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Antecedentes y objetivo: En el contexto de la pandemia por SARS-CoV-2 el desarrollo de nuevas vacunas y su eficacia en pacientes con enfermedades reumáticas inmunomediadas ha sido motivo de estudio. El objetivo de este trabajo es evaluar la tasa de respuesta vacunal en pacientes con enfermedades reumáticas inmunomediadas en tratamiento con inmunomoduladores, incluyendo el rituximab (RTX), así como la influencia de posibles factores implicados en la respuesta vacunal en estos pacientes. Material y métodos: Se realizó un estudio de cohortes prospectivo, unicéntrico, en 130 pacientes con enfermedad reumática inmunomediada en tratamiento con inmunomoduladores, incluyendo RTX, que recibieron la pauta completa de vacunación frente a SARS-CoV-2 con BioNTech/Pfizer, Moderna/Lonza, AstraZeneca o Janssen entre abril y octubre de 2021. Se analizaron factores demográficos como la edad, el sexo, el tipo de enfermedad inmunomediada, el tratamiento inmunomodulador y el tipo de vacuna, así como marcadores serológicos incluyendo los niveles de anticuerpos anti-SARS-CoV-2 IgG al mes y a los 6 meses desde la vacunación, niveles de linfocitos CD19+ y la presencia o no de hipogammaglobulinemia. Se realizó un análisis estadístico para evaluar la influencia en los títulos de anticuerpos de las diferentes variables recogidas en el estudio. Resultados: Se obtuvo una muestra de 130 pacientes, 41 en tratamiento con RTX y 89 con otros inmunomoduladores. Se observó una menor tasa de respuesta vacunal en los pacientes con RTX (12/34, 36,7%) al mes de la primovacunación con respecto al 96,5% (82/85) de pacientes que no recibieron este fármaco y sí alcanzaron respuesta. En el análisis de variables secundarias la hipogammaglobulinemia se asoció de forma significativa a la ausencia de desarrollo de respuesta vacunal. La administración del último RTX en los 6 meses previos a la vacunación y niveles bajos de CD19+ (<20mg/dl) también influyeron de forma negativa en el desarrollo de...(AU)
Background and objective: In the context of the SARS-CoV-2 pandemic, the development of new vaccines and their efficacy in patients with immune-mediated rheumatic diseases has been a target to investigate. The objective of this study is to evaluate the vaccine response rate in patients with immune-mediated rheumatic diseases under treatment with immunomodulators, including rituximab (RTX), as well as the influence of possible factors involved in the vaccination response in these patients. Material and methods: A single-centre, prospective cohort study was conducted in 130 patients with immune-mediated rheumatic disease on treatment with immunomodulators, including RTX, who received the full course of vaccination against SARS-CoV-2 with BioNTech/Pfizer, Moderna/Lonza, AstraZeneca, or Janssen between April and October 2021. Demographic factors such as age, sex, type of immune-mediated disease, immunomodulatory treatment and type of vaccine were analysed, as well as serological markers including anti-SARS-CoV-2 IgG antibody levels measured one and six months after vaccination, CD19+ lymphocyte levels and the presence or absence of hypogammaglobulinemia. A statistical analysis was performed to assess the influence of the different variables collected in the study on the antibody titres. Results: A sample of 130 patients was studied, 41 under treatment with RTX and 89 with other immunomodulators. A lower vaccination response rate was observed in patients with RTX (12/34, 36.7%) one month after the primary vaccination compared to 96.5% (82/85) of patients who did not receive this drug and did respond. In the analysis of secondary variables, hypogammaglobulinemia was significantly associated with lack of development of a vaccine response. The administration of the last RTX cycle in the 6 months prior to vaccination and low CD19+ levels (<20mg/dL) also had a negative influence on the development of a vaccine response...(AU)
Assuntos
Humanos , Masculino , Feminino , Imunidade Humoral , /imunologia , Doenças Reumáticas/imunologia , Reumatologia , Estudos de Coortes , Estudos Retrospectivos , Rituximab/administração & dosagem , Rituximab/efeitos adversosRESUMO
