Distúrbio de movimento por conta de estado hiperosmolar não cetótico em idosa: relato de caso / Movement disorder caused by hyperosmolar hyperglycemic state in an older adult: a case report

O diabetes e suas complicações constituem as principais causas de mortalidade precoce na maioria dos países. O envelhecimento da população e a crescente prevalência da obesidade e do sedentarismo, além dos processos de urbanização, são considerados os principais fatores responsáveis pelo aumento da incidência e da prevalência do diabetes mellitus (DM) em todo o mundo. Este relato de caso objetiva descrever a presença de distúrbio do movimento em idoso por conta do estado hiperosmolar não cetótico. A combinação de hemicoreia-hemibalismo, hiperglicemia não cetótica e envolvimento dos gânglios da base em exames de imagem é considerada uma síndrome única. Os distúrbios do movimento em estado hiperosmolar não cetótico apresentam resposta terapêutica satisfatória com o uso de neurolépticos e controle glicêmico adequado. A escassez de trabalhos publicados proporciona subdiagnósticos clínico e laboratorial, interferindo no prognóstico e no acompanhamento dos pacientes.

Diabetes mellitus (DM) and its complications constitute the leading causes of early mortality in most countries. Population aging and the growing prevalence of obesity and sedentary lifestyles, in addition to spreading urbanization, are considered the main drivers of the increasing incidence and prevalence of DM worldwide. This case report describes the acute onset of movement disorder in an older woman secondary to hyperosmolar hyperglycemic state (HHS). The combination of hemichorea­hemiballismus, HHS, and evidence of basal ganglia involvement on neuroimaging is considered a unique syndrome. Movement disorders secondary to HHS respond satisfactorily to administration of neuroleptic agents and proper glycemic control. The lack of published studies on this pathologic entity may lead to clinical and laboratory underdiagnosis, with negative impacts on patient prognosis and follow-up.

Risk of Malignancy in Thyroid Nodules Using the American College of Radiology Thyroid Imaging Reporting and Data System in the NIFTP Era.

Recently, the American College of Radiology (ACR) proposed a Thyroid Imaging Reporting and Data System (TI-RADS) for thyroid nodules based on ultrasonographic features. It is important to validate this classification in different centres. The present study evaluated the risk of malignancy in solid nodules>1 cm using ACR TI-RADS. The risk of malignancy was defined including noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) and after its exclusion from malignant tumours. For the present study, the original images were revised, and each nodule was assigned to one of the TI-RADS levels proposed for solid nodules: TR3, TR4, or TR5. This risk of malignancy was significantly different for the three levels: 1.7%, 11.2%, and 60.6% for TR3, TR4, and TR5, respectively, when NIFTP was included, and 0.6%, 7.9%, and 60.2% for TR3, TR4, and TR5, respectively, when NIFTP was excluded from malignant tumours. The nodules corresponding to NIFTP were classified according to ACR as TR3 in 28.5% of cases, TR4 in 67.8%, and TR5 in only 3.5%. The nodules corresponding to cancer were classified according to ACR as TR3 in only 2.3% of cases, TR4 in 27%, and TR5 in 70.5%. In conclusion, this study shows the validity of the ACR TI-RADS for solid thyroid nodules, even after the exclusion of NIFTP from malignant tumours.

Is Doppler ultrasound of additional value to gray-scale ultrasound in differentiating malignant and benign thyroid nodules?

The objective of this study was to evaluate whether Doppler ultrasound (DUS) is of additional value to gray-scale ultrasound (GSUS) in predicting the benign or malignant nature of thyroid nodules. A total of 1,502 solid thyroid nodules ≥ 10 mm were evaluated. Suspicious vascularity (predominantly or exclusively central blood flow) was observed in only 5% of the nodules. This finding showed 96% specificity, but only 15% sensitivity. GSUS alone showed sensitivity and specificity of 88.7% and 68.2%, respectively, which did not improve with the addition of DUS (sensitivity of 89.4% and specificity of 66.4%). In non-suspicious nodules on GSUS, the type of vascularity on DUS did not modify the risk of malignancy, which was low. In suspicious nodules on GSUS, suspicious vascularity on DUS increased the risk of malignancy, but non-suspicious vascularity did not reduce this risk. DUS provided no additional value to GSUS in predicting the benign or malignant nature of thyroid nodules.

Is Doppler ultrasound of additional value to gray-scale ultrasound in differentiating malignant and benign thyroid nodules?

The objective of this study was to evaluate whether Doppler ultrasound (DUS) is of additional value to gray-scale ultrasound (GSUS) in predicting the benign or malignant nature of thyroid nodules. A total of 1,502 solid thyroid nodules ≥ 10 mm were evaluated. Suspicious vascularity (predominantly or exclusively central blood flow) was observed in only 5% of the nodules. This finding showed 96% specificity, but only 15% sensitivity. GSUS alone showed sensitivity and specificity of 88.7% and 68.2%, respectively, which did not improve with the addition of DUS (sensitivity of 89.4% and specificity of 66.4%). In non-suspicious nodules on GSUS, the type of vascularity on DUS did not modify the risk of malignancy, which was low. In suspicious nodules on GSUS, suspicious vascularity on DUS increased the risk of malignancy, but non-suspicious vascularity did not reduce this risk. DUS provided no additional value to GSUS in predicting the benign or malignant nature of thyroid nodules. Arch Endocrinol Metab. 2015;59(1):79-83.

