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1.
Eur J Phys Rehabil Med ; 60(2): 340-348, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38483331

RESUMO

BACKGROUND: Cognitive impairment is a long-known negative prognostic factor after hip fracture. Cognition is usually screened by a single easy-to-administer bedside tool, but recent studies have shown that screening tests may be not enough to rule out cognitive impairment with an unfavorable prognostic role. Unfortunately, data on outcome prediction by further cognitive assessments is sparse. AIM: We focused on patients with subacute hip fracture defined cognitively intact or mildly impaired on the screening evaluation performed by the Short Portable Mental Status Questionnaire (SPMSQ). We hypothesized that each of 3 further cognitive tests could independently predict activities of daily living, with optimal prediction of function obtained by performing all three the tests. DESIGN: Short-term prospective study. SETTING: Rehabilitation ward. POPULATION: Inpatients with subacute hip-fracture. METHODS: Three cognitive tests were performed on admission to rehabilitation in the patients who made ≤4 errors on the SPMSQ: Montreal Cognitive Assessment (MoCA), Rey Auditory Verbal Learning Test (RAVLT, immediate and delayed recall) and Frontal Assessment Battery (FAB). We assessed activities of daily living by the Barthel index. Successful rehabilitation was defined with a Barthel Index Score ≥85. RESULTS: Each of the three cognitive tests assessed before rehabilitation significantly predicted the Barthel index scores measured at the end of the rehabilitation course in our sample of 280 inpatients. However, only the MoCA score retained its significant predictive role when the scores from the three tests were included together as independent variables in a multiple regression model, with adjustments for a panel of potential confounders (P=0.007). The adjusted odds ratio to achieve successful rehabilitation for a seven-point change in MoCA score was 1.98 (CI 95% from 1.02 to 3.83; P=0.042). CONCLUSIONS: Contrary to our hypothesis, MoCA but not RAVLT and FAB retained the prognostic role when the scores from the three tests were evaluated together as potential predictors of functional ability in activities of daily living. CLINICAL REHABILITATION IMPACT: In the presence of a normal (or mildly altered) score on the SPMSQ in subacute hip fracture, MoCA scores improve prediction of activities of daily living and should be routinely performed.


Assuntos
Disfunção Cognitiva , Fraturas do Quadril , Humanos , Estudos Prospectivos , Atividades Cotidianas , Fraturas do Quadril/reabilitação , Prognóstico , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Cognição
3.
Aging Clin Exp Res ; 34(12): 2977-2984, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36057082

RESUMO

BACKGROUND: Cognitive impairment assessed by easy-to-administer tests successfully predicts function after hip fracture, whereas the prognostic role of additional cognitive evaluations is largely unknown. AIMS: To investigate the capability of further assessments to discriminate cognitive impairment with prognostic relevance in hip-fracture women defined cognitively intact or mildly impaired on the Short Portable Mental Status Questionnaire (SPMSQ). METHODS: We prospectively investigated women with subacute hip fracture admitted to our rehabilitation facility. The women who made ≤4 errors on the SPMSQ were further assessed by 4 tests: Montreal Cognitive Assessment, Rey Auditory Verbal Learning Test (immediate and delayed recall) and Frontal Assessment Battery. Activities of daily living (ADL) were measured by the Barthel index. Successful rehabilitation was defined with a Barthel index score ≥85. RESULTS: Data from 127 women were available. Each of the 4 cognitive tests assessed at admission significantly predicted the Barthel index scores measured at discharge. The predictive role persisted after multiple adjustments. For a change in cognitive scores corresponding to the difference between 25° and 75° percentiles in their distribution in the sample, the adjusted odds ratio to achieve successful rehabilitation roughly ranged from 2 to 4, depending on which cognitive test was adopted. DISCUSSION: The women with subacute hip fracture defined cognitively intact or mildly impaired on the SPMSQ could have cognitive impairment revealed by further examination, with prognostic disadvantages in ADL. CONCLUSIONS: Assessing cognition by the SPMSQ seems not enough to exclude the presence of cognitive impairment with relevant prognostic disadvantage in hip-fracture women.


