PD-L1 and MCL-1 markers and the relationship with prognostic characteristics of differentiated thyroid carcinoma.

OBJECTIVES: MCL-1 and PD-L1 proteins are related to carcinogenesis mechanisms in differentiated thyroid carcinoma(DTC). Tumor antigens stimulate the expression of PD-1 in immune cells, which binds to PD-L1 of tumor cells, inducing immune escape from the tumor. MCL-1, an anti-apoptotic member of the BCL-2 family, is necessary for the survival of T and B lymphocytes and has a high oncogenic potential. We aim to evaluate the clinical utility and relevance of MCL-1 and PD-L1 in the long-term prognosis of DTC. METHODS: 120 DTC patients after total thyroidectomy and radioiodine therapy followed for a minimum of 2 years were included. Demographic features, tumor histopathology, persistence/recurrence risk, factors associated with outcome, initial response to therapy, persistence or disease-free at the follow-up were related to MCL-1 and PD-L1 immunohistochemical expression and BRAFV600E mutation. RESULTS: 100(83.3%) were women, 46.64 ± 16.73 years old at diagnosis; 37(30.8%) patients were at high, 45(37.5%) of intermediate and 38(31.7%) of low disease recurrence/persistence risk. At the end of follow-up of 124.86 ± 65.36 months, 48(42.5%) had persistent disease. 103(85.8%) patients had papillary thyroid carcinoma (PTC), 17(14.2%) follicular thyroid carcinoma (FTC). In PTC, moderate/strong PD-L1 and MCL-1 expressions were associated to BRAFV600E (p=0.0467; p=0.0044). PD-L1 was also associated with tall cell subtype (p=0.0274). In FTC, weak PD-L1 expression was associated to the largest nodule diameter (p=0.0100). Strong/moderate PD-L1 expression was associated to T2 and the weak expression with T3 in TNM classification (p=0.0490). Moderate MCL-1 expression was associated to smoking (p=0.0350). CONCLUSIONS: PDL-1, marker of progression of tumor cells and MCL-1, anti-apoptotic marker, were associated with PTC carrying BRAFV600E mutation, while PDL-1 was associated with more aggressive PTC subtype. MCL-1 and PD-L1 could be useful in composing a panel to assess the prognosis of PTC patients. On the other hand, both markers seemed to have lower relevance to FTC patients.

Usefulness of pre-thyroidectomy neutrophil-lymphocyte, platelet-lymphocyte, and monocyte-lymphocyte ratios for discriminating lymph node and distant metastases in differentiated thyroid cancer.

OBJECTIVE: This study aimed to analyze the relationship of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) with clinicopathological characteristics of patients with differentiated thyroid cancer (DTC). METHODS: This retrospective study included 390 patients with DTC who had complete blood cell counts available at the time of surgery. NLR, PLR, and MLR were calculated, and the risk of cancer-related death, structural recurrence, and response to therapy were assessed using the eighth edition of the tumor-node-metastasis classification, American Thyroid Association (ATA) Risk Stratification System, and ATA Response to Therapy Reclassification, respectively. RESULTS: PLR was higher in patients with distant metastasis than in those without (133.15±43.95 versus 119.24±45.69, p=0.0345) and lower in patients with disease-free status (117.72±44.70 versus 131.07±47.85, p=0.0089) than in those who experienced persistent disease or death. Patients aged ≥55 years had a higher MLR than those aged <55 years (0.26±0.10 versus 0.24±0.12, p=0.0379). Higher MLR (odds ratio [OR]: 8.775, 95% confidence interval [CI]: 1.532-50.273, p=0.0147), intermediate ATA risk (OR: 4.892, 95% CI: 2.492-9.605, p≤0.0001), and high ATA risk (OR: 5.998, 95% CI: 3.126-11.505, p≤0.0001) were risk factors associated with active disease. NLR was not significantly different among the studied variables. Receiver operating characteristic curve cut-off values for NLR, PLR, and MLR were able to differentiate distant metastasis from lymph node metastasis (NLR>1.93: 73.3% sensitivity and 58.7% specificity, PLR>124.34: 86.7% sensitivity and 69.2% specificity, MLR>0.21: 80% sensitivity and 45.2% specificity). CONCLUSION: Cut-off values of NLR, PLR, and MLR differentiated distant metastasis from lymph node metastasis with good sensitivity and accuracy. PLR was associated with disease-free status and it was higher in DTC patients with distant metastasis, persistent disease, and disease-related death. MLR was a risk factor for active disease.

