Scielo RSS <![CDATA[Archives of Endocrinology and Metabolism]]> http://www.scielo.br/rss.php?pid=2359-399720180004&lang= vol. 62 num. 4 lang. <![CDATA[SciELO Logo]]> http://www.scielo.br/img/en/fbpelogp.gif http://www.scielo.br <![CDATA[Region-specific reference intervals for TSH in pregnancy: time for changes in Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400383&lng=&nrm=iso&tlng= <![CDATA[Recent recommendations from ATA guidelines to define the upper reference range for serum TSH in the first trimester match reference ranges for pregnant women in Rio de Janeiro]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400386&lng=&nrm=iso&tlng= ABSTRACT Objectives: American Thyroid Association (ATA)'s new guidelines recommend use of population-based trimester-specific reference range (RR) for thyrotropin (TSH) in pregnancy. The aim of this study was to determine first trimester TSH RR for a population of pregnant women in Rio de Janeiro State. Subjects and methods: Two hundred and seventy pregnant women without thyroid illness, defined by National Academy of Clinical Biochemistry, and normal iodine status were included in this sectional study. This reference group (RG) had normal median urinary iodine concentration (UIC = 219 μg/L) and negative anti-thyroperoxidase antibodies (TPOAb). Twin pregnancy, trophoblastic disease and use of drugs or supplements that influence thyroid function were excluded. In a second step, we defined a more selective reference group (SRG, n = 170) by excluding patients with thyroiditis pattern on thyroid ultrasound and positive anti-thyroglobulin antibodies. This group also had normal median UIC. At a final step, a more selective reference group (MSRG, n = 130) was defined by excluding any pregnant women with UIC &lt; 150 μg/L. Results: In the RG, median, 2.5th and 97.5th percentiles of TSH were 1.3, 0.1, and 4.4 mIU/L, respectively. The mean age was 270 ± 5.0 and the mean body mass index was 25.6 ± 5.2 kg/m2. In the SRG and MSRG, 2.5th and 975th percentiles were 0.06 and 4.0 (SRG) and 0.1 and 3.6 mIU/L (MSRG), respectively. Conclusions: In the population studied,TSH upper limit in the first trimester of pregnancy was above 2.5 mIU/L. The value of 3.6 mIU/L, found when iodine deficiency and thyroiditis (defined by antibodies and ultrasound characteristics) were excluded, matches recent ATA guidelines. <![CDATA[The effect of levothyroxine treatment on left ventricular function in subclinical hypothyroidism]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400392&lng=&nrm=iso&tlng= ABSTRACT Objective: Treatment of subclinical hypothyroidism (ScH), especially the mild form of ScH, is controversial because thyroid hormones influence cardiac function. We investigate left ventricular systolic and diastolic function in ScH and evaluate the effect of 5-month levothyroxine treatment. Subjects and methods: Fifty-four patients with newly diagnosed mild ScH (4.2 &lt;TSH &lt; 10.0 mU/L) and 30 euthyroid subjects matched by age were analysed. Laboratory analyses and an echocardiography study were done at the first visit and after 5 months in euthyroid stage in patients with ScH. Results: Compared to healthy controls, patients with ScH had a lower E/A ratio (1.03 ± 0.29 vs. 1.26 ± 0.36, p &lt; 0.01), higher E/e' sep. ratio (762 ± 2.29 vs. 6.04 ± 1.64, p &lt; 0.01), higher myocardial performance index (MPI) (0.47 ± 0.08 vs. 0.43 ± 0.07, p &lt; 0.05), lower global longitudinal strain (GLS) (-19.5 ± 2.3 vs. −20.9 ± 1.7%, p &lt; 0.05), and lower S wave derived by tissue Doppler imaging (0.077 ± 0.013 vs. 0.092 ± 0.011 m/s, p &lt; 0.01). Levothyroxine treatment in patients with ScH contributed to higher EF (62.9 ± 3.9 vs. 61.6 ± 4.4%, p &lt; 0.05), lower E/e' sep. ratio (6.60 ± 2.06 vs. 762 ± 2.29, p &lt; 0.01), lower MPI (0.43 ± 0.07 vs. 0.47 ± 0.08%, p &lt; 0.01), and improved GLS (-20.07 ± 2.7 vs. −19.55 ± 2.3%, p &lt; 0.05) compared to values in ScH patients at baseline. Furthermore, in all study populations (ScH patients before and after levothyroxine therapy and controls), TSH levels significantly negatively correlated with EF (r = −0.15, p &lt; 