Graves' disease, myxedema, and papillary thyroid carcinoma / Doença de Graves, mixedema e carcinoma papilífero de tireoide

Graves' disease (GD) is the leading cause of hyperthyroidism and diffuse toxic goiter in iodine-sufficient geographi-cal areas. GD is associated with classical manifestations such as ophthalmopathy and thyroid dermopathy, in addi-tion to diffuse goiter, which may be the site of carcinomas, as a complication. Case report: A 52-year-old woman presented with goiter and symptoms compatible with hyperthyroidism, such as heat intolerance, weight loss, fati-gue, increased sweat, tachycardia, fine tremors, increased intestinal transit, anxiety, emotional lability, insomnia, exophthalmos, and pretibial myxedema. A complementary investigation confirmed the diagnosis of hyperthyroidism (high free T4 and total T3 levels and low thyroid-stimulating hormone - TSH levels). Ultrasound images showed dif-fuse enlargement of the thyroid lobes by approximately 10 times and the presence of three thyroid nodules, one of which was larger than 2 cm with heterogeneous echogenicity and vascularization throughout the nodule; ultrasoun-d-guided fine needle aspiration revealed cytology compatible with Bethesda IV; scintigraphy revealed a low uptake area (cold nodule) amid a diffuse high-uptake goiter. A thyroidectomy was performed, and the anatomical specimen diagnosis revealed papillary thyroid carcinoma in the right lobe, with adjacent parenchyma compatible with GD. Histopathological examination of the skin showed the presence of myxedema compatible with Graves' dermopathy. The patient evolved with the normalization of TSH levels and a reduction of cutaneous manifestations. Conclusion:GD abnormalities may not be restricted to the classic clinical manifestations, and a careful investigation may reveal the coexistence of carcinomas. (AU)

A doença de Graves (DG) é a principal causa de hipertireoidismo e bócio difuso tóxico em áreas geográficas com iodo suficiente. DG está associada a manifestações clínicas clássicas como oftalmopatia e dermopatia da tireoide, além do bócio difuso, que pode ser sítio de carcinomas, como uma complicação. Relato de caso: Mulher de 52 anos apresentou bócio e sintomas compatíveis com hipertireoidismo como intolerância ao calor, emagrecimento, fadiga, sudorese aumentada, taquicardia, tremores finos, trânsito intestinal aumentado, ansiedade, labilidade emocional, insônia, exoftalmia e mixedema pré-tibial. A investigação complementar confirmou o diagnóstico de hipertireoidis-mo (níveis elevados de T4 livre e T3 total; níveis baixos de hormônio estimulante da tireoide - TSH). As imagens ultrassonográficas mostraram aumento difuso dos lobos tireoidianos em aproximadamente 10 vezes e a presença de três nódulos tireoidianos, um dos quais, maior que 2 cm, com ecogenicidade e vascularização heterogêneas em todo o nódulo, cuja punção aspirativa por agulha fina guiada por ultrassom revelou citologia compatível com Bethesda IV; e a cintilografia evidenciou uma área de baixa captação (nódulo frio) em meio a um bócio difuso de alta captação. Foi realizada tireoidectomia e o diagnóstico da peça anatômica revelou carcinoma papilífero de tir-eoide em lobo direito, com parênquima adjacente compatível com DG. O exame histopatológico da pele mostrou a presença de mixedema compatível com dermopatia de Graves. A paciente evoluiu com normalização dos níveis de TSH e redução das manifestações cutâneas. Conclusão: As anormalidades da DG podem não estar restritas às manifestações clínicas clássicas, e uma investigação criteriosa pode revelar a coexistência de carcinomas, (AU)

Diagnostic and therapeutic guidelines for plaque psoriasis - Brazilian Society of Dermatology