Influence of thyroid hormone in the expression of the marker pro-apoptosis BID, in spite of the predominance of anti-apoptosis activation in intratiroidal lymphocytic infiltration in Hashimoto's thyroiditis.

Cell destruction in Hashimoto's thyroiditis (HT) involves autoantibodies and cytotoxic T lymphocytes. Thyrocytes maintenance occurs by pro-apoptotic, anti-apoptotic and cell proliferation balance. OBJECTIVES: To characterize factors related to the mechanisms of apoptosis and cell proliferation in thyroid cells and intrathyroid lymphocytic infiltrate in HT. METHODS: We assessed lymphocytic infiltrate and thyroid cells from HT and normal thyroid by immunohistochemical analysis of cell proliferation (Ki-67), antiproliferation (p27Kip1), pro-apoptosis (Fas, Fas-ligand, BID) and anti-apoptosis (MCL-1, BCL2) markers. RESULTS: Lymphocytic infiltrate presented BCL2 and MCL-1 higher expression, Ki-67 and p27kip1 balance. Thyrocytes exhibited Fas and FasL balance, higher BID expression; MCL-1, BCL-2, Ki-67 similar to the normal thyroid. T4 and higher lymphocytes BID expression were associated. CONCLUSIONS: In lymphocytic infiltrate predominated anti-apoptosis in relation to pro-apoptosis except for BID. Thyrocytes presented pro-apoptosis and anti-apoptosis balance and cell proliferation similar to normal thyroid. T4-associated BID expression in HT lymphocytes suggests the influence of thyroid hormone as a signal to up-regulate the BID pro-apoptotic protein and thus increase lymphocytic apoptosis rates.

Usefulness of pre-thyroidectomy neutrophil-lymphocyte, platelet-lymphocyte, and monocyte-lymphocyte ratios for discriminating lymph node and distant metastases in differentiated thyroid cancer

OBJECTIVE: This study aimed to analyze the relationship of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) with clinicopathological characteristics of patients with differentiated thyroid cancer (DTC). METHODS: This retrospective study included 390 patients with DTC who had complete blood cell counts available at the time of surgery. NLR, PLR, and MLR were calculated, and the risk of cancer-related death, structural recurrence, and response to therapy were assessed using the eighth edition of the tumor-node-metastasis classification, American Thyroid Association (ATA) Risk Stratification System, and ATA Response to Therapy Reclassification, respectively. RESULTS: PLR was higher in patients with distant metastasis than in those without (133.15±43.95 versus 119.24±45.69, p=0.0345) and lower in patients with disease-free status (117.72±44.70 versus 131.07±47.85, p=0.0089) than in those who experienced persistent disease or death. Patients aged ≥55 years had a higher MLR than those aged <55 years (0.26±0.10 versus 0.24±0.12, p=0.0379). Higher MLR (odds ratio [OR]: 8.775, 95% confidence interval [CI]: 1.532-50.273, p=0.0147), intermediate ATA risk (OR: 4.892, 95% CI: 2.492-9.605, p≤0.0001), and high ATA risk (OR: 5.998, 95% CI: 3.126-11.505, p≤0.0001) were risk factors associated with active disease. NLR was not significantly different among the studied variables. Receiver operating characteristic curve cut-off values for NLR, PLR, and MLR were able to differentiate distant metastasis from lymph node metastasis (NLR>1.93: 73.3% sensitivity and 58.7% specificity, PLR>124.34: 86.7% sensitivity and 69.2% specificity, MLR>0.21: 80% sensitivity and 45.2% specificity). CONCLUSION: Cut-off values of NLR, PLR, and MLR differentiated distant metastasis from lymph node metastasis with good sensitivity and accuracy. PLR was associated with disease-free status and it was higher in DTC patients with distant metastasis, persistent disease, and disease-related death. MLR was a risk factor for active disease.

Value of Apoptotic, Antiapoptotic, and Cell Proliferation Markers in the Treatment of Graves' Disease.

