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.

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.

Síndrome de Cushing Ectópica: Um Desafio Diagnóstico e Terapêutico

INTRODUÇÃO: A síndrome de Cushing ectópica é uma entidade rara e a identificação do tumor produtor de hor-mona adrenocorticotrópica (ACTH) pode ocorrer anos após o diagnóstico da síndrome de Cushing, dificultando a orientação terapêutica destes doentes.CASO CLÍNICO: Mulher de 78 anos referenciada à consulta de Endocrinologia por síndrome de Cushing. Apresenta-va sinais e sintomas de hipercortisolismo e a investigação demonstrou síndrome de Cushing ACTH dependente, com ressonância magnética hipofisária sem alterações, cateterismo dos seios petrosos negativo e nódulo pulmonar de 8 mm. A cintigrafia com recetores da somatostatina, a PET-68Ga-SRP, a broncofibroscopia e a citologia do aspirado brônquico não revelaram alterações. Por franco agravamento clínico, iniciou-se terapêutica com metirapona, com resposta clínica e analítica muito favorável. DISCUSSÃO: Este caso revelou-se um desafio diagnóstico e terapêutico. Embora sem localização do tumor primário, atingiu-se o principal objetivo, o controlo do hipercortisolismo, com melhoria da qualidade de vida da doente.

Primary adrenal insufficiency in adult population: a Portuguese Multicentre Study by the Adrenal Tumours Study Group

INTRODUCTION

Primary adrenal insufficiency (PAI) is a rare but severe and potentially life-threatening condition. No previous studies have characterized Portuguese patients with PAI.

AIMS

To characterize the clinical presentation, diagnostic workup, treatment and follow-up of Portuguese patients with confirmed PAI.

METHODS

This multicentre retrospective study examined PAI patients in 12 Portuguese hospitals.

RESULTS

We investigated 278 patients with PAI (55.8% were females), with a mean age of 33.6 ± 19.3 years at diagnosis. The most frequent presenting clinical features were asthenia (60.1%), mucocutaneous hyperpigmentation (55.0%) and weight loss (43.2%); 29.1% of the patients presented with adrenal crisis. Diagnosis was established by high plasma ACTH and low serum cortisol in most patients (43.9%). The most common aetiology of PAI was autoimmune adrenalitis (61.0%). There were 38 idiopathic cases. Autoimmune comorbidities were found in 70% of the patients, the most frequent being autoimmune thyroiditis (60.7%) and type 1 diabetes mellitus (17.3%). Seventy-nine percent were treated with hydrocortisone (mean dose 26.3 ± 8.3 mg/day) mostly in three (57.5%) or two (37.4%) daily doses. The remaining patients were treated with prednisolone (10.1%), dexamethasone (6.2%) and methylprednisolone (0.7%); 66.2% were also on fludrocortisone (median dose of 100 µg/day). Since diagnosis, 33.5% of patients were hospitalized for disease decompensation. In the last appointment, 17.2% of patients had complaints (7.6% asthenia and 6.5% depression) and 9.7% had electrolyte disturbances.

CONCLUSION

This is the first multicentre Portuguese study regarding PAI. The results emphasize the need for standardization in diagnostic tests and etiological investigation and provide a framework for improving treatment.

Hipertensão de Causa Endócrina: Hiperaldosteronismo Primário por Síndrome de Conn

O hiperaldosteronismo primário é uma das principais causas de hipertensão secundária. Carateriza-se pela produção inapropriada e parcialmente autónoma de aldosterona pela suprarrenal. O diagnóstico pressupõe um rácio aldosterona/renina elevado e, na maioria dos casos, uma prova confirmatória positiva. O tratamento preconizado é a adrenalectomia laparoscópica ou terapêutica médica com antagonistas dos recetores dos mineralocorticoides. Descrevemos o caso de uma doente de 55 anos com hipocaliemia e hipertensão arterial refratária à terapêutica com 16 anos de evolução. A investigação diagnóstica foi compatível com hiperaldosteronismo primário por adenoma adrenal unilateral. Foi submetida a adrenalectomia laparoscópica direita, com melhoria franca do quadro clínico. O caso clínico apresentado pretende evidenciar uma causa de hipertensão secundária cuja identificação e orientação adequada pode permitir a resolução da hipertensão. Recebido: 10/10/2016 - Aceite: 03/06/2017

Type 2 Diabetes Decompensation as the Clinical Presentation of Thyroid Storm - Cause or Consequence?

