Leandro Arthur Diehl

Scopus Publications

A serious game prototype for education of medical doctors and students on insulin management for treatment of diabetes mellitus
Leandro A. Diehl, Eldon Lehmann, Rodrigo M. Souza, Juliano B. Alves, Roberto Z. Esteves, Pedro A. Gordan
2011 IEEE 1st International Conference on Serious Games and Applications for Health Segah 2011, 2011
This paper describes the construction of a serious game prototype for training doctors and medical students about insulin management for the treatment of diabetes mellitus (DM). There are a few simulators that are educationally useful for this aim, but they are little attractive for the user, so we intend to create a tool that includes game elements to make it more fun and appealing. A series of hypothetical, clinical cases with increasing complexity are used to develop a minimum curriculum for training, incorporating all the principal aspects of insulin therapy for DM in the context of primary health care. We chose to develop an Adventure game, based on a minimum curriculum of contents about insulin management. The game presents a series of clinical scenarios and asks the players to make decisions about the best diagnostic and therapeutic options for each case. After each decision, the players receive feedback, comparing their decisions with the recommendations from the best-quality medical literature, and have access to additional educational resources (texts, algorithms, links to guidelines).
Increased levothyroxine requirement in a woman with previously well-controlled hypothyroidism and intestinal giardiasis
Rafael de Figueiredo Radaeli, Leandro Arthur Diehl
Arquivos Brasileiros De Endocrinologia E Metabologia, 2011
The most common cause of apparent inefficiency or resistance to oral therapy with levothyroxine for hypothyroidism is nonadhesion. However, in some subjects in whom the control of hypothyroidism is extremely difficult, levothyroxine bioavailability defects should be considered. We report here the case of a 57-year-old woman with hypothyroidism that was well-controlled for the previous 6 years but suddenly presented with poor hormonal control and abdominal symptoms, despite repeatedly reporting good compliance to therapy. Adequate control of thyroid function was only obtained after intestinal giardiasis was diagnosed and treated.
Radioiodine plus recombinant human thyrotropin do not cause acute airway compression and are effective in reducing multinodular goiter
C.C. Albino, H. Graf, G. Paz-Filho, L.A. Diehl, M. Olandoski, A. Sabbag, C. Buchpiguel
Brazilian Journal of Medical and Biological Research, 2010
Recombinant human thyrotropin (rhTSH) reduces the activity of radioiodine required to treat multinodular goiter (MNG), but acute airway compression can be a life-threatening complication. In this prospective, randomized, double-blind, placebo-controlled study, we assessed the efficacy and safety (including airway compression) of different doses of rhTSH associated with a fixed activity of 131I for treating MNG. Euthyroid patients with MNG (69.3 +/- 62.0 mL, 20 females, 2 males, 64 +/- 7 years) received 0.1 mg (group I, N = 8) or 0.01 mg (group II, N = 6) rhTSH or placebo (group III, N = 8), 24 h before 1.11 GBq 131I. Radioactive iodine uptake was determined at baseline and 24 h after rhTSH and thyroid volume (TV, baseline and 6 and 12 months after treatment) and tracheal cross-sectional area (TCA, baseline and 2, 7, 180, and 360 days after rhTSH) were determined by magnetic resonance; antithyroid antibodies and thyroid hormones were determined at frequent intervals. After 6 months, TV decreased significantly in groups I (28.5 +/- 17.6%) and II (21.6 +/- 17.8%), but not in group III (2.7 +/- 15.3%). After 12 months, TV decreased significantly in groups I (36.7 +/- 18.1%) and II (37.4 +/- 27.1%), but not in group III (19.0 +/- 24.3%). No significant changes in TCA were observed. T3 and free T4 increased transiently during the first month. After 12 months, 7 patients were hypothyroid (N = 3 in group I and N = 2 in groups II and III). rhTSH plus a 1.11-GBq fixed 131I activity did not cause acute or chronic changes in TCA. After 6 and 12 months, TV reduction was more pronounced among patients treated with rhTSH plus 131I.
