COVID-19 recurrence is related to disease-early profile T cells while detection of anti-S1 IgG is related to multifunctional T cells.

COVID-19 is caused by SARS-CoV-2 infection and leads from asymptomatic to severe outcomes. The recurrence of the COVID-19 has been described, however, mechanisms involved remains unclear. Thus, the work aimed to investigate the role of multifunctional T cells in patients with recurrent COVID-19. We evaluated clinical characteristics, presence of anti-S1 and anti-Nucleocapsid IgG in patients' sera, and multifunctional T cells (for IFN-γ, IL-2, and TNF-α) in patients with multiple episodes of COVID-19 and controls. Data demonstrate that patients with recurrent COVID-19 have a T cell pattern predominantly related to IFN-γ production. Also, patients with COVID-19 history and absence of anti-S1 IgG had lower levels of CD4+ IFN + IL-2 + TNF + T cells independently of number of disease episodes. Complementary, vaccination changed the patterns of T cells phenotypes and induced IgG seroconversion, despite not induce higher levels of multifunctional T cells in all patients. In conclusion, the data suggest that recurrent disease is related to early-disease T cell profile and absence of anti-S1 IgG is related to lower multifunctional CD4 T cell response, what suggests possibility of new episodes of COVID-19 in these patients.

Choosing Wisely for Thyroid Conditions: Recommendations of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism

ABSTRACT Objective: Choosing Wisely (CW) is an initiative that aims to advance the dialogue between physicians and patients about low-value health interventions. Given that thyroid conditions are frequent in clinical practice, we aimed to develop an evidence-based list of thyroid CW recommendations. Materials and methods: The Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) named a Task Force to conduct the initiative. The Task Force work was based on an electronic Delphi approach. The 10 recommendations that received the highest scores by the Task Force were submitted for voting by all SBEM associates. The 5 recommendations that received the highest scores by SBEM associates are presented herein. Results: The Task Force was composed of 14 thyroidologists from 10 tertiary-care, teaching-based Brazilian institutions. The brainstorming/ideation phase resulted in 69 recommendations. After the removal of duplicates and recommendations that did not adhere to the initiative's scope, 35 remained. Then the Task Force voted to attribute a grade (0 [lowest agreement] to 10 [highest agreement]) for each recommendation. The 10 recommendations that received the highest scores by the Task Force were submitted to all SBEM associates. A total of 683 associates voted electronically, attributing a grade (0 to 10) for each recommendation. The 5 recommendations that received the highest scores by the SBEM associates compose our final list. Conclusion: A set of recommendations to avoid unnecessary medical tests, treatments, or procedures for thyroid conditions are offered with a transparent methodology. This initiative aims to foster productive interactions between physicians and patients, stimulating shared decision-making.

Choosing Wisely for Thyroid Conditions: Recommendations of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism.

OBJECTIVE: Choosing Wisely (CW) is an initiative that aims to advance the dialogue between physicians and patients about low-value health interventions. Given that thyroid conditions are frequent in clinical practice, we aimed to develop an evidence-based list of thyroid CW recommendations. METHODS: The Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) named a Task Force to conduct the initiative. The Task Force work was based on an electronic Delphi approach. The 10 recommendations that received the highest scores by the Task Force were submitted for voting by all SBEM associates. The 5 recommendations that received the highest scores by SBEM associates are presented herein. RESULTS: The Task Force was composed of 14 thyroidologists from 10 tertiary-care, teaching-based Brazilian institutions. The brainstorming/ideation phase resulted in 69 recommendations. After the removal of duplicates and recommendations that did not adhere to the initiative's scope, 35 remained. Then the Task Force voted to attribute a grade (0 [lowest agreement] to 10 [highest agreement]) for each recommendation. The 10 recommendations that received the highest scores by the Task Force were submitted to all SBEM associates. A total of 683 associates voted electronically, attributing a grade (0 to 10) for each recommendation. The 5 recommendations that received the highest scores by the SBEM associates compose our final list. CONCLUSION: A set of recommendations to avoid unnecessary medical tests, treatments, or procedures for thyroid conditions are offered with a transparent methodology. This initiative aims to foster productive interactions between physicians and patients, stimulating shared decision-making.

