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Cohort cholecystectomies in the Brazilian public system: is access to laparoscopy universal after three decades?
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OLIJNYK, JOSÉ GUSTAVO

; VALANDRO, ISABELLE GARIBALDI

; RODRIGUES, MARCELA

; CZEPIELEWSKI, MAURO ANTÔNIO

; CAVAZZOLA, LEANDRO TOTTI

Revista do Colégio Brasileiro de Cirurgiões

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2022, Volumen 49 elocation e20223180

Resumen: Pt En | Texto: Pt En | PDF: Pt | PDF: En

RESUMO Introdução: a videocirurgia no Brasil iniciou em 1990 com a realização da colecistectomia laparoscópica, sendo incluída pelo sistema público de saúde em 2008. Avaliamos a situação atual do emprego desta tecnologia no Sistema Único de Saúde (SUS). Métodos: de 2013 a 2019, 1.406.654 pacientes registrados no Departamento de Informática do SUS (DATASUS) foram analisados para calcular a taxa de colecistectomias laparoscópicas (CL) em relação a colecistectomias abertas (CA). Avaliaram-se características dos pacientes, apresentação da doença e mortalidade pós-operatória. Resultados: a taxa de CL atingiu 41,5%, com crescimento de 68%, sem ocorrer diminuição do número absoluto de CA. Já em Hospitais Universitários (HUs) a taxa de CL chegou a 91,96%. A técnica aberta em urgências esteve mais associada a pacientes masculinos, com 60 anos ou mais, à internação prolongada e em UTI. Aqueles submetidos à CL estiveram menos predispostos à morte pós-operatória, tanto em caráter eletivo (OR 0,49; IC 95% 0,42 - 0,56; NNT = 20) como na urgência (OR 0,23; IC 95% 0,20 - 0,25; NNT ≅ 1), conferindo efeito protetor. Conclusão: apesar do aumento da indicação da CL, a cirurgia aberta durante os anos estudados se manteve estável e a técnica mais utilizada no sistema público de saúde do Brasil. A efetividade de políticas de saúde pública para abreviar a completa implementação da videocirurgia no SUS necessita ser investigada em estudos epidemiológicos futuros, assim como seu impacto na morbimortalidade pós-operatória.

ABSTRACT Objective: videosurgery in Brazil started in 1990 with the performance of laparoscopic cholecystectomy, being included by the public health system in 2008. We evaluated the current situation of the use of this technology in the Unified Health System (SUS - Sistema Único de Saúde). Methods: from 2013 to 2019, 1,406,654 patients registered at the SUS Informatics Department (DATASUS) were analyzed to calculate the rate of laparoscopic cholecystectomies (LC) in relation to open cholecystectomies (OC). Patient characteristics, disease presentation and postoperative mortality were evaluated. Results: the LC rate reached 41.5% (growth of 68%) with no decrease in the absolute number of OC. In University Hospitals (UH), the LC rate reached 91.96%. The open technique in emergencies was more associated with male patients, aged 60 years or older, with prolonged hospitalization and in the ICU. Those undergoing LC were less predisposed to postoperative death, both electively (OR 0.49; 95% CI 0.42 - 0.56; NNT=20) and urgently (OR 0.23; 95% CI 0.20 - 0.25; NNT ≅1), providing a protective effect. Conclusion: despite the increase in the indication of LC, the open technique during the years studied remained stable and the most used in the public health system in Brazil. The effectiveness of public health policies to shorten the complete implementation of videosurgery in SUS needs to be investigated in future epidemiological studies, as well as its impact on postoperative morbidity and mortality.

https://doi.org/10.1590/0100-6991e-20223180-en

Management of hypopituitarism: a perspective from the Brazilian Society of Endocrinology and Metabolism
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Garmes, Heraldo Mendes

; Boguszewski, César Luiz

; Miranda, Paulo Augusto Carvalho

; Martins, Manoel Ricardo Alves

; Silva, Silvia Regina Correa da

; Abucham Filho, Julio Zaki

; Musolino, Nina Rosa de Castro

; Vilar, Lucio

; Portari, Luiz Henrique Corrêa

; Gadelha, Mônica Roberto

; Kasuki, Leandro

; Naves, Luciana Ansaneli

; Czepielewski, Mauro Antônio

; Almeida, Tobias Skrebsky de

; Duarte, Felipe Henning Gaia

; Glezer, Andrea

; Bronstein, Marcello Delano

Archives of Endocrinology and Metabolism

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Abr 2021, Volumen 65 Nº 2 Paginas 212 - 230