To better understand the genesis of autoimmunity in Graves' disease (GD), it is essential to study the mechanism of apoptosis and cell proliferation in thyroid cells and intrathyroidal lymphocytic infiltrate of GD patients. Methods. A cross sectional, observational study performed by evaluating histopathological samples of thyroidectomy products from GD patients using immunohistochemistry. New histological sections were prepared for immunohistochemical analysis with markers of cell proliferation, antiproliferation, apoptosis, and antiapoptosis. Results. Patients with GD who underwent radioiodine therapy (RIT) had a lower lymphocytic expression level of p27Kip1, and those who took beta-blockers had higher expression levels of BID (BH3-interacting domain) and a lower Ki-67 expression level in thyrocytes than those who did not. The association of a shorter diagnostic time with a lower expression level of MCL-1 in thyroid cells suggests that the hyperthyroid state was related to a lower antiapoptotic effect on thyrocytes. In comparison to patients with GD not using antithyroid drugs (ATD), we found a lower expression level of BID in lymphocytes for those who used ATD. Conclusion. In GD, the hyperthyroid state was associated with a lower antiapoptotic effect on thyroid cells. RIT, beta-blockers, and thionamide act by stimulating apoptosis of thyrocytes by intrathyroidal lymphocytes.

Value of ultrasound and cytological classification system to predict the malignancy of thyroid nodules with indeterminate cytology.

Although fine-needle aspiration cytology is considered the gold standard for evaluating thyroid nodules, in about 10-30% of the cases, cytology is indeterminate. This study aimed to determine the value of cytological classification system and ultrasound (US) to predict malignancy in indeterminate thyroid nodule. This retrospective analysis enrolled 80 patients surgically treated at a single center, 75% (60) with benign vs. 25% (20) with malignant lesions at final histology. The clinical, scintigraphic, sonographic, and cytological classification (Bethesda) variables were analyzed in these selected cases of indeterminate cytology, and a prediction model was designed after the multivariate analysis. There was a 25% prevalence of malignancy (20/80). There were no differences in gender, serum thyroid-stimulating hormone and FT4 levels, thyroid auto-antibodies, thyroid dysfunction, and scintigraphic results between benign and malignant nodule groups. The border irregularity in sonographic study was at increased risk for malignancy. The cytological analysis based on Bethesda System (category IV) was an independent predictor for malignancy in indeterminate thyroid nodules. After the multivariate analysis, the model obtained showed border irregularity and Bethesda System category IV as predictive factors of malignancy in indeterminate thyroid nodules, featuring 76.9% of accuracy. This study confirmed a significant increase of risk for malignancy in thyroid nodules with indeterminate cytology showing Bethesda System category IV and suspicious features at US. These findings enhance our current limited predictive armamentarium and can be used to guide surgical decision making.

[Is silent hypoglycemia part of ideal glycemic control in DM1 patients? - hypoglycemic state by CGMS vs. glycemic average]. / A hipoglicemia silenciosa é parte do controle glicêmico ideal em pacientes com DM1? - tempo de hipoglicemia pelo CGMS versus média glicêmica.

BACKGROUND: To evaluate the impact of silent hypoglycemic state in glycemic control in type 1 diabetic patients (DM1) by CGMS. METHODS: 87 DM1 patients (45%M/55%F) submitted to a 72 h CGMS profile were classified in 4 groups. It was analyzed: unrecognized hypoglycemia (<70 mg/dL); duration time of silent hypoglycemia in which patients were classified into G1 (<5%), G2 (5-10%), G3 (10-20%) and G4 (>20%) of hypoglycemic state by CGMS; A1c and mean capillary glucose (MCG) in each group. RESULTS: The silent hypoglycemia was detected in 64.5% of patients and nighttime episodes of hypoglycemia lasted longer (min) than daytime episodes in all groups (p<0.001). It was verified 41.4% of patients under than 5% of time in hypoglycemic state, 21.8% between 5-10%, 23% between 10-20% and 13.8% with more than 20% of CGMS in silent hypoglycemia. This data showed significant decreased in MCG when the duration time of silent hypoglycemia was longer (p=0.006). CONCLUSION: The silent hypoglycemia is common in DM1 patients and most frequently in night time period. To take an average glycemia of 120-160 mg/dL in these patients, it was necessary a 10-20% of CGMS period in silent hypoglycemia in these patients.

