Knowledge about head and neck cancer among adolescents

Introduction: The expansion of knowledge about head and neck cancer can provide greater care and the ability to identify risk factors and symptoms of the disease, as well as the incorporation of healthy habits. The younger these concepts are sedimented, the better results will be, making society healthier and more aware. Objective: To assess knowledge about head and neck cancer among adolescents from private schools, aged between 13 and 22 years. Methods: 200 questionnaires were applied among students, about the profile of adolescents and their knowledge about head and neck neoplasms, treatment, and teaching in schools on this topic. The results were analyzed both quantitatively and qualitatively. Results: Only 55 students (29.9%) identified HPV as a risk factor for the disease. 137 students (74.5%) identified the brain as an organ treated by head and neck surgery. As for the therapeutic strategies used for the treatment of neoplasms in the region, only 67 students (36.4%) are aware. On the topic of teaching in schools, 153 students (83.1%) relate to some deficiency in the approach and learning. Conclusion: Knowledge about head and neck cancer is insufficient. It is necessary to introduce in the curriculum basic cancer education in biology classes. The expansion of acquirements about cancer can provide better care and the ability to identify risk factors, initial signs, and symptoms of the disease, as well as the incorporation of healthy habits in families because these students can propagate valid information in their environment.

Anatomy of the anterior jugular veins: anatomical study of 30 cadavers

Introduction: Human anatomy is essential for both clinical and surgical practice. Although the anterior jugular veins (AJVs) are of great importance in many surgeries, there are few studies addressing the anatomic variations of these vessels. This study highlights the venous drainage of the head and neck and the importance of anatomical variations in the AJVs. Objective: To observe and describe the anatomy of the jugular veins and evaluate whether there are patterns influenced by anthropometric factors or comorbidities. Methods: Neck dissections were performed on 30 cadavers. The anatomical characteristics of the AJVs were described considering diameter, midline distance, anastomosis, and presence of the jugular venous arch. Results: Cadavers of 14 women and 16 men were dissected. Ninety percent (90%) of the jugular veins had a rectilinear path and 37% presented anastomosis: H-shaped (63.7%),N-shaped (27.3% ), and Y-shaped (9%). In relation to the number of veins, 20% of the cadavers had only one AJV, 63.3% had two, 10% had three, and 6.7% presented a total of four. Mean distance between jugular veins was 12 mm, and most veins (60%) had a diameter <5 mm. There was no statistically significant correlation between anatomical variations and anthropometric factors. Conclusion: AJVs were always present in the dissected cadavers, and the configuration most commonly found was two veins, each <5 mm in diameter. They were less than 10 mm away from the cervical midline and, when they presented anastomosis, it was H-shaped in most cases.

Thyroid cancer surgical indication during pregnancy: systematic literature review and series of illustrative cases

Introduction: Thyroid papillary carcinoma is the second most frequent type of cancer during pregnancy. Its diagnosis is related to patient fear and anxiety. There is little consensus on when to perform surgery in those cases. Objective: To evaluate and discuss timing possibilities for surgical treatment in thyroid cancer in pregnant women. Methods: Systematic literature review based on online search at the Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) and National Center for Biotechnology Information (NCBI) databases. Retrospective analysis of thyroidectomies performed in the second trimester of pregnancy by the authors between 1999 and 2019. Results: The systematic review included nine articles. Their conclusions diverge with respect to the optimal timing of thyroid surgery. The medical literature considers thyroidectomy after safe delivery. The most recent studies are more flexible regarding carrying out this surgery during the second trimester of pregnancy. In the authors' experience (n=5), surgical treatment during the second trimester of pregnancy is a good option for more aggressive tumors. Conclusion: More aggressive cases of thyroid papillary carcinoma can be treated with surgery during the second trimester of pregnancy. Performing the surgery after delivery is safer in the case of less aggressive cancer cases. The decision should consider hospital costs, surgery risks, and patient anxiety in relation to cancer.