BACKGROUND AND OBJECTIVE: In the context of the SARS-CoV-2 pandemic, the development of new vaccines and their efficacy in patients with immune-mediated rheumatic diseases has been a target to investigate. The objective of this study is to evaluate the vaccine response rate in patients with immune-mediated rheumatic diseases under treatment with immunomodulators, including rituximab (RTX), as well as the influence of possible factors involved in the vaccination response in these patients. MATERIAL AND METHODS: A single-centre, prospective cohort study was conducted in 130 patients with immune-mediated rheumatic disease on treatment with immunomodulators, including RTX, who received the full course of vaccination against SARS-CoV-2 with BioNTech/Pfizer, Moderna/Lonza, AstraZeneca, or Janssen between April and October 2021. Demographic factors such as age, sex, type of immune-mediated disease, immunomodulatory treatment and type of vaccine were analysed, as well as serological markers including anti-SARS-CoV-2 IgG antibody levels measured one and six months after vaccination, CD19+ lymphocyte levels and the presence or absence of hypogammaglobulinemia. A statistical analysis was performed to assess the influence of the different variables collected in the study on the antibody titres. RESULTS: A sample of 130 patients was studied, 41 under treatment with RTX and 89 with other immunomodulators. A lower vaccination response rate was observed in patients with RTX (12/34, 36.7%) one month after the primary vaccination compared to 96.5% (82/85) of patients who did not receive this drug and did respond. In the analysis of secondary variables, hypogammaglobulinemia was significantly associated with lack of development of a vaccine response. The administration of the last RTX cycle in the 6 months prior to vaccination and low CD19+ levels (<20â¯mg/dL) also had a negative influence on the development of a vaccine response. In the group of patients who were not receiving RTX treatment, the vaccination response was like that observed in the general population. We did not observe statistically significant differences in the vaccine response based on immunomodulatory treatment other than RTX, concomitant corticosteroid treatment, type of immune-mediated pathology, age, or sex. DISCUSSION AND CONCLUSIONS: In patients with rheumatic diseases receiving immunomodulatory treatment, the response to vaccination against SARS-CoV-2 is comparable to the general population, except in the case of patients receiving RTX, who have a lower response rate (around 36.7%) which is associated with factors such as hypogammaglobulinemia, pre-vaccination CD19+ lymphocyte levels, and a period between vaccination and the last dose of RTX of less than 6 months. It is important to take these factors into consideration to optimize vaccination in these patients.
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Agamaglobulinemia , COVID-19 , Doenças Reumáticas , Vacinas , Humanos , Lactente , SARS-CoV-2 , Estudos Prospectivos , COVID-19/prevenção & controle , Vacinação , Rituximab/uso terapêutico , Fatores Imunológicos , Doenças Reumáticas/tratamento farmacológicoRESUMO
OBJECTIVE: To analyze the effectiveness and safety of intravenous immunoglobulin (IVIG) given in routine care to patients with systemic sclerosis (SSc). METHODS: A retrospective multicenter observational study was conducted in SSc patients treated with IVIG. We collected data on epidemiological parameters and clinical outcomes. Firstly, we assessed changes in organ manifestations during IVIG treatment. Secondly, we analyzed the frequency of adverse effects. The following parameters were collected from baseline to the last follow-up: the patient's weight, modified Rodnan Skin Score (mRSS), modified manual muscle strength scale (MRC), laboratory test(creatine kinase(CK), hemoglobin and protein levels), The University of California Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 (UCLA GIT 2.0) questionnaire, pulmonary function tests, and echocardiography. RESULTS: Data were collected on 78 patients (82% females; 59% with diffuse SSc). Inflammatory idiopathic myopathy was the most frequent concomitant overlap disease (41%). The time since Raynaud's phenomenon and SSc onset were 8.8 ± 18 and 6.2 ± 6.7 years respectively. The most frequent IVIG indication was myositis (38/78), followed by gastrointestinal (27/78) and cutaneous (17/78) involvement. The median number of cycles given were 5. 54, 53 and 9 patients have been treated previously with glucocorticoids, synthetic disease-modifying antirheumatic drugs and biologic therapies respectively. After IVIG use we found significant improvements in muscular involvement (MRC ≥ 3/5 92% IVIG, p = 0.001 and CK levels from 1149 ± 2026 UI to 217 ± 224 UI, p = 0.02), mRSS (15 ± 12.4 to 13 ± 12.5, p = 0.015) and improvement in total score of UCLA GIT 2.0 (p = 0.05). None Anti-RNA polymerase III patients showed an adequate response in gastrointestinal involvement (0/7) in comparison with other antibodies (0 vs. 25, p = 0,039). Cardiorespiratory involvement remained stable. A total of 12 adverse events were reported with only one withdrawn due to serious adverse effect. CONCLUSIONS: this study suggest that IVIG may improve myositis, gastrointestinal and skin involvement in SSc patients treated in routine care and seems to have a good safety profile.
