Cristiane de Freitas Cunha

Randomised controlled trial of growth effect of hydrocortisone in congenital adrenal hyperplasia

The influence of 15 or 25 mg/m2 of daily oral hydrocortisone with fludrocortisone 0.1 mg/day on growth and laboratory findings was evaluated in a prospective randomised crossover trial over 12 months in 26 children with 21-hydroxylase deficiency. Nine non-salt losers had fludrocortisone stopped for a further six month period. Height velocity was significantly decreased during treatment with 25 mg/m2 as compared with 15 mg/m2. This was the most sensitive indicator of corticosteroid treatment excess. A dose dependent effect upon plasma concentrations of 17-hydroxyprogesterone, testosterone, and androstenedione was found but increased values were still detected in more than half of the determinations made during the 25 mg/m2 period. Height velocity and 17-hydroxyprogesterone concentrations were positively correlated. Growth hormone response to clonidine stimulation and insulin-like growth factor-1 concentrations were both within reference values and there was no difference between treatment periods. Withdrawal of fludrocortisone did not result in any difference for the non-salt losers. It was concluded that 25 mg/m2 of hydrocortisone depressed growth in children with congenital adrenal hyperplasia, and that full suppression, or even normalisation, of plasma concentrations of 17-hydroxyprogesterone and androgens should not be considered a treatment goal, but instead an indication of corticosteroid treatment excess.

Congenital generalized lipodystrophy

OBJETIVO: Apresentar as principais caracteristicas clinicas e bioquimicas da lipodistrofia generalizada congenita, desordem rara e pouco conhecida dos pediatras. DESCRICAO: Nos ambulatorios de Doencas Nutricionais e de Endocrinologia do Servico de Pediatria do Hospital das Clinicas da UFMG, foram identificados oito pacientes com lipodistrofia generalizada congenita. As caracteristicas clinicas comuns a todos os casos foram hipertrofia muscular, lipoatrofia generalizada e aparencia acromegalica. Manifestacoes clinico-laboratoriais associadas incluiram acantose nigricans em cinco pacientes, hepatoesplenomegalia em seis, hipertrigliceridemia com baixas concentracoes de HDL em sete, hipertrofia cardiaca em um e diabetes melito secundario em dois pacientes. Todos os pacientes estao em controle clinico e dietetico, visando a correcao ou prevencao dos disturbios metabolicos. COMENTARIOS: As caracteristicas fenotipicas da lipodistrofia generalizada congenita sao bem identificadas, possibilitando o diagnostico clinico na maioria dos casos. Trata-se de uma sindrome rara que ilustra a importância do funcionamento normal do tecido adiposo para a maioria dos processos metabolicos vitais do organismo. O seu melhor conhecimento podera abrir novos horizontes em estudos de doencas mais prevalentes como o diabetes melito e a obesidade.

Avaliação da recuperação do eixo hipotalâmico-hipofisário-adrenal após corticoterapia por meio do cortisol basal

The glucocorticoid-induced inhibition that occurs after discontinuation of treatment is the most frequent cause of adrenal insufficiency. There are yet some doubts about the best way of evaluating the hypothalamic-pituitary-adrenal (HPA) axis in those patients. The main objective of this study was to evaluate the utility of basal cortisol in diagnosing adrenal insufficiency. Thirty-five children with acute lymphoid leukemia (ALL) receiving glucocorticoid therapy (median age of 6.9 years) were evaluated. A stimulus test with corticotropin releasing hormone (CRH-1 mcg/kg) was performed before the introduction of dexamethasone (6 mg/m2/day, for 28 days), in the 8th and the 28th days of glucocorticoid therapy, and 48 hours and one month after discontinuation of therapy. Suppression of the basal secretion as well as the maximum concentration of cortisol (post-CRH) occurred during glucocorticoid therapy, which persisted for 48 hours after the steroid was removed from treatment (p< 0.01 and p< 0.0001, respectively, for the three tests). One month after ceasing the administration of the glucocorticoid, the basal secretion, as well as the maximum concentration of cortisol, were similar to that before glucocorticoid therapy. There was a positive and statistically significant correlation between basal secretion and maximum concentration of cortisol in all tests. We observed 95% of specificity for the diagnosis of adrenal insufficiency when the inferior limit of basal cortisol was 8.5 mcg/dl. According to these results we concluded that basal secretion of cortisol is a good marker of supra-renal function in evaluating children after discontinuation of glucocorticoid therapy.