A hipoglicemia silenciosa é parte do controle glicêmico ideal em pacientes com DM1?: tempo de hipoglicemia pelo CGMS versus média glicêmica / Is silent hypoglycemia part of ideal glycemic control in DM1 patients?: hypoglycemic state by CGMS vs. glycemic average

OBJETIVO: Avaliar o impacto do tempo de hipoglicemia silenciosa no controle glicêmico de pacientes diabéticos tipo 1 (DM1) sob monitorização contínua de glicose (CGMS). MÉTODOS: Oitenta e sete pacientes DM1 (45 por centoM/55 por centoF), divididos em quatro grupos, submetidos à CGMS 72 horas. Foram analisados: hipoglicemia silenciosa (HS) (< 70 mg/dL); tempo de hipoglicemia pelo CGMS, sendo os pacientes classificados em G1 (< 5 por cento), G2 (5-10 por cento), G3 (10 por cento a 20 por cento) e G4 (> 20 por cento); níveis de A1c e médias glicêmicas. RESULTADOS: A HS foi detectada em 64,5 por cento dos casos, sendo mais duradoura (mín.) durante a noite versus o dia (p < 0,001). Quanto ao tempo de HS, 41,4 por cento dos pacientes ficaram < 5 por cento, 21,8 por cento entre 5 por cento a 10 por cento, 23 por cento entre 10 por cento a 20 por cento e 13,8 por cento com > 20 por cento do CGMS 72 horas. Verificou-se menor média glicêmica quanto maior o tempo de hipoglicemia (p = 0,006). CONCLUSÃO: A hipoglicemia silenciosa é freqüente em pacientes com DM1, no período noturno. Observou-se tempo de 10 por cento a 20 por cento de hipoglicemia silenciosa para a média glicêmica entre 120 a 160 mg/dL.

BACKGROUND: To evaluate the impact of silent hypoglycemic state in glycemic control in type 1 diabetic patients (DM1) by CGMS. METHODS: 87 DM1 patients (45 percentM/55 percentF) submitted to a 72h CGMS profile were classified in 4 groups. It was analyzed: unrecognized hypoglycemia (<70mg/dL); duration time of silent hypoglycemia in which patients were classified into G1 (<5 percent), G2 (5-10 percent), G3 (10-20 percent) and G4 (>20 percent) of hypoglycemic state by CGMS; A1c and mean capillary glucose (MCG) in each group. RESULTS: The silent hypoglycemia was detected in 64.5 percent of patients and nighttime episodes of hypoglycemia lasted longer (min) than daytime episodes in all groups (p<0.001). It was verified 41.4 percent of patients under than 5 percent of time in hypoglycemic state, 21.8 percent between 5-10 percent, 23 percent between 10-20 percent and 13.8 percent with more than 20 percent of CGMS in silent hypoglycemia. This data showed significant decreased in MCG when the duration time of silent hypoglycemia was longer (p=0.006). CONCLUSION: The silent hypoglycemia is common in DM1 patients and most frequently in night time period. To take an average glycemia of 120-160mg/dL in these patients, it was necessary a 10-20 percent of CGMS period in silent hypoglycemia in these patients.

Eficácia do sistema de monitorização contínua da glicose (CGMS) na detecção de excursões glicêmicas e redução da A1C em pacientes diabéticos / Efficacy of continuous glucose monitoring system (CGMS) to detect glycemic excursions and improve decrease of A1C in diabetic patients

Para avaliar a eficácia do sistema de monitorização contínua da glicose (CGMS) na detecção de excursões glicêmicas e na redução dos níveis de A1c (glico-hemoglobina) em pacientes com diabetes mellitus (DM), foram estudados retrospectivamente 35 pacientes (DM1: 32; DM2: 3); (28,03 ± 15,38 anos), submetidos à monitorização contínua da glicose (CGM) por 72 horas. Os níveis de Alc foram determinados antes (um mês) e três meses após o CGMS. A glicemia capilar (GC) média durante a utilização do CGMS foi de 193,6 ± 50,7mo/d1 vs. 190,1± 51,8mg/d1, detectada pelo censor, com correlação altamente significativa (p<0,001). O CGMS mostrou-se mais eficiente na detecção de excursões glicêmicas em relação à GC (p=0,013). A hiperglicemia pós-prandial (HPP) foi identificada em 78,6% dos pacientes. A avaliação do controle metabólico (A1c), após três meses do CGMS, evidenciou redução significante da A1c (p=0,038). Esses dados demonstram a indicação do CGMS em pacientes diabéticos para detecção de excursões glicêmicas, identificação de HPP e na promoção de ajuste terapêutico e redução importante da A1c nesses pacientes.