0.05), E/A (r = −0.14, p &lt; 0.05), GLS (r = −0.26, p &lt; 0.001), and S/TDI (r = −0.22, p &lt; 0.01) and positively correlated with E/e' sep. (r = 0.14, p &lt; 0.05). Conclusion: Patients with subclinical hypothyroidism versus healthy individuals had subtle changes in certain parameters that indicate involvement of systolic and diastolic function of the left ventricle. Although the values of the parameters were in normal range, they were significantly different compared to ScH and the control group at baseline, as well as to the ScH groups before and after treatment.The results of our study suggest that patients with ScH must be followed up during treatment to assess improvement of the disease. Some of the echocardiography obtained parameters were reversible after levothyroxine therapy. <![CDATA[Association of serum thyrotropin levels with coronary artery disease documented by quantitative coronary angiography: a transversal study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400410&lng=&nrm=iso&tlng= ABSTRACT Objective: The association between coronary artery disease (CAD) and thyroid function remains controversial. We evaluated the thyroid function and graduated well-defined CAD as confirmed by quantitative coronary angiography (CA). Subjects and methods: We evaluated the serum TSH, free thyroxine, free triiodothyronine and thyroid antibody levels in 300 consecutive patients (age 61.6 ± 9.9 years and 54% were male) undergoing CAD diagnosis as confirmed by CA. Plaques with ≥ 50% stenosis being indicative of obstructive CAD, and patients were divided into groups according to main epicardial coronary arteries with plaques (0, 1, 2, 3). Lipid profiles and a homeostasis model assessment (HOMA-IR) were determined. Results: Serum median (25% and 75% percentile) TSH levels in patients with group 2 and 3 (2.25; 1.66-3.12 mU/L and 4.99; 4.38-23.60 mU/L, respectively) had significantly higher TSH concentrations (p &lt; 0.0001) than the group 0 (1.82; 1.35-2.51 mU/L). Furthermore, patients of group 3 had higher TSH concentration (p &lt; 0.0001) than those of group 1 (1.60; 0.89-2.68 mU/L). Group 3 were older (64 ± 8.5 vs. 59 ± 9.5, p = 0.001), had more patients with dyslipidemia (84% versus 58%, p &lt; 0.001), male (54% versus 44%, p = 0.01), hypertension (100% versus 86%, p &lt; 0.001), and smoking (61% versus 33%, p &lt; 0.001) than group 0. Multivariate stepwise logistic analysis showed TSH, age, HbA1c, and HOMA-IR were the CAD associated variables. Conclusions: In this cohort, elevated TSH levels in the high normal range or above are associated with the presence and severity of CAD besides may represent a weak CAD risk factor. <![CDATA[Waist circumference measurement sites and their association with visceral and subcutaneous fat and cardiometabolic abnormalities]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400416&lng=&nrm=iso&tlng= ABSTRACT Objectives: To estimate the degree of variability of the waist circumference (WC) when obtained in different anatomical sites and compare the performance of the measurement sites as predictors of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) and cardiometabolic abnormalities. Subjects and methods: Cross-sectional study involving 119 individuals with overweight (50.3 ± 12.2 years), in which six WC measurement sites were evaluated (minimal waist, immediately below the lowest rib, midpoint between the lowest rib and the iliac crest, 2 cm above the umbilicus, immediately above the iliac crest, umbilicus level), in addition to the VAT and SAT (quantified by computed tomography) and cardiometabolic parameters. Results: The differences between the measurements ranged from 0.2 ± 2.7 cm to 6.9 ± 6.7 cm for men, and from 0.1 ± 3.7 cm to 10.1 ± 4.3 cm for women. The minimum waist showed significant correlation with VAT (r = 0.70) and with a higher number of cardiometabolic parameters among men. Regarding women, the WC measurement showed high correlation with SAT and moderate correlation with VAT, not being found superiority of one measurement protocol in relation to the others when assessed the correlation with VAT and