Morphometry and Frequency of the Pyramidalis Muscle in Adult Humans: A Pyramidalis Muscles Anatomical Analysis

OBJECTIVES: To verify the pyramidalis muscle's frequency (bilaterality, unilaterality, or absence) and morphometry (length of the medial border and width of its origin/base) in a sample of the Brazilian population and the anthropometric influence. METHODS: Dissection of 30 cadavers, up to 24h post-mortem. RESULTS: The pyramidalis muscle was present bilaterally and unilaterally in 83.33% and 3.33% of the cadavers, respectively, and absent in 13.33%. The muscles on the right and left sides were symmetrical in length but not in width; the pyramidalis muscles of men were longer, while those of the women were wider. We also found that there was greater variation in the dimensions (length and width) of the men's muscles. Finally, in this sample of the Brazilian population, the pyramidalis muscle's unilaterality was more prevalent than in other populations, and its complete absence was less prevalent. CONCLUSIONS: There were no cases of muscle duplication in one or both sides, as described in some studies. Despite all of its morphometric variation, the pyramidalis muscle maintained its triangular shape with longitudinal fibers in every case. Furthermore, no statistically significant correlation was noted between the muscles' dimensions and person's age, height, weight, or gender.

Surgical practice in the current COVID-19 pandemic: a rapid systematic review

The coronavirus disease (COVID-19) outbreak </mac_aq>started in Wuhan, China, in December 2019, and evolved into a global problem in a short period. The pandemic has led to many social and health-care challenges. In this context, surgery is an area that is facing the need for many adaptations. In this systematic literature review, we analyzed different perspectives concerning this situation, aiming to provide recommendations that could guide surgeons and </mac_aq>entities toward screening, elective and emergency surgeries, decision making, and operating room management. A computerized search in PubMed, Scopus, and Scientific Electronic Library Online (SciELO) for relevant literature up to April 4, 2020, was performed. Articles were included if they were related to surgery dynamics in the context of the COVID-19 pandemic. Of the 281 articles found in our initial search and 15 articles from alternative sources, 39 were included in our review after a systematic evaluation. Concerning preoperative testing </mac_aq>for severe acute respiratory syndrome coronavirus 2 infection, 29 (74.4%) articles recommended some kind of </mac_aq>screening. Another major suggestion was postponing all (or at least selected) elective operations (29 articles, </mac_aq>74.4%). Several additional recommendations with respect to surgical practice or surgical staff were also assessed and discussed, such as performing laparoscopic surgeries and avoiding the use of electrocauterization. On the basis of the current literature, we concluded that any surgery that can be delayed should be postponed. COVID-19 screening is strongly recommended for all surgical cases. Moreover, surgical staff should be reduced to the essential members and provided with institutional psychological support.

A brief history of medical uniforms: from ancient history to the COVID-19 time / Uma breve história de uniformes médicos: da história antiga aos tempos da COVID-19

ABSTRACT Medical Uniforms date back from medieval times. Nursing uniforms were based on nuns clothes whereas doctors used the famous "plague costumes" and black "frock" coats from about 15th to early 19th century. In latter half 19th century medical uniforms started to change. Nursing uniforms gradually lost their similarities to religious outfits. Doctors started to use white clothing. With great emphasis on hygiene and sanitation, the idea of personal protective equipment (PPE) started to evolve with William Stewart Halsted introducing the use of rubber gloves in 1889. In the 1960s-1970s it became more usual to wear green and blue `scrubs in order to look for a greater contrast in clothing with the all-white hospital environment. In contemporary times, some specialties even stopped using specific uniforms, while others still use them. At the same time, PPE became more and more important, up to nowadays "plague costume" in the combat of the COVID-19 epidemics.

RESUMO Uniformes da área médica datam desde os tempos medievais. Uniformes de enfermeiras eram baseados em roupas de freiras, enquanto o de médicos eram caracterizados pelas "vestimentas da praga" e fraques pretos de meados do século 15 até o início do século 19. No final do século 19, os uniformes começaram a mudar. A vestimenta de enfermeiras perderam suas similaridades com vestes religiosas. Médicos começaram a usar roupas brancas. Com o aumento da ênfase em higiene e no sanitarismo, começa a evoluir a ideia do uso de equipamento de proteção individual (EPI), com William Stewart Halsted utilizando luvas de borracha pela primeira vez em 1889. Nas décadas de 1960 e 1970 começa a se tornar mais usual a adesão ao pijama cirúrgico verdes e azul como roupa hospitalar, devido ao contraste com o ambiente branco já presente. Na contemporaneidade, algumas especialidades deixaram de usar uniformes específicos, enquanto outras ainda a usam. Ao mesmo tempo, EPIs tornaram-se mais e mais importantes, até, hoje em dia, surgir as "vestimentas da praga" atualizadas para o combate da epidemia do COVID-19.

