Diagnostic of andropause: a problem not yet solved

Em processament

Carcinoma de tireoide hiperfuncionante: seguimento de cinco anos

Differentiated thyroid cancer rarely occurs in association with hyperfunctioning nodules. We describe a case of a 47-year-old woman who developed symptoms of hyperthyroidism associated with a palpable thyroid nodule. Thyroid scintigraphy showed an autonomous nodule, and fine-needle aspiration biopsy was suggestive of papillary carcinoma. Laboratorial findings were consistent with the diagnosis of hyperthyroidism. The patient underwent thyroidectomy and a papillary carcinoma of 3.0 x 3.0 x 2.0 cm, follicular variant, was described by histological examination. The surrounding thyroid tissue was normal. Postoperatively, the patient received 100 mCi of 131I, and whole body scans detected only residual uptake. No evidence of metastasis was detected during five years of follow-up. Hot thyroid nodules rarely harbor malignancies, and this case illustrated that, when a carcinoma occurs the prognosis seems to be very good with no evidence of metastatic dissemination during a long-term follow-up.O câncer diferenciado de tireoide raramente ocorre em associação a nódulos hiperfuncionantes. Foi descrito aqui o caso de uma paciente de 47 anos de idade que desenvolveu sintomas de hipertireoidismo associados a um nódulo tireoidiano palpável. A cintilografia da tireoide mostrou tratar-se de um nódulo autônomo, e a biópsia por punção aspirativa por agulha fina foi sugestiva de carcinoma papilar. Os achados laboratoriais foram consistentes com o diagnóstico de hipertireoidismo. A paciente foi submetida à tireoidectomia e um carcinoma papilar de 3,0 x 3,0 x 2,0 cm, variante folicular, foi descrito por exame histopatológico. O tecido tireoidiano circunjacente era normal. No pós-operatório a paciente recebeu 100 mCi de 131I, e a cintilografia de corpo inteiro mostrou apenas captação residual. Nenhuma metástase foi identificada ao longo de cinco anos de acompanhamento. Nódulos quentes raramente albergam doença maligna, e este caso demonstrou que, quando ocorre carcinoma, o prognóstico parece ser muito bom, sem evidência de disseminação metastática em longo prazo

Endocrine treatment of meningiomas: a review

Os meningiomas são tumores benignos do sitema nervoso central. Apresentam altas taxas de recidiva e muitas vezes são considerados inoperáveis, como quando se localizam em local de difícil acesso cirúrgico ou quando englobam estruturas nobres do cérebro. Existem evidências clínicas, epidemiológicas, bioquímicas e de experimentos "in vitro" de que seu crescimento sofre influência do meio hormonal esteróideo. Vários ensaios terapêuticos têm explorado estas características do meningioma através do uso de substâncias que interferem na ação destes esteróides: RU486 (antiprogestínico e antiglicocorticóide), acetato de medroxiprogesterona (antiprogestínico), gestrinona (antiestrogênico e antiprogestínico), tamoxifen (antiestrogênico) e buserelin (superagonista do LHRH), além do octreotide (análogo da somatostatina) e a bromocriptina (agonista dopaminérgico). Outros medicamentos possuem potencial para o tratamento dos meningiomas: aminoglutetimina, suramin e trapidil. Nesta revisão, analizamos a literatura sobre esses aspectos.Meningiomas are begnin tumors of central nervous system. They have high rates of relapse and sometimes are not amenable to total removal mainly when involve vital structures. Clinical, epidemiological, biochemical and "in vitro" experiment show evidence that meningioma growth is influencied by steroid hormonal medium. Several clinical trials have explored these meningioma characteristics with the use of substances interfering with steroid actions: RU486 (antiprogestinic and antiglucocorticoid), medroxiprogesterone acetate (antiprogestinic), gestrinone (antiestrogenic e antiprogestinic), tamoxifen (antiestrogenic) and buserelin (LHRH superagonist), beyond of octreotide (somatostatin analog) and bromocriptine (dopaminergic agonist). Other substances have potential for the meningiomas treatment: aminogluthetimide, suramin and trapidil. In this review, we analyzed the literature about these aspects

The effect of cognitive-behavioral therapy on acromegalics after a 9-month follow-up