ERICA: patterns of alcohol consumption in Brazilian adolescents

ABSTRACT OBJECTIVE To describe the patterns of alcohol consumption in Brazilian adolescents. METHODS We investigated adolescents who participated in the Study of Cardiovascular Risks in Adolescents (ERICA). This is a cross-sectional, national and school-based study, which surveyed adolescents of 1,247 schools from 124 Brazilian municipalities. Participants answered a self-administered questionnaire with a section on alcoholic beverages consumption. Measures of relative frequency (prevalence), and their 95% confidence intervals, were estimated for the following variables: use of alcohol beverages in the last 30 days, frequency of use, number of glasses or doses consumed in the period, age of the first use of alcohol, and most consumed type of drink. Data were estimated for country and macro-region, sex, and age group. The module survey of the Stata program was used for data analysis of complex sample. RESULTS We evaluated 74,589 adolescents, who accounted for 72.9% of eligible students. About 1/5 of adolescents consumed alcohol at least once in the last 30 days and about 2/3 in one or two occasions during this period. Among the adolescents who consumed alcoholic beverages, 24.1% drank it for the first time before being 12 years old, and the most common type of alcoholic beverages consumed by them were drinks based on vodka, rum or tequila, and beer. CONCLUSIONS There is a high prevalence of alcohol consumption among adolescents, as well as their early onset of alcohol use. We also identified a possible change in the preferred type of alcoholic beverages compared with previous research.

ERICA: prevalence of common mental disorders in Brazilian adolescents

ABSTRACT OBJECTIVE To describe the prevalence of common mental disorders in Brazilian adolescent students, according to geographical macro-regions, school type, sex, and age. METHODS We evaluated 74,589 adolescents who participated in the Cardiovascular Risk Study in Adolescents (ERICA), a cross-sectional, national, school-based study conducted in 2013-2014 in cities with more than 100,000 inhabitants. A self-administered questionnaire and an electronic data collector were employed. The presence of common mental disorders was assessed using the General Health Questionnaire (GHQ-12). We estimated prevalence and 95% confidence intervals of common mental disorders by sex, age, and school type, in Brazil and in the macro-regions, considering the sample design. RESULTS The prevalence of common mental disorders was of 30.0% (95%CI 29.2-30.8), being higher among girls (38.4%; 95%CI 37.1-39.7) when compared to boys (21.6%; 95%CI 20.5-22.8), and among adolescents who were from 15 to 17 years old (33.6%; 95%CI 32.2-35.0) compared to those aged between 12 and 14 years (26.7%; 95%CI 25.8-27.6). The prevalence of common mental disorders increased with age for both sexes, always higher in girls (ranging from 28.1% at 12 years to 44.1% at 17 years) than in boys (ranging from 18.5% at 12 years to 27.7% at 17 years). We did not observe any significant difference by macro-region or school type. Stratified analyses showed higher prevalence of common mental disorders among girls aged from 15 to 17 years of private schools in the North region (53.1; 95%CI 46.8-59.4). CONCLUSIONS The high prevalence of common mental disorders among adolescents and the fact that the symptoms are often vague mean these disorders are not so easily identified by school administrators or even by health services. The results of this study can help the proposition of more specific prevention and control measures, focused on highest risk subgroups.

Ritmo de crescimento de crianças com hiperplasia congênita da supra-renal em tratamento com baixas doses de hidrocortisona

We evaluated linear growth of 27 children with congenital adrenal hyperplasia (CAH) treated with low doses of oral hydrocortisone. They were followed-up during 6.1 +/- 1.8 years with daily hydrocortisone doses of 10.84 +/- 2.0 mg/m2 and 0.1 mg fludrocortisone (24 of them). Twenty-three were female. Mean chronological age (CA) was 6.1 +/- 2.9 years and bone age (BA) 6.9 +/- 3.3 (r = 0.66) at the beginning of the study. Five children showed BA advancement > 2 years relating to CA. It was calculated Height SD for CA (SD/H) and for BA (SD/BA) were calculated using NCHS as reference pattern. At the beginning of the study SD/H was -0.8 +/- 1.9 and corresponding SD/BA was -1.5 +/- 2.1; at the end SD/H was -0.17 +/- 1.5 and SD/BA was -1.34 +/- 1.2 (p = 0.02 and p = 0.51, respectively for the beginning and the end). BA changed 1.3 +/- 0.3 per year during this period. Children with advanced BA showed an improvement of SD/BA, from -4.55 +/- 0.9 at from the beginning, -4.55 +/- 0.9 to -2.48 +/- 0.4 at the end of follow-up, -2.48 +/- 0.4 (p = 0.003). The elevated plasma levels of 17-OH Progesterone (17OHP) and androstenedione showed further increase during follow-up. We conclude that children with CAH receiving low doses of hydrocortisone showed adequate growth during the follow-up, without excessive BA advancement, even though full suppression of plasma levels of 17OHP and androgens wasere not achieved.

