The effects of early antithyroid therapy for endogenous subclinical hyperthyroidism in clinical and heart abnormalities.

Subclinical hyperthyroidism has been associated with harmful cardiac effects, but its treatment remains controversial. This study was designed to assess the cardiac effects of the normalization of serum TSH concentration in patients with endogenous subclinical hyperthyroidism. Ten patients (median age, 59 yr; range, 16-72 yr) with normal serum free T(4) and free T(3) concentration and a stable suppression of serum TSH levels were evaluated by Doppler-echocardiography, by standard and 24-h electrocardiography monitoring (Holter), and by the clinical Wayne index. Ten subjects, matched for age and sex, were used as controls. Patients were reevaluated 6 months after achieving stabilized euthyroidism by using methimazole with a median initial dose of 20 mg daily (10-30 mg daily). After reaching euthyroidism, we found a significant decrease in the heart rate (P = 0.008), the total number of beats during 24 h (P = 0.004), and the number of atrial (P = 0.002) and ventricular (P = 0.003) premature beats. Echocardiographical data resulted in a reduction of the left ventricular mass index (P = 0.009), interventricular septum thickness (P = 0.008), and left ventricular posterior wall thickness (P = 0.004) at diastole. Furthermore, the early diastolic peak flow velocity deceleration rate was significantly higher (P = 0.02) in the untreated patients compared with controls. The Wayne clinical index was higher in patients than in controls (P = 0.001) and decreased after treatment (P = 0.004). Serum TSH concentration returned to normal values after 2.5 months (range, 1.0-7.0 months) on methimazole therapy (0.05 vs. 1.42 mU/liter; P = 0.002). Serum free T(4) values were normal in patients before treatment but significantly decreased after reaching the euthyroidism (16.9 vs. 11.5 pmol/liter; P = 0.002). In contrast, serum free T(3) concentration did not differ among the groups. In conclusion, our findings support that early antithyroid therapy should be considered in patients with endogenous subclinical hyperthyroidism, where it is needed to prevent potential progression to a more advanced heart disease.

P450c17 deficiency in Brazilian patients: biochemical diagnosis through progesterone levels confirmed by CYP17 genotyping.

P450c17 deficiency is an autosomal recessive disorder and a rare cause of congenital adrenal hyperplasia characterized by hypertension, hypokalemia, and impaired production of sex hormones. We performed a clinical, hormonal, and molecular study of 11 patients from 6 Brazilian families with the combined 17alpha-hydroxylase/17,20-lyase deficiency phenotype. All patients had elevated basal serum levels of progesterone (1.8-38 ng/ml; 0.57-12 pmol/liter) and suppressed plasma renin activity. CYP17 genotyping identified 5 missense mutations. The compound heterozygous mutation R362C/W406R was found in 1 family, whereas the homozygous mutations R96W, Y329D, and P428L were seen in the other 5 families. The R96W mutation has been described as the cause of p450c17 deficiency in Caucasian patients. The other mutations were not found in 50 normal subjects screened by allele-specific oligonucleotide hybridization (Y329D, R362C, and W406R) or digestion with HphI (P428L) and were recently found in other Brazilian patients. Therefore, we elucidated the genotype of 11 individuals with p450c17 deficiency and concluded that basal progesterone measurement is a useful marker of p450c17 deficiency and that its use should reduce the misdiagnosis of this deficiency in patients presenting with male pseudohermaphroditism, primary or secondary amenorrhea, and mineralocorticoid excess syndrome.

Impacto da Resolução CFM 1.805/06 sobre os médicos que lidam com a morte / Impacto de la Resolución CFM 1.805/06 en Brasil acerca de los médicos quetratan de la muerte / Brazil´s CFM Resolution 1.805/06 impact on physicians dealing with death

A preservação da vida é considerada inerente à atuação médica, que pode aumentar a sobrevida do paciente com o uso de métodos tecnológicos. Surgem, então, questionamentos acerca dos aspectos éticos do prolongamento da vida, o que fomenta a criação da ResoluçãoCFM 1.805/06. O presente artigo decorre de pesquisa destinada a levantar o perfil dos médicos que atuam nos hospitais da Faculdade de Medicina de Marília (Famema), bem como apreender suas opiniões sobre eutanásia, distanásia e ortotanásia, considerando o disposto na citadaresolução, além de investigar os impactos desse documento sobre seu cotidiano profissional.