Introduction: The quality of life of acromegalics is compromised. Treatment with the “Think healthy and feel the difference” technique has been described as effective in the improvement of the quality of life of these patients in the short term. However, its effectiveness in the long term needs to be evaluated. Objective: The purpose of this study was to evaluate whether the good results obtained from the “Think healthy and feel the difference” technique in the short termpersists in the long term, after the end of the treatment. Method: This is a non-randomized longitudinal study with 23 acromegalic divided into two groups: an intervention group with 10 patients and a control group with 13 patients. The intervention itself covered nine group sessions, organized weekly, using a technique called “Think healthy and feel the difference.” The control group did not receive the aforementioned treatment. The Short Form 36 Question Health Survey (SF-36) and the Beck Depression Inventory were administered before the sessions began, at the end of the nine therapy sessions and at the 9-month follow-up. Results: At the end of the treatment, the results of the SF-36 showed improvement in the mental health of the intervention group compared to the control group. The effects of therapy were maintained at the 9 month follow-up. Conclusion: Cognitive-behavioral therapy, applied in a group format, can improve the quality of life of acromegalic patients in the short- and long-term

Safety culture in the perception of public-hospital health professionals

OBJETIVO Avaliar a cultura de segurança na percepção dos profissionais que trabalham nos hospitais públicos do Sistema Único de Saúde (SUS) do Distrito Federal, Brasil, três anos após a implantação do Programa Nacional de Segurança do Paciente (PNSP). MÉTODOS estudo transversal analítico realizado em onze hospitais públicos por meio do Safety Attitudes Questionnaire em formato eletrônico. A amostragem estratificada foi calculada, obedecendo à proporção do total de profissionais em cada hospital, assim como a representatividade de cada grupo profissional. Os resultados do escore total e dos domínios iguais ou maiores que 75 foram considerados positivos. Realizadas análises descritivas e inferenciais dos grupos profissionais e dos hospitais. RESULTADOS Participaram 909 profissionais. O escore total por grupo profissional foi negativo (62,5 a 69,5) e por domínio diferiram estatisticamente entre si em todos. Os onze hospitais tiveram escore total negativo (61,5 a 68,6). Os domínios com desempenho positivo foram satisfação no trabalho, percepção do estresse e clima de trabalho em equipe. Os resultados mais baixos foram condições de trabalho e percepção da gerência, e nenhum dos hospitais obteve média superior à 75 nesses domínios. Também foram encontradas diferenças nas médias dos domínios entre os hospitais, exceto em percepção da gerência. DISCUSSÃO Após três anos de implantação no PNSP, a cultura de segurança nos onze hospitais avaliados se mostrou fragilizada, embora os domínios satisfação no trabalho, percepção do estresse e clima de trabalho em equipe tiveram resultados positivos. Os resultados podem contribuir para a tomada de decisão dos gestores, pois a cultura de segurança é um elemento essencial na implementação da política de segurança do paciente.OBJECTIVE Evaluating safety culture in the perception of professionals working in public hospitals of the Unified Health System (SUS) of Distrito Federal, Brazil, three years after the implementation of the National Patient Safety Program (PNSP). METHODS Analytical cross-sectional study conducted in eleven public hospitals using the Safety Attitudes Questionnaire (SAQ) in electronic format. Stratified sampling was estimated according to the proportion of the total number of professionals in each hospital, as well as the representativeness of each professional group. The results of the total score and domains equal to or greater than 75 were considered positive. Descriptive and inferential analyses of professional groups and hospitals were carried out. RESULTS 909 professionals participated. The total score by professional group was negative (62.5 to 69.5) and the domains differed statistically in all cases. The eleven hospitals had a negative total score (61.5 to 68.6). The domains to attain positive performance were job satisfaction, stress recognition and teamwork climate. The lowest results were in working conditions and management perception domains, for which none of the hospitals had an average above 75. Differences were also found for domain means across hospitals, except in management perception. DISCUSSION Three years after the implementation of PNSP, the safety culture in eleven hospitals evaluated was weak, although the domains of job satisfaction, stress recognition and teamwork climate had positive results. The results can contribute to decision-making by managers, as safety culture is an essential element in the implementation of patient safety policy

Results of glycated hemoglobin during treatment with insulin analogues dispensed in the public health system of Federal District in Brazil