Assuntos
Transtornos Cognitivos , Disfunção Cognitiva , Fraturas do Quadril , Humanos , Feminino , Estudos Prospectivos , Atividades Cotidianas , Prognóstico , Transtornos Cognitivos/diagnóstico , Fraturas do Quadril/complicações , Fraturas do Quadril/reabilitação , Disfunção Cognitiva/diagnóstico
4.
J Clin Med ; 11(13)2022 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-35807046

RESUMO

We aimed to investigate the reproducibility and accuracy of Radiofrequency Echographic Multi-Spectrometry (REMS) for femoral BMD estimation and the reproducibility and discriminative power of the REMS-derived femoral fragility score. 175 patients with primary and disuse-related osteoporosis were recruited: one femoral Dual-energy X-ray Absorptiometry (DXA) scan and two femoral REMS scans were acquired. No significant test-retest differences were observed for all REMS-derived variables. The diagnostic concordance between DXA and REMS was 63% (Cohen's kappa = 0.31) in patients with primary osteoporosis and 13% (Cohen's kappa: -0.04) in patients with disuse-related osteoporosis. No significant difference was observed between REMS and DXA for either femoral neck BMD (mean difference between REMS and DXA: -0.015 g/cm2) or total femur BMD (mean difference: -0.004 g/cm2) in patients with primary osteoporosis. Significant differences between the two techniques were observed in patients with disuse-related osteoporosis (femoral neck BMD difference: 0.136 g/cm2; total femur BMD difference: 0.236 g/cm2). Statistically significant differences in the fragility score were obtained between the fractured and non-fractured patients for both populations. In conclusion, REMS showed excellent test-retest reproducibility, but the diagnostic concordance between DXA and REMS was between minimal and poor. Further studies are required to improve the REMS-derived estimation of femoral BMD.

5.
Eur J Phys Rehabil Med ; 58(4): 638-645, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35412037

RESUMO

BACKGROUND: Several lines of evidence support the view that sarcopenia and osteoporosis are strictly connected. However, the capability of the updated sarcopenia definition to capture the concomitant presence of osteoporosis has been scarcely investigated. AIM: The main aim was to assess the association between sarcopenia defined according to the revised criteria from the European Working Group on Sarcopenia in Older People (EWGSOP2) and osteoporosis in women with a hip fracture. A second aim was to investigate the thresholds for low appendicular lean mass (aLM) and handgrip strength to optimize osteoporosis detection. DESIGN: Cross-sectional study. SETTING: Rehabilitation hospital. POPULATION: Women with subacute hip fracture. METHODS: A scan by dual-energy X-ray absorptiometry (DXA) was performed to assess body composition. A Jamar dynamometer was used to measure handgrip strength. Sarcopenia was diagnosed with both handgrip strength <16 kg and aLM <15 kg. Osteoporosis was identified with femoral bone mineral density lower than 2.5 standard deviations below the mean of the young reference population. RESULTS: We studied 262 of 290 women. Osteoporosis was found in 189 of the 262 women (72%; 95% CI: 67-78%) whereas sarcopenia in 147 (56%; 95% CI: 50-62%). After adjustment for age, time interval between fracture and DXA scan and body fat percentage the odds ratio to have osteoporosis for a sarcopenic woman was 2.30 (95% CI: 1.27-4.14; P=0.006). Receiver operating characteristic curve analyses showed that the best cut-off points to discriminate osteoporosis were 20 kg for handgrip strength and 12.5 kg for aLM. Adopting the optimized thresholds to define sarcopenia, the adjusted odds ratio to have osteoporosis for a sarcopenic woman was 3.68 (95% CI: 1.93-7.03; P<0.001). CONCLUSIONS: This preliminary study shows a positive association between sarcopenia defined according to the EWGSOP2 criteria and osteoporosis in 262 women with hip fracture. The association may be bettered by refining the cut-off points for low aLM and handgrip strength. CLINICAL REHABILITATION IMPACT: Sarcopenia seems to be a risk factor for osteoporosis in hip-fracture women. The issue, and the potential role of optimized thresholds should be addressed by robust longitudinal studies.