The efficacy of continuous glucose monitoring system (CGMS) to detect glycemic excursions and decrease of Alc (glyco-hemoglobin) levels in 35 diabetic mellitus (DM) patients (32 DM type l, 3 type 2) were evaluated. They were submitted to CGMS for 72 hours and retrospectively studied. The Alc levels were measured one month before and three months after starting CGMS. The mean capillary glucose levels were 193.6 ± 50.7 mg/dL vs. 190.1± 51.8 mg/dL by CGMS sensor, with significant correlation (p<0.001). The CGMS was significantly more efficient in detection of glycemic excursion related to capillary glycemia (p=0.013). The post-prandial hyperglycemia (HPF) was identified in 78.6% of patients. These data showed important docreased level of Alc in these patients three months after the CGMS with statistical significanse (p=0.038). These data also demonstrated the efficacy of CGMS in diabetic patients to detect glycemic excursions and post-prandial hyperglycemia and to promote therapeutic adjustment and decrease of Alc levals in this group of patients.

Manejo diagnóstico e terapêutico do hiperaldosteronismo primário / Diagnostic and therapeutic management of primary hyperaldosteronism

O hiperaldosteronismo primário é causa rara de hipertensão arterial persistente, de difícil controle, com hipo ou normocalemia, hiperaldosteronemia e hiporeninemia. A suspeita diagnóstica é baseada na relação aldosterona/renina plasmáticas elevada. O hiperaldosteronismo primário pode raramente associar-se a outros distúrbios metabólicos. Neste trabalho, é relatado o caso de paciente de 56 anos com sinais e sintomas compatíveis com hipotireoidismo, comprovado por alterações laboratoriais e associado à hipertensão arterial persistente e de difícil controle após 10 meses de evolução. A propedêutica revelou hiperaldosteronismo primário causado por microhiperplasia adrenal em paciente com tireoidite de Hashimoto. O tratamento clínico efetivo constituiu-se de orientação dietética, atividade física moderada e terapia farmacológica. Ressalta-se, neste trabalho, a conduta diagnóstica e terapêutica do hiperaldosteronismo primário, de forma racional e com baixos custos.

A 56 years old female with signs and symptoms of hypothyroidism, confirmed by laboratory analysis, is presented. During 10 months, the patient had severe systemic hypertensive disease with the presence of primary hyperaldosteronism caused by bilateral adrenal microhyperplasia and Hashimoto's thyroiditis. The treatment was based on dict orientation, physical education and pharmacological therapy, with an improved evolution. This study emphasizes the therapeutic and diagnostic management of primary hyperaldosteronism. A rational and inexpensive treatment of secondary hypertension is proposed.

Manejo diagnóstico e terapêutico do bócio mergulhante / Diagnostic and therapeutic management of substernal goiter

As condutas clínicas e cirúrgicas no bócio mergulhante ainda são controversas, não havendo um consenso na literatura sobre qual o momento ideal para intervir cirurgicamente nos pacientes com esta enfermidade. É preciso conhecer as indicações, conseqüências e complicações do tratamento cirúrgico do bócio mergulhante. Este trabalho resulta de uma revisão de publicações sobre tratamento do bócio mergulhante no período de 1995 a 2000. As bases de dados utilizadas foram Medline e Lillacs. Objetiva-se atualizar, orientar e esclarecer dúvidas dos profissionais a respeito desses fatores. Discutem-se os métodos diagnósticos e as condutas terapêuticas em casos de bócio mergulhante...

There is no unanimity regarding clinical or surgical procedures in treatment of substernal goiter. Indications, consequences, and complications of substernal goiter surgery must be carefully evaluated. A review of the literaturc based on Medline and Lillacs regarding surgery of substernal goiter from 1995 to 2000 is made and discussed.

Thyroglobulin before ablation and correlation with posttreatment scanning.

OBJECTIVES/HYPOTHESIS: To determine the usefulness of thyroglobulin (Tg) before ablation and the correlation with posttreatment scanning in patients with thyroid carcinoma. STUDY DESIGN: Prospective. METHODS: Tg during hypothyroidism was determined in 212 patients after thyroidectomy and before ablation. The disease stage was based on clinical examination, Tg, posttherapy scanning, other imaging methods, and histologic confirmation in selected cases. RESULTS: One hundred sixty-four patients presented thyroid remnants only, 31 had lymph node metastases, and 17 had distant metastases. Posttreatment scanning showed a sensitivity of 71% for lymph node and of 94.1% for distant metastases. Ectopic uptake was observed in 5.6% of patients with Tg less than 1 ng/mL, in 9% with levels from 1 to 5 ng/mL, in 10.7% with Tg from 5 to 10 ng/mL, and in 51% with Tg greater than 10 ng/mL. The sensitivity of Tg for metastases was 73 and 66.5% and specificity was 73 and 88.4% at a cut-off value of 5 and 10 ng/mL, respectively. CONCLUSIONS: Postoperative Tg less than 10 ng/mL rarely show distant metastases and because these metastases were observed in 31% of patients with values greater than 10 ng/mL, this criterion can be selected for the indication of imaging methods, in addition to neck ultrasound (US). For cases with Tg less than 10 ng/mL, US is necessary because even patients with undetectable Tg had lymph node metastases. The same cut-off can be used for the indication of radioiodine therapy even in the absence of any evidence of disease because 51% of the patients with Tg greater than 10 ng/mL showed ectopic uptake on posttreatment scanning.

