results According to Different Guidelines.

BACKGROUND: Pyometra is a diestrual chronic disease frequently associated with Escherichia coli. Initial pyometra treatment involves empiric antimicrobial therapy whose suitability should be confirmed by antimicrobial susceptibility testing. Antimicrobial resistance is a major health issue for veterinary medicine, rendering surveillance studies essential. Our goal was to determine the susceptibility profile of E. coli isolates obtained from healthy and pyometra-presenting dogs and to compare the application of different antimicrobial susceptibility guidelines. METHODS: The antimicrobial susceptibility profile (ASP) of 74 E. coli isolates was determined by disk diffusion, using six antimicrobials commonly used in veterinary medicine. Profiles were assessed by CLSI VET01S, CLSI M100 and EUCAST guidelines. ß-lactamases-encoding genes blaTEM, blaSHV and blaOXA were detected by multiplex PCR. Biofilm production ability was evaluated by pellicle formation assays in Luria-Bertani medium. RESULTS: Variations in the resistance frequency were observed for amoxicillin/clavulanic acid, cephalexin and cefotaxime (29.7-54.1%, 10.8-16.2% and 1.4-4.1%, respectively). Results varied slightly between clinical and commensal isolates, as well as their biofilm-forming ability. Genes blaTEM, blaSHV and blaOXA were detected in 25.5%, 11.8% and 9.8% of isolates, respectively. CONCLUSIONS: Results show the importance of ASP determination in veterinary isolates and the need for using standardized and validated testing methods and harmonized interpretive criteria.

Postpartum reclassification test in gestational diabetes: can the test be reduced to 1 hour?

PURPOSE: In gestational diabetes mellitus (GDM), a postpartum oral glucose tolerance test (OGTT) is recommended. However, poor adherence to this procedure has been described, and the time required is one of the reasons. Our aims were to identify predictive factors for abnormal 2-h reclassification OGTT values, including OGTT 1-h glucose, and, if it was a factor, to determine the 1-h cutoff point that best identifies abnormal values at 2 h. METHODS: This was a retrospective study of 769 patients diagnosed with GDM between 2014 and 2019 in a tertiary center. The sample was divided into two groups according to the presence/absence of abnormal 2-h reclassification values, and predictive factors were studied. To determine the 1-h glycemia cutoff point capable of identifying 2-h changes, a ROC curve was drawn and the Youden index was used. RESULTS: The mean age of included women was 33.6 ± 4.95 years: 70 of them (9.1%) had an abnormal 2-h test result. Women with a history of GDM (OR = 3.41, p = .012) and higher 1-h glycemia value (OR = 1.05, p < .001) had a higher risk of developing an abnormal 2-h test result. One-hour glycemia ≥ 142 mg/dL had a sensitivity of 91.4% and specificity of 75.1% to identify changes in the test at 2 h; area under the curve to predict 2-h changes was 0.90 (CI 95%: 0.86 - 0.93). CONCLUSION: Glucose measurement at 1 h predicts alterations at 2 h in the reclassification test with excellent diagnostic accuracy, and the cutoff point of  ≥ 142 mg/dL presents high sensitivity. These findings could serve as a foundation for a possible future redefinition of the OGTT procedure, but further investigation is required.

Lipodystrophy: Still an underdiagnosed complication of subcutaneous insulin administration.

Lipodystrophy is a common but often underdiagnosed complication of subcutaneous insulin injections. We present an illustrative case, aiming to remind physicians to consider lipodystrophy when evaluating a patient under insulin therapy with otherwise unexplained metabolic decompensation. A complete physical examination and patient education are crucial in this setting.

Rapid-onset clozapine-induced hyperglycaemia: pathways of glycaemic dysregulation.