This case study aims to discuss the unusual forms of hyperthyroidism presentation, the nonspecific symptoms and precipitating events. A 70-year-old male was taken to the emergency department for hyperglycaemia, nausea, vomiting and altered mental status with a week of evolution. He had a past medical history of type 2 diabetes, hypertension and dyslipidemia. He had no history of any recent intercurrent illness or infection. At the emergency room, besides hyperglycaemia, ketonemia and slightly elevated C-reactive protein, the basic laboratory panel workup was normal, as was the head computed tomography. He was admitted for metabolic compensation and to study the altered neurological status. During hospitalisation, despite the good glycemic control, he had no improvements in neurological status. At day four of hospitalisation, thyrotoxicosis with thyroid storm criteria was diagnosed. He started on adequate treatment with complete clinical recovery. The associated morbidity and mortality of thyroid storm requires immediate recognition and treatment. Elderly patients are frequently misdiagnosed or diagnosed later due to fewer and less pronounced signs and symptoms.

[Fine-needle Aspiration of Thyroid Nodules: Is it Worth Repeating?]

INTRODUCTION

The fine-needle aspiration has a significant role in assessing the malignancy risk of thyroid nodules. There is uncertainty regarding the value of repeat fine-needle aspiration in benign nodules. This study aims to evaluate the concordance of results in consecutive fine-needle aspiration and to study the relevance of repetition in benign results.

MATERIAL AND METHODS

Retrospective study of the 4800 thyroid nodules fine-needle aspiration held in Instituto de Patologia e Imunologia Molecular da Universidade do Porto between January 1, 2014 and May 2, 2016. Of the initial sample, we selected the repeated fine-needle aspiration on the same nodule.

RESULTS

The first fine-needle aspiration result of the 309 nodules underwent revaluation was non-diagnostic in 103 (33.3%), benign in 120 (38.8%) and atypia/follicular lesion of undetermined significance in 86 (27.8%). The agreement between the first and second fine-needle aspiration was significantly higher in cases with an initial benign result (benign: 85.8%, non-diagnostic: 27.2% and atypia/follicular lesion of undetermined significance: 17.4%, p < 0.005). The fine-needle aspiration repeating motifs in initially benign nodules (n = 78) were repetition suggestion in 58, nodule growth in 17 and suspicious ultrasonographic features in 3.

DISCUSSION

The fine-needle aspiration repetition in nodules with initial non-diagnostic and atypia/follicular lesion of undetermined significance result changed the initial diagnosis in a significant proportion of patients, modifying their therapeutic approach. The high concordance of results in initially benign nodules makes fine-needle aspiration repetition not cost-effective in most cases.

CONCLUSION

The fine-needle aspiration should be repeated when the initial cytology result is non-diagnostic or atypia/follicular lesion of undetermined significance.

Ten-year follow-up of a giant prolactinoma

Giant prolactinomas are rare pituitary tumours of which management can be a challenge. A 28-year-old man presented with headaches, visual impairment and behavioural changes. Clinically, the patient was found to have hypogonadism and bitemporal hemianopsia. A MRI demonstrated a pituitary tumour 76 mm in diameter and blood tests revealed a serum prolactin of 158,700 µU/mL (reference range 58-254). Initially, a craniotomy was performed. Immunohistochemistry of the tumour identified a prolactinoma with a high proliferative index and the patient was started on treatment with a dopamine agonist. A year later, neurological symptoms worsened due to regrowth of the lesion's cystic component, and so further surgery was performed. After 10 years of treatment with dopamine agonists, the prolactin levels decreased by 96.8%, there was an effective reduction in tumour size, and the neurological signs and symptoms resolved.

[Vitamin D Insufficiency in a Hospital Population: A Photograph from the Laboratory Perspective]

INTRODUCTION

Although vitamin D deficiency is increasingly recognized around the world, there are few studies on the Portuguese reality. This study aims to analyse vitamin D levels in the assays performed in our hospital and their relationship with age, genre, requesting specialty and moment of sample collection.