Background: Diabetes treatment requires specialized multi-professional teams, supplies for blood glucose monitoring and training for self-injections of human insulin or insulin analogues. The State Health Secretariat of the Federal District (SHS-FD) has dispensed insulin analogues by means of clinical validated protocols since 2004. However, data on outcomes of follow-up are still unknown. Objective: To evaluate the results of glycated hemoglobin (HbA1c) among diabetic patients treated with insulin analogues. Methods: It is a retrospective cohort study involving data of type 1(DM1) and type 2 diabetes (DM2) patients 18 years old and above who were registered to participate at the insulin analogues dispense program of the SHS-FD. Evaluation of criteria of insulin treatment continuity was based on HbA1c values achieved in the follow-up period: in the target, <7 %, patients between 18 and 65 years old; <8 % for those above 65 years old; out of target, when values were superior these cut off points for both age groups; and minimum 0.5 % reduction of two HbA1c values during follow-up. Results: Two hundred and fifteen formularies were analyzed: Type 2 patients (63.7 %) and female sex were the most prevalent (63.7 %), (p < 0.05). Mean age and SD were 41.5 ± 23.5 years among DM1 and 60.5 ± 28.5 in those with DM2. HbA1c in the target was found in 26 %, 48 % were out of target and 26 % achieved 0.5 % minimum reduction in HbA1c value (p < 0.05). The main clinical characteristics associated with HbA1c found to be in the target were older age (>65 years), more than three medical appointments in the follow-up and lower mean HbA1c in the patient selection for inclusion criteria in the dispense program (p < 0.05). Conclusion: The low number of patients using insulin analogues in the target group, considered to be in good control, implies the need to reevaluate both level of patients self-care knowledge and glucose monitoring prior their inclusion in the insulin analogue dispense program. Reinforcement and training of health professional teams in enrollment procedures should be on mandatory basis to avoid protocol failure or deviations

Persistência de hiperprolactinemia após tratamento de hipotiroidismo primário e suspensão do uso prolongado de estrogênio : os neurônios dopaminérgicos túberoinfundibulares são permanentemente lesados?

Uso prolongado de altas doses de estrogênio e a presença de hiperprolactinemia crônica pode, pelo menos no rato, provocar lesão nos neurônios dopaminérgicos tuberoinfundibulares (TIDA) responsáveis pelo controle da secreção de prolactina (Prl). Essa ocorrência, ainda não bem documentada em humanos, pode ter ocorrido em uma paciente em tratamento crônico com contraceptivo oral (OC), que veio para consulta por hipotiroidismo primário, hiperprolactinemia e uma massa hipofisária. Após reposição de hormônio tiroidiano, suspensão do tratamento com o OC e a bromocriptina, essa paciente não manteve níveis normais de Prl, necessitando tratamento contínuo com agonista dopaminérgico, mesmo quando a RM da região selar indicava uma situação normal. A função dos neurônios TIDA foi investigada pelo teste do TRH (200µg IV), realizado antes e após 25mg de carbidopa e 250mg de L-dopa a cada 4 horas por um dia. TSH basal (3,9µU/mL) era normal, enquanto Prl (67,5 ng/mL) estava alta; ambos aumentaram apropriadamente após o estímulo com TRH, com picos de 31,8µU/mL (TSH) e 157,8ng/mL (Prl). Após tratamento com carbidopa/L-dopa, os níveis de TSH (1,6µU/mL) e Prl (34ng/mL) diminuíram e a resposta ao TRH foi parcialmente bloqueada (10,3µU/mL e 61ng/mL, respectivamente). Apesar da resposta normal, discutimos a possibilidade que a persistência da hiperprolactinemia é devida a uma lesão dos neurônios TIDA, produzida pelo longo uso de altas doses de estrogênios e pela presença de hiperprolactinemia crônica.Long term use of high doses of estrogen and the presence of chronic hyperprolactinemia may, at least in the rat, provoke lesions in the tuberoinfundibular dopaminergic (TIDA) neurons responsible for the control of prolactin (Prl) secretion. This occurrence, which is not yet well documented in humans, may have taken place in a patient on chronic oral hormonal contraceptive (OC) treatment who was seen for primary hypothyroidism, hyperprolactinemia and a pituitary mass. After thyroid hormone replacement, OC withdrawn and bromocriptine treatment, this patient could not maintain normal Prl levels, unless continuously treated with a dopaminergic agonist even when MRI was indicative of a normal situation. Function of TIDA neurons was investigated by TRH test (200µg IV) performed before and after treatment with 25mg carbidopa plus 250mg L-dopa every 4 hours for one day. Basal TSH was normal (3.9µU/mL) whereas basal Prl was high (67.5 ng/mL); both TSH and Prl levels appropriately increased after TRH: peaks 31.8µU/mL and 157.8 ng/mL, respectively. After treatment with carbidopa/L-dopa, basal TSH (1.6µU/mL) and Prl (34ng/mL) decreased and the response to TRH was partially blocked (10.3µU/mL and 61ng/mL, respectively). In spite of a normal response, we discuss the possibility that the persistence of hyperprolactinemia is due to lesion of the TIDA neurons produced by the long term use of high doses of estrogens and by the presence of chronic hyperprolactinemia