Clozapine is an atypical antipsychotic used in refractory schizophrenia, also efficient in alleviating dyskinesia in Parkinson's disease. Despite its potency, this drug is associated with severe metabolic side effects, including increased risk for diabetes. We report the case of a 45-year-old overweight woman with Parkinson's disease who presented with rapid-onset hyperglycaemia within 2 months after starting clozapine for refractory dyskinaesia. She had a history of gestational diabetes. At presentation, her blood glucose level was 505 mg/dL and glycated haemoglobin 12.4%, with no catabolic symptoms. Clozapine was suspended and metformin was started, but adequate glycaemic control was achieved only with insulin therapy, along with exenatide and empagliflozin afterwards. We assume that clozapine acted as a trigger for rapid deterioration of glycaemic control through direct pathophysiological mechanisms, rather than an indirect slowly evolving weight gain-related metabolic syndrome pathway. Clinicians should be aware of this complication, enabling timely diagnosis and proper treatment.

Nearly fatal hypokalaemia due to non-hypertensive primary hyperaldosteronism in the post partum.

A previously healthy postpartum 33-year-old woman was admitted at the emergency department after two episodes of syncope. In the waiting room, she collapsed, ventricular fibrillation was detected, and she was reanimated by electric cardioversion. At admission, she was conscient, with blood pressure of 102/74 mm Hg and heart rate of 78 bpm. In the laboratory workup, severe hypokalaemia was found (K+ 1.77 mEq/L). Abdominopelvic CT revealed a 27 mm nodule in the right adrenal gland. High aldosterone and low plasma renin levels were detected, and the diagnosis of primary hyperaldosteronism was made, although she never had hypertension. Posteriorly, a cosecretion of aldosterone and cortisol was found. Two months after admission, the patient remained stable with normal K+ levels under spironolactone and a right adrenalectomy was performed. The cure of primary hyperaldosteronism and a partial adrenal insufficiency were confirmed. K+ levels and blood pressure remained normal without treatment and 10 months after surgery hydrocortisone was suspended.

Clinical Performance of Flash Glucose Monitoring System in Patients with Liver Cirrhosis and Diabetes Mellitus.

Flash glucose monitoring system (FGMS) is an improved subset of continuous glucose monitoring with a recognized effectiveness on glycemic control, though validation in patients with Liver Cirrhosis (LC) is lacking. To evaluate the accuracy of FGMS in patients with Type 2 Diabetes Mellitus (DM) and LC, a prospective, case-control study was performed in 61 ambulatory patients with LC and DM (LC group, n = 31) or DM (Control group, n = 30). During 14 days, patients performed 4 assessments per day of self-monitoring of blood glucose (SMBG, reference value) followed by FGMS scanning. There were 2567 paired SMBG and FGMS values used in the accuracy analysis, with an overall mean absolute relative difference (MARD) of 12.68% in the LC group and 10.55% in the control group (p < 0,001). In patients with LC, the percentage of readings within Consensus Consensus Error Grid analysis Zone A and A + B were 80.36% and 99,26%, respectively. Sensor clinical accuracy was not affected by factors such as body mass index, age, gender, Child-Pugh score or edematoascitic decompensation. This is the first study to approach FGMS clinical accuracy in LC, revealing a potential usability of this system to monitor glycemic control in this population.

Universal vs. risk-factor-based screening for gestational diabetes-an analysis from a 5-Year Portuguese Cohort.