Palliative care: A proposal for undergraduate education in Medicine / Cuidados paliativos: Uma proposta para o ensino da graduação em Medicina

Objective: to propose essential competencies for the teaching of palliative care on undergraduate Medicine courses. Method: a documentary analysis of the literature on general competencies in palliative care was initially carried out, to construct a framework with suggestions of essential competencies for undergraduate education in Brazil. The elaborated material was then presented individually to eight professionals from a range of areas for analysis. All the professionals had specialized training in palliative care, and the material was accompanied by an interview with three open questions. The categorical thematic content analysis proposed by Bardin was used in the documentary analysis and the interviews with the professionals. Results: the initial documentary analysis resulted in five categories, eight subcategories and 96 units of analysis, based on which the researcher was able to construct the suggestions for competences, which were distributed with their respective contents in a framework with five modules. Six categories, 12 subcategories and 168 analysis units emerged from the interviews with the professionals following a reading of the material. From the discourse contained in the subcategories and units of analysis, suggestions emerged for a better distribution of the modules, resulting in the renaming of the same (Basic principles of palliative care, Symptom management, Teamwork, Ethical and legal issues, Care in the last moments of life). Conclusion: the discussion and improvement of the palliative care competencies suggested in this study will be essential at medical education forums, providing clarity about what is really required in general practitioner training.

Objetivo: Propor competências essenciais para o ensino de Cuidados Paliativos nos cursos de graduação em Medicina. Método: Inicialmente, foi feita uma análise documental na literatura sobre competências gerais em Cuidados Paliativos, no sentido de construir um quadro com sugestões de competências essenciais para o ensino de graduação no Brasil. A seguir, o material elaborado foi apresentado individualmente a oito profissionais com formação especializada em cuidados paliativos de diferentes áreas para análise, acompanhado de uma entrevista com três questões abertas. Na análise documental e nas entrevistas com os profissionais, foi utilizada a análise de conteúdo temática categorial proposta por Bardin. Resultados: A análise documental inicial resultou em cinco categorias, oito subcategorias e 96 unidades de análise que deram subsídio ao pesquisador para construção das sugestões de competências, distribuídas num quadro em cinco módulos, com seus respectivos conteúdos. Das entrevistas com os profissionais, após leitura do material que lhes foi entregue, emergiram seis categorias, 12 subcategorias e 168 unidades de análise. Das falas contidas nas subcategorias e unidades de análise, emergiram sugestões para melhor distribuição dos módulos, resultando na renomeação destes (Princípios básicos dos Cuidados Paliativos, Manejo de sintomas, Trabalho em Equipe, Questões Éticas e Legais, Assistência nos Últimos Momentos de Vida). Conclusão: A discussão e aprimoramento das competências em Cuidados Paliativos sugeridas nesse estudo serão essenciais durante os fóruns de educação médica, para que possamos ter mais clareza do que realmente é necessário para a formação do médico generalista.

Neuropsychiatric symptoms and severity of dementia / Sintomas neuropsiquiátricos e gravidade da demência

Neuropsychiatric symptoms (NPS) cause distress, disabilitiy and reduced quality of life for both the patient and their families OBJECTIVE: To evaluate the prevalence of NPS as a specific stage of dementia status. METHODS: A cross-sectional study in patients attending an outpatient clinic for dementia was performed. We applied the Neuropsychiatric Inventory and Clinical Dementia Rating (CDR) scale. Statistical analysis was carried out with SPSS 17 software. RESULTS: The 124 subjects (mean age of 80.4±7.0 years), 88 women (70.9%) had average duration of dementia of 7.1±3.2 years, most common dementias of Alzheimer's disease (35.5%) and mixed (31.5%) and most prevalent NPS of apathy (75%) and irritability (66.9%). Correlation between apathy and a CDR 1 had a PR (prevalence ratio) = 0.289 and p<0.001 while between apathy and CDR 4-5 (PR=8.333, p<0.005). A similar result was found between aberrant motor behavior (AMB) and CDR 1 (PR=0.352, p<0.003) and between AMB and CDR4-5 (PR=2.929, p<0.006). CONCLUSION: Alzheimer's disease and mixed dementia were predominant, while apathy and AMB were detected in association with the progressive stages of dementia.