Fatores adicionais de risco cardiovascular associados à hipertensão arterial sistêmica em população de zona rural de Minas Gerais / Added cardiovascular risk factors due to high blood pressure of population from Minas Gerais's rural area

Devido à escassez de estudos rurais de base populacional no Brasil, buscou-se identificar os principais fatores de risco cardiovascular associado à hipertensão arterial sistêmica em moradores de zona rural. Foi realizado um estudo transversal, com análise dos fatores de risco cardiovascular em pacientes hipertensos do município de Acaiaca (MG), entre outubro e dezembro de 2002. A amostra representativa foi de 156 pacientes hipertensos. O estudo consistiu da avaliação clínica (idade, sexo, tabagismo, diabetes, índice de massa corporal, sedentarismo, relação cintura-quadril (RCQ), circunferência abdominal, medida da pressão arterial (PA)) e avaliação laboratorial (colesterol total e HDL-c) dos pacientes. A análise estatística foi realizada pelo programa Epi info, versão 6.04. Foram estudados 150 pacientes hipertensos (98F/52M), com idade média de 60,3 anos. A frequência de tabagismo, diabetes, sedentarismo e obesidade foi de 24%, 20%, 60,7% e 66%, respectivamente. Houve associação estatisticamente significativa entre hipercolesterolemia e obesidade. O sedentarismo não foi fator de risco significativo para a obesidade, nesse estudo. Os principais fatores de risco detectados foram idade avançada, sexo masculino, tabagismo, diabetes, dislipidemia, PA descontrolada e RCQ alterada. Concluímos que, na zona rural, há prevalência elevada de diabetes mellitus, tabagismo, dislipidemia, obesidade e sedentarismo. A avaliação ambulatorial de rotina dos fatores de risco coronariano dos pacientes hipertensos da zona rural permite identificar os grupos de risco e a tomada de medidas preventivas e terapêuticas, visando à redução da morbimortalidade por doenças cardiovasculares nessas comunidades.

In view of the shortage of population-based rural studies in Brazil, this study evaluated additional risk factors for cardiovascular disease in patients with high blood pressure. A cross sectional study was carried in Acaiaca (MG) from October to December 2002 aiming the evaluation of additional risk factors for cardiovascular disease in patients with high blood pressure in a rural area. A representative sample of 156 hypertensive individuals was selected. The study consisted of clinical evaluation (age; sex; cigarette smoking; diabetes mellitus; body mass index; physical inactivity; waist/hip ratio (RCQ); abdominal circumference; blood pressure), and total (CT) and HDL-cholesterol (HDL-c). The statistical analysis was performed using the Epi-info program, 6.04 version. A total of 150 out of the 156 patients (98F/52M) were studied. The average age was 60.3 years. The prevalence of cigarette smoking, diabetes mellitus, physical inactivity and obesity was 24.0, 20.0, 60,7 and 66.0%, respectively. Significant statistical association between hypercholesterolemia and obesity was found. The physical inactivity was not a significant risk factor for obesity in this study. The major cardiovascular risk factors detected were: age, masculine sex, cigarette smoking; diabetes mellitus, hypercholesterolemia, uncontrolled blood pressure and increased RCQ. There was a high prevalence of diabetes mellitus, cigarette smoking, hypercholesterolemia, obesity and physical inactivity in this population sample. The routine evaluation of cardiovascular risk factors in hypertensive patients from rural area is important to detect patients at increased cardiovascular risk and offer preventive and therapeutic measures to reduce morbidity and mortality due to coronary artery disease in this community.