with cardiometabolic parameters. Conclusions: Greater variability between the measuring sites was observed among women. With respect to men, the minimum waist performed better as a predictor of VAT and cardiometabolic alterations. <![CDATA[Dapagliflozin versus saxagliptin as add-on therapy in patients with type 2 diabetes inadequately controlled with metformin]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400424&lng=&nrm=iso&tlng= ABSTRACT Objective: This analysis compared the efficacy and safety of the sodium-glucose cotransporter-2 (SGLT2) inhibitor, dapagliflozin, and the dipeptidyl peptidase-4 (DPP4) inhibitor, saxagliptin, both added on to metformin. Materials and methods: This was a post-hoc analysis from a double-blind, randomized, 24-week clinical trial (NCT01606007) of patients with type 2 diabetes (T2D) inadequately controlled with metformin. We compared the dapagliflozin 10 mg (n = 179) and saxagliptin 5 mg (n = 176) treatment arms. Results: Dapagliflozin showed significantly greater mean reductions versus saxagliptin in HbA1c (difference versus saxagliptin [95% CI]: −0.32% [-0.54, −0.10]; p &lt; 0.005), fasting plasma glucose (-0.98 [-1.42, −0.54] mmol/L; p &lt; 0.0001), body weight (-2.39 [-3.08, −1.71] kg; p &lt; 0.0001) and systolic blood pressure (SBP) (-3.89 [-6.15, −1.63] mmHg; p &lt; 0.001). More dapagliflozintreated than saxagliptin-treated patients achieved the composite endpoint of HbA1c reduction ≥ 0.5%, weight loss ≥ 2 kg, SBP reduction ≥ 2 mmHg and no major/minor hypoglycemia (24% versus 7%). No major events of hypoglycemia were reported. More patients on dapagliflozin (6%) versus saxagliptin (0.6%) experienced genital infections. Conclusion: Dapagliflozin demonstrated greater glycemic efficacy than saxagliptin with additional benefits on weight and SBP, and the safety profile was consistent with previous studies. <![CDATA[Lean mass as a determinant of bone mineral density of proximal femur in postmenopausal women]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400431&lng=&nrm=iso&tlng= ABSTRACT Objective: To verify which component of body composition (BC) has greater influence on postmenopausal women bone mineral density (BMD). Subjects and methods: Four hundred and thirty women undergoing treatment for osteoporosis and 513 untreated women, except for calcium and vitamin D. Multiple linear regression analysis was performed in order to correlated BMD at lumbar spine (LS), total femur (FT), femoral neck (FN) with body mass (BM), total lean mass (LM) and total fat mass (FM), all determined by DXA. Results: BM significantly correlated with all bone sites in untreated and treated women (r = 0.420 vs 0.277 at LS; r = 0.490 vs 0.418 at FN, r = 0.496 vs 0.414 at FT, respectively). In untreated women, the LM correlated better than FM with all sites, explaining 179% of LS; 32.3% of FN and 30.2% of FT; whereas FM explained 13.2% of LS; 277% of FN, 23.4% of FT In treated women, correlations with BC were less relevant, with the LM explaining 6.7% of BMD at LS; 15.2% of FN, 16% of FT, whereas the FM explained 8.1% of LS; 179% of FN and 176% of FT. Conclusion: LM in untreated women was better predictor of BMD than FM, especialy for distal femur, where it explained more than 30% of the BMD, suggesting that maintaining a healthy muscle mass may contribute to decrease osteoporosis risk. Treatment with anti-osteoporotic drugs seems to mask these relationships. Arch Endocrinol Metab. 2018;62(4):431-7 <![CDATA[Combination therapy of curcumin and alendronate modulates bone turnover markers and enhances bone mineral density in postmenopausal women with osteoporosis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400438&lng=&nrm=iso&tlng= ABSTRACT Objective: This study evaluated the effects of combination therapy of curcumin and alendronate on BMD and bone turnover markers in postmenopausal women with osteoporosis. Subjects and methods: In a randomized, double-blind trial study, 60 postmenopausal women were divided into three groups: control, alendronate, and alendronate + curcumin. Each group included 20 patients. Total body, total hip, lumbar