ACTH-dependent Cushing's syndrome: a revision of 43 cases

AIM: To evaluate the characteristics and outcomes of the patients diagnosed as ACTH-dependent Cushing syndrome, registered in the department. MATERIAL AND METHODS: We reviewed the files of forty-three patients followed from 1974 to 2002. RESULTS: A progressive rise in the number of patients diagnosed was found, being 80% females. Clinical suspicion was based mostly on the typical fat distribution; hirsutism and amenorrhoea were important in women. The more reliable diagnostic tests were: 11 pm cortisol, day curve of ACTH and cortisol, and dexamethasone suppression tests. The ACTH response to CRH during inferior petrosal sinus sampling permitted the diagnosis of ectopic source. In thirty-seven patients a pituitary adenoma was diagnosed. The three patients diagnosed before 1985 went for bilateral adrenalectomy (Nelson's syndrome in two); the others were submitted to transsphenoidal pituitary adenomectomy, obtaining remission in twenty six at the first operation and in two others at the second. Three patients had a recidive. Of the six patients with persistent disease (all treated with metyrapone or ketoconazole), three were submitted to radiotherapy, two to bilateral adrenalectomy, and one was waiting for surgery. Four patients had a bronchial carcinoid, successfully removed in three. One patient was lost to follow-up and another was still being evaluated. CONCLUSIONS: We found a positive evolution in the capacity to diagnose and treat these patients. Neurosurgical ability to achieve remission was 80% in the operated cases. More effective technical methods and drugs, as well as a multidisciplinary and dedicated medical team, lead to long lasting remissions in most of the patients

A Randomized Double-Blind Study Comparing the Efficacy and Safety of Orlistat Versus Placebo in Obese Patients with Mild to Moderate Hypercholesterolemia

INTRODUCTION: Obesity is a chronic disease and a serious health problem that leads to increased prevalence of diabetes, hypertension, dyslipidemia and gallbladder disease. OBJECTIVE: To evaluate the efficacy of orlistat for weight loss and improved lipid profile compared to placebo in obese patients with hypercholesterolemia, treated over a period of 6 months. METHODOLOGY: In a 6-month, multicenter (10 centers in Portugal), double-blind, parallel, placebo-controlled study, 166 patients, aged 18-65 years, body mass index (BMI) > or = 27 kg/m2, LDL cholesterol > 155 mg/dl, were randomized to a reduced calorie diet (600 kcal/day deficit) plus orlistat three times a day or placebo. Exclusion criteria included triglycerides > 400 mg/dl, severe cardiovascular disease, uncontrolled hypertension, type 1 or 2 diabetes under pharmacological treatment, and gastrointestinal or pancreatic disease. RESULTS: The mean difference in weight from baseline was 5.9% (5.6 kg) in the orlistat group vs. 2.3% (2.2 kg) in the placebo group. In the orlistat group 49% of patients achieved 5-10% weight loss and 8.8% achieved > 10%. The orlistat group showed a significant reduction in total and LDL cholesterol, with similar changes for HDL in both treatment groups. The frequency of gastrointestinal adverse events was slightly higher in the orlistat group than in the placebo group, leading to discontinuation in 7 patients. CONCLUSION: Treatment with orlistat plus a reduced calorie diet for 6 months achieved significant reductions in weight, BMI and lipid parameters

Pollination and biological control research: are we neglecting two billion smallholders

Food insecurity is a major world problem, with ca. 870 million people in the world being chronically undernourished. Most of these people live in tropical, developing regions and rely on smallholder farming for food security. Solving the problem of food insecurity is thought to depend, in part, on managing ecosystem services, such as the pollination of crops and the biological control of crop pests, to enhance or maintain food production. Our knowledge regarding regulating ecosystem services in smallholder-farmed (or dualistic) landscapes is limited and whilst pollination has been the focus of considerable research, the provision of natural enemy services, important for every crop worldwide, has been relatively neglected. In order to assess whether ecosystem-service research adequately represents smallholder-farmed landscapes, whilst also considering climatic region and national economic status, we examined the constituent studies of recent quantitative reviews relevant to biological control and pollination. No regulating ecosystem service meta-analysis, to our knowledge, has focussed on smallholder agriculture despite its importance to billions of peoples’ local food security. We found that whilst smallholdings contributed 16% of global farmland area and 83% of the global agricultural population (estimated using FAO’s World Census of Agriculture 2000) only 22 of 190 studies (12%), overall, came from smallholder-farmed landscapes. These smallholder studies mostly concerned coffee production (16 studies). Individual reviews of biological control were significantly and strongly biased towards data from large-scale farming in temperate regions. In contrast pollination reviews included more smallholder studies and were more balanced for climate regions. The high diversity of smallholder-farmed landscapes implies that more research will be needed to understand them compared to large-scale landscapes but we found far more research from the latter. We highlight that these skews in research effort have implications for sustainable intensification and the food security of billions in the developing world. In particular we urge for balance in future ecosystem-services research and synthesis by greater consideration of a diverse range of smallholder-farmed landscapes in Africa and continental Asia