Management of Graves' orbitopathy in Latin America: An international questionnaire study compared with Europe
Helton E. Ramos, Leandro A. Diehl, Cleber P. Camacho, Petros Perros, Hans Graf, and
Clinical Endocrinology, 2008
SummaryContext Management of Graves’ orbitopathy (GO) and dysthyroid optic neuropathy (DON) continues to be challenging. Other surveys have been successful in elucidating trends in GO management. Knowledge of current practice by members of the Latin American Thyroid Society (LATS) who manage patients with GO was targeted by distribution of a questionnaire. We compared our results with a previously reported European Thyroid Association (ETA) survey.Objectives To determine how endocrinologists in Latin America access and treat patients with GO and compare the results with the same European survey.Results One hundred and two responders representing endocrinologists from 10 countries participated in the survey. Most (57%) participate in a multidisciplinary setting for GO management. Access to a surgeon for orbital decompression was available only ‘within months’ according to 48·3% of responders. Despite suspected DON, 32·4% were reluctant to recommend urgent referral to an eyecare physician. Steroids were preferred as the first‐option therapy by 88·2% of responders (by intravenous route by 57·8% of these). The presence of diabetes reduced the use of steroids to 64·7% (P < 0·001) and increased the use of other immunosuppressive agents (from 1% to 9·8%, P < 0·01). Development of cushingoid features resulted in a reduction in steroid use to 40·2% (P < 0·001), with increased preference for irradiation (from 23·5% to 52·9%, P < 0·001) and nonsteroidal immunosuppressive drugs (from 1% to 10·8%, P < 0·01), along with a nonsignificant trend to higher indication of orbital surgery (from 24·5% to 34·3%).Conclusion Some potential deficiencies in the diagnosis and management of DON and hyperthyroidism were observed in our survey, highlighting the need for improvement in specialist education and the quality of care offered to patients with GO in Latin America.
Metformin increases HDL3-cholesterol and decreases subcutaneous truncal fat in nondiabetic patients with HIV-associated lipodystrophy
Leandro A. Diehl, Bruno A. Fabris, Décio S Barbosa, Eliana C. De Faria, Susana L. Wiechmann, Alexandre J.F. Carrilho
AIDS Patient Care and Stds, 2008
The purpose of this study was to assess metformin effects on high-density lipoprotein (HDL) composition of patients with HIV-associated lipodystrophy (LDHIV). Twenty-four adult outpatients were enrolled to receive metformin (1700 mg/d) during 6 months, but 2 were lost to follow-up and 6 stopped the drug due to adverse events (gastrointestinal in 5, and excessive weight loss in 1). From the 16 subjects who completed the study, 69% were female. At baseline, 3 and 6 months, we assessed: weight, waist and hip circumferences, blood pressure, fasting glucose and insulin, homeostasis model assessment of insulin resistance (HOMA2-IR), lipids, and HDL subfractions by microultracentrifugation. At 0 and 6 months, body fat distribution was assessed by computed tomography (CT) scan (L4 and middle femur). Metformin use was associated with reduction of mean weight (-2.4Kg at 6 months; p < 0.001), body mass index, waist, waist-to-hip ratio and a marked decrease in blood pressure (p < 0.001). Subcutaneous (p = 0.01) and total abdominal fat (p = 0.002) were reduced, but no change was found in visceral or thigh fat. No difference was detected on plasma glucose, insulin, HOMA2-IR, cholesterol or triglycerides, except for an increase in HDL3–cholesterol (from 21 mg/dL to 24 mg/dL, p = 0.002) and a reduction of nascent HDL (the fraction of plasma HDL-cholesterol not associated to subfractions HDL2 or HDL3) (p = 0.008). Adverse effects were very common, but most were gastrointestinal and mild. Thus, metformin use in LDHIV increases HDL3–cholesterol (probably due to improved maturation of HDL) and decreases blood pressure, weight, waist, and subcutaneous truncal fat, making this an attractive option for preventing cardiovascular disease in this population.