Sintomas neuropsiquiátricos (SNPs) causam sofrimento, incapacidade e redução da qualidade de vida do paciente e das famílias. OBJETIVO: Avaliar a prevalência de SNPs específicos conforme a fase do estado demencial. MÉTODOS: Estudo transversal em pacientes atendidos em ambulatório de demências. Aplicou-se Inventário Neuropsiquiátrico e Clinical Dementia Rating (CDR). Realizada análise estatística com o software SPSS 17. RESULTADOS: 124 idosos (idade média de 80,4±7,0 anos), 88 mulheres (70,9%). Tempo médio de demência: 7,1±3,2 anos. Demências mais frequentes: doença de Alzheimer (35,5%) e mista (31,5%). Sintomas neuropsiquiátricos mais prevalentes: apatia (75%) e irritabilidade (66,9%). Correlação entre apatia e CDR 1 tem RP (razão de prevalências) = 0,289 e p<0,001 e entre apatia e CDR 4-5; RP=8,333; p<0,005, o mesmo ocorrendo entre comportamento motor aberrante (CMA) e CDR 1 (RP=0,352; p<0.003) e CMA e CDR4-5 (RP=2,929; p<0,006). CONCLUSÃO: Houve predomínio de demência de Alzheimer e demência mista e se detectou apatia e CMA em associação progressiva com as fases do quadro demencial.

Neuropsychiatric symptoms and severity of dementia.

Neuropsychiatric symptoms (NPS) cause distress, disabilitiy and reduced quality of life for both the patient and their families. OBJECTIVE: To evaluate the prevalence of NPS as a specific stage of dementia status. METHODS: A cross-sectional study in patients attending an outpatient clinic for dementia was performed. We applied the Neuropsychiatric Inventory and Clinical Dementia Rating (CDR) scale. Statistical analysis was carried out with SPSS 17 software. RESULTS: The 124 subjects (mean age of 80.4±7.0 years), 88 women (70.9%) had average duration of dementia of 7.1±3.2 years, most common dementias of Alzheimer's disease (35.5%) and mixed (31.5%) and most prevalent NPS of apathy (75%) and irritability (66.9%). Correlation between apathy and a CDR 1 had a PR (prevalence ratio) = 0.289 and p<0.001while between apathy and CDR 4-5 (PR=8.333, p<0.005). A similar result was found between aberrant motor behavior (AMB) and CDR 1 (PR=0.352, p<0.003) and between AMB and CDR4-5 (PR=2.929, p<0.006). CONCLUSION: Alzheimer's disease and mixed dementia were predominant, while apathy and AMB were detected in association with the progressive stages of dementia.

Sintomas neuropsiquiátricos (SNPs) causam sofrimento, incapacidade e redução da qualidade de vida do paciente e das famílias. OBJETIVO: Avaliar a prevalência de SNPs específicos conforme a fase do estado demencial. MÉTODOS: Estudo transversal em pacientes atendidos em ambulatório de demências. Aplicou-se Inventário Neuropsiquiátrico e Clinical Dementia Rating (CDR). Realizada análise estatística com o software SPSS 17. RESULTADOS: 124 idosos (idade média de 80,4±7,0 anos), 88 mulheres (70,9%). Tempo médio de demência: 7,1±3,2 anos. Demências mais frequentes: doença de Alzheimer (35,5%) e mista (31,5%). Sintomas neuropsiquiátricos mais prevalentes: apatia (75%) e irritabilidade (66,9%). Correlação entre apatia e CDR 1 tem RP (razão de prevalências) = 0,289 e p<0,001 e entre apatia e CDR 4-5; RP=8,333; p<0,005, o mesmo ocorrendo entre comportamento motor aberrante (CMA) e CDR 1 (RP=0,352; p<0.003) e CMA e CDR4-5 (RP=2,929; p<0,006). CONCLUSÃO: Houve predomínio de demência de Alzheimer e demência mista e se detectou apatia e CMA em associação progressiva com as fases do quadro demencial.

