Mauro Antonio Czepielewski

Ultrasonography: Is it useful in the diagnosis of cancer in thyroid nodules?

The role of ultrasonography (US) in the diagnosis of cancer in thyroid nodules is not well-established. The aim of the present study was to evaluate US performance in predicting cancer in thyroid nodules using a novel approach. Two hundred and eighty-nine patients with thyroid nodular disease were evaluated with clinical, biochemical and cytopathological examinations. Eighty patients with palpable solitary thyroid nodules or multinodular goiters who were to undergo surgery were included, and had a US exam performed by one of us. Some US characteristics of thyroid nodules were associated to cancer: absent halo, hypoechogenicity and microcalcifications, with sensitivity, respectively, of 56, 44 and 56%, and specificity of, respectively, 80, 83 and 94%. These findings were considered positive and were studied in two different combinations: simultaneous, when two or more were positive, and parallel, when any positive finding was present. When positive findings were studied simultaneously, sensitivity ranged 25 to 38% and specificity ranged 89 to 97%. Microcalcifications, associated or not to other findings, were highly specific for thyroid cancer, but they were only present in half of the malignancies. When positive findings were studied in parallel, sensitivity ranged 69 to 81% and specificity ranged 70 to 81%. The parallel combination of hypoechogenicity or microcalcifications or absent halo improved US sensitivity to 81% with an acceptable specificity (70%). This method is potentially useful to help us select patients for surgery when fine-needle aspiration biopsy is repetitively non-diagnostic or select for biopsy incidentally discovered non-palpable nodules.

Esteróides anabolizantes no esporte

Anabolic steroids in sports Anabolic androgenic steroids ( AAS) are hormones that include or are derivatives of testosterone. They are produced in the testicles and in the adrenal cortex. AAS pro

Management of the Brain-Dead Organ Donor: A Systematic Review and Meta-Analysis

Background The shortage of organs is a limitation for transplantation, making the care of potential organ donors an important issue. The present systematic review and meta-analysis was carried out to assess the efficacy of interventions to stabilize hemodynamics in brain-dead donors or to improve organ function and outcomes of transplantation. Methods Medline, Embase, and Cochrane databases were searched. Of 5096 articles retrieved, 39 randomized controlled trials were selected. Twenty were included in a qualitative synthesis, providing data on 1277 patients. The main interventions described were desmopressin use, triiodothyronine and methylprednisolone replacement, fluid management, vasopressor therapy, mechanical ventilation strategies, and surgical techniques. Results Three meta-analyses were conducted: the first included two studies and showed that desmopressin administered to brain-dead patients was not advantageous with respect to early organ function in kidney recipients (relative risk, 0.97; 95% confidence interval [CI], 0.85–1.10; I2=0%; P=0.809). The second included four studies and showed that triiodothyronine did not add hemodynamic benefits versus standard management (weighted mean difference, 0.15; 95% CI, −0.13 to 0.42; I2=17.4%; P=0.304). The third meta-analysis (two studies) showed that ischemic liver preconditioning during harvesting procedures did not benefit survival (relative risk, 1.0; 95% CI, 0.93–1.08; I2=0%; P=0.459). Conclusion The present results suggest limited efficacy of interventions focusing on the management of brain-dead donors.

Diagnosis and management of hyperprolactinemia: Results of a Brazilian multicenter study with 1234 patients

Objective: The aim of the study was to evaluate clinical and laboratorial features of 1234 patients with different etiologies of hyperprolactinemia, as well as the response of 388 patients with prolactinomas to dopamine agonists. Design, setting, and patients: A total of 1234 hyperprolactinemic patients from 10 Brazilian endocrine centers were enrolled in this retrospective study. Main outcome measure: PRL measurement, thyroid function tests, and screening for macroprolactin were conducted. Results: Patients were subdivided as follows: 56.2% had prolactinomas, 14.5% drug-induced hyperprolactinemia, 9.3% macroprolactinemia, 6.6% non-functioning pituitary adenomas, 6.3% primary hypothyroidism, 3.6% idiopathic hyperprolactinemia, and 3.2% acromegaly. Clinical manifestations were similar irrespective of the etiology of the hyperprolactinemia. The highest PRL levels were observed in patients with prolactinomas but there was a great overlap in PRL values between all groups. However, PRL>500 ng/ml allowed a clear distinction between prolactinomas and the other etiologies. Cabergoline (CAB) was more effective than bromocriptine (BCR) in normalizing PRL levels (81.9% vs 67.1%, p<0.0001) and in inducing significant tumor shrinkage and complete disappearance of tumor mass. Drug resistance was observed in 10% of patients treated with CAB and in 18.4% of those that used BCR (p=0.0006). Side-effects and intolerance were also more common in BCR-treated patients. Conclusion: Prolactinomas, drug-induced hyperprolactinemia, and macroprolactinemia were the 3 most common causes of hyperprolactinemia. Although PRL levels could not reliably define the etiology of hyperprolactinemia, PRL values >500 ng/ml were exclusively seen in patients with prolactinomas. CAB was significantly more effective than BCR in terms of prolactin normalization, tumor shrinkage, and tolerability.

