Hipertensão arterial sistêmica no diabetes : diferença de efeito entre as classes de anti-hipertensivos e monitorização ambulatorial da pressão arterial como preditor de desfechos cardiovasculares em pacientes com diabete melito tipo 2

A prevalência de diabetes melito (DM) vem aumentando no Brasil e no mundo e sua associação com a hipertensão arterial sistêmica (HAS) é bastante comum nos pacientes com DM tipo 2. Tanto a hiperglicemia quanto a HAS são fatores de risco independentes para doenças cardiovasculares (CV) e a sua coexistência aumenta em cerca de 7 vezes o risco de morte dos pacientes. Existe muita controvérsia na literatura em relação à qual é o tratamento ideal para HAS em pacientes com DM tipo 2, em especial se existe benefício de uma classe de anti-hipertensivo em relação às outras na prevenção de eventos cardiovasculares. Não existem ensaios clínicos randomizados que comparem diretamente o efeito de todas as classes de anti-hipertensivos entre si. Dessa forma, realizamos uma metanálise em rede com o objetivo de avaliar o efeito das diferentes classes de anti-hipertensivos na prevenção de morte cardiovascular e morte por qualquer causa. Nessa metanálise, incluímos 27 estudos totalizando 49418 pacientes, com 1306 mortes de causa CV e 5647 mortes de qualquer causa. Na análise em rede, apenas a combinação de inibidores da enzima conversora da angiotensina (iECA) com bloqueadores dos canais de cálcio demonstrou redução no risco de morte CV em relação ao placebo, betabloqueadores, bloqueadores canais de cálcio isolados e bloqueadores do receptor da angiotensina. Entretanto, nos estudos incluídos, essa combinação foi também a que apresentou menor média de pressão arterial (PA) ao final do estudo, podendo ser esse o fator mediador do seu efeito protetor. Além da medida da PA no consultório, diversos parâmetros obtidos com a monitorização ambulatorial da pressão arterial (MAPA) têm sido associados a aumento de risco de desfechos negativos. Em pacientes não diabéticos, a HAS do avental branco (valores de PA elevados no consultório e normais na MAPA) está associada a aumento de risco de eventos CV e morte em pacientes sem tratamento para HAS. Da mesma maneira, a HAS mascarada (valores de PA normais no consultório e elevados na MAPA) também está associada a aumento de risco de 15 doença CV em pacientes com e sem DM não tratados para HAS. Entretanto, poucos estudos prospectivos avaliaram a associação de HAS do avental branco e mascarada em pacientes diabéticos com desfechos clínicos “duros” e morte em longo prazo. Em uma coorte de pacientes com DM tipo 2 do ambulatório de endocrinologia do Hospital de Clínicas de Porto Alegre, com 400 pacientes submetidos a MAPA na avaliação basal, avaliamos a associação dessas duas categorias com a ocorrência de eventos em longo prazo. Consideramos como desfechos: infarto agudo do miocárdio (IAM), acidente vascular cerebral (AVC), doença renal em estágio terminal, amputação não traumática de membros inferiores, revascularização miocárdica ou de membros inferiores e morte. O desfecho primário foi definido como a ocorrência do primeiro de qualquer desses eventos. O desfecho secundário foi a ocorrência de eventos CV maiores (MACE3p – definido como AVC ou IAM não fatal ou morte CV). Ao final do estudo, a ocorrência de eventos foi avaliada em 353 pacientes (88% da coorte original) por meio da revisão de registro de prontuário, contato telefônico ou revisão dos registros de óbitos do estado do Rio Grande do Sul. A média de tempo de seguimento foi de 10,4 anos. Nessa coorte, pacientes com HAS sustentada (valores de PA elevados no consultório e na MAPA) apresentaram maior risco do desfecho combinado, MACE3p, morte CV e amputação de membros inferiores do que os com HAS do avental branco, além de maior risco de morte CV em comparação com os normotensos (valores de PA normais no consultório e na MAPA). Tanto os pacientes com HAS mascarada e sustentada apresentaram maior risco de hemodiálise do que os normotensos. Após ajuste para sexo, tabagismo, hemoglobina glicada e média de PA sistólica nas 24h, as diferenças no desfecho combinado e MACE3p não foram mais observadas. Entretanto, a média da PA sistólica nas 24h manteve-se associada de forma independentemente a ambos os desfechos (desfecho combinado e MACE3p), sugerindo que os valores absolutos de PA tenham impacto mais significativo do que a classificação dos pacientes em categorias pela MAPA