Differences in accuracy of 99mTc-sestamibi scanning between severe and mild forms of primary hyperparathyroidism.

UNLABELLED: Preoperative localization of the parathyroids using (99m)Tc-sestamibi scanning has not yet been established as a routine diagnostic procedure for primary hyperparathyroidism. Several studies have demonstrated a variable degree of accuracy (70%-98%) in asymptomatic patients. METHODS: We evaluated the accuracy of this technique in 64 patients who underwent scanning between January 2000 and January 2005 according to the clinical manifestations of the disease. RESULTS: The study included 25 asymptomatic patients (group I), 18 nephrolithiasis patients without overt bone disease (group II), and 21 patients with severe bone involvement and osteitis fibrosa cystica (group III). Mean serum calcium in groups I, II, and III was 10.98 +/- 0.02, 11.32 +/- 0.17, and 13.35 +/- 0.35 mg/dL, respectively. Mean serum parathyroid hormone in groups I, II, and III was 135.45 +/- 13.50, 165.85 +/- 15.06, and 579.6 +/- 628.4 pg/mL, respectively. The (99m)Tc-sestamibi scan results were positive in 64% of the patients in group I, in 83% of those in group II, and in 100% of those in group III. Of the patients with severe bone disease, 70% showed increased uptake on the initial images, whereas in the other groups, increased uptake was seen only on the delayed images, as expected. CONCLUSION: Our data show a high degree of accuracy for the use of (99m)Tc-sestamibi scanning as a localizing procedure in severe primary hyperparathyroidism.

From mild to severe primary hyperparathyroidism: The Brazilian experience.

Primary hyperparathyroidism often presents as an asymptomatic disorder. In our institution, routine serum calcium measurements have now been used as part of medical examination for 23 years. Out of 124 patients consecutively seen at our institution, 47% presented with no symptoms related to the disease, while 25% presented with severe skeletal involvement and osteitis fibrosa cystica, 25% with renal stone disease without overt bone involvement, and 2% with the typical neuropsychiatric syndrome. This same pattern is seen in the city of São Paulo. In severe disease pathological fractures are frequently seen, especially in long bones of the lower extremities, and also loss of lamina dura of the teeth and salt-and-pepper appearance of the skull. Bone mineral density is extremely low in these patients but usually show remarkable recovery following surgical cure. Serum PTH and bone markers are considerable higher in severely affected patients, who also have a high rate of vitamin D deficiency, and the parathyroid lesion is easier located compared with asymptomatic patients. From pathological specimens 87% had histological confirmation of a single adenoma, 6.4% multiple gland hyperplasia and 3.8% carcinoma.

Paget's disease of bone.

Paget's disease of bone is a focal disorder of bone remodeling accompanied initially by an increase in bone resorption, followed by a disorganized and excessive formation of bone, leading to pain, fractures and deformities. It exhibits a marked geographical variation in its prevalence. In Brazil it predominantly affects persons of European descent. The majority of the reported cases of the disease in Brazil are from Recife, owing to its peculiar mixed European colonization over approximately four centuries. The etiology is complex and involves both genetic and environmental factors. The disease is often asymptomatic and diagnosis is usually based on biochemical markers of bone turnover, radionuclide bone scan and radiological examination. Bisphosphonates, in particular zoledronic acid, are regarded as the treatment of choice for Paget's disease of bone.