Crise tireotóxica: manejo diagnóstico e terapêutico / Thyrotoxic crisis: diagnostic and therapeutic management

A crise tireotóxica é um quadro raro, que acomete cerca de 1% dos casos de tireotoxicose, apresentando altas taxas de morbi-mortalidade, ainda nos dias de hoje. Apresentamos o caso de paciente de 38 anos que apresentava doença de Graves sem tratamento clínico e que evoluiu com insuficiência cardíaca descompensada, culminando com sinais e sintomas compatíveis com crise tireotóxica. Os autores discutem as condutas diagnósticas e terapêuticas na "tempestade tireoidiana".

The thyrotoxic crisis is a rare disease, occurring in less than 1% of all thyrotoxicoses, with high morbimortality. A case is described of a 38 years old male patient with Grave's disease without treatment and congestive heart failure who showed signs and symptoms suggesting thyrotoxic crisis. The diagnostic and therapeutic managment of thyroid storm are discussed.

Terapia com bomba de insulina no tratamento do diabetes tipo 1 / Insulin pump therapy in type 1 diabetes treatment

A evolução tecnológica proporciona o surgimento de novas formas de aplicação da insulina, na busca de maior conforto e comodidade para os pacientes, permitindo o controle adequado da glicemia e a redução das complicações em curto e longo prazo. A terapia com bomba de insulina está cada vez mais disseminada em todo o mundo, trazendo maior conforto e comodidade aos pacientes. Está associada à melhora do controle metabólico, maior aceitação da doença, menor risco de crises hipoglicêmicas, maior segurança de dose, maior facilidade de uso e à melhora da qualidade de vida dessa população. Os autores revisam a literatura médica quanto aos impactos do uso da bomba de insulina em relação à terapia convencional com seringas, no tratamento do diabetes mellitus tipo 1, entre 1992 e 2002. As bases de dados utilizadas foram MEDLINE e LILACS. Objetiva-se contribuir para o maior conhecimento dos aspectos farmacológicos, clínicos, indicações, vantagens e desvantagens da terapia com bomba de insulina em relação à terapia convencional com seringas no tratamento do diabetes mellitus tipo 1.

The new technology bring to us different kinds of insulin administration trying to improve the diabetics patients lives and reduce the risks of short and long term complications, such insulin pump therapy. The use of insulin pump therapy is desseminated all over the world. The most studies showed that this method is related to more comfort and commodity. It is associated to better glycemic control, it is more acceptable and it is related to reduce of hypoglycemic crisis. The use of insulin pump proportionate a better quality of live in this group of patients. This study results from a publication review about insulin pump therapy in type 1 diabetes from 1992 to 2002. This review is based on MEDLINE and LILLACS sites. The aim of this study is to promote the diffusion of the knowledge of the pharmalological, clinical, indications, advantages and disadvantages of insulin pump therapy versus insulin syringes in treatment of children and adolescents with type 1 diabetes.

Sonography in the diagnosis of cervical recurrence in patients with differentiated thyroid carcinoma.

OBJECTIVE: To determine the sensitivity of thyroglobulin (Tg), iodine scanning, and sonography in the diagnosis of cervical recurrence of thyroid cancer. METHODS: This prospective study assessed 81 patients with cervical metastases or extrathyroid invasion at first appearance who underwent clinical examination, scanning, measurement of Tg after thyroxine withdrawal, and sonography about 8 months after thyroidectomy followed by radioiodine treatment. Only patients without distant metastases and without anti-Tg antibodies were included. RESULTS: Fifty patients showed persistence of the disease in the cervical region, with only 16% of them having had a suspicion on clinical examination, 33 with Tg levels of 2 ng/mL or greater (66% sensitivity), and 29 with positive scan findings (58% sensitivity). A combination of the 2 methods detected disease in 40 (80%) of 50 patients but failed to show 20% of cases that were identified by sonography and confirmed by fine-needle aspiration. Sonography had sensitivity of 96%. Specificity values for Tg, iodine scanning, and sonography were 80.6%, 90.3%, and 87%, respectively. CONCLUSIONS: Classic follow-up methods may not detect cervical disease in some patients with differentiated thyroid carcinoma, and sonography is necessary even in patients apparently free of the disease.

Correlation between cervical uptake and results of postsurgical radioiodine ablation in patients with thyroid carcinoma.