Resumen: En | Texto: En | PDF: En

ABSTRACT Hypopituitarism is a disorder characterized by insufficient secretion of one or more pituitary hormones. New etiologies of hypopituitarism have been recently described, including head trauma, cerebral hemorrhage, and drug-induced hypophysitis. The investigation of patients with these new disorders, in addition to advances in diagnosis and treatment of hypopituitarism, has increased the prevalence of this condition. Pituitary hormone deficiencies can induce significant clinical changes with consequent increased morbidity and mortality rates, while hormone replacement based on current guidelines protects these patients. In this review, we will first discuss the different etiologies of hypopituitarism and then address one by one the clinical aspects, diagnostic evaluation, and therapeutic options for deficiencies of TSH, ACTH, gonadotropin, and GH. Finally, we will detail the hormonal interactions that occur during replacement of pituitary hormones.

https://doi.org/10.20945/2359-3997000000335 625 descargas

Brazilian multicenter study on pegvisomant treatment in acromegaly
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Boguszewski, Cesar L.

; Huayllas, Martha Katherine P

; Vilar, Lucio

; Naves, Luciana Ansaneli

; Ribeiro-Oliveira Junior, Antonio

; Soares, Beatriz Santana

; Czepielewski, Mauro Antonio

; Abucham, Julio

; Correa-Silva, Silvia Regina

; Bronstein, Marcello Delano

; Jallad, Raquel Soares

; Duarte, Felipe Gaia

; Musolino, Nina Rosa

; Kasuki, Leandro

; Gadelha, Monica Roberto

Archives of Endocrinology and Metabolism

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Ago 2019, Volumen 63 Nº 4 Paginas 328 - 336

Resumen: En | Texto: En | PDF: En

ABSTRACT Objective Investigate the therapeutic response of acromegaly patients to pegvisomant (PEGV) in a real-life, Brazilian multicenter study. Subjects and methods Characteristics of acromegaly patients treated with PEGV were reviewed at diagnosis, just before and during treatment. All patients with at least two IGF-I measurements on PEGV were included. Efficacy was defined as any normal IGF-I measurement during treatment. Safety data were reviewed. Predictors of response were determined by comparing controlled versus uncontrolled patients. Results 109 patients [61 women; median age at diagnosis 34 years; 95.3% macroadenomas] from 10 Brazilian centers were studied. Previous treatment included surgery (89%), radiotherapy (34%), somatostatin receptor ligands (99%), and cabergoline (67%). Before PEGV, median levels of GH, IGF-I and IGF-I % of upper limit of normal were 4.3 µg/L, 613 ng/mL, and 209%, respectively. Pre-diabetes/diabetes was present in 48.6% and tumor remnant in 71% of patients. Initial dose was 10 mg/day in all except 4 cases, maximum dose was 30 mg/day, and median exposure time was 30.5 months. PEGV was used as monotherapy in 11% of cases. Normal IGF-I levels was obtained in 74.1% of patients. Glycemic control improved in 56.6% of patients with pre-diabetes/diabetes. Exposure time, pre-treatment GH and IGF-I levels were predictors of response. Tumor enlargement occurred in 6.5% and elevation of liver enzymes in 9.2%. PEGV was discontinued in 6 patients and 3 deaths unrelated to the drug were reported. Conclusions In a real-life scenario, PEGV is a highly effective and safe treatment for acromegaly patients not controlled with other therapies.

https://doi.org/10.20945/2359-3997000000159 822 descargas

Controversial issues in the management of hyperprolactinemia and prolactinomas – An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism
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Vilar, Lucio

; Abucham, Julio

; Albuquerque, José Luciano

; Araujo, Luiz Antônio

; Azevedo, Monalisa F.

; Boguszewski, Cesar Luiz

; Casulari, Luiz Augusto

; Cunha Neto, Malebranche B. C.

; Czepielewski, Mauro A.

; Duarte, Felipe H. G.

; Faria, Manuel dos S.

; Gadelha, Monica R.

; Garmes, Heraldo M.

; Glezer, Andrea

; Gurgel, Maria Helane

; Jallad, Raquel S.

; Martins, Manoel

; Miranda, Paulo A. C.

; Montenegro, Renan M.

