Serum Thyrotropin and Triiodothyronine Levels in Levothyroxine-treated Patients.

CONTEXT: Small adjustments in levothyroxine (LT4) dose do not appear to provide clinical benefit despite changes in thyrotropin (TSH) levels within the reference range. We hypothesize that the accompanying changes in serum total triiodothyronine (T3) levels do not reflect the magnitude of the changes in serum TSH. OBJECTIVE: This work aims to characterize the relationships of serum free thyroxine (FT4) vs T3, FT4 vs TSH, and FT4 vs the T3/FT4 ratio. METHODS: This cross-sectional, observational study comprised 9850 participants aged 18 years and older treated with LT4 from a large clinical database from January 1, 2009, to December 31, 2019. Patients had been treated with LT4, subdivided by serum FT4 level. Main outcome measures included model fitting of the relationships between serum FT4 vs TSH, FT4 vs T3, and FT4 vs T3/FT4. Mean and median values of TSH, T3, and T3/FT4 were calculated. RESULTS: The relationships T3 vs FT4 and TSH vs FT4 were both complex and best represented by distinct, segmented regression models. Increasing FT4 levels were linearly associated with T3 levels until an inflection point at an FT4 level of 0.7 ng/dL, after which a flattening of the slope was observed following a convex quadratic curve. In contrast, increasing FT4 levels were associated with steep declines in TSH following 2 negative sigmoid curves. The FT4 vs T3/FT4 relationship was fit to an asymptotic regression curve supporting less T4 to T3 activation at higher FT4 levels. CONCLUSION: In LT4-treated patients, the relationships between serum FT4 vs TSH and FT4 vs T3 across a range of FT4 levels are disproportionate. As a result, dose changes in LT4 that robustly modify serum FT4 and TSH values may only minimally affect serum T3 levels and result in no significant clinical benefit.

Incidence and Clinical Description of Lymphomas in Children and Adolescents with Vertical Transmission of HIV in Rio de Janeiro, Brazil, in Pre- and Post-Combined Antiretroviral Therapy Eras: A Multicentric Hospital-Based Survival Analysis Study.

The incidence of cancer in children living with HIV (CLWH) is high and lymphomas are the most common type of cancer in this population. The combined antiretroviral therapy (cART) changed the natural history of HIV infection. To determine the incidence and profile of these CLWH malignancies in Rio de Janeiro (RJ), Brazil, we conducted a retrospective and observational study of vertically infected CLWH, ranging from 0−20 incomplete years, from 1995 to 2018, at five reference centers. The study period was divided into three eras in accordance with the widespread use of cART in Brazil. 1306 patients were included. Of the 25 lymphomas found, 19 were AIDS-defining malignancies (ADM); 6 were non-AIDS-defining malignancies (NADM). The incidence rate (IR) of lymphoma developing was 1.70 per 1000 children-year (95% CI 1.09−2.50). ADM development IR decreased from 2.09−1.75−0.19 per 1000 children-year (p < 0.001) through cART eras. Cumulative Nelson−Aalen hazards of developing ADM over a 20-year period were 3.73% in the Early-cART era, 3.07% in the Mid-cART era, and 0.32% in the Late-cART era (p = 0.013). This study demonstrates the IR of lymphoma in CLWH in RJ, Brazil, as well as the benefit of cART in reducing ADM and death occurrence in the Post-cART era.

Rickettsia conorii: Unusual case of acute aortic thrombosis.

OBJECTIVES: Mediterranean spotted fever is a common zoonosis in Europe caused by Rickettsia conorii bacterium. Among its wide range of clinical presentations, arterial thrombosis of large vessels has never been described before. METHODS: We report a case of a complete acute infrarenal aortic thrombosis in a 61-year-old male with R. conorii infection. RESULTS AND CONCLUSION: The patient was successfully operated using open aortic surgery and subsequent treatment with doxycycline. To our knowledge, this is the first report of aortic thrombosis associated with infection by this parasite, extending the clinical spectrum of the disease.

No association between vitamin D status and COVID-19 infection in São Paulo, Brazil.