Aderência intertalâmica e Alzheimer: estudo preliminar / Interthalamic adhesion and Alzheimer's: preliminary study

Objetivo: Descrever dimensões e prevalência da Aderência Intertalâmica (AI) em cadáveres do Serviço de Verificação de Óbitos da Capital - USP, considerando idade, sexo, peso, altura e histórico pessoal de doença de Alzheimer (DA). Métodos: Cinquenta e sete cadáveres (31H/26M) foram incluídos no estudo, com média de idade de 66,2 anos (variando entre 15 e 91 anos). A análise da AI foi feita após secção transversal da calota craniana e incisão axial no limite inferior do tronco encefálico seguida de retirada do encéfalo de sua cavidade. Cinquenta e quatro encéfalos foram submetidos a incisão sagital mediana, dois encéfalos foram submetidos a cortes axiais, e um encéfalo a secção coronal. Dados quantitativos foram comparadas pelo teste t de student, e dados qualitativos pelo teste de Qui Quadrado. A análise idade vs área foi feita por regressão linear. Resultados: A prevalência de AI foi de 79%, não havendo diferença significativa entre os sexos (p=0,68).  Observou-se associação entre menores áreas de secção sagital e idades mais avançadas (p=0,02). Não houve diferença significativa na prevalência de AI nem na área de secção transversal em pacientes com DA. Discussão: Ao contrário de estudos prévios, que associaram maior prevalência e tamanho de AI com sexo feminino, isso não foi observado em nossa casuística. Apesar de não ser estatisticamente significativa nota-se uma diferença importante nas áreas médias de secção sagital dos grupos com e sem DA, o que aponta para a necessidade de estudos subsequentes com amostras maiores

Objective: Identifying the prevalence and dimensions of the Interthalamic Adhesion (ITA) in corpses from the "Serviço de Verificação de Óbitos da Capital - USP", considering factors as age, sex, weight, height, and diagnosis of Alzheimer's disease (AD). Methods: Fifty-seven corpses (31M/26F) were included in the study. The mean age was 66.2 (varying between 15 and 91). The analysis of the ITA was made after the encephalon's removal from its cavity, which occurred by the transversal section of the skullcap, and, next, an axial incision in the inferior limit of the pons to separate the encephalon from the spinal cord. Fifty-four encephalons were submitted to medial sagittal incisions, two encephalons were submitted to axial cuts and one to a coronal section. Quantitative data were compared by the Student's T Test, and qualitative data by the Chi-squared test. The Age vs Area analysis was made by linear regression. Results: the prevalence of the ITA was 79%, not having differences in prevalence between sexes (p=0.68). Advanced ages presented lower areas in sagittal sections (p= 0.02). It does not appear to have a significant alteration in prevalence of the ITA and transversal section aerea in patients with AD. Discussion: Unlike previous studies which observed higher prevalence and size of the ITA in females, differences in this parameters were not obtained in this study. Evidence of correlation between AD and lower sagittal section of the ITA, even without statistic significance, points to the need of further studies.

Thyroidectomy in children

Introduction: Surgical management of thyroid disease in children presents several peculiarities and has increasingly developed in recent years, but historically few studies conducted with this population have been published. Objective: Analysis of the surgical approach and postoperative outcomes of 59 pediatric patients submitted to thyroidectomy between 2003 and 2019. Methods: An outpatient postoperative follow-up of 59 patients aged 3-18 years submitted to thyroidectomy for different causes was performed, and immediate and late postoperative outcomes were analyzed. The operations were performed at a University Hospital as well as at Private Tertiary Hospitals. Results: The following postoperative outcomes were observed: three tracheostomies, 22 patients with transient hypoparathyroidism, eight patients with definitive hypoparathyroidism, and three patients with vocal fold paralysis. Conclusion: Thyroidectomy in children is a procedure with a higher complication rate and needs to be performed by a team of high-volume surgeons. This study focuses on the adverse events, so that those interested in the subject are aware of them.

Is the colon mucosa affected by ten days of gastric restriction in an animal model?