PURPOSE: The criteria to screen for Gestational Diabetes Mellitus are not internationally consensual. In opposition to the universal screening performed in Portugal, certain countries advocate a risk-factor-based screening. We aim to compare obstetric and neonatal outcomes in pregnant women with and without risk factors treated for Gestational Diabetes Mellitus. METHODS: Retrospective and multicentric study of 12,006 pregnant women diagnosed with Gestational Diabetes Mellitus between 2011 and 2015, in Portugal. Gestational Diabetes Mellitus was diagnosed according to the International Association of the Diabetes and Pregnancy Study Groups criteria. RISK FACTORS: body mass index > 30kg/m2, history of Gestational Diabetes Mellitus, history of macrossomic newborn (birth weight > 4000 g) or first-degree relatives with Type 2 Diabetes Mellitus. EXCLUSION CRITERIA: lack of data concerning risk factors (n = 1563). RESULTS: At least one risk factor was found in 68.2% (n = 7123) pregnant women. Pregnant women with risk factors were more frequently medicated with insulin (p < 0.001), caesarean section was more commonly performed (p < 0.001), their newborns were more frequently large-for-gestational-age (p < 0.001) and neonatal morbidity was higher (p = 0.040) in comparison to pregnant women without risk factors. The Diabetes Mellitus reclassification test showed an increased frequency of intermediate hyperglycaemia and Diabetes Mellitus in women with risk factors (p < 0.001). CONCLUSION: Almost one-third of pregnant women would have remained undiagnosed if risk-based-factor screening were implemented in Portugal. Women without risk factors presented fewer obstetric and neonatal complications. However, more than one third required insulin therapy.

Iron Deficiency and Obesity - Are we Diagnosing with Appropriate Indicators?

INTRODUCTION: We aim to define the iron deficiency prevalence and eventual differences between obese patients with and without metabolic syndrome. MATERIAL AND METHODS: Analysis of patients evaluated at multidisciplinary consultation of obesity in our institution between 2013 and 2015 (n = 260). Iron deficiency: ferritin levels < 15 ng/mL. EXCLUSION CRITERIA: prior bariatric surgery; lack of ferritin or hemoglobin determinations. RESULTS: We analyzed data from 215 patients (84.2% female) with a mean age of 42.0 ± 10.3 years. The median body mass index was 42.5 (40.0 - 46.8) kg/m2 and 52.1% had metabolic syndrome. Iron deficiency was present in 7.0%, with no differences between genders or between patients with or without metabolic syndrome. Hypertension was associated with lower prevalence of iron deficiency. Type 2 diabetes and hypertension patients had higher levels of ferritin. The multivariate analysis showed that metabolic syndrome and increasing body mass index were predictive of higher risk of iron deficiency while hypertension predicted lower odds of iron deficiency. DISCUSSION: The prevalence of iron deficiency was similar in other published studies. Iron deficiency may be underdiagnosed if based only on ferritin concentrations. In our study, diabetes and hypertension appear to contribute to the increase in ferritin levels described in obesity. CONCLUSION: Ferritin may not be a reliable index for evaluating iron stores in obese patients, particularly when associated with comorbidities such as type 2 diabetes and hypertension. Further studies are needed to guide the diagnosis and iron supplementation in these patients.

Introdução: Os objetivos foram a determinação da prevalência de défice de ferro e de eventuais diferenças entre os doentes obesos com e sem síndrome metabólica. Material e Métodos: Análise dos doentes observados na consulta multidisciplinar de obesidade na nossa instituição entre 2013 e 2015 (n = 260). Défice de ferro: ferritina < 15 ng/mL. Critérios de exclusão: cirurgia bariátrica prévia, ausência de doseamentos de ferritina e de hemoglobina. Resultados: Avaliaram-se 215 doentes (84,2% mulheres) com uma idade média de 42,0 ± 10,3 anos. O índice de massa corporal mediano foi 42,5 (40,0 - 46,8) kg/m2 e 52,1% apresentavam síndrome metabólica. O défice de ferro estava presente em 7,0% sem diferenças entre os géneros e entre os doentes com e sem síndrome metabólica. A hipertensão associou-se a menor prevalência de défice de ferro. Doentes com diabetes tipo 2 e hipertensão apresentaram valores mais elevados de ferritina. Na análise multivariada, a síndrome metabólica e o índice de massa corporal constituíram fatores preditivos de défice de ferro, enquanto a hipertensão se associou a um menor risco. Discussão: A prevalência de défice de ferro foi similar a estudos previamente publicados. O défice de ferro pode ser subdiagnosticado se baseado apenas nas concentrações de ferritina. No nosso estudo, a diabetes e a hipertensão parecem contribuir para os níveis elevados de ferritina descritos na obesidade. Conclusão: A ferritina poderá não ser um índice fiável para avaliação de reservas de ferro na obesidade, particularmente quando associada a diabetes tipo 2 e hipertensão. São necessários mais estudos de forma a orientar o diagnóstico e a suplementação com ferro nestes doentes.

