Treatment of Graves' disease in Brazil: results of a survey among endocrinologists

ABSTRACT Objective: The objective of the study was to determine how physicians in Brazil manage Graves' disease in different scenarios including extrathyroidal manifestations. Materials and methods: This study was conducted via a digital survey. The respondents (n = 573) answered multiple-choice questions based on a clinical case and variations of the case regarding laboratory and imaging evaluation, treatment choice, and follow-up. Results: The preferred initial treatment chosen by 95% of the respondents was ATD with a preferred treatment duration of 18-24 months. For 5% of the respondents, RAI was the initial treatment of choice. None of the respondents chose thyroidectomy. When presented with a patient with a desire for pregnancy in the near future, most respondents (69%) opted for ATD as the initial treatment. For a patient with signs of mild to moderate Graves' orbitopathy, ATD remained the initial therapy for 93.9% of the respondents. For patients initially treated with ATD with disease recurrence after ATD interruption, most respondents (60%) chose definitive treatment with RAI. A similar survey published in 2011 by Burch and cols. had results comparable to those of the present survey but with a higher proportion of respondents choosing RAI (45% in the 2011 survey versus 5% in the present survey). Conclusion: Brazilian endocrinologists choose ATD as the initial management of Graves' disease, and most choose RAI as a definitive treatment for a patient with relapse after ATD therapy.

Cardiotoxicidade por cocaína e disfunção ventricular em paciente jovem / Cocaine cardiotoxicity and ventricular disfunction in a young patient

RESUMO: O uso de substâncias psicoativas pode induzir complicações cardiovasculares. O objetivo deste relato é descrever o caso de um paciente jovem com cardiomiopatia dilatada secundária ao uso de cocaína. Paciente com dispneia há seis meses, com piora progressiva, dispneia paroxística noturna, ortopneia e edema de membros inferiores. Ao exame físico apresentava taquicardia (110 bpm), com demais sinais vitais sem alterações, presença de estertores crepitantes em bases e campos médios, ascite de moderado volume e edema importante de membros inferiores. No eletrocardiogra-ma, apresentava ritmo sinusal com sobrecarga de câmaras esquerdas; na radiografia de tórax, apenas cardiomegalia acentuada. O ecocardiograma evidenciou fração de ejeção (FE) do ventrículo esquerdo (VE) reduzida (7%), aumento de átrio esquerdo e ventrículo direito (VD), com hipertrofia excêntrica e disfunção sistólica acentuada do VE, com disfunção moderada do VD e hipertensão pulmonar (39 mmHg). Na ressonância, apresentou dilatação discreta do átrio direito, VD com dilatação importante, disfunção sistólica biventricular importante, com hipocinesia difusa (FE 8% de VD), além de fibrose miocárdica de padrão não coronariano inferosseptal. O caso relatado evidencia um diagnóstico cujo mecanismo fisiopatológico da cardiomiopatia dilatada não está claro. A associação mais coerente da cardiomiopatia dilatada apre-sentada pelo paciente está relacionada ao uso abusivo de cocaína, devido ao estímulo recorrente e de longa duração que o excesso de catecolaminas provocou no miocárdio. Tendo em vista o espectro de cardiomiopatia, infarto e arritmias que potencialmente podem ocorrer associados ao uso de cocaína, deve-se considerar a hipótese de cardiotoxicidade na avaliação de paciente com história de abuso de cocaína. (AU)

ABSTRACT: The use of psychoactive substances can induce cardiovascular complications. The purpose of this report is to describe the case of a young patient with dilated cardiomyopathy secondary to cocaine use. Patient with dyspnea for six months, with progressive worsening, paroxysmal nocturnal dyspnea, orthopnea, and lower limb edema. Physical examination showed tachycardia (110 bpm), with other vital signs without alterations, presence of crackling rales in the bases and middle fields, moderate volume ascites, and significant lower limb edema. Electrocardiogram showed sinus rhythm with left chamber overload; chest X-ray only marked cardiomegaly. The echocardiogram showed reduced left ventricular (LV) ejection fraction (7%), enlarged left atrium, and right ventricle (RV), with eccentric hypertrophy and severe left ventricular systolic dysfunction, with moderate RV dysfunction and pulmonary hyper-tension (39 mmHg). Resonance presented mild right atrial dilatation, RV with significant dilatation, significant biven-tricular systolic dysfunction, with diffuse hypokinesia, and myocardial fibrosis of non-coronary pattern. The reported case shows a diagnosis whose pathophysiological mechanism of dilated cardiomyopathy is not clear. The most coher-ent association of dilated cardiomyopathy presented by the patient is related to cocaine abuse, due to the long-term recurrent stimulus that excess catecholamines caused in the myocardium. Given the spectrum of cardiomyopathy, infarction, and arrhythmias that may potentially occur associated with cocaine use, the hypothesis of cardiotoxicity should be considered in the evaluation of a patient with a history of cocaine abuse. (AU)