spine and femoral neck BMDs were measured by dual-energy X-ray absorptiometry (DXA) at baseline and after 12 months of therapy. Bone turnover markers such as bone-specific alkaline phosphatase (BALP), osteocalcin and C-terminal cross-linking telopeptide of type I collagen (CTx) were measured at the outset and 6 months later. Results: Patients in the control group suffered a significant decrease in BMD and increased bone turnover markers at the end of study. The group treated with only alendronate showed significantly decreased levels of BALP and CTx and increased levels of osteocalcin compared to the control group. The alendronate group also showed significant increases in the total body, total hip, lumbar spine and femoral neck BMDs at the end of study compared to the control group. In the curcumin + alendronate group, BALP and CTx levels decreased and osteocalcin levels increased significantly at the end of study compared to the control and alendronate groups. BMD indexes also increased in four areas significantly at the end of study compared to the control and alendronate groups. Conclusion: The combination of curcumin and alendronate has beneficial effects on BMD and bone turnover markers among postmenopausal women with osteoporosis. Arch Endocrinol Metab. 2018;62(4):438-45 <![CDATA[Association between undercarboxylated osteocalcin, bone mineral density, and metabolic parameters in postmenopausal women]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400446&lng=&nrm=iso&tlng= ABSTRACT Objective: Osteocalcin has been associated with several effects on energy and glucose metabolism. However, the physiological role of undercarboxylated osteocalcin (U-osc; the hormonally active isoform of osteocalcin) is still controversial. To correlate the serum levels of U-osc with bone mineral density (BMD) values and metabolic parameters in postmenopausal women. Subjects and methods: Cross-sectional study including 105 postmenopausal women (age 56.5 ± 6.1 years, body mass index [BMI] 28.2 ± 4.9 kg/m2) grouped based on the presence of three or less, four, or five criteria of metabolic syndrome according to the International Diabetes Federation (IDF). The subjects underwent dualenergy x-ray absorptiometry (DXA) for the assessment of body composition and BMD and blood tests for the measurement of U-osc and bone-specific alkaline phosphatase (BSAP) levels. Results: The mean U-osc level was 3.1 ± 3.4 ng/mL (median 2.3 ng/mL, range 0.0-18.4 ng/mL) and the mean BSAP level was 12.9 ± 4.0 ng/mL (median 12.1 ng/mL, range 73-24.4 ng/mL). There were no associations between U-osc and BSAP levels with serum metabolic parameters. Lower fasting glucose levels were observed in participants with increased values of U-osc/femoral BMD ratio (3.61 ± 4 ng/mL versus 10.2 ± 1.6 ng/mL, p = 0.036). When the participants were stratified into tertiles according to the U-osc/ femoral BMD and U-osc/lumbar BMD ratios, lower fasting glucose levels correlated with increased ratios (p = 0.029 and p = 0.042, respectively). Conclusion: Based on the ratio of U-osc to BMD, our study demonstrated an association between U-osc and glucose metabolism. However, no association was observed between U-osc and metabolic parameters.The U-osc/BMD ratio is an innovative way to correct the U-osc value for bone mass. <![CDATA[Low serum 25-hydroxy vitamin D levels are associated with aggressive breast cancer variants and poor prognostic factors in patients with breast carcinoma]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400452&lng=&nrm=iso&tlng= ABSTRACT Objective: This study was conducted to assess the serum 25-hydroxy (OH) vitamin D levels in patients with breast cancer compared to healthy controls and to identify its association with aggressive breast cancer phenotypes. Materials and methods: Serum 25-OH vitamin D levels of 78 breast cancer patients and 78 matched healthy controls were estimated using ELISA. The cases and controls were matched with respect to age, menopausal status, parity, weight, height and co-morbidities. Prognostic factors like grade of tumour, hormone receptor status, HER2 neu status and