In recent years the immunomodulatory actions of vitamin D, a steroid hormone, have been extensively studied. In 2020, due to the COVID-19 pandemic, the question arose as to 25(OH)D status would be related to susceptibility to SARS-CoV-2 infection, since several studies pointed out a higher prevalence and severity of the disease in populations with low levels of 25(OH)D. Thus, we investigated the 25(OH)D levels in adults "Detected" positive for SARS CoV-2 by RT-PCR (reverse transcriptase polymerase chain reaction) test, and in negative controls, "not Detected", using the Fleury Group's examination database, in Sao Paulo, Brazil. Of a total of 14.692 people with recent assessments of 25(OH)D and RT-PCR tests for COVID-19, 2.345 were positive and 11.585 were negative for the infection. The groups did not differ in the percentage of men and women, or in the age distribution. There were no differences in the distribution of 25(OH)D between the two groups (p = 0.08); mean 25(OH)D of 28.8 ± 21.4 ng/mL and 29.6 ± 18.1 ng/mL, respectively. In the specific population studied, clinical, environmental, socioeconomic and cultural factors should have greater relevance than 25(OH)D in determining the susceptibility to COVID-19.

Off-label use of Proglide percutaneous closure device in iatrogenic arterial catheterizations: Our experience.

INTRODUCTION: Incidental arterial puncture is one of the main complications associated with central venous catheter placement. Manual compression to achieve hemostasis in subclavian and carotid artery punctures is often ineffective because of the anatomical arterial position. Accidental cannulation has traditionally been treated with open surgery or endovascular treatment, but such procedures are not exempt from complications. OBJECTIVES: Report our experience with ultrasound-guided off-label use of Perclose ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA) in patients with iatrogenic arterial cannulation. METHODS: Six unstable patients with accidental arterial catheterization during placement of a central venous catheter: five of them in the subclavian artery and one in the right common carotid artery. Ultrasound-guided percutaneous closure was performed at bedside using a Perclose ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA). RESULTS: All patients underwent duplex ultrasound 6, 12, 24, and 48 h postprocedure, and no complications associated with percutaneous closure (embolism, ischemia, stenosis, or arterial occlusion, bleeding, pseudoaneurysm, etc.) were described. CONCLUSIONS: Accidental artery puncture during central venous catheterization is an uncommon situation but can be effectively managed by using percutaneous vascular closure device. It is a reliable alternative that should be considered as a first-line approach before endovascular or open surgery, specially in patients with unstable conditions in which it is possible to be performed without transfer to an operation room.

PSA kinetics before 40 years of age.

PURPOSE: The baseline PSA has been proposed as a possible marker for prostate cancer. The PSA determination before 40 years seems interesting because it not suffers yet the drawbacks related to more advanced ages. Considering the scarcity of data on this topic, an analysis of PSA kinetics in this period seems interesting. MATERIALS AND METHODS: A retrospective assay in a database of a private diagnostic center was performed from 2003 to 2016. All subjects with a PSA before 40 years were included. RESULTS: 92995 patients performed PSA between the ages of 21 - 39. The mean value ranged from 0.66 ng / mL (at age 22) to 0.76 ng / mL (at age 39) and the overall mean was 0.73 ng / mL. As for outliers, 3783 individuals presented a baseline PSA > 1.6 ng / mL (p95). A linear regression model showed that each year there is a PSA increase of 0.0055 ng / mL (ß = 0.0055; r² = 0.0020; p < 0.001). A plateau in PSA between 23 and 32 years was found and there were only minimal variations among the ages regardless of the evaluated percentile. CONCLUSION: It was demonstrated that PSA kinetics before 40 years is a very slow and progressive phenomenon regardless of the assessed percentile. Considering our results, it could be suggested that any PSA performed in this period could represent the baseline value without significant distortions.

Aneurisma de aorta abdominal y cáncer colorrectal sincrónico. ¿Cambios en el tratamiento? / Abdominal aorta aneurysm and synchronous colorectal cancer. Changes in treatment?

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Sleep Paralysis in Brazilian Folklore and Other Cultures: A Brief Review.

Sleep paralysis (SP) is a dissociative state that occurs mainly during awakening. SP is characterized by altered motor, perceptual, emotional and cognitive functions, such as inability to perform voluntary movements, visual hallucinations, feelings of chest pressure, delusions about a frightening presence and, in some cases, fear of impending death. Most people experience SP rarely, but typically when sleeping in supine position; however, SP is considered a disease (parasomnia) when recurrent and/or associated to emotional burden. Interestingly, throughout human history, different peoples interpreted SP under a supernatural view. For example, Canadian Eskimos attribute SP to spells of shamans, who hinder the ability to move, and provoke hallucinations of a shapeless presence. In the Japanese tradition, SP is due to a vengeful spirit who suffocates his enemies while sleeping. In Nigerian culture, a female demon attacks during dreaming and provokes paralysis. A modern manifestation of SP is the report of "alien abductions", experienced as inability to move during awakening associated with visual hallucinations of aliens. In all, SP is a significant example of how a specific biological phenomenon can be interpreted and shaped by different cultural contexts. In order to further explore the ethnopsychology of SP, in this review we present the "Pisadeira", a character of Brazilian folklore originated in the country's Southeast, but also found in other regions with variant names. Pisadeira is described as a crone with long fingernails who lurks on roofs at night and tramples on the chest of those who sleep on a full stomach with the belly up. This legend is mentioned in many anthropological accounts; however, we found no comprehensive reference on the Pisadeira from the perspective of sleep science. Here, we aim to fill this gap. We first review the neuropsychological aspects of SP, and then present the folk tale of the Pisadeira. Finally, we summarize the many historical and artistic manifestations of SP in different cultures, emphasizing the similarities and differences with the Pisadeira.