La preservación de la vida es considerada inherente a la actuación médica, que puede aumentar la supervivencia del paciente con la utilización de métodos tecnológicos. Eso plantea cuestionamientos sobre los aspectos éticos de la prolongación de la vida, lo que favorece lacreación de la Resolución CFM 1.805/06. El presente artículo se deriva de la investigación destinada a levantar el perfil de los médicos que trabajan en los hospitales de la Facultad de Medicina de Marília (Famema) así como aprender sus opiniones sobre eutanasia, distanasia e ortotanasia, teniendo en cuenta lo dispuesto en la resolución, además de investigar los impactos de ese documento sobre su cotidiano profesional.

The preservation of life is considered inherent to medical performance, which may increase patient?s survival through the usage of technological methods. This raises questions concerning the ethical aspects of prolonging life, which fosters the creation of CFM Resolution 1,805/06.This paper derives from (was created as a result of a) research aimed at raising physicians? profile working at Marilia Medical School hospitals (Famema), as well as seizing their opinion about euthanasia, dysthanasia and orthotanasia, regarding the provisions of resolution, and investigatingthe impact of such document over their professional routine.

O conhecimento dos estudantes da faculdade de medicina de Marília (Famema) sobre responsabilidade profissional e segredo médico / Medical students' knowledge concerning physician responsibility and patient confidentiality at the Marília School of Medicine in São Paulo State, Brazil

INTRODUÇÃO: O CFM INstituiu o Código de Ética Médica (CEM), cuja violação implica sanções, impondo aos profissionais a ele submetidos seu conhecimento e aplicação, por meio de conduta permeada pelos prima facie ducties. Conhecer o assunto torna-se condição básica para sua observação. Daí a importância deste ensino desde os primeiros anos do curso médico, fornecendo ao estudante capacidade de análise ética na prática profissional futura. OBJETIVOS: Avaliar o grau de conhecimento sobre as disposições do CEM relativas a "responsabilidade profissional" e "segredo médico" entre estudantes de Medicina da Famema e verificar se há evolução desse conhecimento durante a graduação. MÉTODO: Estudo realizado em dez meses, com 479 estudantes do primeiro ao sexto ano, regularmente matriculados. Aplicado questionário anônimo, com duas partes: uma com dados sociodemográficos e outra composta por 11 cenários clínicos, envolvendo questões eticamente conflituosas. RESULTADOS: 395 estudantes responderam o questionário (82,46 por cento da amostra inicial). Ao se comparar a média total de acertos entre as turmas nos cenários, encontrou-se o valor de p = 0,7148, sem significância estatística. CONCLUSÕES: Não há diferença estatisticamente significativa no grau de conhecimento sobre ética entre as séries. Sugere-se a introdução efetiva do assunto na graduação do curso médico, com metodologia de ensino adequada.

INTRODUCTION: The Brazilian National Board of Medicine (CFM) established the Medical Code of Ethics, the infringement of which involves sanctions and requires that physicians be familiar with and comply with it, by means of conduct governed by prima facie duties. Familiarity with the code is essential for adhering to it. Hence the importance of teaching the subject in the early years of undergraduate medical training, furnishing students with the skills for ethical analysis in their future professional practice. OBJECTIVES: Evaluate the degree of knowledge on the provisions of the Medical Code of Ethics concerning "physician responsibility" and "patient confidentiality" among students at the Marília School of Medicine in São Paulo State, Brazil, and verify possible trends and changes in this knowledge during their undergraduate training. METHOD: The study covered a ten-month period, with an initial sample of 479 medical students (first to sixth years) that were presented with an anonymous questionnaire in two parts: one with socio-demographic data and the other with 11 clinical scenarios involving ethically conflictive issues. RESULTS: 395 students answered the questionnaire (82.46 percent of the initial sample). Comparison of the overall average number of correct answers among the various undergraduate years showed a p-value of 0.7148, without statistical significance. CONCLUSIONS: We found no statistically significant difference in the degree of knowledge on medical ethics, when comparing the various years over the course of undergraduate medical training. The results thus suggest the need to introduce the subject of medical ethics into undergraduate medical education, with an appropriate didactic methodology.