lymphovascular invasion were compared with 25-OH vitamin D levels. Results: The mean serum 25-OH vitamin D levels of cases were significantly lower compared to the controls (22.33 ± 8.19 vs. 37.41 ± 12.9 ng/mL; p = 0.0001). Patients with higher grades of tumour, non-luminal types of breast cancer and breast cancers with estrogen receptor negativity had significantly lower serum 25-OH vitamin D levels than their opposing groups. Patients with excellent and good Nottingham's prognostic Index (NPI) had significantly higher serum 25-OH vitamin D levels than the moderate and poor NPI groups. Conclusion: Newly diagnosed breast cancer patients have significantly lower serum 25-OH vitamin D levels than healthy controls. Lower level of serum 25-OH vitamin D correlates with aggressive breast cancer phenotypes. <![CDATA[Hounsfield unit value has null effect on thyroid nodules at <sup>18</sup>F-FDG PET/CT scans]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400460&lng=&nrm=iso&tlng= ABSTRACT Objectives: Detection rate of thyroid nodules is increasing with the use of new imaging modalities, especially in screening for malignancies. Positron emission tomography/computed tomography (PET/ CT)-positive thyroid nodules should be differentiated for malignancy to avoid unnecessary operations and further follow-up. Most trials evaluate the role of SUVmax, but there is no definitive information about the utility of Hounsfield unit (HU) values for prediction of malignancy. This study aimed to evaluate the HU values beside SUVmax for detecting malignancy risk of PET/CT-positive thyroid nodules. Subjects and methods: Results of 98 cancer patients who had fine needle aspiration biopsy (FNAB) for thyroid nodules detected on PET/CT between January 2011 and December 2015 were assessed. The FNABs and surgical pathological results were recorded. Results: FNABs revealed benign results in 32 patients (32.7%), malignant in 18 (18.4%), non-diagnostic in 20 (20.4%), and indeterminate in 28 (28.5%). Twenty-four patients underwent thyroidectomy. The mean HU values were not significantly different in benign and malignant nodules (p = 0.73). However, the mean SUVmax was significantly higher (p &lt; 0.001) in malignant ones. Area under curve (AUC) was 0.824 for SUVmax; the cut-off value was over 5.55 (p &lt; 0.001), with 80% sensitivity, 84.5% specificity. Conclusions: Our current study demonstrated that HU value does not add any additional valuable information for discriminating between malignant and benign thyroid nodules. We also defined a SUV cut-off value of 5.55 for malignant potential of thyroid nodules detected on PET/CT Arch Endocrinol Metab. 2018;62(4):460-5 <![CDATA[Mutation screening in the genes <em>PAX-8, NKX2-5, TSH-R, HES-1</em> in cohort of 63 Brazilian children with thyroid dysgenesis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400466&lng=&nrm=iso&tlng= ABSTRACT Objective: To evaluate the candidate genes PAX-8, NKX2-5, TSH-R and HES-1 in 63 confirmed cases of thyroid dysgenesis. Subjects and methods: Characterization of patients with congenital hypothyroidism into specific subtypes of thyroid dysgenesis with hormone levels (TT4 and TSH), thyroid ultrasound and scintigraphy. DNA was extracted from peripheral blood leukocytes and the genetic analysis was realized by investigating the presence of mutations in the transcription factor genes involved in thyroid development. Results: No mutations were detected in any of the candidate genes. In situ thyroid gland represented 71.1% of all cases of permanent primary congenital hypothyroidism, followed by hypoplasia (9.6%), ectopia (78%), hemiagenesis (6.0%) and agenesis (5.5%). The highest neonatal screening TSH levels were in the agenesis group (p &lt; 0.001). Conclusions: Thyroid dysgenesis is possibly a polygenic disorder and epigenetic factors could to be implicated in these pathogeneses. <![CDATA[A brief review about melatonin, a pineal hormone]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400472&lng=&nrm=iso&tlng= ABSTRACT Melatonin is a ubiquitous molecule in nature, being locally synthesized in several cells and tissues, besides