Prevalence of HIV-associated lipodystrophy in Brazilian outpatients: Relation with metabolic syndrome and cardiovascular risk factors
Leandro A. Diehl, Janaína R. Dias, Aline C. S. Paes, Maria C. Thomazini, Lorena R. Garcia, Eduardo Cinagawa, Susana L. Wiechmann, Alexandre J. F. Carrilho
Arquivos Brasileiros De Endocrinologia E Metabologia, 2008
A lipodistrofia associada ao HIV (LAHIV) acomete 40% a 50% dos pacientes infectados pelo vírus, mas sua prevalência no Brasil é desconhecida. O objetivo deste trabalho foi avaliar a prevalência de LAHIV entre adultos brasileiros infectados, bem como sua relação com fatores de risco cardiovascular e síndrome metabólica (SM). Foram avaliados 180 pacientes maiores de 18 anos, infectados por HIV, atendidos no Ambulatório de Infectologia da Universidade Estadual de Londrina. Por meio de entrevista e revisão de prontuário, foram avaliados dados antropométricos, pressão arterial, antecedentes mórbidos pessoais e familiares, duração da infecção por HIV e da aids, drogas anti-retrovirais utilizadas, CD4+, carga viral, glicemia e perfil lipídico. A LAHIV foi definida como a presença de alterações corporais percebidas pelo próprio paciente e confirmadas ao exame clínico. A SM foi diagnosticada usando os critérios do Adult Treatment Panel III (NCEP-ATPIII), revistos e atualizados pela American Heart Association (AHA/NHLBI). A prevalência observada de LAHIV foi de 55%. Os pacientes com LAHIV apresentaram maior duração da infecção por HIV, da aids e do uso de anti-retrovirais. Na análise multivariada, estiveram independentemente associados ao risco de LAHIV: sexo feminino (p = 0,006) e duração da aids > 8 anos (p < 0,001). Quanto aos critérios para SM, hipertensão foi detectada em 32%, baixo HDL-colesterol em 68%, hipertrigliceridemia em 55%, cintura aumentada em 17% e glicemia aumentada e/ou diabetes em 23% dos indivíduos. A cintura aumentada e a hipertrigliceridemia foram mais comuns em portadores de LAHIV. A SM foi identificada em 36% dos pacientes. Na análise multivariada, estiveram associados à SM: IMC > 25 kg/m² (p < 0,001), história familiar de obesidade (p = 0,01), uso de indinavir (p = 0,001) e idade > 40 anos no diagnóstico do HIV (p = 0,002). A LAHIV apresentou tendência a ser mais comum em portadores de SM (65% versus 50%, p = 0,051). A prevalência de LAHIV que se observou neste grupo (55%) foi similar à descrita em estudos prévios de outros países. A prevalência de SM nestes pacientes parece ser diferente da descrita em adultos brasileiros não-infectados pelo HIV.
Octreotide-LAR-associated erythema multiforme in an acromegalic subject: Case report
Leda R. Cavalin, Maria L. de Oliveira, Leandro A. Diehl
Arquivos Brasileiros De Endocrinologia E Metabologia, 2008
Long-acting somatostatin analogs are often used for treating acromegaly, either as adjuvant to surgery or radiotherapy or, more recently, as a primary therapeutic option. These drugs seem to be reasonably safe, but new adverse effects not yet described may occur during the use of the relatively new long-acting formulations. In this case report, we describe a severe cutaneous reaction (erythema multiforme) in a patient treated with long-acting release (LAR) octreotide, and also discuss the need of previous "testing" with short subcutaneous preparation of octreotide.
Management of amiodarone-induced thyrotoxicosis in Latin America: An electronic survey
Leandro Arthur Diehl, João Hamilton Romaldini, Hans Graf, Luigi Bartalena, Enio Martino, Claudio Cordeiro Albino, Wilmar M. Wiersinga
Clinical Endocrinology, 2006
SummaryObjective To assess diagnostic and therapeutic approaches to amiodarone‐induced thyrotoxicosis (AIT) among members of the Latin American Thyroid Society (LATS).Methods LATS members responded to an online questionnaire that presented an index case (a 62‐year‐old man on amiodarone, with thyrotoxic symptoms and a nodular goitre) and a variant (same patient, no goitre).Results About 25% of invited members responded to the questionnaire. Most respondents lived in iodine‐sufficient areas and observed that amiodarone‐induced hypothyroidism (AIH) is more common than AIT. Nearly all assessed TSH, and the most used combination of tests was TSH and free T4 (37%). Thyroid autoimmunity was assessed by about 90%. Interleukin‐6 (IL‐6) was useful to 80%. Additional tests ordered for the index case were: radioactive iodine uptake (RAIU; 57%), echo‐colour Doppler sonography (ECDS; about 50%) and fine‐needle aspiration biopsy (FNAB; 44%). For the variant, ECDS and RAIU were judged unhelpful by 16%. Most defined the index case as type I AIT and the variant as type II AIT, but 16% in LATS suggested a mixed form in the index case. As initial treatment, nearly all used thionamides in the index case [with potassium perchlorate (KClO4) in one‐third], while glucocorticoids were indicated to the variant by 66%. Only about 5% considered amiodarone withdrawal unnecessary. If initial strategy is ineffective in type I AIT, KClO4(half) or glucocorticoids (a third) are added; in type II, glucocorticoids are indicated by most. Once euthyroidism is restored, ablative therapy is prescribed by a third of respondents for type I AIT.Conclusions There are several points of disagreement among thyroidologists regarding AIT management, mainly in the radiological evaluation and the approach to the already stabilized patient if amiodarone needs to be restarted.