; Musolino, Nina R. C.

; Naves, Luciana A.

; Ribeiro-Oliveira Júnior, Antônio

; Silva, Cíntia M. S.

; Viecceli, Camila

; Bronstein, Marcello D.

Archives of Endocrinology and Metabolism

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Mar 2018, Volumen 62 Nº 2 Paginas 236 - 263

Resumen: En | Texto: En | PDF: En

ABSTRACT Prolactinomas are the most common pituitary adenomas (approximately 40% of cases), and they represent an important cause of hypogonadism and infertility in both sexes. The magnitude of prolactin (PRL) elevation can be useful in determining the etiology of hyperprolactinemia. Indeed, PRL levels > 250 ng/mL are highly suggestive of the presence of a prolactinoma. In contrast, most patients with stalk dysfunction, drug-induced hyperprolactinemia or systemic diseases present with PRL levels < 100 ng/mL. However, exceptions to these rules are not rare. On the other hand, among patients with macroprolactinomas (MACs), artificially low PRL levels may result from the so-called “hook effect”. Patients harboring cystic MACs may also present with a mild PRL elevation. The screening for macroprolactin is mostly indicated for asymptomatic patients and those with apparent idiopathic hyperprolactinemia. Dopamine agonists (DAs) are the treatment of choice for prolactinomas, particularly cabergoline, which is more effective and better tolerated than bromocriptine. After 2 years of successful treatment, DA withdrawal should be considered in all cases of microprolactinomas and in selected cases of MACs. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) is to provide a review of the diagnosis and treatment of hyperprolactinemia and prolactinomas, emphasizing controversial issues regarding these topics. This review is based on data published in the literature and the authors' experience.

https://doi.org/10.20945/2359-3997000000032 36158 descargas

A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism
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Machado, Márcio Carlos

; Fragoso, Maria Candida Barisson Vilares

; Moreira, Ayrton Custódio

; Boguszewski, César Luiz

; Vieira Neto, Leonardo

; Naves, Luciana A.

; Vilar, Lucio

; Araújo, Luiz Antônio de

; Musolino, Nina Rosa Castro

; Miranda, Paulo Augusto C.

; Czepielewski, Mauro A.

; Gadelha, Monica R.

; Bronstein, Marcello Delano

; Ribeiro-Oliveira Jr., Antônio

Archives of Endocrinology and Metabolism

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Feb 2018, Volumen 62 Nº 1 Paginas 87 - 105

Resumen: En | Texto: En | PDF: En

ABSTRACT The treatment objectives for a patient with Cushing's disease (CD) are remission of hypercortisolism, adequate management of co-morbidities, restoration of the hypothalamic-pituitary-adrenal axis, preservation of fertility and pituitary function, and improvement of visual defects in cases of macroadenomas with suprasellar extension. Transsphenoidal pituitary surgery is the main treatment option for the majority of cases, even in macroadenomas with low probability of remission. In cases of surgical failure, another subsequent pituitary surgery might be indicated in cases with persistent tumor imaging at post surgical magnetic resonance imaging (MRI) and/or pathology analysis of adrenocorticotropic hormone-positive (ACTH+) positive pituitary adenoma in the first procedure. Medical treatment, radiotherapy and adrenalectomy are the other options when transsphenoidal pituitary surgery fails. There are several options of medical treatment, although cabergoline and ketoconazole are the most commonly used alone or in combination. Novel treatments are also addressed in this review. Different therapeutic approaches are frequently needed on an individual basis, both before and, particularly, after surgery, and they should be individualized. The objective of the present review is to provide the necessary information to achieve a more effective treatment for CD. It is recommended that patients with CD be followed at tertiary care centers with experience in treating this condition.

https://doi.org/10.20945/2359-3997000000014 5266 descargas

Recommendations of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism for the diagnosis of Cushing’s disease in Brazil
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Machado, Márcio Carlos

; Fragoso, Maria Candida Barisson Vilares

; Moreira, Ayrton Custódio

; Boguszewski, César Luiz

; Vieira Neto, Leonardo

; Naves, Luciana A.

; Vilar, Lucio

; Araújo, Luiz Antônio de

; Czepielewski, Mauro A.

; Gadelha, Monica R.

; Musolino, Nina Rosa Castro

; Miranda, Paulo Augusto C.