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Miosite , Escleroderma Sistêmico , Feminino , Humanos , Masculino , Imunoglobulinas Intravenosas/uso terapêutico , Escleroderma Sistêmico/complicações , Escleroderma Sistêmico/tratamento farmacológico , Estudos Retrospectivos , Pele , Miosite/tratamento farmacológico , Estudos Multicêntricos como Assunto , Estudos Observacionais como AssuntoRESUMO
BACKGROUND AND OBJECTIVE: In the context of the SARS-CoV-2 pandemic, the development of new vaccines and their efficacy in patients with immune-mediated rheumatic diseases has been a target to investigate. The objective of this study is to evaluate the vaccine response rate in patients with immune-mediated rheumatic diseases under treatment with immunomodulators, including rituximab (RTX), as well as the influence of possible factors involved in the vaccination response in these patients. MATERIAL AND METHODS: A single-centre, prospective cohort study was conducted in 130 patients with immune-mediated rheumatic disease on treatment with immunomodulators, including RTX, who received the full course of vaccination against SARS-CoV-2 with BioNTech/Pfizer, Moderna/Lonza, AstraZeneca, or Janssen between April and October 2021. Demographic factors such as age, sex, type of immune-mediated disease, immunomodulatory treatment and type of vaccine were analysed, as well as serological markers including anti-SARS-CoV-2 IgG antibody levels measured one and six months after vaccination, CD19+ lymphocyte levels and the presence or absence of hypogammaglobulinemia. A statistical analysis was performed to assess the influence of the different variables collected in the study on the antibody titres. RESULTS: A sample of 130 patients was studied, 41 under treatment with RTX and 89 with other immunomodulators. A lower vaccination response rate was observed in patients with RTX (12/34, 36.7%) one month after the primary vaccination compared to 96.5% (82/85) of patients who did not receive this drug and did respond. In the analysis of secondary variables, hypogammaglobulinemia was significantly associated with lack of development of a vaccine response. The administration of the last RTX cycle in the 6 months prior to vaccination and low CD19+ levels (<20mg/dL) also had a negative influence on the development of a vaccine response. In the group of patients who were not receiving RTX treatment, the vaccination response was like that observed in the general population. We did not observe statistically significant differences in the vaccine response based on immunomodulatory treatment other than RTX, concomitant corticosteroid treatment, type of immune-mediated pathology, age, or sex. DISCUSSION AND CONCLUSIONS: In patients with rheumatic diseases receiving immunomodulatory treatment, the response to vaccination against SARS-CoV-2 is comparable to the general population, except in the case of patients receiving RTX, who have a lower response rate (around 36.7%) which is associated with factors such as hypogammaglobulinemia, pre-vaccination CD19+ lymphocyte levels, and a period between vaccination and the last dose of RTX of less than 6 months. It is important to take these factors into consideration to optimize vaccination in these patients.