Abstract: Psoriasis is a chronic inflammatory disease that affects 1.3% of the Brazilian population. The most common clinical manifestations are erythematous, scaling lesions that affect both genders and can occur on any anatomical site, preferentially involving the knees, elbows, scalp and genitals. Besides the impact on the quality of life, the systemic nature of the disease makes psoriasis an independent risk factor for cardiovascular disease, especially in young patients with severe disease. By an initiative of the Brazilian Society of Dermatology, dermatologists with renowned clinical experience in the management of psoriasis were invited to form a work group that, in a partnership with the Brazilian Medical Association, dedicated themselves to create the Plaque Psoriasis Diagnostic and Treatment Guidelines. The relevant issues for the diagnosis (evaluation of severity and comorbidities) and treatment of plaque psoriasis were defined. The issues generated a search strategy in the Medline-PubMed database up to July 2018. Subsequently, the answers to the questions of the recommendations were devised, and each reference selected presented the respective level of recommendation and strength of scientific evidence. The final recommendations for making up the final text were worded by the coordinators.

The association between psoriasis and health-related quality of life, work productivity, and healthcare resource use in Brazil

Abstract: Background: Psoriasis is a chronic, immune mediated inflammatory condition that affects a significant amount of the global population. Yet geographic variability in the consequences of psoriasis warrants region-level analyses. Objective: The current study contributes to the psoriasis outcomes literature by offering a comprehensive assessment of the humanistic and economic burden in Brazil. Methods: The 2012 Brazil National Health and Wellness Survey (N=12,000) was used to assess health-related quality of life (Short Form-12, version 2), work productivity, and healthcare resource use associated with experiencing psoriasis vs. no psoriasis, along with varying levels of psoriasis severity. Results: A total of 210 respondents reported diagnosis of psoriasis (N=157, 42, and 11 reporting mild, moderate, and severe psoriasis, respectively). Compared with controls, respondents with psoriasis reported diminished mental component summary scores and health utilities, as well as increased presenteeism, activity impairment, and physician visits over the past six months, adjusting for covariates. Among those with psoriasis, physical health decreased as psoriasis severity increased. Although work productivity and healthcare resource utilization did not differ with psoriasis severity, the high rates of productivity loss (e.g. 45.5% presenteeism in the severe psoriasis group) suggest an economic burden. Study limitations: Cost analyses were not performed, and cross-sectional patient-reported data limit causal conclusions and may reflect reporting biases. Conclusions: Nevertheless, these results suggest a significant burden to patients with psoriasis across both humanistic and economic outcomes. The association between psoriasis and mental health aspects and health utilities were particularly strong and exceeded what would be considered clinically meaningful.

Metabolic syndrome, C-reactive protein and cardiovascular risk in psoriasis patients: a cross-sectional study

Abstract: Background: Psoriasis has been associated with co-morbidities and elevated cardiovascular risk. Objectives: To analyze the relationships among metabolic syndrome, cardiovascular risk, C-reactive protein, gender, and Psoriasis severity. Methods: In this cross-sectional study, plaque Psoriasis patients (n=90), distributed equally in gender, were analyzed according to: Psoriasis Area and Severity Index, cardiovascular risk determined by the Framingham risk score and global risk assessment, C-reactive protein and metabolic syndrome criteria (NCEPT-ATP III). Results: Metabolic syndrome frequency was 43.3% overall, without significance between genders (P=0.14); but women had higher risk for obesity (OR 2.56, 95%CI 1.02-6.41; P=0.04) and systemic arterial hypertension (OR 3.29, 95%CI 1.39-7.81; P=0.006). The increase in the Psoriasis Area and Severity Index also increased the risk for metabolic syndrome (OR 1.060, 95%CI 1.006-1.117; P=0.03). Absolute 10-year cardiovascular risk was higher in males (P=0.002), but after global risk assessment, 51.1% patients, 52.2% women, were re-classified as high-intermediate cardiovascular risk; without significance between genders (P=0.83). C-reactive protein level was elevated nearly six-fold overall, higher in metabolic syndrome (P=0.05), systemic arterial hypertension (P=0.004), and high-intermediate 10-year cardiovascular risk patients (P<0.001); positively correlated to: Framingham risk score (P<0.001; r=0.60), absolute 10-year cardiovascular risk (P<0.001; r=0.58), and age (P=0.001; r=0.35); but not to Psoriasis Area and Severity Index (P=0.14; r=0.16); increased the 10-year cardiovascular risk (R2=33.6; P<0.001), MetS risk (OR 1.17, 95%CI 0.99-1.37; P=0.05) and with age (P=0.001). HDL-cholesterol level was higher in normal C-reactive protein patients (t=1.98; P=0.05). Study limitations: Restricted sample, hospital-based and representative of a single center and no specification of psoriatic arthritis. Conclusions: Psoriasis, metabolic syndrome, systemic arterial hypertension and age share the increase in C-reactive protein, which could implicate in additional burden for increasing the cardiovascular risk and be an alert for effective interventions.