MATERIAL AND METHODS

Cross-sectional study of measurements of 25(HO)D performed in our Hospital between June 2012 and November 2014. Included variables: gender, age, requesting specialty, month of sample collection. Vitamin D status classified as: 'Deficiency' (≤ 20 ng/mL), 'Insufficiency' (21 - 29 ng/ml) and 'Sufficiency' (≥ 30 ng/mL).

RESULTS

We included 5 439 assays; 55.0% from women; the median age was 64.0 years. Sixty per cent had 'Deficiency', 20.7% 'Insufficiency' and 18.9% 'Sufficiency'. We found a negative correlation between age and vitamin D level (p < 0.001). We didn't find differences in vitamin D levels between genres. Nine specialties requested 98% of the assays, namely Nephrology (56.2%). We found differences between specialties based on age and vitamin D level (p < 0.001). Vitamin D levels changed throughout the year, with higher levels in the summer, followed by autumn, spring and winter (p < 0.001). Despite this seasonal fluctuation, vitamin D sufficiency was only present in a minority of assays (27.8% in summer and 9.2% in winter).

DISCUSSION

Vitamin D deficiency is prevalent in this population, affects individuals of all ages and is not offset by the seasonal variation of sunlight.

CONCLUSION

Vitamin D deficiency is a real and prevalent problem in our population that needs further attention and action, given its clinical implications.

Carência de Vitamina D numa População Hospitalar: Uma Fotografia pela Perspetiva Laboratorial

<strong>Introduction:</strong> Although vitamin D deficiency is increasingly recognized around the world, there are few studies on the Portuguese reality. This study aims to analyse vitamin D levels in the assays performed in our hospital and their relationship with age, genre, requesting specialty and moment of sample collection.<br /><strong>Material and Methods:</strong> Cross-sectional study of measurements of 25(HO)D performed in our Hospital between June 2012 and November 2014. Included variables: gender, age, requesting specialty, month of sample collection. Vitamin D status classified as: ‘Deficiency’ (≤ 20 ng/mL), ‘Insufficiency’ (21 - 29 ng/ml) and ‘Sufficiency’ (≥ 30 ng/mL).<br /><strong>Results:</strong> We included 5 439 assays; 55.0% from women; the median age was 64.0 years. Sixty per cent had ‘Deficiency’, 20.7% ‘Insufficiency’ and 18.9% ‘Sufficiency’. We found a negative correlation between age and vitamin D level (p &lt; 0.001). We didn’t find differences in vitamin D levels between genres. Nine specialties requested 98% of the assays, namely Nephrology (56.2%). We found differences between specialties based on age and vitamin D level (p &lt; 0.001). Vitamin D levels changed throughout the year, with higher levels in the summer, followed by autumn, spring and winter (p &lt; 0.001). Despite this seasonal fluctuation, vitamin D sufficiency was only present in a minority of assays (27.8% in summer and 9.2% in winter).<br /><strong>Discussion:</strong> Vitamin D deficiency is prevalent in this population, affects individuals of all ages and is not offset by the seasonal variation of sunlight.<br /><strong>Conclusion:</strong> Vitamin D deficiency is a real and prevalent problem in our population that needs further attention and action, given its clinical implications.

Are there associations between early emotional trauma and anxiety disorders? Evidence from a systematic literature review and meta-analysis

BACKGROUND

Previous studies indicate a possible association between early emotional trauma (EET) and the development of anxiety disorders (ADs) in adult life. However, no previous studies have compiled the findings of such studies and analyzed their statistical significance. Therefore, the objective of this study was to conduct a systematic literature review and meta-analysis to determine possible associations between EET and three ADs (panic, generalized anxiety, and social anxiety disorders).

METHODS

A systematic search was conducted in PubMed, PsycInfo, and Scielo with no publication date limitations. A total of 2127 studies were found, 32 studies of which were selected for the systematic review and 13 studies of which were selected for the meta-analysis.

RESULTS

High prevalence rates of different EETs were observed among the individuals with ADs (median: 18%-45%). The results of the meta-analysis indicated that individuals with EETs were 1.9- to 3.6-fold more likely to develop ADs compared with a control group of healthy individuals. Emotional traumas were the main risk factor for social anxiety disorder. However, no specific associations were found for the other ADs.