Assuntos
Fraturas do Quadril , Osteoporose , Sarcopenia , Absorciometria de Fóton/efeitos adversos , Idoso , Índice de Massa Corporal , Densidade Óssea , Estudos Transversais , Feminino , Força da Mão , Fraturas do Quadril/etiologia , Humanos , Osteoporose/complicações , Osteoporose/diagnóstico , Sarcopenia/complicações , Sarcopenia/diagnóstico
6.
Eur J Phys Rehabil Med ; 57(6): 940-947, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33759440

RESUMO

BACKGROUND: The prognostic role exerted by the concurrent presence of sarcopenia and obesity after hip fracture has not been elucidated. AIM: To assess the effect of sarcopenic obesity on ability to function in women with subacute hip fracture. DESIGN: Short-term prospective study. SETTING: Rehabilitation hospital. POPULATION: Women with subacute hip fracture. METHODS: At admission, grip strength, by a Jamar dynamometer, and body composition by dual-energy x-ray absorptiometry were assessed. Sarcopenia was defined according to the criteria released by the European Working Group for Sarcopenia in Older People in 2019, with both grip strength <16 kg and appendicular lean mass (aLM)<15 kg. Alternatively, aLM/(height)2<5.5 kg/m2 was substituted for aLM<15 kg to confirm sarcopenia in the women with grip strength <16 kg. Obesity was diagnosed with fat mass exceeding 40% of total body mass. Function was assessed by the Barthel index. RESULTS: We assessed 183 of 200 women. Sarcopenic women had lower Barthel index scores assessed at the end of subacute inpatient rehabilitation (U=300,0; z=-4.3; P<0.001) and lower Batrhel index effectiveness (U=310,0; z=-4.2; P<0.001) than non-sarcopenic women. Conversely, we found no significant differences in function between obese and non-obese women. The concurrent presence of sarcopenia and obesity did not worsen the functional prognosis versus the presence of isolated sarcopenia. After adjustment for Barthel index scores before rehabilitation, age, hip-fracture type and cognitive impairment, sarcopenia was significantly associated with Barthel index scores (P=0.001) and Barthel index effectiveness (P<0.001), whereas obesity was not. The results did not materially change when aLM/(height)2<5.5 kg/m2 was substituted for aLM <15 kg to confirm sarcopenia in the women whose handgrip strength was <16 kg. CONCLUSIONS: The concurrent presence of obesity did not worsen the negative prognostic role of sarcopenia in the short-term recovery of ability to function after hip fracture in women. CLINICAL REHABILITATION IMPACT: In women with subacute hip fracture, sarcopenia but not obesity should be assessed to contribute to the prediction of the short-term functional outcome.


Assuntos
Sarcopenia , Idoso , Força da Mão , Humanos , Obesidade/complicações , Obesidade/diagnóstico , Obesidade/epidemiologia , Estudos Prospectivos , Sarcopenia/diagnóstico , Sarcopenia/epidemiologia
7.
Arch Gerontol Geriatr ; 91: 104190, 2020 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-32721661

RESUMO

AIM: In 2019 the European Working Group on Sarcopenia in Older People (EWGSOP) indicated weakness as the key characteristic of sarcopenia and released the threshold of 16 kg for handgrip strength to define weakness in women. We aimed to externally validate the 16 kg cut-off point for predicting functional recovery in 258 women with subacute hip fracture admitted to our rehabilitation ward. METHODS: We assessed handgrip strength by a hand-grip Jamar dynamometer at admission to inpatient rehabilitation and functional ability in activities of daily living by the Barthel index at the end of the rehabilitation course. Successful rehabilitation was defined with a Barthel index score ≥85 and highest possible recovery with a Barthel index effectiveness = 100 %. RESULTS: A handgrip strength ≥16 kg significantly predicted both successful rehabilitation (χ2 = 23.5, P < 0.001) and highest possible recovery (χ2 = 31.05, P < 0.001). For the women with a handgrip strength ≥16 kg, the odds ratios to gain successful rehabilitation and highest possible recovery were 2.68 (95 % CI from 1.19 to 6.04; P = 0.018) and 2.81 (95 % CI from 1.47 to 5.37; P = 0.002), after adjustment for Barthel index scores before rehabilitation, age, hip-fracture type (either medial or lateral), cognitive impairment and 25-hydroxyvitamin D levels. CONCLUSION: Our results provide an external validation of the 16 kg handgrip strength threshold recently released to discriminate functional outcomes: it significantly predicted the short-term ability to perform activities of daily living after hip fracture in women.