; Bronstein, Marcello Delano

; Ribeiro-Oliveira Jr., Antônio

Archives of Endocrinology and Metabolism

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Jun 2016, Volumen 60 Nº 3 Paginas 267 - 286

Resumen: En | Texto: En | PDF: En

ABSTRACT Although it is a rare condition, the accurate diagnosis and treatment of Cushing’s disease is important due to its higher morbidity and mortality compared to the general population, which is attributed to cardiovascular diseases, diabetes mellitus and infections. Screening for hypercortisolism is recommended for patients who present multiple and progressive clinical signs and symptoms, especially those who are considered to be more specific to Cushing’s syndrome, abnormal findings relative to age (e.g., spinal osteoporosis and high blood pressure in young patients), weight gain associated with reduced growth rate in the pediatric population and for those with adrenal incidentalomas. Routine screening is not recommended for other groups of patients, such as those with obesity or diabetes mellitus. Magnetic resonance imaging (MRI) of the pituitary, the corticotropin-releasing hormone (CRH) test and the high-dose dexamethasone suppression test are the main tests for the differential diagnosis of ACTH-dependent Cushing’s syndrome. Bilateral and simultaneous petrosal sinus sampling is the gold standard method and is performed when the triad of initial tests is inconclusive, doubtful or conflicting. The aim of this article is to provide information on the early detection and establishment of a proper diagnosis of Cushing’s disease, recommending follow-up of these patients at experienced referral centers. Arch Endocrinol Metab. 2016;60(3):267-86

https://doi.org/10.1590/2359-3997000000174 6344 descargas

Vitamin D deficiency is independently associated with mortality among critically ill patients
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Moraes, Rafael Barberena

; Friedman, Gilberto

; Wawrzeniak, Iuri Christmann

; Marques, Leonardo S.

; Nagel, Fabiano Márcio

; Lisboa, Thiago Costa

; Czepielewski, Mauro Antonio

Clinics

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May 2015, Volumen 70 Nº 5 Paginas 326 - 332

Resumen: En | Texto: En | PDF: En

OBJECTIVE: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients. METHOD: In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity. RESULTS: Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity. CONCLUSIONS: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients.

https://doi.org/10.6061/clinics/2015(05)04 2411 descargas

Aldosterone secretion in patients with septic shock: a prospective study
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Moraes, Rafael Barberena

; Friedman, Gilberto

; Viana, Marina Verçoza

; Tonietto, Tiago

; Saltz, Henrique

; Czepielewski, Mauro Antônio

Arquivos Brasileiros de Endocrinologia & Metabologia

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Nov 2013, Volumen 57 Nº 8 Paginas 636 - 641

Resumen: Pt En | Texto: Pt En | PDF: Pt | PDF: En

OBJETIVO: Avaliar os níveis séricos dos principais fatores que regulam a ativação da zona glomerulosa e a produção de aldosterona em pacientes com choque séptico, assim como sua resposta ao teste de cortrosina em alta dose (250 µg). SUJEITOS E MÉTODOS: Em 27 portadores de choque séptico, foram aferidos níveis basais de aldosterona, cortisol, ACTH, renina, sódio, potássio e lactato, bem como realizado teste de cortrosina. RESULTADOS: Renina se correlacionou com níveis basais de aldosterona e sua variação após teste de cortrosina. Cortisol basal e sua variação não se correlacionaram com ACTH. Apenas três pacientes apresentaram disfunção concomitante da secreção de aldosterona e cortisol. CONCLUSÕES: Ativação das zonas fasciculada e glomerulosa são independentes. Secreção de aldosterona é dependente da integridade do sistema renina-angiotensina-aldosterona, enquanto secreção de cortisol não parece predominantemente dependente do eixo hipotálamo-hipófise-adrenal. Esses resultados sugerem que a ativação da adrenal em pacientes críticos ocorre por múltiplos mecanismos.

OBJECTIVE: To assess serum levels of the main factors that regulate the activation of the zona glomerulosa and aldosterone production in patients with septic shock, as well as their response to a high-dose (250 µg) adrenocorticotropic hormone (ACTH) stimulation test. SUBJECTS AND METHODS: In 27 patients with septic shock, baseline levels of aldosterone, cortisol, ACTH, renin, sodium, potassium, and lactate were measured, followed by a cortrosyn test. RESULTS: Renin correlated with baseline aldosterone and its variation after cortrosyn stimulation. Baseline cortisol and its variation did not correlate with ACTH. Only three patients had concomitant dysfunction of aldosterone and cortisol secretion. CONCLUSIONS: Activation of the zona glomerulosa and zona fasciculata are independent. Aldosterone secretion is dependent on the integrity of the renin-angiotensin-aldosterone system, whereas cortisol secretion does not appear to depend predominantly on the hypothalamic-pituitary-adrenal axis. These results suggest that activation of the adrenal gland in critically ill patients occurs by multiple mechanisms.

