ABSTRACT Objective: Diabetes mellitus (DM) has a high healthcare system cost worldwide. Educational strategies are important to improve self-care and control this disease. This study aimed to evaluate satisfaction and clinical efficacy of a Short Message Service (SMS) educational intervention in self-care and nutrition at a Brazilian university hospital. Materials and methods: We conducted a trial of educational intervention and assigned eligible patients with DM to either receive weekly educational SMS for 6 months (intervention group [IG]) or no SMS at all (control group). A satisfaction questionnaire was applied before and after the intervention in both groups. Laboratory (fasting glucose, hemoglobin [Hb] A1c, total cholesterol, triglycerides, high-density lipoprotein, and low-density lipoprotein) and clinical (blood pressure) data were also collected. Data were analyzed using nonparametric tests with the Statistical Package for the Social Sciences. Results: We included 128 patients (64 in each group). Responses to the satisfaction questionnaire with self-care and healthcare professionals from 112 patients revealed an improvement in the perception of receiving information regarding helpful eating habits and in healthy eating behavior and an improvement in satisfaction with their diabetes care in the IG. In the post-intervention period, improved systolic blood pressure and HbA1c levels were observed in the IG as illustrated by delta % (post-intervention minus pre-intervention data divided by pre-intervention data multiplied by 100) reductions of 2.3% and 3.9%, respectively Conclusion: SMS intervention was useful as an educational tool for improving satisfaction and glycemic and blood pressure control of patients with DM observed at a Brazilian university hospital.

OBJETIVO: Avaliar o metabolismo da glicose em pacientes acromegálicos antes e após o tratamento com octreotide LAR. PACIENTES E MÉTODOS: Este foi um estudo longitudinal e prospectivo com 30 pacientes do ambulatório de pesquisa em acromegalia do Serviço de Endocrinologia do Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro (HUCFF/UFRJ). Eles foram submetidos à avaliação clínica e laboratorial com dosagens de hormônio do crescimento (GH), fator de crescimento semelhante à insulina tipo I (IGF-I), insulina, pró-insulina, peptídeo C, hemoglobina glicosilada (HbA1c), proteína de ligação do IGF tipo 1 (IGFBP-1) e a um teste oral de tolerância à glicose (TOTG), antes e após seis meses de tratamento com octreotide LAR. Foi aplicado o teste dos postos sinalizados de Wilcoxon e o critério de determinação de significância adotado foi o nível de 5%. RESULTADOS: Encontraram-se 16 pacientes (54%) com tolerância normal à glicose, sete (23%) com intolerância à glicose e sete (23%) com diabetes melito (DM). Doze pacientes completaram os seis meses de tratamento, sendo que houve piora da tolerância à glicose em três e piora do controle glicêmico dos dois pacientes diabéticos. Houve aumento da circunferência abdominal (p = 0,03) e queda do GH (p = 0,04), % IGF-I acima do limite superior do valor de referência (%LSVR) (p = 0,001), insulina (p = 0,019), peptídeo C (p = 0,002) e do modelo de avaliação homeostática (HOMA-IR) (p = 0,039). CONCLUSÕES: Nesta série, o tratamento com octreotide LAR acarretou piora da tolerância à glicose em três pacientes não-diabéticos e piora do controle glicêmico em dois diabéticos, apesar da diminuição da resistência insulínica (RI).