8.
Eur J Phys Rehabil Med ; 56(2): 184-190, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32052946

RESUMO

BACKGROUND: The concurrent presence of sarcopenia and osteoporosis may enhance fracture risk. AIM: The aim of this study was to evaluate the association between sarcopenia, osteoporosis, or the concurrent presence of both the conditions (osteosarcopenia) and the burden (number and severity) of vertebral fractures in women with hip fracture. DESIGN: Cross-sectional study. SETTING: Division of Physical and Rehabilitation Medicine. POPULATION: We studied 350 women with subacute hip fracture. METHODS: Lateral radiographs of the spine were taken 18.2±4.5 days after fracture occurrence and the Spine Deformity Index (SDI) was calculated. Body composition was assessed by dual-energy X-ray absorptiometry. Low muscle mass was identified with appendicular lean mass <15.02 kg and low bone mineral density with a femoral T-Score <-2.5. RESULTS: The presence of sarcopenia (P=0.033) and osteoporosis (P=0.032) was associated with the SDI scores independently of each other and independently of age, percentage of body fat and hip-fracture type. The 350 women were categorized into 3 groups according to the absence of both osteoporosis and sarcopenia (N.=25), presence of either osteoporosis or sarcopenia (N.=95) or presence of osteosarcopenia (N.=230). We found a significant difference in SDI scores across the 3 groups: χ2 (2, N.=350) = 15.29; P<0.001. The categorization of the 350 women into the 3 groups was associated with the SDI scores (P=0.001) independently of age, percentage of body fat and hip-fracture type. CONCLUSIONS: Both osteoporosis and sarcopenia were independently associated with the burden of prevalent vertebral fractures in women with hip fracture. The concurrent presence of sarcopenia and osteoporosis was associated with a higher SDI Score than the presence of only one of the 2 conditions. CLINICAL REHABILITATION IMPACT: Subjects with both low bone mass and low muscle mass should be considered at particularly high risk for vertebral fractures. Interventions targeting both the components of the muscle-bone unit, including exercise, nutrition, and possibly new medications, should be investigated to optimize fracture prevention.


Assuntos
Fraturas do Quadril/etiologia , Osteoporose/complicações , Fraturas por Osteoporose/etiologia , Sarcopenia/complicações , Fraturas da Coluna Vertebral/etiologia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Fraturas do Quadril/diagnóstico por imagem , Humanos , Osteoporose/diagnóstico por imagem , Fraturas por Osteoporose/diagnóstico por imagem , Sarcopenia/diagnóstico por imagem , Fraturas da Coluna Vertebral/diagnóstico por imagem
9.
Aging Clin Exp Res ; 32(9): 1707-1712, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31641971