Association between metabolic syndrome and periodontitis : a systematic review and meta-analysis

The aim of the present study was to evaluate the association between metabolic syndrome (MS) and periodontitis (PD), through a systematic review and meta-analysis. Original observational studies assessing the association between MS and PD in adults, published before May 11th (2017), were identified through electronic searches of MEDLINE, EMBASE and Cochrane Library databases. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was used. For studies to be included, they had to mention the criteria used to diagnose MS and to have used at least one clinical measure to diagnose PD. There was no language restriction. Three reviewers independently identified eligible studies for possible inclusion in the systematic review and meta-analysis. The quality of the studies was evaluated by the Newcastle-Ottawa scale for observational studies. A random model meta-analysis was conducted. The strategies used to investigate heterogeneity were sequential analysis, subgroup analysis, univariate meta-regression and sensitivity analysis. Thirty-three studies met the inclusion criteria for the systematic review, and 26 had enough information to be included in the meta-analysis, totaling 52,504 patients. MS and PD were associated with an odds ratio of 1.38 (95%CI 1.26–1.51; I2 = 92.7%; p < 0.001). Subgroup analysis showed that complete periodontal examination (I2 = 70.6%; p < 0.001) partially explained the variability between studies. The present findings suggest an association between MS and PD. Individuals with MS are 38% more likely to present PD than individuals without this condition. Prospective studies should be conducted to establish cause and effect relations between MS and PD

MIELOLIPOMA GIGANTE – RELATO DE CASO E REVISÃO DA LITERATURA

Mielolipomas são tumores benignos raros compostos por tecido adiposo maduro e por elementos hematopoiéticos. Geralmente são menores que 5 cm e assintomáticos, embora lesões maiores podem apresentar-se com dor ou hemorragia retroperitoneal. Descrevemos um caso de mielolipoma gigante, associado à hemorragia retroperitoneal após biópsia por punção comagulha fina. Unitermos: mielolipoma, tumor adrenal, incidentaloma adrena

El magisterio español : Revista General de la Enseñanza: Año LVIII Número 7093 - 1924 Diciembre 04

Copia digital. Madrid : Ministerio de Cultura. Subdirección General de Coordinación Bibliotecaria, 200

Association between metabolic syndrome and periodontitis : a systematic review and meta-analysis

The aim of the present study was to evaluate the association between metabolic syndrome (MS) and periodontitis (PD), through a systematic review and meta-analysis. Original observational studies assessing the association between MS and PD in adults, published before May 11th (2017), were identified through electronic searches of MEDLINE, EMBASE and Cochrane Library databases. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was used. For studies to be included, they had to mention the criteria used to diagnose MS and to have used at least one clinical measure to diagnose PD. There was no language restriction. Three reviewers independently identified eligible studies for possible inclusion in the systematic review and meta-analysis. The quality of the studies was evaluated by the Newcastle-Ottawa scale for observational studies. A random model meta-analysis was conducted. The strategies used to investigate heterogeneity were sequential analysis, subgroup analysis, univariate meta-regression and sensitivity analysis. Thirty-three studies met the inclusion criteria for the systematic review, and 26 had enough information to be included in the meta-analysis, totaling 52,504 patients. MS and PD were associated with an odds ratio of 1.38 (95%CI 1.26–1.51; I2 = 92.7%; p < 0.001). Subgroup analysis showed that complete periodontal examination (I2 = 70.6%; p < 0.001) partially explained the variability between studies. The present findings suggest an association between MS and PD. Individuals with MS are 38% more likely to present PD than individuals without this condition. Prospective studies should be conducted to establish cause and effect relations between MS and PD