AIM OF THE STUDY: To evaluate the glucose metabolism in acromegalic patients before and after treatment with octreotide LAR. PATIENTS AND METHODS: This was a prospective and longitudinal study involving 30 patients from the acromegaly research outpatient clinic of the Endocrinology unit of the HUCFF/UFRJ. They underwent clinical and laboratorial evaluations, with measurements of growth hormone (GH), insulin-like growth factor type I (IGF-I), insulin, proinsulin, C peptide, glycosylated hemoglobin (HbA1c), IGF binding protein type 1 (IGFBP-1) and glucose, during oral glucose tolerance test (OGTT), before and after six months of treatment with octreotide LAR. The Wilcoxon signed-rank test was used and values of 5% were considered statistically significant. RESULTS: We found 16 (54%) patients with normal glucose tolerance, 7 (23%) with impaired glucose tolerance and 7 (23%) diabetics. Twelve patients completed the six-month treatment, out of which three showed worsening of glucose tolerance and two (diabetics) had worse blood glucose control. Whereas there was an increase in waist circumference (p=0.03), there was a decrease in GH (p=0.04), with %IGF-I above the upper limit of reference values (% ULRV) [p=0.001], insulin (p=0.019), C peptide levels (p=0.002) and homeostatic model assessment (HOMA-IR) [p=0.039]. CONCLUSIONS: In this series, treatment with octreotide LAR led to a worsening of glucose tolerance in three non-diabetic patients and worsened glycemic control in two diabetics, in spite of reducing insulin resistance.

A acromegalia é uma doença sistêmica com diversas etiologias. A grande maioria dos casos se manifesta de forma esporádica, e uma minoria tem transmissão familiar. Além disso, a acromegalia pode ser acompanhada de várias complicações como alterações endócrinas, cardiovasculares, respiratórias, metabólicas, osteoarticulares e neoplásicas que devem ser consideradas quando a estratégia de tratamento for estabelecida. O acompanhamento dos pacientes requer reavaliações periódicas do status das complicações. Neste artigo serão abordados os aspectos etiológicos e o manejo da acromegalia.

Acromegaly is a systemic disease with various etiologies. It can occur as a sporadic or, more rarely, as a familial disease. Numerous complications such as endocrine, cardiovascular, respiratory, metabolic, osteoarticular and neoplastic disturbances occur and must be taken into account when establishing a therapeutic strategy. For this reason, the decision as to a treatment modality of acromegaly must be followed by a thorough evaluation of the patient and once the diagnosis of complications is settled, adequate treatment should be instituted. Follow up of the patients requires periodical re-assessment of complications’ status.

Os análogos da somatostatina são muito utilizados no tratamento da acromegalia. Com o objetivo de determinar o valor do teste agudo (TA) com octreotide subcutâneo (SC) como preditor da resposta ao tratamento com octreotide LAR®, analisamos os dados de 20 pacientes. Para o TA, amostras de sangue foram colhidas antes e duas horas após a administração de octreotide SC para a dosagem de GH. Os níveis de GH antes e após o TA foram 21,9 (2,3-143,4) e 3,1ng/mL (0,3-61,3), respectivamente. Foi considerado controle de doença: GH< 2,5ng/mL e IGF-I normal em algum momento durante o tratamento. A sensibilidade, especificidade e os valores preditivos positivo e negativo do TA foram 0,9, 0,6, 0,69 e 0,86 para redução de 75% do GH no teste. Concluímos que, em nossa casuística, um decréscimo de 75% dos níveis de GH no TA teve um bom poder discriminatório entre pacientes com maior e menor chance de resposta ao tratamento.

Somatostatin analogues are frequently used to treat acromegaly. To determine the value of the acute test (AT) with subcutaneous (SC) octreotide as a predictor of the response to treatment with octreotide LAR®, we analyzed data from 20 patients. For the AT, blood was drawn before and two hours after the SC administration of octreotide for measuring GH. GH levels before and after the AT were 21.9ng/mL (2.3-143.4) and 3.1ng/mL (0.3-61.3), respectively. Control of the disease was defined as: GH< 2.5ng/mL and normal IGF-I anytime during treatment. Sensitivity, specificity, positive and negative predictive values of the AT were 0.9, 0.6, 0.69 and 0.86 for a reduction of 75% of the GH on the test. From our sample we conclude that a 75% reduction of the GH levels during the acute test was able to discriminate patients with a higher or lower chance of responding to treatment.