Abstract Purpose To identify whether the colon mucosa is affected by ten days of gastric restriction in an animal model. Methods An experimental model of gastric restriction was devised using rats. The animals were submitted to surgical gastrostomy, and a cylindrical loofah was inserted into the stomach. We studied 30 adult male Wistar rats divided into three groups: the stomach restriction group (R10); the sham group (S10), which underwent the same procedure except for the loofah insertion; and the control group (C10). The expression of neutral and acid mucins was evaluated using histochemical techniques. Goblet cells and protein content were compared between groups using generalized estimation equations (GEEs). Bonferroni's multiple comparison was applied to identify differences between the groups. All tests considered a 5% significance level. Results There was an increased expression of neutral mucins, acid mucins and goblet cells in the R10 group. Collagen was also enhanced in the R10 group. Conclusion The colon mucosa is affected by ten days of gastric restriction in an animal model, increasing neutral mucins, acid mucins and collagen content with trophic maintenance.

Linfonodos do nível VI: estudo anatômico dos linfonodos localizados entre o nervo laríngeo recorrente e a artéria carótida comum direita / Level VI lymph nodes: an anatomic study of lymph nodes located between the recurrent laryngeal nerve and the right common carotid artery

RESUMO Objetivo: descrever a presença de linfonodos e suas relações com características demográficas e antropométricas em uma região específica ainda não descrita pelos compêndios de anatomia, por nós denominada de Recesso Carotídeo Recorrencial (RCR), localizada entre o nervo laríngeo recorrente direito, a artéria carótida comum direita e a artéria tireoidea inferior direita. Métodos: foram dissecadas 32 regiões cervicais à direita de cadáveres com até 24 horas de post mortem. O tecido fibrogorduroso do RCR foi ressecado e preparado com fixação em formol. Em seguida, foi submetido a uma sequência crescente de álcoois (70%, 80% e 90%), posteriormente a uma solução de Xilol e, por fim, a uma solução de Salicilato de Metila, respeitando o tempo necessário de cada etapa. O estudo macroscópico foi realizado na peça diafanizada, observando a presença ou não de linfonodos. Quando presentes, foram fotografados e suas medidas foram aferidas com um paquímetro digital. No estudo microscópico, foi utilizada a coloração hematoxilina-eosina para confirmação do linfonodo. Resultados: observou-se a presença de linfonodos em 22 dos 32 espécimes (68,75%), com o número de linfonodos por cadáver variando de zero a seis (média de 1,56±0,29) e tamanho com média de 7,82mmx3,86mm (diâmetros longitudinal x transversal). Conclusão: a relação entre dados antropométricos e presença de linfonodos no RCR (teste exato de Fischer) foi significante para indivíduos normolíneos (p=0,03) e também significante entre a etnia branca (p=0,04).

ABSTRACT Objective: to describe the presence of lymph nodes and their relationships with demographic and anthropometric characteristics in a specific region, not yet described in anatomy compendiums, called by us Recurrent Carotid Recess (RCR) and located among the right recurrent laryngeal nerve, the right common carotid artery, and the right inferior thyroid artery. Methods: 32 right cervical regions were harvested from cadavers within 24 hours post-mortem. The fibro-fatty tissue of the RCR was resected and prepared with formalin fixation. It was then subjected to an increasing sequence of alcohols (70%, 80%, and 90%), subsequently to a solution of Xylol, and finally to a solution of Methyl Salicylate, respecting the time required for each step. The macroscopic study was carried out on the diaphanized piece, observing the presence or not of lymph nodes. When present, they were photographed and their measurements were gauged with a digital caliper. In the microscopic study, hematoxylin-eosin staining was used to confirm the lymph node. Results: the presence of lymph nodes was observed in 22 (68.75%) of the 32 specimens. The number of lymph nodes ranged from zero to six (mean of 1.56±0.29), per cadaver, and their mean size was 7.82mmx3.86mm (longitudinal x transversal diameters). Conclusion: the relationship between anthropometric data and presence of lymph nodes in the RCR (Fisher's exact test) was significant for medium-height individuals (p=0.03) and also white ones (p=0.04).

