Cláudia Freitas

Diabetic foot ulcer location is a known independent predictor for cure with a better healing gradient proximal to distal. Although advanced age is one of the main factors associated with greater diabetic foot ulcer severity, there are no studies evaluating diabetic foot ulcer location specifically in the elderly population in an outpatient setting. This study evaluated diabetic foot ulcer location and age-group interactions in diabetic foot presentation. A retrospective cohort study including adult patients with diabetic foot ulcers observed on their first visit to our center's Diabetic Foot Unit in 2018, divided into younger adults (YA) (18 to 64 years) and older adults (OA) (≥65 years). A total of 435 patients were included in the study with 159 (36.6%) in the YA, and 276 (63.4%) in the OA group. Neuro-ischemic diabetic foot ulcers were more frequent in the OA group (71.4% vs 43.4%, p<0.001). The number of patients with a history of diabetic foot ulcers was lower in the OA group (18.1% vs 25.2%, p=0.03). A smaller proportion of forefoot diabetic foot ulcers (74.9% vs 86.2%, p=0.007) and plantar location diabetic foot ulcers (9.4% vs 24.5%, p<0.001) occurred in the OA group. By univariate logistic regression analysis, we found two associations with older age: proximal (odds ratio (OR) 2.09 (1.23-3.53), p=0.006), and non-plantar (OR 3.13 (1.82-5.37), p<0.001) diabetic foot ulcer location. After adjusting for potential confounders in a multivariate analysis, older age lost the association to more proximal (OR 1.72 (0.94-3.15), p=0.081) and non-plantar (OR 1.78 (0.83-3.77), p=0.133) diabetic foot ulcer location. There are essential age differences in diabetic foot ulcer presentation. The OA group more frequently presents neuro-ischemic diabetic foot ulcers with more proximal and non-plantar locations.

Background: Thyroid nodules are a challenge in clinical practice and thyroid ultrasonography is essential for assessing the risk of malignancy. The use of ultrasound-based malignancy risk classification systems has been recommended by several scientific societies but radiologist’s adherence to these guidelines may vary. The authors aimed to analyze the quality of the information provided by the thyroid ultrasound report, to assess the malignancy risk of thyroid nodules, in Portugal. Methods: Multicenter and retrospective study, conducted in three of the five Portuguese NUTS2 corresponding to about 88.3% of the mainland population. We included 344 consecutive unselected participants aged ≥ 18 years who underwent thyroid ultrasonography in 2019. The description of six features of the dominant thyroid nodule was analyzed: maximum size, shape, margins, composition, echogenicity and echogenic foci. A utility score, including these six features, was used as an indicator of the report’s quality. A score of 4 was considered as a minimum value. Results: Maximum diameter was reported for all nodules. Shape, margins, composition, echogenicity and echogenic foci were reported in 8.1%, 25.0%, 76.5%, 53.2% and 20.9%, respectively. Only 21.8% of the nodules had a score ≥ 4. At least one of four suspicious features, including marked hypoechogenicity, microcalcifications, irregular margins and non-oval shape, was identified in 8.7% of the nodules. Cervical lymph nodes’ status was reported in 93% of the exams. The risk category was only reported in 7.8% of the participants. Conclusion: The adherence of Portuguese radiologists to a standardized reporting model and to an ultrasound-based malignancy risk stratification system is still low and has implications for the correct characterization of the malignancy risk of nodules and the decision to perform fine-needle aspiration biopsy.

Introduction: Thyroid-stimulatory antibody (TSAb) assays have been recently optimized, potentially allowing to determine thyrotropin receptor antibodies' (TRAbs) functionality in routine clinical practice. We aimed to determine TSAb's predictive role of relapse at antithyroid drug (ATD) withdrawal in Graves’ disease (GD). Methods: Retrospective study of GD patients with stable normal thyroid function under low ATD doses that were proposed for withdrawal. Thyroid function tests and TRAb and TSAb levels were obtained at ATD suspension and every three to six months after that, for a minimum of 16 months. Clinical factors associated with GD relapse, such as age at diagnosis, sex, smoking status, thyroid volume, and presence of orbitopathy, were also evaluated. Results: Thirty-five patients with GD were included for analysis, with a median follow-up period of 24 months, during which 14 patients (40%) relapsed. Relapse was more common in patients with positive TSAb than patients with negative TSAb at ATD withdrawal (79% vs. 33%, p=0.01). Relapse-free survival was shorter in TSAb-positive patients (p=0.01). There were no differences in relapse rates according to TRAb positivity at ATD withdrawal (42.9% vs. 36.4%, p=0.74). We also did not find any differences in relapse rate regarding age, sex, smoking status, thyroid volume, or presence of Graves’ orbitopathy. On multivariate analysis, only TSAb positivity at ATD withdrawal was independently associated with relapse (hazard ratio [HR] 6.63, 95% confidence interval [CI], 1.30-33.7, p=0.02). Conclusion: At ATD withdrawal, TSAb-positive patients demonstrated a higher risk for GD relapse. Measuring TSAb before ATD suspension, instead of TRAbs, could become an important tool for the clinical management of these patients.