Mycotic Abdominal Aortic Aneurysm Secondary to Septic Embolism of a Thoracic Aorta Graft Infection.

Mycotic aneurysms account for 1% of abdominal aortic aneurysms. There are very few cases published that describe the formation of mycotic aneurysms after septic embolism due to graft infection. We present the first case to our knowledge to be described in the literature of a mycotic aneurysm caused by septic embolism derived from a thoracic aorta graft infection, treated with conventional surgery leading to a successful outcome and evolution.

TERRIBLE TRIAD OF THE ELBOW: EVALUATION OF SURGICAL TREATMENT.

OBJECTIVES: To evaluate the epidemiology of and surgical results from treating elbow fracture-dislocations, including only the cases in which dislocation is associated with fracture of the coronoid process and the radial head (terrible triad). METHODS: Nineteen patients were evaluated: 12 males and 7 females. The medical records were analyzed to gather data about the mechanism of injury, fracture pattern, time elapsed until surgery and type of procedure applied. A clinical assessment was made to measure elbow range of motion, and the MEPS questionnaire was applied. RESULTS: The most common mechanism of injury in our sample was a fall from a height (12 patients). All the patients underwent surgical treatment and the mean time elapsed between the date of the injury and the surgery was 16.1 days. The mean follow-up was 50.3 months. The mean range of flexion-extension obtained was 112° and the mean range of pronation-supination obtained was 127.9°. The mean score from the MEPS questionnaire was 86 points, and excellent and good results were obtained for 15 patients (79%). The time elapsed until surgery, final flexion-extension range greater than 100° and flexion contracture of less than 30° were shown to have a statistically significant relationship with a good final clinical result. Five patients had complications, of which three cases related to peripheral nerves, one case to pseudarthrosis and one case to recurrent instability. CONCLUSIONS: Despite the severity of the injuries found in the terrible triad of the elbow, most of the patients evaluated here achieved elbow stability with good clinical results. The factors that led to better clinical results were surgery not more than 14 days after the injury, flexion-extension range greater than 100° and flexion contracture less than 30°.

The EPICS Trial: Enabling Parents to Increase Child Survival through the introduction of community-based health interventions in rural Guinea Bissau.

BACKGROUND: Guinea-Bissau is a small country in West Africa with a population of 1.7 million. The WHO and UNICEF reported an under-five child mortality of 203 per 1000, the 10th highest amongst 192 countries. The aim of the trial is to assess whether an intervention package that includes community health promotion campaign and education through health clubs, intensive training and mentoring of village health workers to diagnose and provide first-line treatment for children's diseases within the community, and improved outreach services can generate a rapid and cost-effective reduction in under-five child mortality in rural regions of Guinea-Bissau. Effective Intervention plans to expand the project to a much larger region if there is good evidence after two and a half years that the project is generating a cost-effective, sustainable reduction in child mortality. METHODS/DESIGN: This trial is a cluster-randomised controlled trial involving 146 clusters. The trial will run for 2.5 years. The interventions will be introduced in two stages: seventy-three clusters will receive the interventions at the start of the project, and seventy-three control clusters will receive the interventions 2.5 years after the first clusters have received all interventions if the research shows that the interventions are effective. The impact of the interventions and cost-effectiveness will be measured during the first stage.The package of interventions includes a community health promotion campaign and education through health clubs, and intensive training and mentoring of village health workers to diagnose and provide first-line treatment for common children's diseases within the community. It also includes improved outreach services to encourage provision of antenatal and post natal care and provide ongoing monitoring for village health workers.The primary outcome of the trial will be the proportion of children that die under 5 years of age during the trial. Secondary outcomes will include age at and cause of child deaths, neonatal mortality, infant mortality, maternal mortality, health knowledge, health seeking behaviour, morbidity and costs. DISCUSSION: The trial will be run by research and service delivery teams that act independently, overseen by a trial steering committee. A data monitoring committee will be appointed to monitor the outcome and any adverse effects. TRIAL REGISTRATION: Current Controlled Trials ISRCTN52433336.