CONCLUSIONS

EET is a risk factor for ADs, underscoring the importance of preventive measures to combat the development of these disorders. Moreover, the identification of EETs among patients with ADs is essential for implementing remedial measures to minimize the impact and damage arising from this association by decreasing the risk and severity of symptoms and to improve the response rate to treatment of ADs.

A high pressure x-ray photoelectron spectroscopy study of CO oxidation over Rh(100)

We have studied the oxidation of CO over Rh(100) using high pressure x-ray photoelectron spectroscopy under CO and O2 pressures ranging from 0.01 to 1 mbar. The results show a very low or no conversion for the CO covered surface found at low temperatures, while the activity rises slightly when the temperature is high enough for some CO to desorb, exposing surface sites for dissociative O2 adsorption. As the temperature is increased further, more CO desorbs and oxygen replaces CO as the dominating species at the surface. At the same time we find a sudden increase in the reactivity, such that all CO that reaches the surface is instantly transformed into CO2. We find that the O coverage in the active state is highly dependent on the total pressure and, although we do not detect any presence of a surface oxide as in previous surface x-ray diffraction studies, the highest O coverage indicates that the surface is close to being oxidized.

Verbal definitions of familiar objects in blind children reflect their peculiar perceptual experience

BACKGROUND

The aim of the present study was to examine to what extent the verbal definitions of familiar objects produced by blind children reflect their peculiar perceptual experience and, in consequence, differ from those produced by sighted children.

METHODS

Ninety-six visually impaired children, aged between 6 and 14 years, and 32 age-matched sighted children had to define 10 words denoting concrete animate or inanimate familiar objects.

RESULTS

The blind children evoked the tactile and auditory characteristics of objects and expressed personal perceptual experiences in their definitions. The sighted children relied on visual perception, and produced more visually oriented verbalism. In contrast, no differences were observed between children in their propensity to include functional attributes in their verbal definitions.

CONCLUSIONS

The results are discussed in line with embodied views of cognition that postulate mandatory perceptuomotor processing of words during access to their meaning.

Outcome and quality of life in patients with postoperative delirium during an ICU stay following major surgery

Introduction

Delirium is an acute disturbance of consciousness and cognition that has been shown to be associated with poor outcomes, including increased mortality. We aimed to evaluate outcome after postoperative delirium in a cohort of surgical intensive care unit (SICU) patients.

Methods

This prospective study was conducted over a 10-month period in a SICU. Postoperative delirium was diagnosed in accordance with the Intensive Care Delirium Screening Checklist (ICDSC). The primary outcome was mortality at 6-month follow-up. Hospital mortality and becoming dependent were considered as secondary outcomes, on the basis of the evaluation of the patient’s ability to undertake both personal and instrumental activities of daily living (ADL) before surgery and 6 months after discharge from the SICU. For each dichotomous outcome - hospital mortality, mortality at 6-month follow-up, and becoming dependent - a separate multiple logistic regression analysis was performed, which included delirium as an independent variable. Another outcome analyzed was changes in health-related quality of life, as determined using short-form 36 (SF-36), which was administered before and 6 months after discharge from the SICU. Additionally, for each SF-36 domain, a separate multiple linear regression model was used for each SF-36 domain, with changes in the SF-36 domain as a dependent variable and delirium as an independent variable.

Results

Of 775 SICU-admitted adults, 562 were enrolled in the study, of which 89 (16%) experienced postoperative delirium. Delirium was an independent risk factor for mortality at the 6-month follow-up (OR = 2.562, P <0.001) and also for hospital mortality (OR = 2.673, P <0.001). Delirium was also an independent risk factor for becoming dependent for personal ADL (P-ADL) after SICU discharge (OR = 2.188, P <0.046). Moreover, patients who experienced postoperative delirium showed a greater decline in SF-36 domains after discharge, particularly in physical function, vitality, and social function, as compared to patients without postoperative delirium.

Conclusions

Postoperative delirium was an independent risk factor for 6-month follow-up mortality, hospital mortality, and becoming independent in P-ADL after SICU discharge. It was also significantly associated with a worsening in the quality of life after surgery.