Atypical cellular blue nevus or malignant blue nevus?

Abstract: Blue nevus is a benign melanocytic lesion whose most frequent variants are dendritic (common) blue nevus and cellular blue nevus. Atypical cellular blue nevus presents an intermediate histopathology between the typical and a rare variant of malignant blue nevus/melanoma arising in a cellular blue nevus. An 8-year-old child presented a pigmented lesion in the buttock since birth, but with progressive growth in the last two years. After surgical excision, histopathological examination revealed atypical cellular blue nevus. Presence of mitoses, ulceration, infiltration, cytological atypia or necrosis may occur in atypical cellular blue nevus, making it difficult to differentiate it from melanoma. The growth of blue nevus is unusual and considered of high-risk for malignancy, being an indicator for complete resection and periodic follow-up of these patients.

Psoriasis comorbidities: complications and benefits of immunobiological treatment

Abstract During the last decade, different studies have converged to evidence the high prevalence of comorbidities in subjects with psoriasis. Although a causal relation has not been fully elucidated, genetic relation, inflammatory pathways and/or common environmental factors appear to be underlying the development of psoriasis and the metabolic comorbidities. The concept of psoriasis as a systemic disease directed the attention of the scientific community in order to investigate the extent to which therapeutic interventions influence the onset and evolution of the most prevalent comorbidities in patients with psoriasis. This study presents scientific evidence of the influence of immunobiological treatments for psoriasis available in Brazil (infliximab, adalimumab, etanercept and ustekinumab) on the main comorbidities related to psoriasis. It highlights the importance of the inflammatory burden on the clinical outcome of patients, not only on disease activity, but also on the comorbidities. In this sense, systemic treatments, whether immunobiologicals or classic, can play a critical role to effectively control the inflammatory burden in psoriatic patients.

Princípios básicos de desenho curricular para cursos das profissões da saúde / Basic principles to curriculum design on health professions education (HPE)

Nesta revisão são discutidos os aspectos conceituais e princípios básicos para a construção de currículos para os cursos de graduação das profissões da saúde. Serão abordados alguns modelos, fundamentos e passos essenciais para a construção de currículos, em paralelo ao contexto das Diretrizes Curriculares Nacionais. No planejamento e na organização dos currículos, é destacada a relevância do comprometimento do professor, aluno e equipe; do emprego de estratégias apropriadas no processo de ensino-aprendizagem e dos instrumentos de avaliação que possam contribuir para a revisão e melhorias do currículo proposto.

In this review we present the concepts and the basic principles for curriculum design in health professions education (HPE), and present some curriculum design models as well as the essential steps for those who are facing this challenge. All the discussion brings the perspective of National Curriculum Guidelines for HPE in Brazil. It is highlighted the importance of the stakeholders’ engagement in this process and the correct use of appropriate strategies of teaching-learning, students’ assessment tools that can contribute to the implementation/review and improvement of curriculum in HPE courses.

Estratégias inovadoras para métodos de ensino tradicionais: aspectos gerais / New approaches to traditional learning: general aspects

Novos desafios se impõem nos cenários atuais da educação e currículos universitários altamente complexos. Para atender as demandas sociais, transformações na educação de profissionais de saúde enovas formas de trabalhar com o conhecimento foram exigidas do aparelho formador. Nesse artigo serão discutidos: o avanço em diferentes âmbitos, as características e obstáculos para a ruptura com a estrutura tradicional e a implantação de metodologias de ensino-aprendizagem inovadoras, sob a perspectiva institucional, do docente e do aluno.