Prospective Evaluation of Transsphenoidal Pituitary Surgery in 108 Patients with Cushing's Disease

Transsphenoidal pituitary surgery (TSS) remains the treatment of choice for Cushings disease (CD). Despite the widespread acceptance of this procedure as the first line treatment in CD, the indication of a second TSS in not cured or relapsed DC patients is not consensus. We report the results of TSS in 108 patients with CD (a total of 117 surgeries). The mean postoperative follow-up period was 6 years. Remission was defined as clinical and laboratorial signs of adrenal insufficiency, period of glucocorticoid dependence, serum cortisol suppression on oral 1-mg dexamethasone overnight suppression test and clinical remission of hypercortisolism. We evaluated 103 patients with CD by the time of the first TSS. Fourteen patients underwent second TSS (5 had already been operated in others centers; in 5 patients the first surgery was not curative; in 4 patients CD relapsed). Remission rates were 85.4% and 28.6% (p < 0.001) after first and second TSS, respectively. In microadenomas, remission rates were higher than macroadenomas (94.9% vs. 73.9%; p = 0.006). In patients with negative pituitary imaging remission rates were 71.4% (p = 0.003; vs. microadenomas). Postoperative complications were: transient diabetes insipidus, definitive diabetes insipidus, hypopituitarism, stroke and one death. Only hypopituitarism was more frequent after second TSS (p = 0.015). In conclusion, TSS for CD is an effective and safe treatment. The best remission rates were observed at the first surgery and in microadenomas. The low remission rates after a second TSS suggest that this approach could not be a good therapeutic choice when the first one was not curative.O tratamento de escolha para a doenca de Cushing (DC) ainda e a cirurgia transesfenoidal (CTE) para resseccao do adenoma hipofisario produtor de ACTH. Porem, a indicacao de uma segunda CTE representa uma questao controversa, tanto nos pacientes nao curados apos a primeira cirurgia quanto nos casos de recidiva. Neste trabalho, relatamos os resultados da CTE em 108 pacientes com DC (totalizando 117 cirurgias). O tempo medio de seguimento foi de 6 anos. Criterios de cura: ocorrencia de insuficiencia adrenal (clinica ou laboratorial), periodo de dependencia ao glicocorticoide, supressao do cortisol serico pos-1 mg de dexametasona overnight e remissao clinica do hipercortisolismo. Foram avaliados 103 pacientes com DC submetidos a primeira CTE. Quatorze pacientes foram submetidos a uma segunda CTE (5 ja tinham sido operados em outros centros; a primeira cirurgia nao fora curativa em 5; 4 pacientes com recidiva da DC). Indices de cura: 85,4% e 28,6% (p < 0,001) apos a primeira e segunda CTE, respectivamente. Nos microadenomas, remissao maior que nos macroadenomas (94,9% vs. 73,9%; p = 0,006). Nos pacientes com imagem hipofisaria negativa, cura foi de 71,4% (p = 0,003; vs. micro). Complicacoes pos-operatorias: diabetes insipidus transitorio e definitivo, hipopituitarismo, acidente vascular cerebral e um obito. Apenas a ocorrencia de hipopituitarismo foi mais frequente apos a segunda CTE (p = 0,015). Assim sendo, a CTE para a DC representa uma terapeutica efetiva e segura. Os melhores indices de cura foram obtidos na primeira cirurgia e em microadenomas. O baixo indice de cura apos a segunda CTE sugere que esta abordagem nao deve ser considerada uma boa opcao terapeutica quando a primeira cirurgia nao for curativa.

Evaluation of Cushing's disease remission after transsphenoidal surgery based on early serum cortisol dynamics

To evaluate the ability of post‐transsphenoidal pituitary surgery (TSS) serum cortisol levels (s‐cortisol) to predict surgical remission and recurrence of Cushings disease (CD).