Prevalência de Síndrome metabólica em mulheres climatéricas / Prevalence of metabolic Syndrome in menopausal women

Fundamentos: Apesar da importância da síndrome metabólica no contexto das doenças metabólicas e cardiovasculares, tanto a sua prevalência como demais características epidemiológicas ainda são pouco conhecidas no climatério. Objetivos: Identificar a presença de síndrome metabólica em mulheres no climatério e correlacionar com os fatores sociodemográficos, clínicos e antropométricos. Métodos: Estudo transversal e descritivo com 85 mulheres climatéricas, realizado no período de maio a junho 2013 no Núcleo de Atenção à Saúde e de Práticas Profissionalizantes (NASPP) das Faculdades Integradas Pitágoras (FIPMoc). Foi avaliada a presença de síndrome metabólica (SM) segundo os critérios da International Diabetes Federation (IDF) e análise sanguínea laboratorial. Para a avaliação dos dados sociodemográficos e clínicos aplicou-se um questionário. Os dados antropométricos foram avaliados pelo índice de massa corpórea (IMC) e pela circunferência abdominal (CA). Realizada análise descritiva dos dados, expressos em médias e porcentagens; utilizados os testes binominal e de Spearman para a correlação das variáveis, considerando-se o nível de significância de 5 %. Resultados: SM foi encontrada em 50,6 % das mulheres. Os componentes mais frequentes foram: HDL-colesterol baixo (61,2 %) e circunferência abdominal elevada (85,9 %). Os outros fatores determinantes da síndrome, isoladamente, não foram significativos, porém a SM apresentou correlação moderada com os fatores determinantes.

Background: Despite the importance of metabolic syndrome in the context of metabolic and cardiovascular diseases, its prevalence during the climacteric and other epidemiological characteristics are still little known.Objectives: To identify the presence of metabolic syndrome in menopausal women, correlated with socio-demographic, clinical and anthropometric factors.Methods: Cross-sectional descriptive study of 85 menopausal women conducted in May-June 2013 at the Center for Health Care and Vocational Practice (NASPP), Faculdades Integradas Pitágoras college (FIPMoc). The presence of metabolic syndrome (MS) was assessed in compliance with the criteria established by the International Diabetes Federation (IDF) and laboratory blood analyses, using a questionnaire to assess socio-demographic and clinical data. Anthropometric data were assessed by Body Mass Index (BMI) and Waist Circumference (WC). A descriptive analysis of the data was performed, expressed as means and percentages, using the binomial and Spearman tests to correlate the variables, with a significance level of 5%.Results: MS was found in 50.6% of the women, with the most common components being low HDL cholesterol (61.2%) and large waist circumference (85.9%). The other syndrome determinants were not significant individually, although MS showed moderate correlation with the determinants.

Preparation with recombinant human thyroid-stimulating hormone for thyroid remnant ablation with 131I is associated with lowered radiotoxicity.

UNLABELLED: Preparation with recombinant human thyroid-stimulating hormone (rhTSH) for thyroid remnant ablation results in lower extrathyroidal radiation than does hypothyroidism. The objective of this prospective study was to compare the damage caused by 131I (3.7 GBq) when these 2 preparations are used. METHODS: Ninety-four consecutive patients who underwent total thyroidectomy and remnant ablation with 3.7 GBq of 131I were studied. Thirty patients (group A) received rhTSH, and 64 (group B) were prepared by levothyroxine withdrawal. Damage to salivary glands, ovaries, and testes; hematologic damage; and oxidative injury were evaluated by measurement of serum amylase, follicle-stimulating hormone (FSH), complete blood count, and plasma 8-epi-PGF2alpha before and after radioiodine. The 2 groups were similar in sex, age, and the results of baseline assessment. RESULTS: The rate of successful ablation (stimulated thyroglobulin level < 1 ng/mL and negative findings on neck ultrasonography) was 90% in group A and 80% in group B. Considering only patients with a preablation thyroglobulin level greater than 1 ng/mL, these rates were 80% and 70.6%, respectively. Only 1 patient (3.3%) reported transient headaches with rhTSH. Elevated FSH levels after therapy were observed in 4 of 9 (44%) men in group A versus 16 of 18 (89%) in group B (P < 0.03), with a mean increase of 105% versus 236% (P < 0.001), respectively. In women, elevated FSH was observed in 1 of 13 (7.7%) patients in group A versus 6 of 30 (20%) in group B (P = 0.4), with a mean increase of 65% versus 125% (P < 0.001). Thrombocytopenia or neutropenia occurred in 2 of 28 (7%) patients in group A versus 12 of 56 (21.4%) in group B (P = 0.1), with a mean decrease of 20% versus 45% and 25% versus 52% (P < 0.01) for neutrophils and platelets, respectively. Hyperamylasemia and symptoms of acute sialoadenitis occurred in 11 of 30 (36.6%) versus 48 of 60 (80%) (P < 0.001) and in 9 of 30 (30%) versus 35 of 60 (58.3%) (P = 0.01), respectively. 8-Epi-PGF2alpha was found to be elevated after 131I in 14 of 25 (56%) patients in group A versus 45 of 45 (100%) in group B (P < 0.001), with a mean increase of 60% versus 125% (P < 0.001). CONCLUSION: The lower radiotoxicity with rhTSH, suggested in dosimetry studies, was confirmed in the present prospective investigation, and this advantage occurred without compromising the efficacy of treatment.