Gestational diabetes mellitus: different management strategies should be adopted for different subsets of patients diagnosed by oral glucose tolerance test.

PURPOSE: To compare women diagnosed with gestational diabetes mellitus (GDM) according to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria based on the number of OGTT diagnostic criteria, which OGTT parameters are altered and the glycemic deviation from proposed diagnostic cutoffs. METHODS: Cross-sectional, multicentric study of women diagnosed with GDM between 24-28 weeks of pregnancy according to the IADPSG criteria, in Portugal, between 2012-2014. Primary outcomes: large for gestational age (LGA) and maternal glucose metabolism status after delivery. Secondary outcome: small for gestational age (SGA). RESULTS: Three-thousand three-hundred fourteen patients were included; 67% had 1 OGTT altered value; 3.6% had LGA and 13% had SGA newborns; 7% had prediabetes/diabetes after delivery. Three diagnostic criteria in OGTT (OR 3.02; p < 0.001), a diagnostic value at 0 min (OR 2.09; p = 0.002) and 60 min (OR 1.70; p = 0.022) and glucose deviation at 0 min (OR 1.02; p = 0.014) were predictors of LGA. Having 2 (OR 1.94; p < 0.001) or 3 (OR 3.93; p < 0.001) diagnostic criteria in OGTT, a diagnostic value at 0 min (OR 1.76; p = 0.002), at 60 min (OR 1.57; p = 0.007) and at 120 min (OR 3.11; p < 0.001), the glucose deviation at 0 (OR 1.02; p = 0.017) and 120 min (OR 1.02; p < 0.001) were predictors of prediabetes/diabetes after delivery. Insufficient weight gain in pregnancy (OR 1.49; p < 0.001) and lower maternal BMI (OR 0.97; p = 0.024) were associated with SGA. CONCLUSION: IADPSG diagnostic criteria include a heterogeneous group of women, for whom different management strategies should be adopted to obtain ideal pregnancy outcomes.

Isotopic evolution of the protoplanetary disk and the building blocks of Earth and the Moon.

Nucleosynthetic isotope variability among Solar System objects is often used to probe the genetic relationship between meteorite groups and the rocky planets (Mercury, Venus, Earth and Mars), which, in turn, may provide insights into the building blocks of the Earth-Moon system. Using this approach, it has been inferred that no primitive meteorite matches the terrestrial composition and the protoplanetary disk material from which Earth and the Moon accreted is therefore largely unconstrained. This conclusion, however, is based on the assumption that the observed nucleosynthetic variability of inner-Solar-System objects predominantly reflects spatial heterogeneity. Here we use the isotopic composition of the refractory element calcium to show that the nucleosynthetic variability in the inner Solar System primarily reflects a rapid change in the mass-independent calcium isotope composition of protoplanetary disk solids associated with early mass accretion to the proto-Sun. We measure the mass-independent 48Ca/44Ca ratios of samples originating from the parent bodies of ureilite and angrite meteorites, as well as from Vesta, Mars and Earth, and find that they are positively correlated with the masses of their parent asteroids and planets, which are a proxy of their accretion timescales. This correlation implies a secular evolution of the bulk calcium isotope composition of the protoplanetary disk in the terrestrial planet-forming region. Individual chondrules from ordinary chondrites formed within one million years of the collapse of the proto-Sun reveal the full range of inner-Solar-System mass-independent 48Ca/44Ca ratios, indicating a rapid change in the composition of the material of the protoplanetary disk. We infer that this secular evolution reflects admixing of pristine outer-Solar-System material into the thermally processed inner protoplanetary disk associated with the accretion of mass to the proto-Sun. The identical calcium isotope composition of Earth and the Moon reported here is a prediction of our model if the Moon-forming impact involved protoplanets or precursors that completed their accretion near the end of the protoplanetary disk's lifetime.