New challenges are needed in today’s educational settings and highly complex university curricula. To meet the social demands, changes in health professional education and new ways of working with knowledge of the educational institutions were required. In this article will be discussed: the advancement indifferent spheres, characteristics and barriers to break with the traditional structure and implementation of innovative teaching methodologies and learning. The institutional, the teacher and the student perspectives of this process will be discussed.

Linfoma subcutâneo de células T paniculite-símile: [relato de caso] / Subcutaneous panniculitis-like T-cell lymphoma: [case report]

Linfoma subcutâneo de células T paniculite-símile foi recentemente reconhecido como entidade clínico-patológica. Paciente do sexo feminino, 17 anos, relatou nodosidades eritêmato-violáceas e depressões nos membros e abdome há três anos e discreta perda ponderal, sem outros sintomas gerais. Adenomegalia, visceromegalias e infiltração da medula óssea estavam ausentes, e a histopatologia da pele mostrou densa infiltração de linfócitos atípicos CD3/CD8 no subcutâneo. A quimioterapia interrompeu o surgimento de novas lesões com remissão das pré-existentes no seguimento de oito meses. Aspectos imunofenotípicos e moleculares são relevantes para elucidação diagnóstica e avaliação do prognóstico.

Subcutaneous panniculitis-like T-cell lymphoma is extremely rare and has recently been recognized as a clinicopathological entity. Young female, 17 years old, has complained of subcutaneous nodules and plaques in the limbs and abdomen for three years, accompanied of mild weight loss without other constitutional symptoms. Nodal, visceral and bone marrow involvement was absent, and subcutaneous CD3/CD8 atypical lymphocyte infiltration was observed in the skin sample. Chemotherapy interrupted the onset of new lesions and led to remission in the 8-month follow-up. Immunophenotypic and molecular aspects were relevant to the diagnosis and as prognosis makers.

Double-blind, crossover, placebo-controlled clinical trial with clobetasol propionate in desquamative gingivitis

The aim of this study was to evaluate the efficacy of a 0.05 percent clobetasol propionate ointment administered in trays to 22 patients with desquamative gingivitis in a double-blind, crossover, placebo-controlled trial. Patients received container number 1 and were instructed to apply the ointment 3 times a day for 2 weeks, and to reduce the application to once a day in the third week. Next, the patients were then instructed to discontinue the treatment for 2 weeks, and were then given container 2, used in the same way and for the same length of time as container 1. Regarding signs, 17 patients presented some improvement, while 5 experienced worsening with clobetasol propionate. With the placebo, 14 patients presented some improvement, and 8 patients presented worsening. For symptoms, there was complete improvement in 2 patients, partial improvement in 12, no response in 7, and worsening in 1 with clobetasol propionate. With the placebo, there was partial improvement in 8 patients, no response in 12 and worsening in 2. No statistically significant difference was found between clobetasol and placebo (p>0.05). Within the period designed to treat the gingival lesions of the patients, clobetasol propionate did not significantly outperform the placebo.

O objetivo deste estudo foi avaliar a eficácia do propionato de clobetasol a 0,05 por cento administrada com moldeiras em 22 pacientes com gengivite descamativa por meio de estudo duplo-cego, cruzado, placebo-controlado. Pacientes receberam bisnaga número 1 e foram instruídos a aplicar a pomada 3 vezes ao dia por um período de 2 semanas, e reduzir a aplicação para 1 vez ao dia na terceira semana. Os pacientes foram instruídos a suspender o tratamento por 2 semanas, e então receberam a bisnaga 2, usando-a da mesma maneira que o container 1. Com relação aos sinais, 17 pacientes apresentaram alguma melhora, enquanto 5 apresentaram piora com o propionato de clobetasol. Com o uso do placebo, 14 pacientes apresentaram alguma melhora, e 8 pacientes apresentaram piora do seu quadro clínico. Com relação aos sintomas, houve completa melhora em 2 pacientes, melhora parcial em 12, ausência de resposta em 7, e piora em 1 pacientes durante o uso do propionato de clobetasol. Com o uso do placebo, houve melhora parcial em 8 pacientes, ausência de resposta em 12 e piora dos sintomas em 2 pacientes. Não foi verificada diferença estatisticamente significante em nenhum dos parâmetros entre o uso do clobetasol e placebo; p>0,05. Baseado no protocolo utilizado neste grupo de pacientes, o propionato de clobetasol não demonstrou efetividade significante quando comparado ao placebo.