RESUMO

BACKGROUND AND AIMS: Factors associated with simultaneous fractures at hip and upper limb have scarcely been investigated. Our aim was to assess the association between Geriatric Nutritional Risk Index (GNRI) scores and concurrent upper-limb fractures in women with a fall-related hip fracture. METHODS: We investigated 858 of 907 women admitted to our Physical and Rehabilitation Medicine ward following a fall-related hip fracture. RESULTS: GNRI scores were significantly lower in the 41 women with a simultaneous upper-limb fracture than in the 817 with an isolated hip fracture: median (interquartile range) were 85.9 (80.6-94.1) ad 90.3 (83.4-98.0), respectively, in the two groups (p = 0.021). After adjustment for age, height, body mass index, 25-hydroxyvitamin D, parathyroid hormone, femoral-neck bone mineral density, cognitive impairment, neurologic impairment and type of hip fracture we confirmed a significant association between GNRI scores and the concomitant upper-limb fractures (p = 0.001). The adjusted odds ratio for suffering a concomitant fracture was 7.53 (95% CI from 1.79 to 31.72; p = 0.006) for the 190 women of the GNRI lowest class (GNRI score < 82) versus the 213 women of the highest class (GNRI score > 98). CONCLUSIONS: Data show that GNRI scores were significantly lower in the subgroup of women with hip fracture and concurrent upper-extremity fracture than in the controls with isolated hip fracture. Although caution is needed in interpreting our results due to the cross-sectional design of the study, we suggest that low GNRI scores may have a role in the genesis of the concurrent fractures.


Assuntos
Fraturas Ósseas , Fraturas do Quadril , Idoso , Densidade Óssea , Estudos Transversais , Feminino , Fraturas Ósseas/epidemiologia , Fraturas do Quadril/epidemiologia , Humanos , Avaliação Nutricional , Fatores de Risco , Extremidade Superior , Deficiência de Vitamina D
10.
Am J Phys Med Rehabil ; 98(11): 1005-1009, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31149904

RESUMO

OBJECTIVE: The aim of the study was to investigate the relationship between measures of muscle mass and grip strength in women with subacute hip fracture. Firstly, we aimed to assess the capability of the current thresholds for appendicular lean mass, appendicular lean mass/body mass index ratio and appendicular lean mass/height to separate weak and nonweak women. Secondly, we aimed to explore alternative thresholds for the three measures of muscle mass to discriminate weakness. DESIGN: This is cross-sectional study of 160 women with hip fracture admitted to a rehabilitation hospital. We assessed appendicular lean mass by dual-energy x-ray absorptiometry and grip strength by a Jamar hand dynamometer. Weakness was defined as grip strength of less than 16 kg. RESULTS: Weakness was not significantly associated with appendicular lean mass of less than 15.02 kg, appendicular lean mass/body mass index ratio of less than 0.512 or appendicular lean mass/height of less than 5.67 kg/m. For appendicular lean mass (but not for the other 2 measures of muscle mass), an alternative threshold (11.87 kg instead of 15.02 kg) significantly discriminated weakness: χ (1, n = 160) = 10.77 (P = 0.001). The association between appendicular lean mass of less than 11.87 kg and grip strength of less than 16 kg persisted after adjustment for age and body mass index (odds ratio = 2.50, 95% confidence interval = 1.17-5.34, P = 0.018). CONCLUSIONS: Data suggest that the current thresholds for measures of muscle mass do not discriminate weakness in women with subacute hip fracture. For appendicular lean mass, an alternative cutoff point actually separated weak and nonweak women.


Assuntos
Índice de Massa Corporal , Avaliação Geriátrica/estatística & dados numéricos , Força da Mão , Fraturas do Quadril/fisiopatologia , Debilidade Muscular/diagnóstico , Absorciometria de Fóton , Idoso , Composição Corporal , Estatura , Estudos Transversais , Feminino , Fraturas do Quadril/complicações , Humanos , Dinamômetro de Força Muscular , Debilidade Muscular/complicações , Valores de Referência
11.
Eur J Nucl Med Mol Imaging ; 41(8): 1482-91, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24781870