Regionalização da saúde no Brasil: uma perspectiva de análise

Este artigo visa a contribuir com o debate sobre a política de regionalização do SUS e a constituição das regiões de saúde no Brasil. Compreendê-las pressupõe reconhecer a dicotomia entre saúde coletiva e saúde individual - que marca a história da saúde pública brasileira - e identificar as diferentes racionalidades que conduzem esse processo. Tais racionalidades permitem não apenas considerar o legado da municipalização no atual processo de regionalização, como também estabelecer nexos entre dois campos do conhecimento fundamentais para o debate, a epidemiologia e a geografia. A epidemiologia clínica, ao privilegiar a saúde individual, fundamenta um modelo assistencial que prioriza a otimização de recursos. O reconhecimento da saúde no seu conceito ampliado, na epidemiologia social, fundamenta um modelo de atenção voltado para os determinantes sociais. Com a geografia, podem-se formular regiões funcionais, baseadas na teoria de Christaller, ou regiões lablachianas, que reconhecem a estrutura social loco/regional, possibilitando a intervenção nos determinantes ou condicionantes da maneira de adoecer e morrer das populações

Non-bee insects are important contributors to global crop pollination

Wild and managed bees are well documented as effective pollinators of global crops of economic importance. However, the contributions by pollinators other than bees have been little explored despite their potential to contribute to crop production and stability in the face of environmental change. Non-bee pollinators include flies, beetles, moths, butterflies, wasps, ants, birds, and bats, among others. Here we focus on non-bee insects and synthesize 39 field studies from five continents that directly measured the crop pollination services provided by non-bees, honey bees, and other bees to compare the relative contributions of these taxa. Non-bees performed 25–50% of the total number of flower visits. Although non-bees were less effective pollinators than bees per flower visit, they made more visits; thus these two factors compensated for each other, resulting in pollination services rendered by non-bees that were similar to those provided by bees. In the subset of studies that measured fruit set, fruit set increased with non-bee insect visits independently of bee visitation rates, indicating that non-bee insects provide a unique benefit that is not provided by bees. We also show that non-bee insects are not as reliant as bees on the presence of remnant natural or seminatural habitat in the surrounding landscape. These results strongly suggest that non-bee insect pollinators play a significant role in global crop production and respond differently than bees to landscape structure, probably making their crop pollination services more robust to changes in land use. Non-bee insects provide a valuable service and provide potential insurance against bee population declines

Crop pests and predators exhibit inconsistent responses to surrounding landscape composition

The idea that noncrop habitat enhances pest control and represents a win–win opportunity to conserve biodiversity and bolster yields has emerged as an agroecological paradigm. However, while noncrop habitat in landscapes surrounding farms sometimes benefits pest predators, natural enemy responses remain heterogeneous across studies and effects on pests are inconclusive. The observed heterogeneity in species responses to noncrop habitat may be biological in origin or could result from variation in how habitat and biocontrol are measured. Here, we use a pest-control database encompassing 132 studies and 6,759 sites worldwide to model natural enemy and pest abundances, predation rates, and crop damage as a function of landscape composition. Our results showed that although landscape composition explained significant variation within studies, pest and enemy abundances, predation rates, crop damage, and yields each exhibited different responses across studies, sometimes increasing and sometimes decreasing in landscapes with more noncrop habitat but overall showing no consistent trend. Thus, models that used landscape-composition variables to predict pest-control dynamics demonstrated little potential to explain variation across studies, though prediction did improve when comparing studies with similar crop and landscape features. Overall, our work shows that surrounding noncrop habitat does not consistently improve pest management, meaning habitat conservation may bolster production in some systems and depress yields in others. Future efforts to develop tools that inform farmers when habitat conservation truly represents a win–win would benefit from increased understanding of how landscape effects are modulated by local farm management and the biology of pests and their enemies

Safeguarding pollinators and their values to human well-being

Wild and managed pollinators provide a wide range of benefits to society in terms of contributions to food security, farmer and beekeeper livelihoods, social and cultural values, as well as the maintenance of wider biodiversity and ecosystem stability. Pollinators face numerous threats, including changes in land-use and management intensity, climate change, pesticides and genetically modified crops, pollinator management and pathogens, and invasive alien species. There are well-documented declines in some wild and managed pollinators in several regions of the world. However, many effective policy and management responses can be implemented to safeguard pollinators and sustain pollination services