A fim de avaliar a incidência, comportamento, evolução clínica e determinação de possíveis fatores preditivos da associação entre carcinoma de tireóide (CT) e Doença de Graves (DG), analisamos os prontuários de todos os pacientes submetidos à tireoidectomia para tratamento definitivo de DG em 2 hospitais universitários, entre 01/79 e 11/02. Dos 341 pacientes identificados, o exame histológico das peças cirúrgicas revelou CT em 7 (2,1%). A idade dos pacientes do grupo sem CT variou de 13 a 79 anos (mediana: 34) e naqueles com CT variou de 19 a 50 anos (mediana: 29), sem diferença significativa entre os grupos. Havia 293 mulheres (87,7%) e 41 homens (12,3%) no grupo sem CT e 5 mulheres (71,5%) e 2 homens (28,5%) no grupo com CT. O tipo histológico presente em todos os casos foi carcinoma papilífero de tireóide (CPT), sendo um caso de CPT multicêntrico sem acometimento extra-tireoidiano, 2 casos de variante folicular com 8 e 25mm de diâmetro, sem invasão capsular, um caso de CPT clássico com 15mm de diâmetro e nos 3 restantes, microcarcinoma (<10mm de diâmetro). O acompanhamento dos pacientes variou de 6 a 16 anos, e nenhum apresentou recorrência local da doença, ou metástases à distância. Nesta casuística, a incidência de CT em pacientes operados por DG foi concordante com dados da literatura. Não observamos agressividade maior do que a usual, talvez pela grande freqüência de carcinomas ocultos.

To evaluate the incidence, behavior, clinical outcome and identify possible predictive factors of the association between thyroid cancer (TC) and Graves’ disease (GD), we reviewed the records from all patients submitted to thyroidectomy for treatment of GD between 01/79 and 11/02 from 2 university hospitals. Histology of the excised specimens identified TC in 7 of the 341 patients (2.1%). In the group with TC, age varied from 19 to 50 years (median: 29) and in those without TC, from 13 to 79 years (median: 34), which were not significantly different. There were 293 women (87.7%) and 41 men (12.3%) in the non-TC group and 5 women (71.5%) and 2 men (28.5%) in the TC group. By histology, all 7 cases of TC were papillary thyroid carcinoma (PTC): one with a multicentric PTC without extra-thyroidal involvement, two with the follicular variant of PTC (with 8 and 25mm diameter) but no capsular involvement, one with classic PTC (with 15mm diameter), and the remaining 3 with microcarcinomas (<10mm). Patients were followed from 6 to 16 years and none had local recurrence or distant metastasis. Our data showed an incidence of TC in patients submitted to surgery for GD concordant with those previously reported. Tumors were not more aggressive than usual, probably because of the high frequency of occult microcarcinomas.

Resistência insulínica imunológica é uma entidade reconhecida na prática clínica há muitos anos. Sua patogênese está relacionada ao aparecimento de anticorpos anti-insulina, e o tratamento baseia-se em imunossupressão. Apresentamos aqui o caso de uma paciente de 33 anos, com diagnóstico de diabetes desde a infância, que referia uso de hipoglicemiantes orais durante a adolescência. Durante o acompanhamento em nosso serviço, a dose de insulina foi progressivamente reduzida até ser substituída por hipoglicemiantes orais. Permaneceu 11 meses com esquema de glibenclamida, metformina e acarbose até ser internada em coma hiperosmolar não-cetótico. Após internação prolongada, recebeu alta usando insulina NPH, sendo necessário o aumento da dose nos meses subseqüentes. Quando atingiu a dose de 2,7U/Kg/dia, foi investigada e excluída a possibilidade de diabetes secundário, sendo diagnosticada resistência insulínica imunológica. Foram tentados diversos esquemas imunossupressores sem sucesso. A paciente está atualmente em uso de bomba de infusão subcutânea de insulina Lispro, micofenolato mofetil e prednisona com melhora do controle glicêmico.