Substernal goiter and laryngopharyngeal reflux

ABSTRACT Objective This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. Subjects and methods A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. Results The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. Conclusion This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

Thyroid gland invasion in advanced squamous cell carcinoma of the larynx and hypopharynx / Invasão da glândula tireoide no carcinoma espinocelular avançado de laringe e hipofaringe

Abstract Introduction: Squamous cell carcinoma of the larynx and hypopharynx has the potential to invade the thyroid gland. Despite this risk, the proposition of either partial or total thyroidectomy as part of the surgical treatment of all such cases remains controversial. Objectives: To evaluate the frequency of invasion of the thyroid gland in patients with advanced laryngeal or hypopharyngeal squamous cell carcinoma submitted to total laryngectomy or pharyngolaryngectomy and thyroidectomy; to determine whether clinic-pathological characteristics can predict glandular involvement. Methods: A retrospective case series with chart review, from January 1998 to July 2013, was undertaken in a tertiary care university medical center. An inception cohort of 83 patients with larynx/hypopharynx squamous cell carcinoma was considered. All patients had advanced stage disease (clinically T3-T4) and underwent total laryngectomy or total pharyngolaryngectomy in association with thyroidectomy. Adjuvant therapy was indicated when tumor or neck conditions required. Frequency of thyroid cartilage invasion was calculated; univariate and multivariate analysis of demographic, clinical and pathological characteristics associated with cartilage invasion were performed. Results: The overall frequency of invasion of the thyroid gland was 18.1%. Glandular involvement was associated with invasion of the following structures: anterior commissure (odds ratio = 5.13; 95% confidence interval 1.07-24.5), subglottis (odds ratio = 12.44; 95% confidence interval 1.55-100.00) and cricoid cartilage (odds ratio = 15.95; 95% confidence interval 4.23-60.11). Conclusions: Invasion of the thyroid gland is uncommon in the context of laryngopharyngeal squamous cell carcinoma. Clinical and pathological features such as invasion of the anterior commissure, subglottis and cricoid cartilage are more associated with glandular invasion.

Resumo Introdução O carcinoma espinocelular de laringe e hipofaringe tem potencial para invadir a glândula tireoide. Apesar desse risco, a proposição de tireoidectomia parcial ou total como parte do tratamento cirúrgico de todos esses casos permanece controversa. Objetivos Avaliar a frequência de invasão da glândula tireoide em pacientes com carcinoma espinocelular avançado de laringe ou hipofaringe submetidos a laringectomia total ou faringolaringectomia e tireoidectomia; determinar se características clínico‐patológicas podem prever o envolvimento glandular. Método Uma série de casos retrospectivos com revisão de prontuários, entre janeiro de 1998 e julho de 2013, foi feita em um centro médico universitário de cuidados terciários. Uma coorte inicial de 83 pacientes com carcinoma espinocelular de laringe/hipofaringe foi considerada. Todos os pacientes tinham doença em estágio avançado (clinicamente T3‐T4) e foram submetidos a laringectomia total ou faringolaringectomia em associação com tireoidectomia. Foi indicada terapia adjuvante quando o tumor ou as condições do pescoço exigiram. A frequência de invasão de cartilagem da tireoide foi calculada; análises univariada e multivariada das características demográficas, clínicas e patológicas associadas à invasão de cartilagem foram feitas. Resultados A frequência global de invasão da glândula tireoide foi de 18,1%. O envolvimento glandular foi associado à invasão das seguintes estruturas: comissura anterior (odds ratio = 5,13; intervalo de confiança 95%, 1,07‐24,5), subglote (odds ratio = 12,44; intervalo de confiança 95%, 1,55‐100,00) e cartilagem cricoide (odds ratio = 15,95; intervalo de confiança 95%, 4,23‐60,11). Conclusões A invasão da glândula tireoide é rara no contexto de carcinoma espinocelular laringofaríngeo. As características clínicas e patológicas, como a invasão da comissura anterior, subglote e cartilagem cricoide, estão mais associadas a invasão glandular.

Acometimento da glândula tireoide em pacientes submetidos a laringectomia total por carcinoma espinocelular / Involvement of the thyroid gland in patients who underwent total laryngectomy by squamous cell carcinoma