Criteria of Cure and Remission in Cushing's Disease: An Update

We review the clinical and biochemical criteria used for evaluation of the transsphenoidal pituitary surgery results in the treatment of Cushings disease (CD). Firstly, we discuss the pathophysiology of the hypothalamic-pituitary-adrenal axis in normal subjects and patients with CD. Considering the series published in the last 25 years, we observed a significant variation in the remission or cure criteria, including the choice of biochemical tests, timing, threshold values to define remission, and the interference of glucocorticoid replacement or previous treatment. In this context we emphasize serum cortisol levels obtained early (from hours to 12 days) in the postoperative period without any glucocorticoid replacement or treatment. Our experience demonstrates that: (i) early cortisol < 5 to 7 microg/dl, (ii) a period of glucocorticoid dependence > 6 mo, (iii) absence of response of cortisol/ACTH to CRH or DDAVP, (iv) return of dexamethasone suppression, and circadian rhythm of cortisol are appropriate indices of remission of CD. In patients with undetectable cortisol levels early after surgery, recurrence seems to be low. Finally, although certain biochemical patterns are more suggestive of remission or surgical failure, none has been proven to be completely accurate, with recurrence observed in approximately 10 to 15% of the patients in long-term follow-up. We recommended that patients with CD should have long-term monitoring of the CRH-ACTH-cortisol axis and associated co-morbidities, especially hypopituitarism, diabetes mellitus, hypertension, cardiovascular disturbances, and osteoporosis.

Effects of oral and transdermal estrogen on IGF1, IGFBP3, IGFBP1, serum lipids, and glucose in patients with hypopituitarism during GH treatment: a randomized study

OBJECTIVE To evaluate the effects of oral estradiol and transdermal 17β-estradiol on serum concentrations of IGF1 and its binding proteins in women with hypopituitarism. DESIGN Prospective, comparative study. METHODS Eleven patients with hypopituitarism were randomly allocated to receive 2 mg oral estradiol (n=6) or 50 μg/day of transdermal 17β-estradiol (n=5) for 3 months. RESULTS The oral estrogen group showed a significant reduction in IGF1 levels (mean: 42.7%±41.4, P=0.046); no difference was observed in the transdermal estrogen group. There was a significant increase in IGFBP1 levels (mean: 170.2%±230.9, P=0.028) in the oral group, but not in the transdermal group. There was no significant difference within either group in terms of median IGFBP3 levels. In relation to lipid profiles, there was a significant increase in mean high-density lipoprotein cholesterol levels in the oral group after 3 months of treatment, (27.8±9.3, P=0.003). We found no differences in the anthropometric measurements, blood pressure, heart rate, glucose, insulin, C-peptide, or the homeostasis model assessment index after treatment. CONCLUSIONS Our preliminary data indicate that different estrogen administration routes can influence IGF1 and IGFBP1 levels. These findings in patients with hypopituitarism have an impact on their response to treatment with GH, since patients receiving oral estrogen require increased GH dosage. These results suggest that oral estrogens may reduce the beneficial effects of GH replacement on fat and protein metabolism, body composition, and quality of life.

Vitamin D deficiency is independently associated with mortality among critically ill patients

OBJECTIVE: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients. METHOD: In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity. RESULTS: Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity. CONCLUSIONS: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients.

Prevalência de lesão adrenal incidental em pacientes submetidos a tomografia computadorizada de tórax e abdome em um hospital geral brasileiro

Prevalence of Adrenal Incidentaloma at Computed Tomography (Chest and Abdominal) in a General Hospital in Brazil. O b j e c t i v e : To prospectively determine the prevalence of incidental adrenal lesions at computed tomography (CT) at an University Hospital in Brazil. Patients and Method: A cross-sectional prospective study was performed to evaluate 3,382 consecutive patients with no known adrenal disease or malignancies who underwent chest and abdominal CT scans over a ten-month period. The cases of adrenal incidentaloma were defined by the presence of any change in gland contour, size or density. Kappa values were calculated, evaluating the intra and inter-observer agreement. R e s u l t s : One hundred and one incidental adrenal masses were identified, corresponding to 83 cases and a prevalence of 2.5% (CI 95%: 1.0%‐3.2%). Male patients presented a higher prevalence of incidentaloma than female (3.3% vs. 1.5%; p= 0.01). There was a significant a s s o c i ation between older age and higher frequency of incidentaloma. Kappa of 0.76 and 0.83 (good and excellent agreement, respectively), were obtained in evaluating the intra and inter-observer agreements. C o n c l u s i o n s : The prevalence of adrenal incidentaloma detected by CT was similar to that of various published retrospective clinical series. The two factors that independently influenced the distribution of incidentalomas were older age and being male. (Arq Bras Endocrinol Metab 2005;49/5:769-775)