Characterization of Rabies virus isolated from canids and identification of the main wild canid host in Northeastern Brazil.

The rabies cases in dogs and wild canids in Northeastern Brazil are a public and animal health problem. This paper describes the identities of the coding region of the N-gene of Rabies virus (RABV) isolated in canids from Northeastern Brazil. The genetic tree generated using the sequence data described here divided the cluster BRAZILAN CANIDS into two subclusters (DOG-RELATED STRAINS and WILD CANID-RELATED STRAINS) with identities greater than those already described. The two subclusters are sub-divided into geographic groups related to the origin of the isolates, suggesting a long-standing ecological coexistence of the sequence types characteristic of the groups. This article also analyzes the 513-nucleotide stretch of the mitochondrial DNA control region of rabies-positive canids from Northeastern Brazil with a view to identifying the main RABV host among them. Among the four species of wild canids found in the region, two (Cerdocyon thous and Pseudalopex vetulus) are frequently associated with rabies. Phylogenetic analysis of sequence data generated from mtDNA suggests that C. thous is the main wild canid host in the region. The results obtained in this study are in concordance with the zoology and ecology of wild canids, and thus, help improve epidemiologic vigilance of rabies and allow a more targeted control of the disease.

Similitudes y discrepancias en las características clinicopatológicas de feocromocitomas y paragangliomas / Clinical and pathological similarities and differences between pheochromocytomas and paragangliomas

Objetivo: Comparar características clínicas, principalmente adrenérgicas, de los feocromocitomas (FC), paragangliomas simpáticos (PGLS) y parasimpáticos (PGLPS).Pacientes y método: Se incluyó en el estudio a 34 pacientes diagnosticados y tratados consecutivamente de FC (20), PGLS (9) y PGLPS (5), con una edad media de 44 (rango, 17-74) años. Se comparó formas de presentación, manifestaciones clínicas, producción hormonal, características patológicas y resultados tras el tratamiento. Resultados: Los pacientes fueron atendidos por múltiples servicios. Los FC se diagnosticaron predominantemente por clínica adrenérgica (65%); los PGLS, por clínica adrenérgica (44%) y por efecto compresivo (45%), y los PGLPS, por efecto masa (100%). Sin embargo, cuando se evaluó de forma dirigida la clínica adrenérgica, el 80% de los FC, el 66,7% de los PGLS y el 40% de los PGLPS la habían manifestado. Presentaron secreción hormonal el 82,4% de los FC y el 100% de los PGLS. No se realizó estudio bioquímico en 3 FC, 5 PGLS y en ningún PGLPS. El tamaño tumoral (en mm) de los FC fue significativamente mayor que los PGLS y PGLPS (59 ± 28, 39 ±16 y 34 ± 26). Tras la extirpación del tumor, 17pacientes con FC, 7 con PGS y 4 con PGLPS quedaron libres de enfermedad, en 1 con PGLPS, éste persiste parcialmente, 1 PGLS recidivó y 5 pacientes murieron (3 con FC y 2 con PGLS).Conclusiones: En nuestro estudio observamos que se diagnostica por clínica adrenérgica los FC (65%) y los PGLS (44%), y además los PGLPS también presentaron clínica compatible con producción de catecolaminasen el interrogatorio dirigido en un 40%. Queremos reseñar el alto porcentaje de manifestaciones adrenérgicas en el grupo de tumores extra adrenales, que no se suele estudiarlos en este sentido, por tanto creemos que deben ser manejados como una misma entidad nosológica por una unidad de referencia (AU)