A terapia fotodinâmica com ácido 5-aminolevulínico como modalidade de tratamento para neoplasias cutâneas não-melanoma / Topical 5-aminolevulinic acid photodynamic therapy as a treatment modality for nonmelanoma skin cancer

FUNDAMENTOS: A terapia fotodinâmica baseia-se na associação de fonte de luz e fotossensibilizador para destruir seletivamente as células. OBJETIVO: Avaliar os efeitos imediatos e tardios, a resposta clínica e os resultados estéticos da terapia fotodinâmica com ácido 5-aminolevulínico em neoplasias cutâneas não-melanoma. MÉTODOS: Trinta e quatro lesões, sendo 19 disceratoses de Bowen e 15 carcinomas basocelulares, foram submetidas à aplicação tópica e oclusiva do ácido 5-aminolevulínico a 20 por cento, por seis horas, e posteriormente a sessão única de laser de diodo (630nm). RESULTADOS: Foram registrados: sensação de queimação durante as sessões; eritema, edema e erosões, nas primeiras 72 horas; cicatrização em média de quatro semanas; resultados estéticos variáveis de excelentes a bons. Aos três meses, a resposta clínica foi de 91,2 por cento, sendo reduzida, aos 18 meses, para 73,3 por cento, de modo similar tanto para disceratose de Bowen (72,2 por cento) quanto para carcinoma basocelular (75 por cento). Foi evidenciada relação de tendência linear entre a redução da freqüência da resposta clínica e o aumento da dimensão das neoplasias cutâneas não-melanoma (p<0,001). CONCLUSÃO: A terapia fotodinâmica com ácido 5-aminolevulínico tópico mostrou destacadas vantagens: minimamente invasiva no tratamento de lesões múltiplas em sessão única ou em sítios de pobre cicatrização com superioridade dos resultados estéticos. O tipo/subtipo(clínico e histopatológico), a dimensão e o adequado seguimento devem ser considerados para a sua indicação no tratamento de neoplasias cutâneas não-melanoma.

BACKGROUND: Photodynamic therapy is based on the association of a light source and photosensitizer in order to selectively destroy cells. OBJECTIVE: To evaluate the short and long-term effects, clinical response, and cosmetic outcome of the photodynamic therapy with 5-aminolaevulinic acid for non-melanoma skin cancer. METHODS: TThirty-four non-melanoma skin cancer - 19 Bowen’s diseases and 15 basal cell carcinomas, were submitted to a single 6-hour topical and occlusive application of 20 percent 5-aminolaevulinic acid, and were later exposed to 630 nm diode laser single session. RESULTS: Burning sensation during the session; erythema, edema and erosions in the first 72 hours; healing process after 4 weeks on average and excellent or good cosmetic results were observed. After 3 months, tumor-free rate was 91.2 percent whereas at 18 months,73.3 percent, similarly in Bowen’s disease (72.2 percent) and basal cell carcinoma (75 percent). It was noticed a linear relation between the reduction in complete clinical response frequency and the increase in tumor dimension (p<0.001). CONCLUSION: The 5-aminolaevulinic acid photodynamic therapy showed significant advantages such as minimally invasive for the treatment of multiple lesions in only one session or lesions in poor healing sites with superior esthetical outcome. The clinical and histopathological type/sub-type, the dimension and an appropriate follow-up must be considered to indicate topical 5-aminolaevulinic acid photodynamic therapy for non-melanoma skin cancer.