[Subclinical Hypothyroidism on the Elderly]. / Hipotiroidismo Subclínico no Idoso.

INTRODUCTION: Subclinical hypothyroidism, defined as an increase of thyroid stimulating hormone levels with normal levels of thyroid hormones, could have a multiorgan impact. There seem to be differences in the elderly (over 65 years of age) which indicate that there should be a different approach in terms of diagnosis and the treatment. MATERIAL AND METHODS: Electronic database search and narrative bibliographical review. RESULTS: Different case studies showing the multiorgan consequences of subclinical hypothyroidism suggest that, in the elderly, there is a minor impact or even a lack of repercussion, especially in those over 80 - 85 years old. Additionally, there is evidence indicating that the levels of thyroid stimulating hormone rise with the age of the patient. The standard treatment, in the beginning, is a low dose of levothyroxine when the levels of thyroid stimulating hormone are over 10.0 mIU/L, when there are noticeable symptoms or positive anti-thyroid antibodies. However, the treatment is not consensual when the levels of thyroid stimulating hormone are between 4.5 and 10.0 mIU/L, in such a way that the TRUST study concluded that no benefits have outcome from treating these patients. DISCUSSION: The non-definition of the reference range and the age gap are the key factors that contribute the most to biased results. However, there is consensus regarding non-treatment of mild thyroid dysfunctions (4.5 - 7.0 mIU/L) in the elderly, particularly above 80 years of age. Nevertheless, for positive anti-thyroid antibodies, suggestive ultrasound changes or iatrogenic side effects, the reference level should be 4.5 mIU/L. CONCLUSION: The general impact of subclinical hypothyroidism is different in elderly people, meaning that an individualized therapeutic approach and long-term monitoring is the appropriate strategy.

Introdução: O hipotiroidismo subclínico, definido como um aumento da hormona estimulante da tiróide com níveis normais de hormonas tiroideias, poderá ter um impacto multiorgânico. No idoso (acima de 65 anos) parece haver diferenças que corroboram uma abordagem diagnóstica e terapêutica distintas. Material e Métodos: Revisão bibliográfica através das bases de dados eletrónicas. Resultados: Foram apresentados diferentes estudos que demonstram as consequências multiorgânicas do hipotiroidismo subclínico no idoso e que sugerem um impacto menor ou até ausente nesta população, principalmente acima dos 80 - 85 anos. Adicionalmente, estudos evidenciam que os valores de hormona estimulante da tiróide aumentam à medida que a idade avança. É consensual o início do tratamento com baixa dose de levotiroxina para valores de hormona estimulante da tiróide superiores a 10,0 mUI/L, presença de sintomas ou anticorpos anti-tiroideus positivos. O tratamento é discutível para hormona estimulante da tiróide entre 4,5 e 10,0 mUI/L, de tal forma que o estudo TRUST concluiu não haver benefícios no tratamento destes doentes. Discussão: A indefinição do intervalo de referência e da faixa etária são os fatores de enviesamento que mais dificultam a objetividade dos resultados. Todavia parece haver consenso em não tratar a disfunção tiroideia ligeira (4,5 - 7,0 mUI/L) no idoso, particularmente acima dos 80 anos. No entanto, se anticorpos anti-tiroideus positvos, alterações ecográficas sugestivas de tiroidite ou iatrogenia, deve ser considerado o limiar de 4,5 mUI/L. Conclusão: O impacto global do hipotiroidismo subclínico é diferente no idoso, pelo que uma abordagem terapêutica individualizada e monitorizada ao longo do tempo é a estratégia mais adequada.