RESUMO

PURPOSE: Our aim was to investigate the association between (18)F-fluorodeoxyglucose (FDG) uptake and event-free survival in patients in whom a differentiated thyroid cancer (DTC) was detected by (18)F-FDG positron emission tomography (PET)/CT. METHODS: Among 884 focal (18)F-FDG PET thyroid incidentalomas referred to our 4 Nuclear Medicine Departments, we investigated 54 patients in whom a DTC was confirmed and a clinical follow-up was available. The ratio between maximum standardized uptake value (SUVmax) of DTC and SUVmean of the liver (SUV ratio) was recorded for each scan. All patients underwent total thyroidectomy and (131)I remnant ablation. After a median follow-up of 39 months we assessed the outcome. The association between disease persistence/progression, (18)F-FDG uptake and other risk factors (T, N, M and histological subtype) was evaluated through univariate and multivariate analyses. RESULTS: Of the 54 patients, 39 achieved complete remission. The remaining 15 showed persistence/progression of disease. High (18)F-FDG uptake, i.e. SUV ratio ≥3, showed a low positive predictive value (48 %). Low (18)F-FDG uptake (SUV ratio < 3) displayed a high negative predictive value (93 %). The median of SUV ratios in T1-T2 (2.2), in M0 (2.7) and in non-virulent subtypes (2.7) were significantly lower (p < 0.03) than in T3-T4 (5.0), M1 (7.3) and virulent subtypes (6.0). Kaplan-Maier analysis showed a significant association between high (18)F-FDG uptake and disease persistence/progression (p = 0.001). When we adjusted risk estimates by using a multivariate Cox model, only T (p = 0.05) remained independently associated with disease persistence/progression. CONCLUSION: An intense (18)F-FDG uptake of the primary DTC is associated with persistence/progression of disease. However, when all other prognostic factors have been taken into account, (18)F-FDG uptake does not add further prognostic information.


Assuntos
Fluordesoxiglucose F18 , Imagem Multimodal , Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos , Neoplasias da Glândula Tireoide/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes
12.
Eur J Endocrinol ; 170(5): 659-66, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24510913

RESUMO

OBJECTIVE: Differentiated thyroid cancer (DTC) commonly occurs in women of child-bearing age and represents the second most frequent tumor diagnosed during pregnancy only behind breast cancer. It is possible that associated physiological changes could favor tumor development and growth. However, few data are available about the outcome of DTC related to pregnancy, leading to conflicting results. METHODS: Among the study population, 340 patients with DTC <45 years old were retrospectively studied. Patients were divided into three groups according to the time of tumor diagnosis in respect of pregnancy. Group 1, diagnosis of DTC at least 2 years after delivery; group 2, diagnosis during pregnancy or within the second year after delivery; and group 3, nulliparous patients at the time of diagnosis. We evaluated clinical outcome and immunohistochemical expression of estrogen receptor α (ERα), ERß, progesterone receptor, and aromatase. We also analyzed the gene expression of NIS (SLC5A5) and the prevalence of BRAF(V600E) mutations. RESULTS: Persistence/recurrence of disease was significantly higher in group 2 patients than control groups (P=0.023). No significant differences were observed in other clinical parameters. Furthermore, no differences among the groups were recorded about ER pattern, NIS expression, and BRAF mutations. CONCLUSIONS: Persistence/recurrence of DTC is significantly higher in pregnant patients, suggesting that pregnancy could really exert a negative prognostic role in patients with DTC. The underlying mechanisms are not yet clarified and further studies are required. Our results suggest that a more careful follow-up is needed when diagnosis of DTC occurs during pregnancy or shortly after.


Assuntos
Complicações Neoplásicas na Gravidez/diagnóstico , Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/diagnóstico , Adolescente , Adulto , Transformação Celular Neoplásica , Terapia Combinada/efeitos adversos , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/prevenção & controle , Estadiamento de Neoplasias , Período Pós-Parto , Gravidez , Complicações Neoplásicas na Gravidez/patologia , Complicações Neoplásicas na Gravidez/prevenção & controle , Complicações Neoplásicas na Gravidez/terapia , Prognóstico , Cintilografia , Compostos Radiofarmacêuticos/efeitos adversos , Compostos Radiofarmacêuticos/uso terapêutico , Indução de Remissão , Estudos Retrospectivos , Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/metabolismo , Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/prevenção & controle , Neoplasias da Glândula Tireoide/terapia , Nódulo da Glândula Tireoide/diagnóstico , Nódulo da Glândula Tireoide/patologia , Nódulo da Glândula Tireoide/prevenção & controle , Nódulo da Glândula Tireoide/terapia , Tireoidectomia/efeitos adversos , Adulto Jovem
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