being a hormone that is centrally produced in the pineal gland of vertebrates, particularly in mammals. Its pineal synthesis is timed by the suprachiasmatic nucleus, that is synchronized to the light-dark cycle via the retinohypothalamic tract, placing melatonin synthesis at night, provided its dark. This unique trait turns melatonin into an internal synchronizer that adequately times the organism's physiology to the daily and seasonal demands. Besides being amphiphilic, melatonin presents specific mechanisms and ways of action devoted to its role as a time-giving agent, being widely spread in the organism. The present review aims to focus on melatonin as a pineal hormone with specific mechanisms and ways of action, besides presenting the clinical syndromes related to its synthesis and/or function disruptions. <![CDATA[The low-density lipoprotein receptor-related protein 5 <em>(LRP5) 4037C>T</em> polymorphism: candidate for susceptibility to type 1 diabetes mellitus]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400480&lng=&nrm=iso&tlng= ABSTRACT Objective: The present study has investigated the association between low-density lipoprotein receptor-related protein 5 (LRP5) 4037C&gt;T polymorphism and type 1 diabetes mellitus (T1DM) susceptibility in a Brazilian population. Subjects and methods: A total number of 134 T1DM patients and 180 normoglycemic individuals (NG) aged 6-20 years were studied. Glycated hemoglobin and glucose levels were determined. Genotyping of LRP5 4037C&gt;T (rs3736228) was performed. Results: T1DM patients showed poor glycemic control. Genotypes in the codominant (CT: OR = 2.99 [CI 95%: 1.71-5.24], p &lt; 0.001; TT: OR = 5.34 [CI 95%: 1.05-2702], p &lt; 0.001), dominant (CT + TT: OR = 3.16 [CI 95%: 1.84-5.43], p &lt; 0.001) and log-additive (OR = 2.78 [CI 95%: 1.70-4.52], p &lt; 0.001) models, and LRP5 4037T allele (OR = 2.88, [CI 95%: 1.78-4.77], p &lt; 0.001) were associated with an increased risk of developing T1DM. LRP5 4037CT and CT+TT carriers in T1DM group showed higher concentrations of serum glucose and glycated hemoglobin when compared with CC carriers. Conclusion: The LRP5 4037C&gt;T may represent a candidate for T1DM susceptibility, as well as poor glycemic control. <![CDATA[Type 1 diabetes mellitus: can coaching improve health outcomes?]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2359-39972018000400485&lng=&nrm=iso&tlng= ABSTRACT Objective: To evaluate the introduction of coaching in the interdisciplinary care of individuals with type 1 diabetes mellitus in the public health care system. Subjects and methods: Ten patients routinely attending a public health care service and with a glycated hemoglobin (HbA1c) level above 75% participated in eight coaching sessions. This study evaluated the patients' self-management of the disease and personal behavior. The participants were assessed at the beginning of the program and on two occasions after the intervention, with evaluation of biochemical and anthropometric data, and frequency of self-monitoring of blood glucose (SMBG). Questionnaires were applied during these evaluations to analyze emotional burden (B-PAID), medication adherence (Morisky Adherence Scale), and self-efficacy (IMDSES). Results HbA1c had a median level of 8.0% (range 76-10.3%) at the beginning of the study and reduced significantly 3 months after initiation of the intervention (7.78% [6.5-10%], p = 0.028), with no significant increase at 6 months (8.3% [713-9.27%], p = 0.386). SMBG improved significantly from the beginning to the end of the study, with the median number of glucose tests per week varying from 16.5 (range 0-42) at baseline to 29.0 (7-42) at 3 months and 27.5 (10-48) at 6 months (p = 0.047). No significant differences were observed in anthropometric parameters or in the scores of the instruments between the three measurements. Conclusion: A coaching intervention focused on patients' values and sense of purpose may provide added benefit to traditional diabetes education programs and could be an auxiliary method to help individuals with type 1 diabetes achieve their treatment goals.