Objective: To compare the clinical features, mainly adrenergic manifestations, in patients with pheochromocytoma (PCT), sympathetic paraganglioma (SPGL) and parasympathetic paraganglioma (PSPGL).Patients and method: Thirty-four patients consecutively diagnosed and treated for PCT (n = 20), SPGL (n = 9) and PSPGL (n = 5) were included in the present study. The mean age was 44 years (range, 17-74). The forms of presentation, clinical manifestations, results of diagnostic tests, pathological characteristics, and postsurgery outcomes were analyzed. Results: The patients were treated in different medical units in our hospital. Diagnosis of PCT was mainly based on adrenergic symptoms (65%), SPGL on adrenergic symptoms (44%) and compressive symptoms (65%) and PSPGL on the basis of the tumor mass effect (100%). However, exhaustive analysis of adrenergic manifestations revealed that 80%, 66.7% and 40% of patients with PCT,SPGL and PSPGL respectively had adrenergic manifestations. Eighty-two percent of patients with PCT and 100% of those with SPGL showed increased urinaryexcretion of catecholamines and their metabolites. Biochemical studies were not performed in three patients with PCT and five with SPGL and were performed in all patients with PSPGL. The mean tumoral size (in mm) was significantly higher in PCT than in SPGL and PSPGL (59 ± 28, 39 ± 16 and 34 ± 26). After surgery, 17 patients with PCT, seven with PGS and four with PSPGL were considered cured, one patient showed partially persistent PSPGL, one patient with SPGL relapsed, and five patients died (three with PCT and two with SPGL).Conclusions: In the present study, 65% of PCT and 44% of SPGL were diagnosed on the basis of adrenergic symptoms, while 40% of PSPGL also showed symptoms compatible with catecholamine production. We highlight the high percentage of adrenergic manifestations in the group of extra-adrenal tumors, which are not usually investigated in this context. Therefore, we believe that PCT, SPGL and PSPGL should be considered as the same nosological entity in different locations and should be managed in referral units (AU)

Análisis crítico del tratamiento fibrinolítico en la trombosis del bypass femoropoplíteo / A critical analysis of fibrinolytic treatment in femoral-popliteal bypass thrombosis

Objetivo. Evaluar el resultado de la terapia fibrinolítica en el tratamiento de la trombosis del injerto femoropoplíteo. Pacientes y métodos. Desde enero de 1998 a diciembre de 2005 se han tratado 50 casos de trombosis de bypass femoropoplíteo con fibrinólisis local con urocinasa. La muestra se compone de 30 pacientes con edad media de 67,7 años, portadores de bypass a primera (16%) o tercera porción (84%), con material protésico (88%) o vena (12%). La trombosis sucedió en el primer año de control clínico en el 73% de los casos. Presentaron una isquemia grado I y IIa (escala de Rutherford) el 58%. Se trató del primer episodio de trombosis en el 66% de la muestra. El tiempo de evolución de la isquemia fue menor de 14 días en el 58% de los casos. Resultados. La eficacia técnica fue del 80%. Se identificó lesión causante de la trombosis en el 90% de los casos, tratándose con terapia endovascular (69,4%) o cirugía (19,4%). La permeabilidad y el salvamento de extremidad al año fueron del 26,8 y 50,6%, respectivamente, y a los dos años del 22,3 y 47,2%, respectivamente. Los injertos que se fibrinolisaron por primera vez presentaron mayor permeabilidad (p = 0,008) y mayor salvamento de extremidad (p = 0,006), que los injertos que ya se habían tratado previamente. Conclusiones. La terapia trombolítica es una técnica útil para restablecer la permeabilidad de los injertos femoropoplíteos; no obstante, los resultados obtenidos en la segunda y tercera fibrinólisis de un mismo bypass hacen replantear la necesidad de un tratamiento alternativo

Aim. To evaluate the results of fibrinolytic therapy in the treatment of femoral-popliteal graft thrombosis. Patients and methods. Between January 1998 and December 2005, 50 cases of femoral-popliteal bypass thrombosis were treated by local fibrinolysis using urokinase. The sample consisted of 30 patients with a mean age of 67.7 years who had received a bypass made of either prosthetic material (88%) or vein (12%) in the first (16%) or third portion (84%). Thrombosis occurred during the first year of clinical monitoring in 73% of cases. Grade I and IIa ischaemia (Rutherford scale) was present in 58% of them. It was the first episode of thrombosis for 66% of the sample. Progression time of the ischaemia was 14 days or less in 58% of cases. Results. Technical efficiency was 80%. The lesions causing the thrombosis were found in 90% of cases and were treated with endovascular therapy (69.4%) or surgery (19.4%). Patency and limb salvage at one year were 26.8 and 50.6%, respectively, and at two years the figures were 22.3 and 47.2%, respectively. The grafts submitted to fibrinolysis for the first time offered greater patency (p = 0.008) and higher limb salvage rates (p = 0.006) than grafts that had been treated previously. Conclusions. Thrombolysis therapy is a useful technique for restoring the patency of femoral-popliteal grafts; yet, the outcomes of second and third-time fibrinolysis of the same bypass make it necessary to consider an alternative treatment