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Avaliação do eixo hipotálamo-hipófise adrenal no diagnóstico e na remissão da doença de Cushing
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Costenaro, Fabíola

; Rodrigues, Ticiana C.

; Rollin, Guilherme A. F.

; Czepielewski, Mauro A.

Arquivos Brasileiros de Endocrinologia & Metabologia

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Abr 2012, Volumen 56 Nº 3 Paginas 159 - 167

Resumen: Pt En | Texto: Pt En | PDF: Pt | PDF: En

A doença de Cushing (DC) permanece um desafio médico com muitas questões ainda não respondidas. O sucesso terapêutico dos pacientes com DC está ligado à correta investigação do diagnóstico síndrômico e etiológico, além da experiência e talento do neurocirurgião. A adenomectomia hipofisária transesfenoidal constitui-se no tratamento de escolha para a DC. A avaliação da remissão da doença no pós-operatório e da recorrência em longo prazo constitui um desafio ainda maior. Especial destaque deve ser dado para o cortisol sérico no pós-operatório como marcador de remissão. Adicionalmente, o uso de corticoide exógeno no pós-operatório apenas em vigência de insuficiência adrenal tem sido sugerido por alguns autores como requisito essencial para permitir a correta interpretação do cortisol sérico nesse cenário. Neste artigo, revisamos as formas de avaliação da atividade da DC e os marcadores de remissão e recidiva da DC após a realização da cirurgia transesfenoidal.

Cushing's disease (CD) remains a medical challenge, with many questions still unanswered. Successful treatment of CD patients is closely related to correct approach to syndromic and etiological diagnosis, besides the experience and talent of the neurosurgeon. Pituitary transsphenoidal adenomectomy is the treatment of choice for DC. Assessment of remission after surgery and recurrence in the long term is an even greater challenge. In this regard, special attention should be paid to the role of postoperative serum cortisol as a marker of CD remission. Additionally, the postoperative use of exogenous glucocorticoids only in cases of adrenal insufficiency has been suggested by some authors as an essential practice to enable the use of serum cortisol in this scenario. In this article, we review the forms of evaluation of DC activity, and markers of remission and relapse of CD after transsphenoidal surgery.

10450 descargas Citado 1 vez en SciELO

10.

Diabetes mellitusin a cohort of patients with acromegaly
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Rodrigues, Ticiana Costa

; Costenaro, Fabiola

; Fedrizzi, Daniela

; Oliveira, Marcelle D.

; Lima, Paula B. de

; Boschi, Vitor

; Czepielewski, Mauro Antônio

Arquivos Brasileiros de Endocrinologia & Metabologia

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Dic 2011, Volumen 55 Nº 9 Paginas 714 - 719

Resumen: Pt En | Texto: Pt En | PDF: Pt | PDF: En

OBJETIVOS: Avaliar a presença de diabetes melito (DM) em uma coorte de acromegálicos. MÉTODOS: Este é um estudo transversal. RESULTADOS: Cinquenta e oito pacientes acromegálicos foram analisados. Apenas 29% preencheram critérios de cura e 27% estavam com a doença controlada. Vinte e dois pacientes (38%) apresentaram DM, HbA1c 7,34 ± 2,2%. Destes, 18 não preencheram critérios de cura. Pacientes com DM foram mais frequentemente hipertensos [16/22 (73%) vs. 17/36 (46%), p = 0,04] e usavam mais estatina [14/22 (64%) vs.8/36 (21%), p = 0,004]. Após regressão múltipla, hipertensão foi associada a DM [razão de chances (RC): 9,28 (95% CI: 1,59 - 54,00), p = 0,01], e acromegalia curada/controlada foi fator protetor para presença de diabetes [OR: 0,17 (95% CI: 0,03-0,78), p = 0,02]. CONCLUSÕES: A presença de DM esteve associada com acromegalia ativa e com a presença de hipertensão. No entanto, os níveis absolutos de GH e IGF-1 não diferiram entre aqueles com e sem diabetes.

OBJECTIVES: To evaluate the presence of diabetes mellitus (DM) in a cohort of patients with acromegaly. METHODS: This was a cross sectional study. RESULTS: Fifty-eight acromegalic patients were assessed. Only 29% met the criteria for cure, and 27% had the disease controlled. Twenty-two had DM; HbA1c was equal to 7.34 ± 2.2%. Most of the diabetic patients (18 out of 22, 82%) did not meet criteria for cure. They were more often hypertensive [16/22 (73%) vs. 17/36 (46%), p = 0.04], and used statins more frequently [14/22 (64%) vs. 8/36 (21%), p = 0.004]. After regression analysis, hypertension was associated with diabetes [odds ratio (OR): 9.28 (95% CI: 1.59 - 54.00), p = 0.01], and cured/ controlled acromegaly was associated with protection against the presence of diabetes [OR: 0.17 (95% CI: 0.03 - 0.78), p = 0.02]. CONCLUSIONS: The presence of DM was associated with active acromegaly and presence of hypertension. However, absolute levels of GH and IGF-1 did not differ between patients with and without diabetes.

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11.

Recomendações do Departamento de Neuroendocrinologia da Sociedade Brasileira de Endocrinologia e Metabologia para o Diagnóstico e Tratamento da Acromegalia no Brasil
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Vieira Neto, Leonardo

; Abucham, Julio

; Araujo, Luiz Antônio de

; Boguszewski, Cesar L.

; Bronstein, Marcello D.

; Czepielewski, Mauro

; Jallad, Raquel S.

; Musolino, Nina R. de C.

; Naves, Luciana A.

; Ribeiro-Oliveira Júnior, Antônio

; Vilar, Lucio

; Faria, Manuel dos S.

; Gadelha, Mônica R.

Arquivos Brasileiros de Endocrinologia & Metabologia

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Dic 2011, Volumen 55 Nº 9 Paginas 725 - 726

Resumen: Pt | Texto: Pt | PDF: Pt

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12.

Hypertension-related factors in patients with active and inactive acromegaly
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Fedrizzi, Daniela

; Rodrigues, Ticiana Costa

; Costenaro, Fabíola

; Scalco, Rosana

; Czepielewski, Mauro Antônio

Arquivos Brasileiros de Endocrinologia & Metabologia

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Oct 2011, Volumen 55 Nº 7 Paginas 468 - 474

Resumen: Pt En | Texto: Pt En | PDF: Pt | PDF: En

INTRODUÇÃO: Existem várias complicações no sistema cardiovascular causadas pela acromegalia, especialmente a hipertensão. OBJETIVOS: Avaliar as características da hipertensão em pacientes com acromegalia curada/controlada e com doença ativa. PACIENTES E MÉTODOS: Estudo transversal com 44 pacientes com acromegalia seguidos em nosso serviço. Eles foram submetidos a avaliação clínica, exames laboratoriais e ecocardiograma. Pacientes com doença curada/controlada foram avaliados como um grupo único e os indivíduos com doença ativa como outro grupo. RESULTADOS: Quarenta e sete por cento dos pacientes apresentaram acromegalia ativa. Esses indivíduos foram mais jovens e apresentaram níveis mais baixos de pressão arterial que os indivíduos com doença controlada/curada. A hipertensão foi detectada em 50% da amostra. Indivíduos com doença ativa mostraram uma correlação positiva entre os níveis de IGF-1 e os níveis de pressão arterial sistólica e de pressão arterial diastólica (r = 0,48, p = 0,03; e r = 0,42, p = 0,07, respectivamente) e também apresentaram uma correlação positiva entre IGF-1 e excreção urinária de albumina (EUA). Em pacientes com doença ativa, o IGF-1 foi um preditor da pressão arterial sistólica, embora não tenha sido independente da taxa de EUA. Para indivíduos com doença curada/controlada, a circunferência da cintura e os triglicérides foram os preditores associados aos níveis de pressão arterial sistólica e diastólica. CONCLUSÕES: Nossos resultados sugerem que os níveis pressóricos em pacientes com acromegalia ativa dependem do excesso de GH. No entanto, uma vez que a doença torna-se controlada e os níveis de IGF-1 reduzem, os níveis de pressão arterial dependerão de outros fatores de risco cardiovasculares.

INTRODUCTION: There are several complications of the cardiovascular system caused by acromegaly, especially hypertension. OBJECTIVES: To evaluate hypertension characteristics in patients with cured/controlled acromegaly and with the active disease. PATIENTS AND METHODS: Cross-sectional study of the follow-up of forty-four patients with acromegaly submitted to clinical evaluation, laboratory tests and cardiac ultrasound. Patients with cured and controlled disease were evaluated as one group, and individuals with active disease as second one. RESULTS: Forty-seven percent of the patients had active acromegaly, and these patients were younger and had lower blood pressure levels than subjects with controlled/cured disease. Hypertension was detected in 50% of patients. Subjects with active disease showed a positive correlation between IGF-1 and systolic and diastolic blood pressure levels (r = 0.48, p = 0.03; and r = 0.42, p = 0.07, respectively), and a positive correlation between IGF-1 and urinary albumin excretion (UAE) rates. In patients with active disease, IGF-1 was a predictor of systolic blood pressure, although it was not independent of UAE rate. For individuals with cured/controlled disease, waist circumference and triglycerides were the predictors associated with systolic and diastolic blood pressure. CONCLUSIONS: Our findings suggest that blood pressure levels in patients with active acromegaly are very similar, and depend on excess GH. However, once the disease becomes controlled and IGF-1 levels decrease, their blood pressure levels will depend on the other cardiovascular risk factors.

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13.

Diagnosis of adrenal failure in critically ill patients
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Moraes, Rafael Barberena

; Czepielewski, Mauro A.

; Friedman, Gilberto

; Borba, Evandro Lucas de

Arquivos Brasileiros de Endocrinologia & Metabologia

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Jun 2011, Volumen 55 Nº 5 Paginas 295 - 302

Resumen: Pt En | Texto: Pt En | PDF: Pt | PDF: En

Nas últimas décadas, houve uma importante evolução no conhecimento sobre a função do eixo hipotálamo-pituitária-adrenal. Na última década, foi cunhada a expressão "insuficiência adrenal relativa" (IAR) e, mais recentemente, a expressão "insuficiência adrenal relacionada à doença grave" (CIRCI) foi utilizada para designar aqueles pacientes nos quais a produção de cortisol não era suficientemente elevada em situações de estresse. Pacientes com CIRCI apresentam elevada morbidade e mortalidade em hospitais. Atualmente, há uma ampla discussão sobre os critérios de diagnóstico para essa desordem. Além do cortisol basal, algumas publicações analisaram o papel de outros testes, tais como o teste de estímulo com ACTH (cortrosina), com doses baixas (1 mg) ou altas (250 mg), cortisol livre, cortisol salivar, teste da metirapona e outros. O objetivo desta revisão foi resumir os resultados dos artigos mais importantes que buscaram definir os critérios de diagnóstico para a CIRCI. Também sugerimos uma abordagem para o diagnóstico da CIRCI e deixamos claro que a decisão sobre a terapia com esteroides em pacientes em choque séptico é uma questão separada da IAR.

In the last two decades there was important evolution on the knowledge of the function of the hypothalamic-pituitary-adrenal axis. In the last decade, the expression "relative adrenal insufficiency" (RAI) was created, and more recently "critical illness-related corticosteroid insufficiency" (CIRCI) was used to designate those patients in which cortisol production was not sufficiently increased in stress situations. Patients with CIRCI have elevated hospital morbidity and mortality. Currently, there is a wide discussion about diagnostic criteria for this dysfunction. Besides basal cortisol, some publications now study the role of other tests, such as cortrosyn test - either in low (1 μg) or high doses (250 μg); free cortisol, salivary cortisol, metyrapone test and others. With this review, we aimed at summarizing the results of the most influent papers that intended to define diagnostic criteria for CIRCI. We also suggest an approach for CIRCI diagnosis and make it clear that the decision about steroid therapy in septic shock patients is matter apart from RAI.

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14.

Pseudotumor cerebri during Cushing's disease treatment with ketoconazole
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Costenaro, Fabiola

; Rodrigues, Ticiana C.

; Ferreira, Nelson P.

; Costa, Tiago G. da

; Schuch, Tiago

; Boschi, Vitor

; Czepielewski, Mauro A.