Giant paraselar aneurysm simulating pituitary tumour

Revisamos 7 pacientes com comprometimento da sela turca ao raio X do crânio que apresentavam aneurisma gigante da porção intracavernosa da artéria carótida (6 casos) e aneurisma da artéria comunicante anterior (1 caso). As alterações encontradas foram: cefaléia (7/7), oftalmoplegia complexa interessando III, IV e VI nervos cranianos (5/7) e comprometimento do V nervo (4/7), dor ocular (4/7). Outras alterações encontradas foram: sinais meníngeos (2/7), cegueira unilateral (1/7), hemiparesia (1/7) cacosmia (1/7) e quadrantanopsia bitemporal inferior (1/7). Cinco pacientes com aneurisma da porção intracavernosa da artéria carótida beneficiaram-se com a ligadura progressiva da artéria carótida interna a nível cervical; o outro paciente faleceu antes da realização da operação. O paciente com aneurisma da artéria comunicante anterior foi submetido a clipagem do aneurisma, tendo boa evolução. Baseados neste estudo e em concordância com a literatura, concluímos que o diagnóstico diferencial entre aneurisma localizado na região parasselar e outras patologias dessa área freqüentemente apresenta dificuldade. O diagnóstico definitivo requer a realização de angiografia cerebral. O tratamento cirúrgico, por ligadura da carótida interna na região cervical, é benéfico e quase desprovido de complicações.Seven cases of compromised pituitary fossa at the conventional skull X-ray, who had the final diagnosis of giant aneurysm of the intracavernous portion of the carotid artery (6 cases) and one of the anterior communicant artery, are reported. The main findings were: headache (7/7), complex ophtalmoplegia involving the III, IV and VI cranial nerves (5/7), compromised V cranial nerve (4/7) and eyeball pain (4/7). Other manifestations were: meningeal signs (2/7), unilateral blindness (1/7), hemiparesis (1/7), cacosmia (1/7) and inferior bitemporal quadrantanopsia (1/7). Five patients with intracavernous carotid artery aneurysm showed benefits with progressive occlusion of the internal carotid artery at the cervical level. One died before surgery. The case with anterior communicant artery aneurysm improved after its surgical clipping. Our data, in accord with the literature, support the conclusion that the differential diagnosis of aneurysms in the parasellar egion remains a very difficult task. The accurate final diagnosis requires cerebral angiography and the surgical treatment with progressive occlusion at the cervical portion of the internal carotid artery has a relatively low risk with promising results

Evaluación de la cultura de seguridad en un hospital público en el Distrito Federal, Brasil

Objetivo: avaliar a percepção dos profissionais de saúde sobre a cultura de segurança de um hospital público de alta complexidade do Distrito Federal, Brasil. Método: estudo transversal e descritivo. Utilizou-se o Questionário Atitudes de Segurança no formato eletrônico. Foram realizadas análises descritivas e inferenciais. Resultados: participaram 358 profissionais, sendo 242 (67,6%) do sexo feminino. Destes, 224 (62,6%) trabalhavam direta ou indiretamente com o paciente em atividades assistenciais; 79 (22,1%) em administrativas; 14 (3,9%) em gerenciais; e 41 (11,5%) em outras. O escore total foi de 57,1; os fatores satisfação no trabalho e percepção do estresse tiveram os resultados mais expressivos, 76,2 e 68,8, respectivamente. O quesito condições de trabalho teve o resultado mais baixo, 40,7. Conclusão: os resultados estão abaixo do escore 75, valor recomendado como indicativo de um clima de segurança positivo. Sugere-se a implementação de ações para a promoção da cultura de segurança e novos estudos com amostra representativa de todos os segmentos de trabalhadores.Objective: to assess the perception of health professionals regarding safety culture of a high complexity public hospital of the Federal District, Brazil. Method: cross-sectional and descriptive study. The Safety Attitudes Questionnaire was used in electronic format. Descriptive and inferential analyses were carried out. Results: 358 professionals participated, with 242 (67.6%) being female. Of these, 224 (62.6%) worked directly or indirectly with patients in assistance activities; 79 (22.1%) in administrative activities; 14 (3.9%) in management; and 41 (11.5%) in others. The total score was 57.1. Job satisfaction factors and stress perception had the most expressive results, 76.2 and 68.8, respectively. The category "working conditions" presented the lowest result, 40.7. Conclusion: the results are below the score of 75, value recommended as indicative of a positive safety atmosphere. We suggest the implementation of actions for the promotion of safety culture and new studies with representative samples of all segments of workers.Objetivo: evaluar la percepción de los profesionales de salud sobre la cultura de seguridad de un hospital público de alta complejidad del Distrito Federal, Brasil. Método: estudio transversal y descriptivo. Se utilizó el Cuestionario Actitudes de Seguridad en el formato electrónico. Se realizaron análisis descriptivos e inferenciales. Resultados: participaron 358 profesionales, siendo 242 (67,6%) mujeres. De estos, 224 (62,6%) trabajaban directa o indirectamente con el paciente en actividades asistenciales; 79 (22,1%) en administrativas; 14 (3,9%) en gerenciales; y 41 (11,5%) en otras. La puntuación total fue de 57,1; los factores de satisfacción en el trabajo y percepción del estrés tuvieron los resultados más expresivos, 76,2 y 68,8, respectivamente. La categoría de las condiciones de trabajo tuvo el resultado más bajo, 40,7. Conclusión: los resultados están por debajo de la puntuación 75, valor recomendado como indicativo de un clima de seguridad positivo. Se sugiere la implementación de acciones para la promoción de la cultura de seguridad y nuevos estudios con muestra representativa de todos los segmentos de trabajadores