Immunologic insulin resistance is an entity recognized in the clinical practice for many years. Its pathogenesis is related to the presence of anti-insulin antibodies and treatment is based upon immunossuppression. We hereby present a case of a 33-year-old patient with the diagnosis of diabetes since the childhood that reported using oral hypoglicemic drugs during adolescence. During follow up, the insulin dose was gradually reduced until she was switched to oral hypoglicemic agents. She remained for 11 months in a regimen of glyburide, metformin and acarbose when she was admitted in a hyperosmolar non-ketotic coma. At discharge she was using insulin NPH and in the following months the dose needed to be gradually increased, as she remained hyperglycemic, until we reached 2.7U/Kg/day. Secondary diabetes was investigated and discarded, and she was diagnosed with immunologic insulin resistance. Several immunossuppressive regimens were tried with disappointing results. She is actually using a continuous subcutaneous infusion pump with insulin lispro, micophenolate mophetil and prednisone with improving glycemic control.

Avaliamos a influência da gordura corporal (GC) determinada por bioimpedância, índice de massa corpórea (IMC) e a medida da cintura abdominal (CA) em determinadas variáveis clínicas e laboratoriais em 43 pacientes com diabetes tipo 2 (DM2), 26F/17M, pareados pela idade, com 13,6±9,1 anos de duração do DM. As mulheres apresentaram maior IMC: 30,3±5,4 vs. 26,9±2,9kg/m² (p= 0,04), GC: 35,4±6,2 vs. 19,6±6,2% (p= 0,000), níveis de colesterol total (CT): 235±41 vs. 204± 39mg/dL (p= 0,017), triglicerídeos (TG): 146± 61 vs. 116±57mg/dL (p= 0,06) e HbA1c (HPLC): 7,1±1,7 vs. 6,9±1,4% (p= 0,02) do que os homens, não havendo diferença entre HDL e LDL colesterol. A GC correlacionou-se significativamente com os níveis de TG, HbA1c, pressão arterial diastólica (PAD), IMC e CA. Na regressão múltipla com GC, CA e IMC como variáveis independentes e TG (r= 0,34; r²= 0,11; p= 0,02) e PAD (r= 0,39; r²= 0,15; p= 0,008) como dependentes, a GC foi a variável independente significativa. No mesmo modelo com a HBA1c como variável dependente, a GC (r= 0,31; r²= 0,10; p= 0,037) e o IMC (r= 0,43; r²= 0,19; p= 0,01) foram as variáveis significativas. Concluímos que o aumento da GC no paciente com DM2 constituiu um importante fator de risco para piora do controle metabólico e dos níveis tensionais. As mulheres, por terem tido maior percentual de GC e níveis de lipídios, devem ter uma abordagem mais agressiva e diferenciada para sua redução.

We evaluate the relationship between body adiposity (BA) by bioelectrical impedance, body mass index (BMI) and waist circumference (WC) in some clinical and laboratorial parameters in 43 patients with type 2 diabetes (DM2), 26F/17M, matched for age, with a DM duration of 13.6±9.1 years. Women had greater BMI: 30.3±5.4 vs. 26.9±3.0kg/m² (p= 0.04), BA: 35.4±6.2 vs. 19.6±6.2% (p= 0,000), cholesterol: 235± 41 vs. 204±39mg/dL (p= 0,017), triglycerides (TG): 146±61 vs. 116± 57mg/dL (p= 0.06) and HbA1c (HPLC): 7.1±1.7 vs. 6.9±1.4% (p= 0,02) than men, but HDL and LDL cholesterol were not different. When correlated to BA, the following variables were statistically significant: TG, HbA1c, diastolic blood pressure (DBP) and WC. In the stepwise multiple regression analysis using BA, WC and BMI as independent variables and TG (r= 0.34; r²= 0.11; p= 0.02) and DBP (r= 0.39; r²= 0.15; p= 0.008) as the dependent ones, BA was found to be statistically significant. By using the same model having HbA1c as the dependent variable, BA (r= 0.31; r²= 0.10; p= 0.037) and BMI (r= 0.43; r²= 0.19; p= 0.01) became significant. In conclusion, elevated BA in patients with DM2 is an important risk factor to worse metabolic control and blood pressure levels. Women, by virtue of their greater BA and worst plasma lipid profile must need more aggressive intervention to reduce body fat.