Terapia fotodinâmica com ftalocianina de zinco tópica: avaliação da intensidade de fluorescência, absorção cutânea, alterações histológicas e imuno-histoquímicas na pele do modelo animal / Topical photodynamic therapy with zinc phthalocyanine: evaluation of fluorescence intensity, skin absorption, skin histological and immunohistochemical changes in animal model

FUNDAMENTOS - Ftalocianinas são promissores agentes fotossensibilizadores na terapia fotodinâmica (TFD). OBJETIVOS - Avaliar intervalos, veículos e a incorporação de promotor de absorção na formulação tópica da ftalocianina de zinco (FC-Zn). Avaliar alterações macro e micromorfológicas e a expressão de Fas promovidas pela TFD com FC-Zn tópica no modelo murino. MÉTODOS - Por meio da espectrometria de fluorescência, foram avaliadas combinações de diferentes períodos de oclusão tópica das formulações gel ou emulsão de FC-Zn (1mg/dl), com ou sem monoleína 5 por cento, no dorso do camundongo hairless. Após oito horas das diferentes formulações, os camundongos foram expostos ao laser de diodo de 670nm, dose de 50J/cm-². RESULTADOS - A fluorescência foi discretamente superior após oito horas e com a emulsão nos intervalos de uma, duas e quatro horas de oclusão. A intensidade do edema e da erosão correspondeu à necrose da epiderme e à imunoexpressão de Fas nos cortes histológicos de pele. CONCLUSÕES - Os achados indicam a ação fotodinâmica promovida pela interação entre FC-Zn e fonte de luz de 670nm. As alterações macro e micromorfológicas foram correspondentes e mais substanciais com a emulsão FC-Zn e monoleína, sugerindo a acentuação dos efeitos com essa formulação. A imunoexpressão de Fas e as alterações histológicas sugeriram a apoptose como mecanismo de morte celular na TFD com FC-Zn tópica.

BACKGROUND - Phthalocyanines are promising photosensitizers used in photodynamic therapy (PDT). OBJECTIVES - To evaluate the following parameters: intervals, vehicles and enhancer using topical zinc-phthalocyanine (Zn-PC) formulation. To examine macro and micromorphological changes and Fas expression induced by topical Zn-PC-PDT on murine skin. MATERIAL AND METHODS - Using fluorescence spectrometry, different intervals of topical occlusion employing Zn-PC gel or emulsion, with or without monolein 5 percent were studied. After an 8-hour occlusion of different formulations, the mice were exposed to 670 nm laser, at a 50 J.cm-² dose. RESULTS - Fluorescence was slightly higher after 8 hours, and also with emulsion formulation at one-, two- and four-hour occlusion periods. The intensity of edema and erosion were correlated to epidermal necrosis and to Fas immunoexpression in skin histological specimens. CONCLUSIONS - The results show the effects of photodynamic action promoted by the interaction between Zn-PC formulation and a 670-nm light source. Macro and micromorphological alterations were correlated and more substantial with monolein and Zn-PC emulsion, suggesting more marked effects with this formulation. The Fas immunoexpression and histological changes suggested that apoptosis plays a role in the mechanism of cell death caused by PDT based in Zn-PC.

Corticosteróide tópico oclusivo no tratamento de manifestações gengivais de doenças vesicobolhosas auto-imunes / Topical occlusive corticosteroid for the treatment of gingival manifestations of vesicobullous autoimmune diseases

O tratamento das lesões gengivais de doenças vesicobolhosas auto-imunes constitui grande desafio na estomatologia, principalmente pela natureza crônica das lesões. O tratamento sistêmico é necessário no controle das apresentações mais graves; entretanto, quando possível, o tratamento tópico é preferível. Este artigo descreve uma técnica oclusiva para aplicação de corticosteróide tópico que tem demonstrado ser eficaz no controle dessas lesões, sobretudo em pacientes com manifestações exclusivamente gengivais.

Infecções de tecidos moles: erisipela, celulite, síndromes infecciosas mediadas por toxinas / Soft tissue infections: erysipela, cellulitis, infectious syndromes mediated by toxins

Pacientes com aids são freqüentemente atendidos em serviços de emergências. Com o objetivo de sistematizar o atendimento de urgência a tais pacientes, são apresentadas, no presente trabalho, as normas gerais de conduta para a abordagem inicial do caso, bem como as complicações mais comuns, verificadas em nosso meio. São abordados ainda os processos infecciosos mais freqüentes, com ênfase na apresentação clínica, no diagnóstico laboratorial e no tratamento