Late effects on hypothalamic-pituitary function following treatment of paraselar tumours

O acompanhamento a longo prazo de pacientes submetidos a tratamento de tumores da região parasselar é importante para detectar complicações tardias da terapêutica. Neste estudo avaliamos 6 pacientes com craniofaringioma, 1 com meningioma, 1 com germinoma e 1 com cisto epidermóíde, localizados na região parasselar. Eles haviam sido tratados, em média, 3,8±3,2 anos antes, por cirurgia e radioterapia (6 casos) ou somente cirurgia (3 casos). Cinco pacientes eram do sexo feminino e a média de idade era de 24,3±18,8 anos. A avaliação consistiu na infusão endovenosa de TRH (200 mg), GnRH (100 mg) e insulina regular (0,1 UI Kg/peso), bem como na dosagem dos hormônios hipofisários antes (0) e após 20, 40, 60 e 80 minutos. Encontramos os seguintes resultados: (a) resposta deficitária do GH e do cortisol era todos pacientes; (b) 7/9 pacientes não tiveram respostas adequadas do FSH e 3/9 do L.H; (c) 4/9 tiveram respostas inadequadas da prolactina e 2/8 do TSH. Concluimos que: (a) o déficit de GH e cortisol são os mais frequentes nestes pacientes; (b) a lesão após radioterapia pode localizar-se tanto no hipotálamo quanto na hipófise ou, ainda, em ambos; (c) a sensibilidade das células hipofisárias e hipotalâmicas à irradiação é diferente de acordo com os hormônios que produzem; (d) é necessário o acompanhamento endocrinológico frequente dos pacientes submetidos a tratamento de tumores parasselares, a fim de detectar déficits hormonais tardios.Long term follow-up of patients submitted to treatment of paraselar tumours region is important for the detection of late therapeutic complications. In this study the authors conducted an evaluation of six patients with craniopharyngioma, one with germinoma, one with meningioma, and one epidermoid cyst. All above tumours were localized at paraselar region. Six out of nine patients had been treated both by surgery and by radiotherapy and the other three surgically only, on an average 3.8±3.2 years before this observation was carried out. Five patients were female with their ages average 24.3±18.8 years old. Evaluation consisted: in the first place, an intravenous infusion of thyrotropin-releasing hormone (TRH, 200 mg), gonadotropin-releasing hormone (GnRH, 100 mg), and insulin tolerance test (0,1 IU/Kg, regular insulin); and secondly, in measurements of pituitary hormones secretion at different time points - 0, 20,40, 60 and 80 minutes. We found both diminished response of growth hormone and Cortisol in all the patients. Seven out of nine patients did not have adequate response to follicle-stimulating hormone. Three out of nine responded unsatisfactory to luteinizing hormone. Four out of nine showed inadequate responses to prolactin as well as, two out of eight to thyrotropin. We concluded that: (a) growth hormone and Cortisol deficiency are the most frequent finding in these patients; (b) post-radiotherapy lesions can be located in the hypothalamus or pituitary, or even in both; (c) hypophsial and hypothalamic cell sensitivity to irradiation is different, according to their respective hormones; and (d) it is necessary a frequent endocrinologic follow-up of patients to detect late hormonal deficiences