Introdução: A tireoidectomia é considerada um procedimento complementar para o tratamento de carcinomas epidermoides avançados de laringe e hipofaringe. Entretanto poucos dados apontam o real acometimento glandular e suas indicações para extirpação. Objetivos: Avaliar o real acometimento da glândula tireoide em pacientes que foram submetidos a laringectomias total ou faringolaringectomias com tireoidectomia por carcinoma epidermoide e comparar os resultados com a literatura mais recente. Casuística e Método: Avaliação retrospectiva dos últimos 20 (vinte) pacientes submetidos ao tratamento proposto no serviço de cirurgia de cabeça e pescoço da Universidade Federal de São Paulo / Escola Paulista de Medicina. Os dados epidemiológicos foram obtidos da revisão do prontuário médico. A avaliação final foi baseada no resultado do exame anatomopatológico definitivo. Resultados: A idade média encontrada foi de 61,7 anos, com uma prevalência de 85% do gênero masculino. Dezenove dos vinte pacientes eram tabagistas. Todos se encontravam em estádios avançados da doença, 19(dezenove) em estádio IVA e 01(um) em III. A glândula tireoide apresentou acometimento pelo tumor em 05(cinco) casos. Conclusão: Nos pacientes submetidos a tireoidectomia complementar por carcinoma epidermoide avançado de laringe em nosso serviço encontramos 25% de comprometimento neoplásico da glândula tireoide, dado compatível com trabalhos recentes publicados por outros autores.

Introduction: Thyroidectomy is considered an additional procedure for the treatment of advanced squamous cell carcinomas of the larynx and hypopharynx . However few data indicate the actual glandular involvement and its indications for removal. Objectives: Assess the actual involvement of the thyroid gland in patients who underwent total laryngectomy with thyroidectomy for squamous cell carcinoma and compare the results with the recent literature. Materials and Methods: Retrospective evaluation of the last twenty (20) patients undergoing the proposed i treatmentn the service of the head and neck surgery at the Federal University of São Paulo / Escola Paulista de Medicina. Epidemiological data were obtained from review of medical records. The final evaluation was based on the outcome of the final pathology exam. Results: Mean age was 61.7 years, with a prevalence of 85% male gender. Nineteen of twenty patients were smokers. All were in advanced stages of disease, 19 (nineteen) in stage IVA and 01 in III. The thyroid gland showed involvement by tumor in five (05) cases. Conclusion: In patients undergoing thyroidectomy supplemented by advanced laryngeal squamous cell carcinoma in our hospital we found 25% of neoplastic involvement of the thyroid gland, as consistent with recent work published by other authors.

Avaliação discente é importante ferramenta no aperfeiçoamento dos cursos de anatomia clínica / Student's evaluation is a valuable tool to improve clinical anatomy courses

Introdução: O conhecimento médico e a demanda docente estão em constante e progressiva mudança e os processos pedagógicos devem ser adaptados conforme as necessidades para prover o máximo rendimento. Analisamos retrospectivamente a avaliação discente de três métodos diferentes utilizados no curso de Anatomia Clínica da FMUSP na última década. Métodos: A Faculdade de Medicina da Universidade de São Paulo oferece avaliação sistemática de cada Disciplina, com avaliação dos estudantes de 38 diferentes aspectos relacionados ao curso, de estrutura física até a qualidade das aulas. Neste estudo, métodos diferentes de ensino de Anatomia Clínica para os alunos de 2o e 3o anos de Medicina foram confrontados com as avaliações discentes ao final do curso. Foram analisadas as mudanças pedagógicas no curso desde 1994 até o presente e seu impacto baseado na avaliação dos estudantes. Resultados: Observou-se melhora significativa na avaliação geral quando o curso foi mudado da técnica de Aprendizagem Baseada em Problemas para uma abordagem mais formal, com aulas teóricas dadas por especialistas, em sua maioria convidada de outras Disciplinas da Faculdade. Uma avaliação ainda mais positiva ocorreu quando os aspectos práticos focaram aspectos demonstrados em aulas teóricas, na sua maioria dada por especialistas com formação em Anatomia. Discussão: A avaliação dos estudantes permite aos coordenadores do curso redirecionar os objetivos e os métodos pedagógicos para ajustar o formato do curso como necessário. As notas finais também podem ser analisadas conjuntamente para que a efetividade do método empregado possa ser avaliada em conjunto com a avaliação discente. Conclusão: A contínua avaliação dos estudantes é essencial para que os coordenadores dos cursos possam adequar suas estratégias para enfrentar os desafios atuais dos processos pedagógicos e obter os melhores resultados nos cursos de Anatomia Clínica.