From mild to severe primary hyperparathyroidism: the Brazilian experience / Do hiperparatiroidismo primário leve ao severo: a experiência brasileira

Primary hyperparathyroidism often presents as an asymptomatic disorder. In our institution, routine serum calcium measurements have now been used as part of medical examination for 23 years. Out of 124 patients consecutively seen at our institution, 47 percent presented with no symptoms related to the disease, while 25 percent presented with severe skeletal involvement and osteitis fibrosa cystica, 25 percent with renal stone disease without overt bone involvement, and 2 percent with the typical neuropsychiatric syndrome. This same pattern is seen in the city of São Paulo. In severe disease pathological fractures are frequently seen, especially in long bones of the lower extremities, and also loss of lamina dura of the teeth and salt-and-pepper appearance of the skull. Bone mineral density is extremely low in these patients but usually show remarkable recovery following surgical cure. Serum PTH and bone markers are considerable higher in severely affected patients, who also have a high rate of vitamin D deficiency, and the parathyroid lesion is easier located compared with asymptomatic patients. From pathological specimens 87 percent had histological confirmation of a single adenoma, 6.4 percent multiple gland hyperplasia and 3.8 percent carcinoma.

Na maioria dos relatos da literatura recente, o hiperparatiroidismo primário apresenta-se, com freqüência, na forma assintomática. Em nossa instituição utilizamos a determinação rotineira do cálcio sérico há 23 anos. Em nossa série de 124 casos consecutivos, 45 por cento não apresentavam sintomas relacionados com a doença, 25 por cento tinham envolvimento esquelético intenso com osteíte fibrosa cística, 25 por cento tinham nefrolitíase sem envolvimento ósseo severo, e 2 por cento apresentavam a síndrome neuro-psiquiátrica típica. Esse mesmo padrão tem sido observado na cidade de São Paulo. Na doença severa são freqüentes as fraturas patológicas, especialmente nos ossos longos dos membros inferiores, como também a reabsorção da lâmina dura dos dentes e o aspecto em "sal e pimenta" nas radiografias do crânio. A densidade mineral óssea mostra-se extremamente reduzida nesses pacientes, mas em geral exibe melhora marcante após a cura cirúrgica. O PTH no soro e os marcadores bioquímicos da remodelação óssea estão significativamente mais altos nos pacientes com doença severa, os quais freqüentemente apresentam deficiência de vitamina D e localização mais fácil da lesão paratiroideana, quando comparados aos pacientes assintomáticos. Ao exame anátomo-patológico, 87 por cento tiveram confirmação de adenoma único, 6,4 por cento hiperplasia glandular difusa e 3,8 por cento carcinoma.

Paget's disease of bone / Doença de Paget óssea

Paget's disease of bone is a focal disorder of bone remodeling accompanied initially by an increase in bone resorption, followed by a disorganized and excessive formation of bone, leading to pain, fractures and deformities. It exhibits a marked geographical variation in its prevalence. In Brazil it predominantly affects persons of European descent. The majority of the reported cases of the disease in Brazil are from Recife, owing to its peculiar mixed European colonization over approximately four centuries. The etiology is complex and involves both genetic and environmental factors. The disease is often asymptomatic and diagnosis is usually based on biochemical markers of bone turnover, radionuclide bone scan and radiological examination. Bisphosphonates, in particular zoledronic acid, are regarded as the treatment of choice for Paget's disease of bone.

Doença de Paget óssea é uma desordem focal da remodelação óssea, inicialmente acompanhada de um aumento da reabsorção óssea, seguida de desorganizada e excessiva formação óssea, levando a dor, deformidades e fraturas. Exibe uma variável distribuição geográfica em sua prevalência. No Brasil acomete predominantemente pacientes de descendência européia. Recife, devido à sua peculiar colonização mista européia por cerca de 4 séculos, tem a maioria dos casos relatados no Brasil. A etiologia é complexa e envolve fatores ambientais e genéticos. A doença é freqüentemente assintomática e o diagnóstico é feito usualmente através dos marcadores bioquímicos do turnover ósseo associado a cintilografia óssea e dos sinais típicos do exame radiológico. Os bisfosfonatos representam o tratamento de escolha na doença de Paget óssea, particularmente o ácido zolidrônico.