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Ceftolozane/tazobactam (C/T) and ceftazidime/avibactam (CZA) are new possibilities of antimicrobial treatment that combined a ß-lactam with a ß-lactamase inhibitor. The United States (US) and European regulatory agencies approved their clinical use in adults with complicated intra-abdominal infections. This study aims to know if one of the two antibiotics obtain better efficacy in adults with complicated intra-abdominal infections and by specific pathogens such as P. aeruginosa or E. coli. A search of all trials in MEDLINE, Scopus, and Web of Science comparing a C/T or CZA based antimicrobial regimen with other treatments in patients with intraabdominal infections until August 2021 was performed. To make indirect comparisons, we used a frequentist approach using the R package netmeta.The effects have been expressed through the relative risk (RR) with its confidence interval. Considering the clinical cure and failure rates between the different trial populations (mMITT, CE, ME) and the mortality at the end of the study, we have not found significant differences between CZA and C/T. In the case of Pseudomonas, the RR of treatment failure between these two antibiotics is 1 (95% CI 0.55-1.18). In the case of E. Coli, although it seems that CZA would have a worse result than C/T, differences did not reach statistical significance (RR1.06; 95% CI 0.9-1.14). In conclusion, we have not found statistically significant differences between ceftolozane-tazobactam and ceftazidime-avibactam in treating cIAI. In regards to E. Coli, our results do not reach significance, but it would be possible that C/T and meropenem had better results than CZA. Perhaps new trials would allow a better profile of the role in different types of patients or infections caused by specific microorganisms in the future.
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Infecções Intra-Abdominais , Infecções por Pseudomonas , Adulto , Humanos , Ceftazidima/uso terapêutico , Ceftazidima/farmacologia , Inibidores de beta-Lactamases/uso terapêutico , Meropeném/farmacologia , Escherichia coli , Compostos Azabicíclicos/uso terapêutico , Compostos Azabicíclicos/farmacologia , Cefalosporinas/uso terapêutico , Cefalosporinas/farmacologia , Tazobactam/uso terapêutico , Tazobactam/farmacologia , Infecções Intra-Abdominais/tratamento farmacológico , Combinação de Medicamentos , Antibacterianos/uso terapêutico , Antibacterianos/farmacologia , Pseudomonas aeruginosa , Testes de Sensibilidade Microbiana , Infecções por Pseudomonas/tratamento farmacológicoRESUMO
Snyder-Robinson syndrome is an extremely rare genetic disorder, caused by mutations of the spermine synthase gene. We report a novel case of Snyder-Robinson syndrome, caused by a de novo mutation and first misdiagnosed with osteogenesis imperfecta. Clinical features, course, and genetic analysis are presented. The patient was treated with bisphosphonates for a decade, until developing an atypical femoral fracture. Teriparatide was then administered for 2 years and then changed to denosumab every 6 months, improving his bone density mass and preventing further fractures.
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Deficiência Intelectual Ligada ao Cromossomo X , Osteogênese Imperfeita , Espermina Sintase , Diagnóstico Diferencial , Humanos , Deficiência Intelectual Ligada ao Cromossomo X/diagnóstico , Deficiência Intelectual Ligada ao Cromossomo X/genética , Osteogênese Imperfeita/diagnóstico , Osteogênese Imperfeita/tratamento farmacológico , Osteogênese Imperfeita/genética , Espermina Sintase/genéticaRESUMO
Arterial stiffness can enhance cardiovascular risk by increasing atherogenesis or adverse hemodynamic effects. We examined whether the arterial stiffness markers of aortic pulse wave velocity (PWV) and the augmentation index (AIx) are independently associated with carotid artery intima-media thickness (IMT) and plaque in patients with rheumatoid arthritis (RA). PWV and AIx were determined by brachial oscillometry using the Mobil-O-Graph® system and carotid IMT and plaque by ultrasound in 194 consecutive RA patients without established cardiovascular disease, chronic kidney disease, and diabetes at disease onset. In crude analysis, PWV was associated with IMT (ß (95% CI) = 0.04 (0.03 to 0.05), p value < 0.0001) and plaque (OR (95% CI) = 1.69 (1.40 to 2.04), p value < 0.0001). Upon adjustment for the confounders of age, sex, mean blood pressure, body height, and cardiovascular risk factors comprising smoking, the atherogenic index, and diabetes, PWV was not related to IMT (ß (95% CI) = 0.01 (-0.02 to 0.04), p value = 0.5) or plaque (OR (95% CI) = 0.99 (0.96 to 1.01), p value = 0.3). AIx was not associated with IMT in crude (ß (95% CI) = -0.002 (-0.004 to 0.007), p value = 0.2) and adjusted analyses (ß (95% CI) = -0.002 (-0.004 to 0.000), p value = 0.06). AIx was also unrelated to carotid plaque in crude (OR (95% CI) = 1.04 (0.60 to 1.82), p value = 0.9) and adjusted analyses (OR (95% CI) = 0.97 (0.94 to 1.01), p value = 0.1). PWV and AIx are not independently associated with subclinical carotid atherosclerosis in RA.