Disfonia e bulimia: avaliação dos sintomas e sinais vocais e laríngeos

PURPOSE: To describe vocal and laryngeal signs and symptoms in patients with bulimia. METHODS: A blind, descriptive, randomized, transversal study was carried out. Eleven female subjects with the diagnosis of purgative bulimia nervosa and ages ranging from 18 to 34 years underwent otorhinolaryngological and vocal evaluations. RESULTS: The most common vocal and laryngeal symptoms were throat clearing and globus faringeus, related by 10 subjects (90.9%). In the auditory-perceptive evaluation, the most common scores were characterized as light in all analyzed parameters. The accumulation of thick mucus over the larynx occurred in five patients (45.4%), followed by median-posterior triangular glottic chink and mucosal thickening at the interaytenoid region, in four patients (36.3%). CONCLUSION: The laryngeal and perceptual findings were less expressive than vocal and laryngeal complaints.

Risco e Sinthome: A Psicanálise no Sistema Socioeducativo

We intend to discuss the application of psychoanalytic theory to public policies towards delinquent adolescents. We start from a review of adolescence and psychoanalytic practice, especially with young offenders. With a case of a teenager in under socio-educational measure in assisted liberty, two considerations raised about psychoanalysis in this service: the uniqueness of the case against the universal legal regulation, as well as limitations and potential of institutional care. We conclude by the importance of the word and the gathering surplus in the subjective labor of the adolescent and finally, we see the need for actions that forward the effects of interventions. We state that the expected social-political effect of applying an educational measure needs to consider the uniqueness of each teenager, of which his or her subjective position is testimony, delimiting a way of being an exception to the rule and inhabiting the world.

Alteração do perfil de atendimento dos hospitais psiquiátricos públicos de Belo Horizonte, Brasil, no contexto da reforma da assistência à saúde mental

This article seeks to describe the profile of treatment and internment in public psychiatric hospitals in Belo Horizonte, Brazil, from 2002 to 2011. The changes in the characteristics of treatment and the profiles of the patients treated are analyzed in the context of health care reform. It is a study of temporal series with trend analysis by means of linear regression. There was a reduction in the total of patients treated in the period under scrutiny. Inversely, there was an increase in internments with a reduction in length of stay, though no change in readmission rates. Patients from Belo Horizonte prevailed, however a relative increase in demand from the surrounding area was observed. There was a reversal in the prevalence of morbidity switching from psychotic disorders to disorders resulting from the use of alcohol and/or other drugs. The alteration observed in the profile of treatment in public psychiatric hospitals in Belo Horizonte was concomitant with the progressive implementation of community mental health services, which have probably met the demand that was formerly directed to these hospitals. Currently the psychiatric hospital is not the first, much less the only venue for treatment in the mental health network in Minas Gerais.

Resposta Hipofisária-Adrenal ao Teste de Estímulo Com o Hormônio Liberador da Corticotrofina em Crianças Hospitalizadas

Hospitalization and sickness are known as possible interference factors on the neuroendocrine (pituitary-adrenal) response to stimulation tests. To evaluate this response, we studied 11 hospitalized children (mean age: 5.4 ± 3.3 years). The stimuluation test using ovine corticotropin-releasing hormone (CRH; 1 ±g/kg) was performed at 8:00 am. Blood samples were collected at 0, 30, 60, and 90 min after CRH injection, to measure ACTH and cortisol. No adverse effect related to the use of CRH was observed. Basal levels of ACTH and cortisol were high in 3 and 4 children, respectively, probably reflecting the response of HPA axis to stress. The mean basal level of ACTH was 9.9 ± 8.0 pmol/l and its mean maximum concentration was 15.1 ± 11.9 pmol/l (p>0.05). There was no significant difference between the basal and maximun levels. The mean basal level of cortisol was 725.6 ± 264.9 nmol/dl and its mean maximum concentration was significantly higher: 1095.3 ± 479.9 nmol/dl (p<0.05). ACTH peak level preceeded the cortisol peak level. Thus, a large interindividual variation was observed, suggesting that the interference of individual factors and those related to the procedure should be considered in the correct interpretation of the results for the CRH stimulation test.