Background: Medical knowledge and students’ demands are under continuous changes and learning process must adapt accordingly. We retrospectively analyzed students’ evaluation of three different approaches employed in our course of Clinical Anatomy in the last decade. Methods: The University of São Paulo Medical School has a systematic evaluation of each discipline where students grade 38 different topics ranging to physical conditions to the quality of the classes. In this study, different methods to teach Clinical Anatomy to 2nd and 3rd year students of Medicine were confronted to the students’ evaluations, comparing the general appreciation of the course in different teaching approaches. We analyzed the changes in the Anatomy course from 1994 to the present and their impact based on the students´ evaluations. Results: Significant improvement in general evaluation was observed when the course changed from Problem Based Learning technique to a more formal approach with theoretical classes given by specialists, most of them invited from other Clinical Departments of the University. A still better evaluation was obtained as the practical demonstrations focused aspects showed in theoretical classes, which were given mostly by specialists trained in Anatomy. Discussion: Students´ evaluation allows course coordinators to redirect objectives and teaching methods to adjust the course format as needed. Performance in final exams may also be analyzed together so effectiveness of the teaching method can be measured along with students’ satisfaction. Conclusion: Continuous feedback from students is essential to course coordinators to adequate strategies to face the modern challenges in the teaching/learning process and obtain the best results in courses of Clinical Anatomy.

Parathyroid carcinoma and hungry bone syndrome / Carcinoma de paratiroide e fome óssea

We hereby report two patients with parathyroid carcinoma presenting extremely high calcium and PTH levels, severe bone disease, and palpable neck mass at diagnosis. They both underwent parathyroidectomy, and one of them evolved to lung metastasis. Important hypocalcemia was observed after surgery in both: after parathyroidectomy in one patient, and only after surgical removal of the metastasis in the other. Both required intravenous calcium replacement, thus revealing hungry bone syndrome (HBS). HBS usually reflects rapid mineralization after correction of hyperparathyroidism. The more severe the bone disease before surgery, the more prone the patient is to HBS after surgery. Despite being an unfavorable outcome, HBS state suggests that surgical removal of hypersecretory parathyroid tissue was accomplished. In this study, HBS was observed in both patients, who presented severe bone disease prior to surgery. HBS would be expected post-operatively in successful parathyroid carcinoma removal.

O presente artigo descreve o relato de dois pacientes com carcinoma de paratiroide que apresentavam valores intensamente elevados de cálcio sérico e de PTH, associado a doença óssea e presença de nódulo cervical palpável ao diagnóstico. Ambos foram submetidos à paratiroidectomia, sendo que um evoluiu com metástases pulmonares. Hipocalcemia importante foi observada após a paratiroidectomia em um paciente e somente após remoção cirúrgica das metástases pulmonares em outro. Ambos necessitaram de reposição endovenosa de cálcio, revelando, assim, o estado de fome óssea (FO). A presença da FO usualmente reflete rápida mineralização óssea após correção do hiperparatiroidismo; assim, quanto mais severa a doença óssea previa à cirurgia, maior será a FO observada no pós-operatório desses pacientes. Embora inicialmente considerada um evento indesejável, a FO representa a bem-sucedida remoção cirúrgica do tecido paratiroideano hipersecretor. Fome óssea deve ser esperada no pós-operatório do tratamento cirúrgico bem-sucedido do carcinoma de paratiroide.

Parathyroid hormone: an early predictor of symptomatic hypocalcemia after total thyroidectomy / Hormônio da paratireoide: um preditor precoce da hipocalcemia sintomática após a tireoidectomia total

OBJECTIVE: The purpose of this study was to evaluate if the measurement of peri-operative parathyroid hormone (PTH) is able to identify patients with increased risk of developing symptoms of hypocalcemia. SUBJECTS AND METHODS: Forty patients who underwent total thyroidectomy were studied prospectively. Ionized serum calcium and PTH were measured after induction of anesthesia, one hour (PTH1) and one day after surgery (PTH24). Patients were evaluated for symptoms of hypocalcemia and treated with calcium and vitamin D supplementation as necessary. RESULTS: Symptomatic hypocalcemia developed in 16 patients. Symptomatic patients had significant lower PTH1 and greater drops in PTH levels. The selection of 12.1 ng/L as PTH1 level cutoff level divided patients with and without symptoms with 93.7% sensitivity and 91.6% specificity. The selection of 73.5% as the cutoff value for PTH decrease resulted in 91.6% sensitivity and 87.5% specificity. CONCLUSION: PTH1 levels and the drop in PTH levels are reliable predictors of developing symptomatic hypocalcemia after total thyroidectomy.