Background: Metabolic syndrome (MS) is a condition associated with obesity that identifies individuals with increased cardiovascular risk. Gastric bypass improves several MS components, such as glucose, lipid metabolism and hypertension. The aim of this study was to evaluate the effect of long-limb gastric bypass on the remission of MS criteria associated with morbid obesity. Methods: Obese patients who met the “harmonized” criteria for MS (n = 153) that underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) with a long biliopancreatic limb were prospectively evaluated with regards to body weight, body mass index (BMI), percentage of excess BMI lost (% EBMIL), fasting glucose, blood pressure and lipid profile up to 36 months after surgery. Results: Before surgery, patients had a BMI of 44.3 ± 0.5 kg/m²; 66% were under anti-diabetic treatment; 78.4% were under anti-hypertensive treatment and 44.3% were under anti-dyslipidemic treatment. After a mean follow-up time of 2.4 ± 0.1 years, MS remission rates were 32.7% at 6 months, 69.7% at 12 months, 63.4% at 24 months, and 59.2% at 36 months; when only 32.9%, 43.4% and 15.8% of patients were still under anti-diabetic, anti-hypertensive and anti-dyslipidemic treatment, respectively. The %EBMIL and BMI were the parameters that showed the highest accuracy to predict the MS remission at all-time points after the surgery. Conclusions: Long limb gastric bypass in obese patients results in significant and sustained weight loss which predicts a high remission rate of MS and allows the discontinuation of drug therapy for several metabolic disturbances in most patients.

ResumoIntroduçãoA diabetes mellitus (DM) é uma patologia com prevalência crescente na população, mas frequentemente subvalorizada em ambiente hospitalar.ObjetivosDeterminar a prevalência da DM num hospital central e caracterizar o perfil glicémico dos doentes de acordo com o diagnóstico principal e tempo de internamento.Material e métodosFoi feita uma avaliação transversal no dia 13/12/2011 nas enfermarias de adultos do CHP, excetuando Obstetrícia. Os doentes com diabetes foram definidos pelo historial/registos clínicos ou pela presunção do diagnóstico (2 valores de glicemia plasmática ≥200mg/dl). O controlo glicémico foi avaliado pelas glicemias capilares mínima e máxima na véspera do estudo, categorizadas em hipoglicemia (<70mg/dl), normoglicemia (70‐179mg/dl) e hiperglicemia (≥180mg/dl). Foi classificado o diagnóstico principal em infeção/não infeção e a duração do internamento até ao dia do estudo em grupos: A 1‐3 dias, B 4‐7 dias, C 8‐14 dias, D 15‐30 dias e E mais de 30 dias.ResultadosEntre 523 doentes avaliados, 145 tinham DM (27,7%), a maioria do tipo 2 (92,4%). Apenas 21,9% dos doentes se encontravam normoglicémicos e o sliding scale foi o tratamento hipoglicémico mais prescrito (49,6%). As glicemias mínimas foram significativamente diferentes entre grupos de tempos de internamento (superiores para o grupo B e progressivamente menores para doentes com internamentos mais prolongados, p=0,002). O grupo com maior tempo de internamento registou maior taxa de insulinização relativamente ao grupo B (57,1 vs. 19,4%, p=0,02). A taxa de insulinização foi menor no grupo «infeção» (p=0,01).Discussão e conclusãoApesar da grande prevalência da diabetes nos doentes internados, apenas uma minoria parece estar bem controlada ou sob um esquema insulínico basal. O pior controlo metabólico e a menor taxa de insulinização ocorreram no final da primeira semana de internamento e em doentes com diagnóstico de infeção. Os autores alertam para a importância do controlo metabólico dos doentes, principalmente em contexto infecioso.AbstractBackgroundDiabetes mellitus (DM) is a growing condition, although frequently underestimated in the hospital setting.AimTo determine the prevalence of DM in a general hospital, as well as the glycemic profile of patients with diabetes according to main diagnosis and length‐of‐stay (LOS).Material and methodsA cross‐sectional analysis was performed in adult wards of CHP except Obstetrics’ on the 13th December 2011. Patients with diabetes were defined by the previous history or clinical registry of DM and; those with 2 or more venous glycemia ≥200mg/dl were also assumed to have DM. Glycemic control was estimated by capillary glycemia in the day before evaluation 2 and categorized in hypoglycemia (<70mg/dl), normoglycemia (70‐179mg/dl) or hyperglycemia (≥180mg/dl). Main diagnosis was categorized in infection/non‐infection and the duration of hospitalization until the study day in groups A:1‐3 days, B:4‐7 days, C:8‐14 days, D:15‐30 days or E:more than 30 days.Results523 patients were analysed, 145 were diabetic (27.7%), mostly type 2. Only 21.9% had normoglycaemic control and most of them were under sliding scale treatment. Comparison between groups showed that mean minimal glycemia was significantly different between them (highest in group B and decreasing from B to E, p=0.002). Group E had higher insulin treatment rate than group B (57.1% vs 19.4%, p=0.02). Patients at the “infection” group were less frequently under basal insulin regimen than the non‐infection one (p=0.01).Discussion and conclusionDespite the high prevalence of diabetes among hospitalized patients, only a minority seemed to be normoglycemic. The worst metabolic control and lowest insulin treatment rate was seen at the end of first week and in those patients at the “infection” category. The authors emphasize the relevance to achieve good inpatient metabolic control, especially in infected subjects