Las Provincias : diario de Valencia: Año XLII Número 14904 - 1907 Junio 23

Mielolipomas são tumores benignos raros compostos por tecido adiposo maduro e por elementos hematopoiéticos. Geralmente são menores que 5 cm e assintomáticos, embora lesões maiores podem apresentar-se com dor ou hemorragia retroperitoneal. Descrevemos um caso de mielolipoma gigante, associado à hemorragia retroperitoneal após biópsia por punção com agulha fina.Myelolipomas are rare benign tumors composed of mature fat and haematopoietic tissue. Myelolipomas are usually smaller than 5 cm and asymptomatic, although larger lesions can present with pain or retroperitoneal hemorrhage. We describe a case of a giant myelolipoma, associated with haemorrhagic complication after diagnostic fine needle aspiration

Thyroid ultrasound features and risk of carcinoma : a systematic review and meta-analysis of observational studies

Background: Thyroid nodules are a common finding in the general population, and their detection is increasing with the widespread use of ultrasound (US). Thyroid cancer is found in 5–15% of cases depending on sex, age, and exposure to other risk factors. Some US parameters have been associated with increased risk of malignancy. However, no characteristic seems sufficiently reliable in isolation to diagnose malignancy. The objective of this meta-analysis was to evaluate the diagnostic performance of US features for thyroid malignancy in patients with unselected thyroid nodules and nodules with indeterminate fine-needle aspiration (FNA) cytology. Methods: Electronic databases were reviewed for studies published prior to July 2012 that evaluated US features of thyroid nodules and reported postoperative histopathologic diagnosis. A manual search of references of review and key articles, and previous meta-analyses was also performed. A separate meta-analysis was performed including only nodules with indeterminate cytology. Analyzed features were solid structure, hypoechogenicity, irregular margins, absence of halo, microcalcifications, central vascularization, solitary nodule, heterogeneity, taller than wide shape, and absence of elasticity. Results: Fifty-two observational studies (12,786 nodules) were included. Nine studies included nodules with indeterminate cytology as a separate category, comprising 1851 nodules. In unselected nodules, allUS featureswere significantly associated with malignancy with an odds ratio varying from 1.78 to 35.7, and microcalcifications, irregular margins, and a taller than wide shape had high specificities (Sp; 87.8%, 83.1%, 96.6%) and positive likelihood ratios (LHR; 3.26, 2.99, 8.07). Absence of elasticity was the single feature with the best diagnostic performance (sensitivity 87.9%, Sp 86.2%, and positive LHR 6.39). Conclusions: US features in isolation do not provide reliable information to select nodules that should have a FNA performed.Acombination ofUS characteristics with higher likelihood ratios and consequently with higher post-test probabilities of malignancy—microcalcifications, or a taller than wide shape, or irregular margins, or absence of elasticity—will probably identify nodules with an increased risk for malignancy. Further studies are required to standardize elastography techniques and evaluate outcomes, especially in nodules with an indeterminate cytology

The association between sulfonylurea use and all-cause and cardiovascular mortality : a meta-analysis with trial sequential analysis of randomized clinical trials

Background Sulfonylureas are an effective and inexpensive treatment for type 2 diabetes. There is conflicting data about the safety of these drugs regarding mortality and cardiovascular outcomes. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyze whether the available sample was powered enough to support the results. Methods and Findings Electronic databases were reviewed from1946 (Embase) or 1966 (MEDLINE) up to 31 December 2014. Randomized clinical trials (RCTs) of at least 52 wk in duration evaluating second- or third-generation sulfonylureas in the treatment of adults with type 2 diabetes and reporting outcomes of interest were included. Primary outcomes were all-cause and cardiovascular mortality. Additionally, myocardial infarction and stroke events were evaluated. Data were summarized with Peto odds ratios (ORs), and the reliability of the results was evaluated with TSA. Forty-seven RCTs with 37,650 patients and 890 deaths in total were included. Sulfonylureas were not associated with all-cause (OR 1.12 [95%CI 0.96 to 1.30]) or cardiovascular mortality (OR 1.12 [95%CI 0.87 to 1.42]). Sulfonylureas were also not associated with increased risk ofmyocardial infarction (OR 0.92 [95% CI 0.76 to 1.12]) or stroke (OR 1.16 [95% CI 0.81 to 1.66]). TSA could discard an absolute difference of 0.5% between the treatments, which was considered theminimal clinically significant difference. Themajor limitation of this review was the inclusion of studies not designed to evaluate safety outcomes. Conclusions Sulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded