Postoperative serum magnesium levels as a predictor for the need for calcium replacement after total thyroidectomy: a prospective study

ABSTRACT Objective: Our aim was to assess the ability of serum magnesium (Mg), measured on the first postoperative day (Mg1PO), to predict the need for calcium (Ca) replacement in patients undergoing total thyroidectomy (TT). Subjects and methods: Eighty patients undergoing TT, with Mg1PO and PTH dosage in the first (PTH1h) and eighth (PTH8h) hours after TT, were evaluated for the need for Ca replacement. Data were evaluated by uni/multivariate logistic regression and Receiver Operating Characteristic (ROC) curve. Results: 32 patients (40%) required Ca replacement. Median PTH1h, PTH8h and Mg1PO were higher in the no replacement group: 17 versus (vs) 3 pg/mL (p < 0.001), 18.2 vs 3.0 pg/mL (p < 0.001) and 2 vs 1.6 mg/dL (p < 0.001), respectively. Mg1PO was the isolated predictor for this replacement (odds ratio = 0.0004, 95% confidence interval: 0.000003-0.04; p = 0.001), with the cut-off value of 1.8 mg/dL showing sensitivity and specificity of 78.1% and 87.5%, respectively. Conclusions: In this group of patients, serum Mg1PO was the isolated predictor for the need for Ca replacement.

Is there a relationship between preoperative cytological diagnosis and evolution in patients with differentiated thyroid carcinoma? A retrospective study

ABSTRACT Objective: Cytological analysis and Bethesda classification of thyroid nodules is the standard method of diagnosing differentiated thyroid carcinoma (DTC). However, even for nodules with a non-malignant cytological diagnosis, there is a not insignificant risk of cancer. There are doubts whether this lack of certainty would influence patient prognosis. Our aim was to compare patients with DTC, classified according to the preoperative cytological diagnosis, regarding their evolution. Subjects and methods: A retrospective study was carried out with 108 DTC patients submitted to total thyroidectomy (TT) between 2009 and 2015, divided into three groups according to preoperative cytological diagnosis (Bethesda classification): classes I/II, III/IV, and V/VI. Groups were compared for evolution considering response to treatment at last evaluation as well as time disease free. Statistical analysis used ANOVA, chi squared, and Kaplan-Meier curves with p<0.05 considered significant. Results: Groups differed for time between nodule puncture and TT [in months; V/VI (2.35 ± 2.48) < III/IV (7.32 ± 6.34) < I/II (13.36 ± 8.9); p < 0.0001]. There was no significant difference between groups for evolution at final evaluation (disease free status; classes I/II: 71.4%; classes III/IV: 60%; classes V/VI: 66.6%; p = 0.7433), as well as time disease free (in months; classes I/II: 34.57 ± 25.82; classes III/IV: 38.04 ± 26.66; classes V/VI: 30.84 ± 26.34; p = 0.3841). Conclusions: DTC patients classified according to preoperative cytological diagnosis did not differ for evolution. Although patients with non-malignant cytological diagnoses were submitted to TT later, this did not affect the evolution of the cases.

Thyroglobulin/thyrotropin ratio for predicting long-term response in differentiated thyroid carcinoma: a retrospective study

ABSTRACT Objective: Thyrotropin-stimulated thyroglobulin (STg) after total thyroidectomy is a prognosis marker for differentiated thyroid carcinoma (DTC). As Tg level is influenced by thyrotropin (TSH), perhaps the STg/TSH ratio is also a prognosis marker for these tumours. We aimed to compare STg/TSH ratio and first STg level in differentiated thyroid carcinoma patients for their ability to predict the long-term response to initial treatment. Subjects and methods: This retrospective study evaluated data from 181 DTC patients for first (1st) STg and STg/TSH ratio, at 1-3 months post-total thyroidectomy and before iodine-131 therapy, according to response to initial therapy [Excellent/Indeterminate or Incomplete (Biochemical/Structural)] observed at final evaluation, and with the survival time with excellent/indeterminate response. Results: Cases with incomplete response presented higher STg level [225.13 ± 585.26 ng/mL versus (vs) 20.4 ± 192.9 ng/mL; p < 0.001] and STg/TSH ratio (3.01 ± 7.8 vs 0.27 ± 2.58; p < 0.001). Cutoffs of 5 ng/mL for STg and 0.085 for STg/TSH displayed sensitivities of 76.7% and 76.9%, and specificities of 79.2% and 82.6%, respectively, in predicting response to therapy. Values below these cutoffs were associated with longer survival time in excellent/indeterminate response (140.4 vs 15.9 and 144.6 vs 15.9 months, respectively). Conclusion: STg/TSH ratio has a similar performance to the 1st STg in predicting long-term response to initial therapy.

Case for diagnosis. Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder

Abstract: Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder is a rare disease, with an indolent evolution and benign course. The classic presentation is a solitary nodule on the face or trunk. The disorder's rarity and clinical and histopathological characteristics, can make the diagnosis difficult. We present the case of a 36-year-old Caucasian woman with a purplish erythematous nodule, hardened, shiny, asymptomatic, on the left nasal ala, which had grown progressively for 45 days. Histopathological examination and immunohistochemistry panel demonstrated alterations consistent with primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder. There was complete remission of the condition within 60 days of treatment with potent occlusive corticosteroids.

Fas-ligand and caspase-3 positivity in three cases of histiocytic sarcoma: a different etiopathogenic pathway?

Histiocytic sarcoma (HS) is a rare malignant neoplasia of hematopoietic origin and unknown etiology. We studied three patients with histiocytic sarcoma reviewing the morphological and immunohistochemical aspects. We evaluated in particular, if apoptosis may be unbalanced in this disease. All cases have morphological and immunohistochemical features consistent with the diagnosis of histiocytic sarcoma. The markers CD163, CD68, vimentin, lysozyme, and S-100 were positive in all cases. Similarly, the three samples were positive for Fas-ligand and Caspase-3. It is well-known that neoplasms may induce increased levels of Fas-ligand with the blockade of the apoptosis process. In the context of HS, the increased Fas-ligand expression represents a new area for research. Indeed, it is linked to proinflammatory stimulus and, maybe with the association of an infection.

Lymphoepithelioma-like carcinoma of the skin

Abstract: Primary cutaneous lymphoepithelioma-like carcinoma is a rare disease with low metastatic potential. Its morphologic and pathological features are similar to those of nasopharyngeal lymphoepithelial carcinoma. We report the case of a 60-year-old man with an infrapalpebral pearly papule, measuring 0.6 cm in diameter. The lesion was excised with a clinical hypothesis of basal cell carcinoma or squamous cell carcinoma. Histopathological analysis revealed a malignant neoplasm with syncytial arrangement of cells with vesicular nuclei, associated with dense lymphocytic infiltrate. Immunohistochemistry revealed cytokeratin-positive cells (AE1/AE3) and p63 protein, indicating epithelial histogenesis and squamous differentiation. A negative Epstein-Barr virus test result was achieved by immunohistochemistry. Primary lymphoepithelioma-like carcinoma of the skin is a differential diagnosis of lesions with prominent inflammatory infiltrates.

Endobronchial solitary fibrous tumor

Solitary fibrous tumor (SFT) is a mesenchymal neoplasm that appears primarily in the pleura and rarely in intrapulmonary or endobronchial topography. The authors report the case of a 47-year-old woman who presented obstructive respiratory symptoms for 4 years. The chest computed tomography and bronchoscopy showed an obstructive polypoid lesion located between the trachea and the left main bronchus associated with distal atelectasis of the left lung. A resection of the lesion was performed and, macroscopically, the mass was oval, encapsulated, and firm, measuring 2.3 × 1.7 × 1.5 cm. Histology revealed low-grade mesenchymal spindle cell neoplasm, with alternating cellularity, myxoid areas, and mature adipose tissue outbreaks, as well as blood vessels with irregular walls. The immunohistochemical study was positive for CD34, CD99, and BCL2. The diagnosis was SFT in an unusual topography. The patient's symptoms remitted after tumor excision, and no systemic problems were evident. SFTs primarily affect adults and often follow a benign course; however, their behavior is unpredictable. The presence of necrosis and mitotic activity may portend a poor prognosis. Endobronchial SFTs are rare but should be evaluated and monitored similar to SFTs at other sites, with a long-term follow-up

Emphysematous pyelonephritis in a transplanted kidney

Emphysematous pyelonephritis is a rare infection characterized by necrosis and gas accumulation in the renal parenchyma, adjacent tissues, and/or urinary collecting system. This entity is rarely reported in transplanted kidneys. Computed tomography imaging is necessary for diagnosis and risk classification. The authors described the case of a 58-year-old man who underwent a kidney transplant and presented sepsis from a urinary tract infection. An abdominal tomography showed some characteristics of emphysematous pyelonephritis associated with an abscess. A graft biopsy, performed 45 days after the transplant, failed to show signs of infection, and tubule-interstitial and vascular rejection were ruled out. The patient had a poor outcome, and a nephrectomy was needed, the pathological analysis of which yielded the diagnosis of chronic pyelonephritis with necrotizing papillitis. The patient became hemodynamically unstable and died. The authors highlight the current tomographic criteria for the diagnosis and treatment of emphysematous pyelonephritis and question the validity of accepting the same standards used to guide the treatment of patients without transplants, and call attention to the importance of the clinical status for the indication of nephrectomy in cases of emphysematous pyelonephritis.

Granuloma faciale: clinical, morphological and immunohistochemical aspects in a series of 10 patients

Abstract Granuloma faciale is a chronic, benign, cutaneous vasculitis with well-established clinical and morphological patterns, but with an unknown etiology. This study describes clinical and pathologic aspects of patients diagnosed with granuloma faciale. The authors analyzed demographic, clinical, morphological and immunohistochemical data from patients with a final diagnosis of granuloma faciale, confirmed between 1998 and 2012. There was a proportional and mixed inflammatory infiltrate, Grenz zones were present in almost all the samples. Immunophenotyping confirmed a higher intensity of T lymphocytes than B lymphocytes in thirteen samples, with a predominance of T CD8 lymphocytes in 64% of cases, in contrast to the literature, which indicates that the major component is T CD4 lymphocytes. All cases were positive for IgG4 but the majority (12/14) had less than 25% of stained cells. The pathogenesis of granuloma faciale remains poorly understood, making studies of morphological and immunohistochemical characterization important to better understand it.

Absence of Wharton's jelly: case report / Ausência da geleia de Wharton: relato de caso

There are few reports in the literature of the absence of Wharton's Jelly. Here we report the seventh case in a primigravida, 22 years old, admitted after vaginal delivery of stillborn. The umbilical cord have a long segment with disruption of cord structures and the three blood vessels were completely separated from each other, with a minimum amount of Wharton's jelly remaining around each vessel. The absence of Wharton' jelly is associated with fetal distress, intrauterine growth restriction, and fetal death. Quantitative/qualitative studies of Wharton's jelly represent an open field of research for possible correlations with obstetric conditions and fetal deaths.

Na literatura, há poucos relatos sobre a ausência de geleia de Wharton. Relatamos o sétimo caso em uma primigesta de 22 anos, admitida após parto vaginal de feto natimorto. O cordão umbilical apresentava longo segmento com esfacelo da geleia e três vasos sanguíneos completamente separados uns dos outros, com mínima quantidade de geleia de Wharton remanescente ao redor de cada vaso. Ausência de geleia de Wharton associa-se a estresse, restrição de crescimento e óbitos fetais. Estudos quantitativos/ qualitativos sobre a geleia de Wharton representam campo de pesquisa aberto para possíveis correlações com condições e doenças obstétricas e óbitos fetais.

EVOLUTION OF PATIENTS WITH AIDS AFTER cART: CLINICAL AND LABORATORY EVOLUTION OF PATIENTS WITH AIDS AFTER 48 WEEKS OF ANTIRETROVIRAL TREATMENT / Evolucao de pacientes com AIDS pos cART: evolucao clinica e laboratorial de pacientes com AIDS apos 48 semanas de tratamento antirretroviral

SUMMARY Combination Antiretroviral Therapy (cART) aims to inhibit viral replication, delay immunodeficiency progression and improve survival in AIDS patients. The objective of this study was to compare two different schemes of cART, based on plasma viral load (VL) and CD4+ T lymphocyte count, during 48 weeks of treatment. For this purpose, 472 medical charts of a Specialized Outpatient Service were reviewed from 1998 to 2005. Out of these, 58 AIDS patients who had received a triple drug scheme as the initial treatment were included in the study and two groups were formed: Group 1 (G1): 47 individuals treated with two nucleoside reverse-transcriptase inhibitors (NRTI) and one non-nucleoside reverse-transcriptase inhibitor; Group 2 (G2): 11 patients treated with two NRTI and one protease inhibitor. In G1 and G2, 53.2% and 81.8% respectively were patients with an AIDS-defining disease. The T CD4+ lymphocyte count increased progressively up until the 24th week of treatment in all patients, while VL became undetectable in 68.1% of G1 and in 63.6% of G2. The study concluded that the evolutions of laboratory tests were similar in the two treatment groups and that both presented a favorable clinical evolution. .

RESUMO A terapia antirretroviral na aids visa inibir a replicação viral, retardar a progressão da imunodeficiência e melhorar a sobrevida do paciente. O objetivo do estudo foi comparar dois esquemas de tratamentos antirretrovirais, quanto à carga viral plasmática (CV) e contagem de linfócitos T CD4+, durante 48 semanas de tratamento, pela revisão de 472 prontuários no período de 1998 a 2005, em um Serviço de Ambulatórios Especializados. Foram incluídos para o estudo 58 pacientes que receberam esquema tríplice como terapêutica inicial, os quais formaram dois grupos: Grupo 1 (G1): 47 indivíduos em tratamento com dois inibidores de transcriptase reversa análogos de nucleosídeos (ITRN) e um inibidor de transcriptase reversa não análogo de nucleosídeo; Grupo 2 (G2): 11 pacientes em tratamento com dois ITRN e um inibidor de protease. Entre os pacientes de G1 e G2, 53.2% e 81.8%, respectivamente, foram classificados como portadores de aids com doença definidora. A contagem de linfócitos T CD4+ aumentou progressivamente até a 24ª semana de tratamento, em todos os doentes e, a CV tornou-se indetectável em 68,1% dos casos de G1 e em 63,6%, do G2. O estudo concluiu que, em ambos os grupos de tratamento, houve evolução laboratorial semelhante e essa observação foi compatível com evolução clínica favorável dos pacientes estudados. .

Feedback de usuários como subsídio para avaliação do estudante de medicina / Patient's feedback for medical students' evaluation

A avaliação é fundamental para o processo ensino-aprendizagem. Diferentes métodos de avaliação e diversos atores envolvidos na avaliação podem fornecer elementos distintos, que, somados, fornecem melhor compreensão sobre a efetividade do processo educacional em suas variadas dimensões. A avaliação de habilidades e atitudes de estudantes tem recebido grande atenção recentemente. O envolvimento de pacientes no processo pode ser contributivo, pois sua perspectiva acrescenta informações ímpares. O presente estudo avaliou a aquisição de competências e habilidades de estudantes de Medicina no internato de Obstetrícia, sob o ponto de vista de gestantes. As pacientes responderam a um questionário segundo escala de Likert, com itens de avaliação divididos em habilidades de comunicação, exame físico e profissionalismo. Os resultados mostraram boa avaliação dos estudantes em geral, o que atribuímos ao sentimento de gratidão das pacientes. Algumas questões com maiores frequências de respostas negativas, porém, apontam aspectos que merecem maior atenção da escola médica pelo impacto que podem trazer à prática profissional. A perspectiva de pacientes na avaliação do estudante de Medicina poderá balizar estratégias de feedback para qualificar a formação médica.

Evaluation is a very important part of the teaching-learning process. Different methods and actors may provide distinct elements for a better comprehension on the efficacy of the educational process. This way, there is an increasing attention for evaluation of students' abilities and attitudes. To involve patients in the evaluation may also provide special information. The present study evaluated students abilities and competences during Obstetrics clerkship through patients' perspectives. The questionnaire used a Likert scale and it was divided into three aspects: abilities of communication, clinical exam and professionalism. The results showed a good evaluation possibly due to a gratitude bias. However some items had a higher percentage of negative answers and these points should be noted by medical schools, as they can impact professional behavior. Patients' perspectives to evaluate medical students may provide feedback in order to improve medical education.

Violência e saúde: concepções de profissionais de uma Unidade Básica de Saúde / Violence and health: conceptualizations by professionals from a Primary Healthcare Service

INTRODUÇÃO: A Organização Mundial da Saúde (OMS) e o Ministério da Saúde (MS) brasileiro definem violência como fenômeno multicausal, de múltiplas manifestações, cujas consequências afetam também o setor da saúde. OBJETIVOS: Identificar concepções dos profissionais de uma Unidade Básica de Saúde (UBS) sobre violência. MÉTODOS: A metodologia desenvolvida foi qualitativa, identificando-se as representações sociais sobre violência. Realizaram-se 17 entrevistas semiestruturadas, audiogravadas, cujo conteúdo foi analisado pela identificação de núcleos recorrentes nas falas dos sujeitos. RESULTADOS: Independentemente da formação, os profissionais reconheceram a pluralidade da violência, destacando suas manifestações, revelando, porém, despreparo para sua abordagem, reflexo da formação fundamentalmente biomédica. A violência, nessa comunidade, é subnotificada, pois a população é intimidada pelo problema, e o profissional não consegue abordá-lo. CONCLUSÃO: A violência subnotificada nessa localidade representa um microcosmo das fragilidades do sistema de saúde na capacitação de profissionais e assistência multidisciplinar, justificando a inserção da temática da violência na agenda da saúde pública.

INTRODUCTION: The World Health Organization (WHO) and the Brazilian Ministry of Health define violence as a multi-causal phenomenon with multiple manifestations whose outcomes affect the healthcare sector, among others. OBJECTIVES: The study aimed to identify perceptions of violence among professionals in a primary healthcare service. METHODS: The methodology was qualitative, identifying social representations of violence. Seventeen semi-structured interviews were conducted and audio-taped. The content was analyzed for recurrent core themes in the subjects'statements. RESULTS: Regardless of their training, the professionals acknowledged the plural nature of violence and emphasized its manifestations. However, they displayed a lack of preparedness to deal with violence, thus reflecting their essentially biomedical training. Violence in the community in question is underreported, since the local population is intimidated by the problem, and health professionals are unprepared to deal with it. CONCLUSION: Underreported violence in this community reveals weaknesses in the healthcare system to train professionals and organize multidisciplinary care, thus justifying the inclusion of violence on the public health agenda.

Avaliação da utilização de biópsia transbrônquica em pacientes com suspeita clínica de doença pulmonar intersticial / Evaluation of the use of transbronchial biopsy in patients with clinical suspicion of interstitial lung disease

OBJETIVO: Estudar os padrões clínicos, radiológicos e histopatológicos da biópsia transbrônquica (BTB) utilizados para a confirmação diagnóstica em pacientes com suspeita clinica de doença pulmonar intersticial (DPI) atendidos em um hospital universitário de nível terciário. MÉTODOS: Os prontuários, laudos radiológicos e de biópsias transbrônquicas de todos os pacientes com suspeita de DPI submetidos a BTB entre janeiro de 1999 e dezembro de 2006 no Hospital das Clínicas de Botucatu, localizado na cidade de Botucatu (SP), foram revisados. RESULTADOS: Foram incluídos no estudo 56 pacientes. Desses, 11 (19,6 por cento) apresentaram o diagnóstico definitivo de fibrose pulmonar idiopática (FPI), que foi significativamente maior nos casos nos quais DPI era uma possibilidade diagnóstica em comparação com aqueles nos quais DPI era a principal suspeita (p = 0,011), demonstrando a contribuição da BTB para a definição diagnóstica dessas doenças. O exame histopatológico dessas biópsias revelou que 27,3 por cento dos pacientes com FPI apresentavam o padrão de pneumonia organizante, o que pode sugerir doença mais avançada. O padrão histológico indeterminado foi o mais frequente, refletindo a característica periférica da FPI. Entretanto, o padrão fibrose apresentou alta especificidade e alto valor preditivo negativo. Para os padrões sugestivos de FPI em TC, a curva ROC indicou que a melhor relação entre sensibilidade e especificidade ocorreu com a presença de cinco alterações radiológicas, sendo o aspecto de favo de mel fortemente sugestivo de FPI (p = 0,01). CONCLUSÕES: Nas DPIs, a TC de tórax deve ser sempre realizada e a BTB usada em situações individualizadas, conforme a suspeita e distribuição das lesões.

OBJECTIVE: To study the clinical, radiological, and histopathological patterns of transbronchial biopsy (TBB) used in order to confirm the diagnosis in patients with clinical suspicion of interstitial lung disease (ILD) treated at a tertiary-care university hospital. METHODS: We reviewed the medical records, radiology reports, and reports of transbronchial biopsies from all patients with suspected ILD who underwent TBB between January of 1999 and December of 2006 at the Hospital das Clínicas de Botucatu, located in the city of Botucatu, Brazil. RESULTS: The study included 56 patients. Of those, 11 (19.6 percent) had a definitive diagnosis of idiopathic pulmonary fibrosis (IPF), the rate of which was significantly higher in the patients in which ILD was a possible diagnosis in comparison with those in which ILD was the prime suspect (p = 0.011), demonstrating the contribution of TBB to the diagnostic confirmation of these diseases. The histopathological examination of the biopsies revealed that 27.3 percent of the patients with IPF showed a pattern of organizing pneumonia, which suggests greater disease severity. The most common histological pattern was the indeterminate pattern, reflecting the peripheral characteristic of IPF. However, the fibrosis pattern showed high specificity and high negative predictive value. For CT scan patterns suggestive of IPF, the ROC curve showed that the best relationship between sensitivity and specificity occurred when five radiological alterations were present. Honeycombing was found to be strongly suggestive of IPF (p = 0.01). CONCLUSIONS: For ILDs, chest CT should always be performed, and TBB should be used in specific situations, according to the suspicion and distribution of lesions.

Pesquisa em educação médica conduzida por estudantes: um ano de experiência do núcleo acadêmico de pesquisa em educação Médica / Research by students in medical education: a one-year experience at the academic center for research in Medical education

A pesquisa em educação médica vem se desenvolvendo muito nos últimos anos. A participação de estudantes nos processos de mudanças curriculares também é crescente e bastante contributiva. Ainda, a iniciação científica está sendo amplamente defendida por seu impacto positivo na formação profissional. Relatamos um ano de experiência do Núcleo Acadêmico de Pesquisa em Educação Médica (Napem), que integra as propostas de participação discente nas discussões de ensino médico através de trabalhos de iniciação científica em educação médica. O Napem foi fundado em 2008 e foi bem aceito na comunidade acadêmica da Faculdade de Medicina de Botucatu/Universidade Estadual Paulista (FMB/Unesp). Seus projetos de pesquisa atuais investigam: avaliação do curso médico, avaliação do estudante, fatores que influenciam a busca por iniciação científica, Ligas Acadêmicas e interdisciplinaridade. Estão envolvidos 17 estudantes e dez professores. Em um ano, o Napem apresentou trabalhos em congressos, publicou artigo em periódico indexado e está certificado como grupo de pesquisa no CNPq. Dentre seus desafios estão a necessidade de contínua renovação dos estudantes e o avanço nas pesquisas, de modo que os projetos não se encerrem em si mesmos, mas constituam um continuum de investigação à medida que novas informações sejam agregadas ao conhecimento.

Research on medical education has expanded in recent years. Students' participation in curriculum change has also increased, with major contributions. Initiation in scientific research has also been widely defended due to its positive impact on professional training. We report on the one-year experience at the Academic Center for Research in Medical Education (NAPEM), which incorporates proposals for student participation in discussions on medical teaching through scientific initiation projects in medical education. Founded in 2008, NAPEM was well-received by the academic community at the Botucatu School of Medicine/São Paulo State University (FMB/UNESP). Its current research projects focus on the evaluation of the course in medicine, student evaluation, factors influencing the search for scientific initiation, Student Leagues, and interdisciplinary approaches. A total of 17 students and ten faculty members are involved. In one year, NAPEM has presented papers at congresses, published an article in an indexed journal, and is certified by the Brazilian National Research Council (CNPq). Its challenges include the need for constant renewal of students and progress in research projects, to keep the latter from becoming self-contained, but rather to serve as a continuum in research, to the extent that new findings are added to the body of knowledge on medical education.