Carcinoma medular de tireóide: abordagem para prática clínica / Medullary thyroid carcinoma: na approach to clinical practice

O carcinoma medular da tireóide (CMT) representa 5 por cento dos tumores malignos dessa glândula e aproximadamente 25 por cento são hereditários, estes associados a mutações no proto-oncogene RET e ocasionalmente a outras neoplasias endócrinas (feocromocitona hiperparatireoidismo). O rastreamento familiar seguido da tireoidectomia naqueles com mutação no RET evita o aparecimento da doença em muitos indivíduos. O CMT esporático geralmente se apresenta como nódulo palpável ou já com sintomas de extensão extratireoidiana. Hipercalcitoninemia ocorre invariavelmente na doença clinicamente aparente. Recomenda-se tireoidectomia total com ressecção bilateral de lifonodos como tratamento inicial e, ocasionalmente, radioterapia, mas não (131) como terapia adjuvante. O seguimento é feito com as dosagens de CT e CEA, com realização de métodos de imagens nos pacientes com marcadores elevados. Presença de metástases linfonodais extensas e invasão extratireoidiana são fatores associados à menor chance de cura bioquímica (CT indetectável). Quando esta é alcançada, a sobrevida livre de doença em longo prazo é de 95 por cento.

Ultrasonographic differentiation between metastatic and benign lymph nodes in patients with papillary thyroid carcinoma.

OBJECTIVE: The purpose of this study was to evaluate the ultrasonographic characteristics of metastatic lymph nodes in patients with papillary thyroid carcinoma. METHODS: The ultrasonographic characteristics of lymph nodes were analyzed in 112 consecutive patients who underwent thyroidectomy and lymph node dissection, with the diagnosis being confirmed by anatomopathologic examination. RESULTS: A total of 198 lymph nodes were metastatic, and 152 were benign (normal or with nonspecific lymphadenitis). Minimum axial diameters of 7 mm for level II (upper internal jugular chain) and 6 mm for the rest of the neck were observed in 93% of metastatic lymph nodes, absence of an echogenic hilum in 88%, hyperechogenicity in relation to the adjacent muscles in 86%, a round shape in 80%, calcifications in 49.5%, and intranodal cystic necrosis in 20%. These ultrasonographic characteristics were observed in 17%, 10%, 4.5%, 29.5%, 0%, and 0% of benign lymph nodes, respectively. CONCLUSIONS: Even basic ultrasonographic characteristics (shape, echogenicity and echogenic hilum, calcifications, and intranodal cystic necrosis) help in the differentiation between metastatic and nonmetastatic lymph nodes in patients with papillary thyroid carcinoma.

Is stimulation of thyroglobulin (Tg) useful in low-risk patients with thyroid carcinoma and undetectable Tg on thyroxin and negative neck ultrasound?

OBJECTIVE: To determine the usefulness of thyroglobulin (Tg) stimulation in low-risk patients with undetectable Tg on T4 and negative neck ultrasound (US) after initial therapy of thyroid carcinoma. METHODS: We evaluated 122 consecutive patients classified as low risk 6 months to 1 year after total thyroidectomy and remnant ablation. All patients had a normal clinical exam, Tg < or = 1 ng/ml during suppressive therapy (TSH < 0.1 mIU/l), and undetectable antithyroglobulin antibodies. RESULTS: After T4 withdrawal and elevation of TSH to values > 30 mIU/l, 26 patients (21.3%) converted Tg to levels > 1 ng/ml. Metastases were detected in 10 patients, nine showing stimulated Tg levels > 1 ng/ml. Cervical metastases were observed in 9/10 patients and lung metastases in one patient. Neck US identified all cervical metastases. Seventeen patients with stimulated Tg levels > 1 ng/ml initially showed no apparent disease, with a reduction in Tg being observed upon subsequent measurements, and 13 patients presented undetectable Tg off T4 at the end of the study. Undetectable Tg on T4 showed a high negative predictive value (NPV; 91.8%), which increased to 99.1% when combined with neck US. Stimulated Tg levels < 1 ng/ml presented a 98.9% NPV. A total of 113 patients with undetectable Tg on T4 and negative US had to be exposed to hypothyroidism in order to diagnose one further case of metastases. CONCLUSION: Undetectable Tg on T4 combined with negative neck US presented a high NPV in low-risk patients and Tg stimulation might be avoided in these patients.