ResumoA elevação isolada da paratormona (PTH) associada a normocalcemia tem surgido em alguns doentes com hiperparatiroidismo primário (HPTP) submetidos a paratiroidectomia com intenção curativa. Vários fatores têm sido associados a essa elevação, nomeadamente o défice de vitamina D, a hipomagnesemia e a insuficiência renal crónica, situações em que a elevação da PTH é encarada num quadro de hiperparatiroidismo secundário. No entanto, a possibilidade da elevação isolada da PTH ser um primeiro sinal de persistência ou recorrência do hiperparatiroidismo primário, inserida em situações de HPTP normocalcémico, também deve ser ponderada. Os autores discutem os fatores etiológicos passíveis de estarem implicados nesta entidade clínica e o seu tratamento, bem como as situações de persistência de elevação de PTH apesar de revertidos os fatores de risco tratáveis e ainda as situações de hiperparatiroidismo primário normocalcémico.AbstractPostoperative elevation of parathyroid hormone (PTH) after parathyroidectomy for primary hyperparathyroidism has been reported in some patients. It may occur just after surgery, being detected in the first postoperative test analysis, or it can appear later on, after a period of time with normal PTH. Several factors have been implicated in the isolated PTH elevation, such as vitamin D or magnesium deficiencies or even chronic renal failure, which represent cases of secondary hyperparathyroidism. However, the possibility of persistent or recurrent primary hyperparathyroidism (including normocalcemic primary hyperparathyroidism) must also be considered. The authors discuss etiological factors which may be associated with elevated PTH and their treatment, as well as cases of persistently elevated PTH despite correction of treatable risk factors. Normocalcemic primary hyperparathyroidism is also discussed

Bariatric surgery has been proposed as the most effective treatment for patients with type 2 diabetes mellitus (T2DM) and body mass index (BMI) above 35 kg/m². The purpose of our study was to access remission rate and improvement of metabolic control of T2DM after gastric bypass. A prospective study was carried out on 94 diabetic patients, who underwent gastric bypass with a 200-cm biliopancreatic limb. Characteristics evaluated included weight, BMI, percentage of excess BMI lost (% EBMIL), fasting glucose, HbA1c, and lipid profile up to 36 months after surgery, as well as anti-diabetic treatment before and after surgery. At the time of surgery, patients had a mean BMI of 44.3 ± 0.65 kg/m² and length of T2DM diagnosis of 6.2 ± 0.98 years and HbA1c of 6.6 ± 0.21%. After a mean time of follow-up of 2.6 ± 0.13 years, the weight loss was significant from 3 months onwards after surgery, reaching its peak at 24 months with a BMI of 32.1 ± 0.9 kg/m² and corresponding % EBMIL of 69.0 ± 2.84%. Remission rates of diabetes were 87.91% at 6 months, 92.68% at 12 months, 92.85% at 24 months, and 100% at 36 months of follow-up. Gastric bypass in obese patients is associated with a high remission rate of diabetes and improvement of the metabolic control. Although confirmation with randomized controlled studies is needed, these results suggest that this type of surgery might be particularly indicated for obese diabetic patients with good pancreatic reserve.