Management of the nontoxic multinodular goiter in Latin America: Comparison with North America and Europe, an electronic survey
Leandro Arthur Diehl, Valdinei Garcia, Steen J. Bonnema, Laszlo Hegedüs, Claudio Cordeiro Albino, Hans Graf
Journal of Clinical Endocrinology and Metabolism, 2005
To assess diagnostic and therapeutic approaches to nontoxic multinodular goiter and to compare them with previously reported American Thyroid Association (ATA) and European Thyroid Association (ETA) surveys, an online questionnaire was distributed to Latin American Thyroid Society (LATS) members. An index case was presented (42-yr-old woman with an enlarged, irregular, nontender, 50- to 80-g thyroid and no clinical suspicion of malignancy or dysfunction), and 11 variations were proposed to evaluate how each alteration would affect management. We obtained 148 responses (response rate, 50%). In the index case, the most used blood tests were TSH (96%), antithyroid peroxidase antibodies (76%), and free T(4) (64%); 5% included a calcitonin assay. Nearly 90% would perform ultrasound, and only 16% used scintigraphy. Fine needle biopsy was indicated by 88%, with ultrasound guidance in 75% of times. For treatment, observation was preferred by 39%, surgery by 28%, levothyroxine by 21%, and radioiodine by 7% (60% with recombinant TSH prestimulation). A suppressed TSH level prompted 45% of the respondents to recommend radioiodine, whereas 70-78% indicated surgery in the presence of a large goiter or suspicion of malignancy. In conclusion, no consensus exists concerning the ideal management of nontoxic goiter among LATS members, in agreement with previous ATA and ETA surveys. Levothyroxine therapy is less used by LATS than by ATA or ETA members, and a more aggressive therapeutic strategy is generally preferred by members of LATS and ETA compared with ATA.
Prevalence of thyroid autoimmunity in a group of patients with type 1 diabetes mellitus in Londrina, PR
Otton Luis Raffo Souza, Leandro Arthur Diehl, Lineu Domingos Carleto Jr., Valdinei Garcia, Alexandre José F. Carrilho, Maria Leocádia de Oliveira, Henriqueta G.G. de Almeida
Arquivos Brasileiros De Endocrinologia E Metabologia, 2005
A auto-imunidade tireoidiana é uma co-morbidade freqüente entre pacientes com diabetes mellitus tipo 1 (DM1). Neste estudo, avaliamos a prevalência da positividade para auto-anticorpos anti-tireoidianos (anti-microssomal, anti-Tg e anti-TPO), bem como características clínicas (idade, sexo, duração do DM) e laboratoriais (função tireoidiana, HbA1) de 101 pacientes (idade média de 20 ± 9,6 anos; 62 do sexo feminino) com DM atendidos no HC/UEL. RESULTADOS: A presença de auto-anticorpos foi detectada em 31 pacientes (30,7%). No grupo com idade <12 anos, a prevalência de anticorpos foi de 15%; entre 12-18 anos, 32%, e >18 anos, 35,7% (p= 0,22). Entre os 31 pacientes com anticorpos positivos, 40% apresentava alguma disfunção tireoidiana, comparados a apenas 4,4% daqueles sem anticorpos (p<0,001). O TSH médio foi maior no grupo com anticorpos presentes (3,75 vs. 2,32µU/mL; p= 0,01). CONCLUSÃO: A prevalência da positividade para anticorpos marcadores de tireoidite auto-imune foi de em 30,7%, compatível com a literatura.

Leandro Arthur Diehl

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Scopus Publications