OBJECTIVE: The objective of this study was to determine the relationship between cervical uptake after thyroidectomy and the success of treatment of cervical remnants with high-dose radioiodine (100 mCi). METHODS: Cervical uptake was retrospectively analyzed after total thyroidectomy and before treatment with radioactive iodine in 142 patients seen at our service who received 100 mCi iodine-131 and whose posttreatment scan only showed cervical uptake without distant metastases. The patients were divided into 5 groups according to the uptake result obtained before ablative therapy. RESULTS: Successful treatment, defined as stimulated thyroglobulin levels <5 ng/mL and a clean scan or only discrete cervical uptake (0.5%) 6 months to 1 year after surgery, was obtained as follows: patients with uptake <1% (n = 48) showed 95.8% treatment efficacy, those with uptake of 1-2% (n = 32) 94% efficacy, and those with uptake of 2-5% (n = 30) reached 83% success, whereas patients with uptake of 5-10% (n = 20) presented 70% efficacy, and treatment was successful in only 50% of patients with uptake >10% (n = 12). CONCLUSIONS: Postoperative measurement of cervical I-131 uptake could be a reasonable predictor of the success of the remnant ablation, and perhaps a guide in deciding the ablative dose of I-131, based on the inverse correlation between the uptake and ablation efficacy.

Incidentaloma adrenal: manejo diagnóstico e terapêutico / Adrenal incidentaloma: diagnostic and therapeutic management

Incidentaloma adrenal consiste em massa benigna, assintomática e näo funcionante na maioria dos casos. A investigaçäo hormonal e por métodos de imagem é essencial para se definir o estado funciona e a natureza benigna e maligna (primária ou metastática) da lesäo, uma vez que o diagnóstico influi diretamente na conduta conservadora ou cirúrgica a ser adotada. Apresentamos o caso de um paciente idoso em que se detectou a presença de massa adrenal à esquerda como achado ocasional de ressonância magnética de abdome, compatível com indicentaloma de supra-renal. Esse exame evidenciou lesäo com menos de 4 cm e características benignas. A avaliaçäo endócrina näo mostrou alteraçöes hormonais significativas (cortisol livre urinário, 17-OH-progesterona, SDHEA, metanefrinas e catecolaminas urinárias, aldosterona, atividade plasmática de renina, potássio), que levou ao diagnóstico de adenoma adrenal näo funcionante. Optou-se pela conduta conservadora, com seguimento clínico, hormonal e de imagem criterioso. Objetiva-se contribuir para a disseminaçäo do conhecimento acerca do manejo diagnóstico e terapêutico do incidentaloma adrenal. Permite-se atualizar e orientar clínicos e cirurgiöes das condutas no incidentaloma de adrenal.

Anticoncepçäo na primeira relaçäo sexual como fator de risco para a gravidez em adolescentes / Contraception use in first sexual intercourse like risk factor for pregnancy in adolescents

Foi realizado estudo do tipo transversal entre maio de 2000 e abril de 2001 que visava a avaliar a relaçäo entre o uso de anticoncepçäo na primeira relaçäo sexual e o índice de gravidez em adolescentes de baixa renda. Buscou-se evidenciar o grau de conhecimento sobre métodos contraceptivos e determinar a prevalência de gravidez e aborto em adolescentes de escolas públicas de Belo Horizonte. O estudo consistiu na aplicaçäo de questionário sobre contracepçäo, gravidez e aborto em adolescentes. A populaçäo-alvo foi estudantes, entre 14 e 24 anos, cursando a 8ª série do primeiro grau, 1§, 2§ e 3§ anos do segundo grau, com renda familiar inferior a cinco salários mínimos. O estudo realizou-se em quatro escolas da rede pública de Belo Horizonte. Os dados foram arquivados e analisados pelo programa Epi Info, versäo 6.04. A amostra final foi de 601 estudantes. A idade variou entre 14 e 24 anos, sendo a idade média 16,4 anos. Foram registrados 17 casos de gravidez. Desses, cinco (29,4 por cento) evoluíram para o aborto. Do total 282 (46,9 por cento) apresentavam atividade sexual ativa. O método contraceptivo mais conhecido foi a camisinha masculina (91,8 por cento). O método mais usado foi o mais conhecido. A principal fonte de informaçäo foi a escola (66,5 por cento). A primeira relaçäo ocorreu em média aos 14,8 anos. Nessa primeira relaçäo, 167 (59,2 por cento) usaram algum método contraceptivo. Houve seis (3,5 por cento) casos de gravidez precoce. Dos 98 adolescentes que näo usaram anticoncepçäo nessa relaçäo, 11 (11,2 por cento) evoluíram para gravidez (p<0,05). A primeira relaçäo sexual é cada vez mais precoce. A ausência de uso de anticoncepçäo nessa relaçäo está associada a maior índice de gravidez na adolescência, sendo importante fator de risco neste estudo.