Relationship between serum vitamin d status and clinical manifestations of primary hyperparathyroidism.

OBJECTIVE: To compare vitamin D status represented by serum 25-hydroxyvitamin D (25-OHD) levels in a group of patients with primary hyperparathyroidism, stratified by clinical manifestations. METHODS: We studied 22 patients (18 women and 4 men) with primary hyperparathyroidism--5 patients with severe osteitis fibrosa cystica, 10 symptomatic patients with active renal stone disease without overt bone disease, and 7 asymptomatic patients. Bone mineral density (BMD) measurements (T-scores) were done at the lumbar spine, femoral neck, and distal radius, and laboratory data for the three subgroups were analyzed. RESULTS: Although considerably younger than the asymptomatic group, patients with osteitis fibrosa had significantly lower mean serum 25-OHD levels (16.7 +/- 1.1 ng/mL versus 29.9 +/- 2.9 ng/mL; P = 0.003). Moreover, patients with osteitis fibrosa had significantly lower BMD in comparison with patients who had renal stone disease as well as asymptomatic patients for all sites measured. Serum parathyroid hormone levels were significantly higher in patients with osteitis fibrosa than in asymptomatic patients (1,352.8 +/- 297.2 pg/mL versus 145.0 +/- 43.7 pg/mL; P<0.02) as well as in comparison with patients who had renal stone disease (P<0.02). Patients with osteitis fibrosa had urinary N-telopeptide levels that were significantly higher than those in asymptomatic patients (501.5 +/- 201.7 versus 51.3 +/- 6.4 nmol/mmol creatinine; P = 0.02) and those in patients with renal stone disease (P = 0.01). CONCLUSION: The findings in this study demonstrate that vitamin D deficiency or insufficiency may contribute to disease severity in primary hyperparathyroidism.

Agitaçäo no idoso - Aspectos terapêuticos / Agitation in the elderly - Therapeutic features

Essa revisäo tem por objetivo definir as principais estratégias de manejo psicofarmacológico, ambiental e de reabilitaçäo no idoso. Os autores apresentam as principais classes de fármacos utilizados para esse fim e discutem doses e efeitos colaterais para essa faixa etária. As linhas de manejo do meio ambiente e do comportamento por técnicas näo medicamentosas também säo ressaltadas e descritas. Por ser de difícil definiçäo e operacionalizaçäo, o tratamento da agitaçäo no idoso ainda carece de pesquisas tanto com corte transversal como longitudinal, seja em relaçäo a novos psicofármacos com menor potencial de efeitos colaterais, seja em relaçäo a estratégias näo farmacológicas

Primary growth hormone insensitivity syndrome - A case reporte

Aproximadamente 230 casos da síndrome de insensibilidade ao GH (síndrome de Laron) foram descritos até o presente, e destes, dois o foram no Brasil. Esta síndrome caracteriza-se por achados clínicos de deficiência severa de hormônio do crescimento, associados à níveis séricos elevados de GH. Estamos relatando o terceiro paciente brasileiro, o primeiro do mundo com descendência portuguesa, que se apresentou com quadro clínico e laboratorial típicos da doença.

Distúrbio de pânico e comorbidade clínica / Panic disorder and clinical comorbidity

Os autores abordam o distúrbio do pânico considerando nao só as manifestaçoes psiquiátricas mas também as possibilidades biológicas bem como as várias patologias que podem cursar com sintomatologia semelhante às crises de pânico.

Disturbios de panico e comorbidade clinica

Os autores abordam o disturbio do panico considerando nao so as manifestacoes psiquiatricas mas tambem as possibilidades biologicas bem como as varias patologias que podem cursar com sintomatologia semelhante as crises de panico.

Depressao no idoso

Os autores abordam a depressao no idoso revendo as particularidades fisiologicas, epidemiologicas, clinicas, diagnosticas e terapeuticas que ocorrem nesta faixa etaria.