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Jun 2011, Volumen 55 Nº 4 Paginas 284 - 287

Resumen: Pt En | Texto: Pt En | PDF: Pt | PDF: En

Hipertensão intracraniana benigna (Pseudotumor cerebral) tem sido descrita relacionada à redução dos níveis de esteroides séricos na doença de Cushing (DC), especialmente após a remissão cirúrgica. O cetoconazol é uma opção efetiva e de uso rotineiro como adjuvante na terapêutica do hipercortisolismo, tendo como paraefeito mais temido a toxicidade hepática. Relatamos o caso de uma menina com 12 anos de idade portadora de DC que desenvolveu hipertensão intracraniana benigna durante tratamento com cetoconazol. Apresentou-se com cefaleia, vômitos, comprometimento do campo visual temporal direito e sinais de hipertensão intracraniana. A ressonância magnética (RM) de hipófise era normal e todos os sinais e sintomas resolveram-se com uso de acetazolamida. Chamamos a atenção para esse diagnóstico nos pacientes com DC, especialmente crianças, em tratamento com cetoconazol, porque ele pode ser confundido com insuficiência adrenal e causar comprometimento visual severo e definitivo.

Benign intracranial hypertension (Pseudotumor cerebri) has been described as related to the reduction in steroid levels in Cushing's disease (CD), especially after surgical remission. Ketoconazole is a common and effective adjuvant therapy for hypercortisolism, but the major concern is liver enzyme dysfunction. We describe here the case of a 12-year old girl with CD who developed benign intracranial hypertension during treatment with ketoconazole. She presented headache, vomiting, a black spot on her right temporal visual field, and signs of elevated intracranial pressure. Pituitary image was normal on magnetic resonance image (MRI), and all symptoms improved after treatment with acetazolamide. We call attention to the diagnosis of this disorder in CD patients, especially children on ketoconazole treatment, because it could be confounded with adrenal insufficiency and lead to definitive severe visual impairment.

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15.

Recomendações do Departamento de Neuroendocrinologia da Sociedade Brasileira de Endocrinologia e Metabologia para o diagnóstico e tratamento da acromegalia no Brasil
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Vieira Neto, Leonardo

; Abucham, Julio

; Araujo, Luiz Antônio de

; Boguszewski, Cesar L.

; Bronstein, Marcello D.

; Czepielewski, Mauro

; Jallad, Raquel S.

; Musolino, Nina R. de C.

; Naves, Luciana A.

; Ribeiro-Oliveira Júnior, Antônio

; Vilar, Lucio

; Faria, Manuel dos S.

; Gadelha, Mônica R.

Arquivos Brasileiros de Endocrinologia & Metabologia

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Mar 2011, Volumen 55 Nº 2 Paginas 91 - 105

Resumen: Pt En | Texto: Pt En | PDF: Pt | PDF: En

A acromegalia é uma doença associada à elevada morbidade e à redução da expectativa de vida. Em virtude do seu caráter insidioso e do seu não reconhecimento, o diagnóstico é frequentemente realizado com atraso, o que, associado às complicações relacionadas ao excesso do GH/IGF-I, determina elevada morbimortalidade. No entanto, um diagnóstico precoce e um tratamento efetivo minimizam a morbidade e normalizam a taxa de mortalidade. Nesta publicação, o objetivo do Departamento de Neuroendocrinologia da Sociedade Brasileira de Endocrinologia e Metabologia é divulgar quando suspeitar clinicamente da acromegalia e como diagnosticá-la. Além disso, discute-se a maneira mais eficaz e segura de realizar o tratamento da acromegalia, enfatizando que este deve ser realizado em centros de referência. Assim, com base em dados publicados em periódicos de nível científico reconhecido e na experiência dos autores, são apresentadas as recomendações para o diagnóstico e tratamento da doença.

Acromegaly is a disease associated with increased morbidity and reduced life expectancy. Because of its insidious character and its non-recognition, the diagnosis is often made with delay, which, along with the complications related to GH/IGF-I excess, determines high morbidity and mortality. However, an early diagnosis and an effective treatment reduce the morbidity and normalize the mortality rate. In this publication, the goal of Neuroendocrinology Department from Brazilian Society of Endocrinology and Metabolism is to disclose which clinical set should arouse the suspicious of acromegaly and how to diagnose it. Furthermore, we discuss the most effective and safe approach to perform the treatment of acromegaly, emphasizing that it must be carried out in reference centers. Therefore, based on data published in journals with recognized scientific level and authors' experience, recommendations are presented for diagnosis and treatment of the disease.

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