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Artrite Reumatoide/fisiopatologia , Aterosclerose/fisiopatologia , Velocidade do Fluxo Sanguíneo/fisiologia , Doenças das Artérias Carótidas/fisiopatologia , Fatores Etários , Idoso , Artrite Reumatoide/complicações , Artrite Reumatoide/diagnóstico por imagem , Aterosclerose/complicações , Aterosclerose/diagnóstico por imagem , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico por imagem , Artéria Carótida Primitiva/diagnóstico por imagem , Espessura Intima-Media Carotídea , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Onda de Pulso , Fatores de Risco , Fatores Sexuais , UltrassonografiaRESUMO
Genetic biomarkers could be useful for orienting treatment of patients with rheumatoid arthritis (RA), but none has been convincingly validated yet. Putative biomarkers include 14 single nucleotide polymorphisms that have shown association with response to TNF inhibitors (TNFi) in candidate gene studies and that we assayed here in 755 RA patients. Three of them, in the PTPRC, IL10 and CHUK genes, were significantly associated with response to TNFi. The most significant result was obtained with rs10919563 in PTPRC, which is a confirmed RA susceptibility locus. Its RA risk allele was associated with improved response (B=0.33, P=0.006). This is the second independent replication of this biomarker (P=9.08 × 10(-8) in the combined 3003 RA patients). In this way, PTPRC has become the most replicated genetic biomarker of response to TNFi. In addition, the positive but weaker replication of IL10 and CHUK should stimulate further validation studies.
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Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Quinase I-kappa B/genética , Interleucina-10/genética , Antígenos Comuns de Leucócito/genética , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adalimumab/uso terapêutico , Artrite Reumatoide/genética , Feminino , Estudos de Associação Genética , Marcadores Genéticos , Humanos , Infliximab/uso terapêutico , Masculino , Pessoa de Meia-Idade , Polimorfismo de Nucleotídeo Único , RiscoRESUMO
BACKGROUND: Parathyroid failure is the most common complication after total thyroidectomy but factors involved are not completely understood. Accidental parathyroidectomy and parathyroid autotransplantation resulting in fewer than four parathyroid glands remaining in situ, and intensity of medical treatment of postoperative hypocalcaemia may have relevant roles. The aim of this study was to determine the relationship between the number of parathyroid glands remaining in situ and parathyroid failure after total thyroidectomy. METHODS: Consecutive patients undergoing first-time total thyroidectomy were studied prospectively, recording the number of Parathyroid Glands Remaining In Situ (PGRIS = 4 - (glands autografted + glands in the specimen)) and the occurrence of postoperative hypocalcaemia, and protracted and permanent hypoparathyroidism. Demographic, disease-related, laboratory and surgical variables were recorded. Patients were classified according to the PGRIS number into group 1-2 (one or two PGRIS), group 3 (three PGRIS) and group 4 (all four glands remaining in situ), and were followed for at least 1 year. RESULTS: A total of 657 patients were included, 43 in PGRIS group 1-2, 186 in group 3 and 428 in group 4. The prevalence of hypocalcaemia, and of protracted and permanent hypoparathyroidism was inversely related to the PGRIS score (group 1-2: 74, 44 and 16 per cent respectively; group 3: 51·1, 24·7 and 6·5 per cent; group 4: 35·3, 13·1 and 2·6 per cent; P < 0·001). Intact parathyroid hormone concentrations at 24 h and 1 month were inversely correlated with PGRIS score (P < 0·001). Logistic regression identified PGRIS score as the most powerful variable influencing acute and chronic parathyroid failure. In addition, a normal-high serum calcium concentration 1 month after thyroidectomy influenced positively the recovery rate from protracted hypoparathyroidism in all PGRIS categories. CONCLUSION: In situ parathyroid preservation is critical in preventing permanent hypoparathyroidism after total thyroidectomy. Active medical treatment of postoperative hypocalcaemia has a positive synergistic effect.
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Hipoparatireoidismo/prevenção & controle , Tratamentos com Preservação do Órgão/métodos , Glândulas Paratireoides/lesões , Tireoidectomia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Criança , Feminino , Bócio Nodular/cirurgia , Humanos , Hipocalcemia/etiologia , Hipocalcemia/prevenção & controle , Hipoparatireoidismo/sangue , Hipoparatireoidismo/etiologia , Complicações Intraoperatórias/prevenção & controle , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/metabolismo , Estudos Prospectivos , Fatores de Risco , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/efeitos adversos , Transplante Autólogo/efeitos adversos , Adulto JovemRESUMO
BACKGROUND: Staged thyroidectomy has been recommended when loss of the signal from intraoperative nerve monitoring is observed after first-side dissection of the recurrent laryngeal nerve. There is no high-quality evidence supporting this recommendation. In addition, it is not clear whether signal loss predicts postoperative vocal cord paralysis. METHODS: This was a prospective observational study of consecutive adult patients undergoing neuromonitored total thyroidectomy for either malignancy or multinodular goitre. The prevalence of first-side loss of signal was recorded. Surgery was completed, and vagus and laryngeal nerves on the first side were rechecked at the end of the procedure. RESULTS: Two-hundred and ninety patients were included. Loss of signal on the first side was noted in 16 procedures (5.5 per cent). Thyroidectomy was completed and, at retesting, 15 of 16 initially silent nerves recovered an electromyographic signal with a mean(s.d.) amplitude of 132(26) mcV. Mean time to recovery was 20.2 (range 10-35) min. In no patient was the signal lost on the opposite side. Only three of 15 nerves with a recovered signal were associated with transient vocal cord dysfunction. CONCLUSION: After loss of signal of the recurrent laryngeal nerve dissected initially, there was a 90 per cent chance of intraoperative signal recovery. In this setting, judicious bilateral thyroidectomy can be performed without risk of bilateral recurrent nerve paresis.
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Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/etiologia , Nervo Laríngeo Recorrente/cirurgia , Tireoidectomia/métodos , Paralisia das Pregas Vocais/etiologia , Adulto , Dissecação/métodos , Eletromiografia , Feminino , Bócio Nodular/cirurgia , Humanos , Masculino , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Recuperação de Função Fisiológica/fisiologia , Nervo Laríngeo Recorrente/fisiologia , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Neoplasias da Glândula Tireoide/cirurgia , Paralisia das Pregas Vocais/fisiopatologiaAssuntos
Humanos , Masculino , Adulto , Tuberculose Meníngea/diagnóstico , Infarto Cerebral/complicações , Ampicilina/uso terapêutico , Gentamicinas/uso terapêutico , Diplopia/complicações , Isoniazida/uso terapêutico , Rifampina/uso terapêutico , Pirazinamida/uso terapêutico , Etambutol/uso terapêutico , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Meníngea , Infarto Cerebral , Anfotericina B/uso terapêutico , Dexametasona/uso terapêutico , Radiografia Torácica , Punção Espinal/métodos , Mesencéfalo/patologia , Mesencéfalo , Imageamento por Ressonância Magnética/métodos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Although the variables that influence the development of post-thyroidectomy hypocalcaemia are now better understood, the risk factors and long-term outcome of persistent hypoparathyroidism (HPP) are poorly defined. A retrospective review of a prospective protocol for the management of post-thyroidectomy hypocalcaemia was performed. METHODS: Patients with a serum calcium level below 8 mg/dl (2 mmol/l) 24 h after total thyroidectomy were prescribed oral calcium with or without calcitriol and followed for at least 1 year. Protracted HPP was defined as an intact parathyroid hormone (iPTH) level below 13 pg/ml and need for calcium medication at 1 month after thyroidectomy. RESULTS: Of 442 patients (343 with goitre, 99 with carcinoma) undergoing total thyroidectomy, 222 (50.2 per cent) developed postoperative hypocalcaemia. Eleven patients were lost to follow-up. Parathyroid function recovered in 131 patients within 1 month and 80 developed protracted HPP, which was associated with lymphadenectomy, fewer than three glands left in situ and incidental parathyroidectomy. Parathyroid function recovered within 1 year in 78 per cent of patients with protracted HPP. Factors associated with late recovery of parathyroid function were higher serum calcium and low but detectable iPTH levels 1 month after surgery. These factors were associated with higher calcitriol and calcium dosages at hospital discharge. Parathyroid autotransplantation did not protect against permanent HPP. CONCLUSION: Higher serum calcium levels at 1 month after total thyroidectomy are associated with recovery of parathyroid function. It is hypothesized that intensive medical treatment of hypocalcaemia-'parathyroid splinting'-may improve the outcome of patients with protracted HPP.
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Hipocalcemia/etiologia , Hipoparatireoidismo/etiologia , Glândulas Paratireoides/transplante , Tireoidectomia/efeitos adversos , Calcitriol , Cálcio/metabolismo , Métodos Epidemiológicos , Feminino , Bócio/cirurgia , Humanos , Hipocalcemia/fisiopatologia , Hipoparatireoidismo/fisiopatologia , Masculino , Pessoa de Meia-Idade , Glândulas Paratireoides/fisiopatologia , Recuperação de Função Fisiológica , Neoplasias da Glândula Tireoide/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The bone mineral density (BMD) response to parathyroidectomy is heterogeneous and difficult to predict. Available data come from mixed populations of men and women, of different age and degrees of disease severity, and preoperative BMD loss. METHODS: This was a longitudinal, prospective cohort study of 103 postmenopausal women with osteopenia or osteoporosis at the femoral neck site, successfully operated on for primary hyper parathyroidism. BMD and metabolic variables were recorded before and 1 year after parathyroidectomy. RESULTS: After surgery, there was a 1.3 per cent increase in the median BMD at the femoral neck site (0.615 versus 0.623 g/cm(2); P = 0.001). Overall, positive responses were also observed at total hip (0.4 per cent) and lumbar spine (2.3 per cent) sites. Analysing the individual responses, however, only 45 (46 per cent) of 97 patients showed a significant (at least 3.7 per cent) increase in BMD at the femoral neck site compared with the preoperative value and 52 had a decreased (15) or unchanged (37) femoral neck BMD. Patients who gained BMD were younger, had more severe hyperparathyroidism and better renal function. CONCLUSION: Almost half of the postmenopausal women with hyperparathyroidism and low BMD have a significant remineralization response 1 year after parathyroidectomy. Differential mineralization responses of BMD after surgery appear to be related to severity of primary hyperparathyroidism, age and renal function.
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Densidade Óssea/fisiologia , Doenças Ósseas Metabólicas/fisiopatologia , Hiperparatireoidismo/cirurgia , Paratireoidectomia , Pós-Menopausa/fisiologia , Absorciometria de Fóton , Idoso , Doenças Ósseas Metabólicas/complicações , Feminino , Colo do Fêmur , Humanos , Hiperparatireoidismo/complicações , Pessoa de Meia-Idade , Osteoporose/complicações , Osteoporose/fisiopatologia , Período Pós-Operatório , Estudos ProspectivosRESUMO
BACKGROUND: Transient recurrent laryngeal nerve palsy affects to 5-10 per cent of patients after extracapsular thyroidectomy. This prospective study assessed the impact of surgical injury and extralaryngeal branching of the inferior laryngeal nerve (ILN) on vocal cord dysfunction (VCD). METHODS: Total thyroidectomy or lobectomy was performed in 188 patients, with 302 ILNs at risk. The anatomy of the ILN and degree of injury to the nerve, based on the Laryngeal Nerve Injury Score (LNIS), were recorded. Fibreoptic laryngoscopy was performed a mean(s.d.) of 10.6(4.1) days after thyroidectomy. RESULTS: Some 37.4 per cent of ILNs showed extralaryngeal branching. In all, 10.9 per cent of patients developed VCD; 4.3 per cent had paresis and 6.6 per cent paralysis. All paretic and all but one paralytic cords recovered fully after 61(17) days. VCD was more frequently associated with branched than non-branched ILNs (15.8 versus 8.1 per cent; P = 0.022). Injuries were more common in branched nerves (mean(s.e.m.) total LNIS 0.94(0.08) versus 0.51(0.05); P < 0.001). Branched nerves were more likely to be associated with VCD (odds ratio 2.2 (95 per cent confidence interval 1.1 to 4.5)). CONCLUSION: Branched ILNs suffer more surgical injuries and are twice as likely to be associated with VCD.
Assuntos
Traumatismos do Nervo Laríngeo Recorrente , Tireoidectomia/efeitos adversos , Paralisia das Pregas Vocais/etiologia , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Recidiva , Nervo Laríngeo Recorrente/anatomia & histologia , Nervo Laríngeo Recorrente/fisiopatologia , Fatores de Risco , Paralisia das Pregas Vocais/fisiopatologiaRESUMO
Debido al riesgo trombótico, y a sus implicaciones en la fertilidad, el síndrome antifosfolipídico (SAF) conlleva consideraciones particulares respecto a cualquier tipo de terapia hormonal y a la gestación. En el presente artículo, se procede a revisar ampliamente todos estos aspectos. Se desglosa lo referente a anticoncepción, terapia hormonal sustitutiva y moduladores selectivos de los receptores de estrógenos en el SAF. Se revisa la fertilización in vitro/transferencia embrionaria y la inducción ovárica en estas pacientes. Por último, se detallan las posibles complicaciones fetales y maternas durante la gestación, y basándose en la bibliografía, se indica una posible guía para el manejo del embarazo en mujeres con SAF(AU)
Antiphospholipid syndrome (APS) carries a risk of thrombosis and infertility. Consequently the use of any type of hormone therapy and pregnancy in APS requires special considerations. The present article provides a broad review of all these issues. The use of contraception, hormone replacement therapy and selective estrogen receptor modulators in APS are described. In vitro fertilization/embryo transfer and ovarian induction in these patients are reviewed. Lastly, the possible fetal and maternal complications that can occur during pregnancy are described and, based on the literature, recommendations for the management of pregnancy inwomen with APS are provided(AU)
Assuntos
Humanos , Síndrome Antifosfolipídica/tratamento farmacológico , Hormônios/uso terapêutico , Síndrome Antifosfolipídica/complicações , Complicações na Gravidez , Fertilidade , Anticoncepcionais Orais Hormonais/uso terapêutico , Transferência Embrionária , Terapia de Reposição HormonalRESUMO
Antiphospholipid syndrome (APS) carries a risk of thrombosis and infertility. Consequently the use of any type of hormone therapy and pregnancy in APS requires special considerations. The present article provides a broad review of all these issues. The use of contraception, hormone replacement therapy and selective estrogen receptor modulators in APS are described. In vitro fertilization/embryo transfer and ovarian induction in these patients are reviewed. Lastly, the possible fetal and maternal complications that can occur during pregnancy are described and, based on the literature, recommendations for the management of pregnancy in women with APS are provided.
RESUMO
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