OBJETIVO: O objetivo deste estudo é avaliar se a medida perioperatória do hormônio da paratireoide (PTH) pode identificar os pacientes com maior risco de desenvolver sintomas de hipocalcemia. SUJEITOS E MÉTODOS: Foram estudados quarenta pacientes submetidos à tireodiectomia total. A medida do cálcio sérico e do PTH foi feita após a indução anestésica, uma hora (PTH1) e um dia após a cirurgia. Os pacientes foram avaliados quanto à presença de sintomas de hipocalcemia e tratados com suplementação de cálcio e vitamina D quando necessário. RESULTADOS: Dezesseis pacientes apresentaram sintomas de hipocalcemia. Os pacientes sintomáticos apresentaram PTH1 significantemente menor e queda no PTH significativamente maior. Usando o valor de 12,1 ng/L como corte, conseguimos distinguir pacientes com e sem sintomas de hipocalcemia com sensibilidade de 93,7% e especificidade de 91,6%. Utilizando como corte a queda de 73,5% no valor do PTH, temos sensibilidade de 91,6% e especificidade de 87,5%. CONCLUSÃO: O PTH1 e a queda no PTH são bons preditores de hipocalcemia no pós-operatório de tireoidectomia total.

Reabordagem cirúrgica do nível VI para carcinoma de tiroide: experiência de um hospital universitário / Reoperation of the level VI for thyroid carcinomas: our experience

Introdução: A neoplasia de tiroide é a segunda neoplasiaendócrina maligna mais comum, sendo o carcinoma papilíferode tiroide o mais comum. Esses tumores costumam cursar commetástases linfonodais em 30 a 80% dos casos, havendo recidivascervicais em 5 a 15% dos pacientes. Nos casos de recidivas, areabordagem costuma ser necessária, aumentando a morbidadedesses pacientes. Objetivo: mostrar a experiência de nossoserviço nos casos de reabordagem do nível VI e descrever suascomplicações. Método: Estudo retrospectivo a partir da análisede prontuários dos pacientes submetidos à reabordagem do nívelVI entre abril de 2007 e abril de 2009. Todos os pacientes forampreviamente tratados com tiroidectomia total, sem abordagemdo nível VI. Pacientes: Foram 10 operações em 10 pacientes,com predominância do sexo feminino, 9:1, com idade média de48,3 anos. O seguimento médio dos pacientes foi de 8,1 meses.Resultados: O tempo médio de recidiva foi de 6,9 anos. A taxade complicações foi de 20%, com 2 casos com hipoparatiroidismodefinitivo, 1 caso com paralisia do nervo laríngeo, e nesse mesmopaciente, necessidade de sacrifício do laríngeo por invasãotumoral. Conclusão: A reabordagem do nível VI é uma cirurgiaque implica uma maior morbidade pelo risco aumentado dehipoparatiroidismo e lesão de nervo laríngeo inferior. No entanto,ela é passível de ser realizada nos casos indicados, sempre porum cirurgião experiente, para minimizar esses riscos.

Introduction: The thyroid neoplasms corresponds to the secondmost common endocrine tumors, while the papillary carcinoma isthe most common type. This tumors tend to have cervical metastasisin 30 to 80 % of the cases, with local reccurrence or persistencein about 5 to 15 % of the patients. In this cases, a new surgeryis necessary, wich implicates in higher complications. Objective:Describe the experience of our hospital in reoperation of the levelVI as well as it?s complications. Method: Retrospective studywith review of the pronctuaries of patients who were submitted toreoperation of the level VI between april of 2007 and april of 2009.All patients had been previous treated with total thiroidectomywithout dissection of the level VI. Patients: It was performed 10surgeries in 10 patients, being 9 females and 1 male. Average agewas 48,3 years, with average follow up of 8,1 months. Results: Themean time of reccurrence was 6,9 years. Our complications rateswere 20% of definitive hypoparathyroidism (2 cases) and 20% oflaryngeal nerve paralysis ( 2 cases). Conclusion: Reoperation ofthe level VI is a surgery with a higher risk of complications, suchas definitive hypoparathyroidism and/or laryngeal nerve paralysis.However, it?s still the current treatment for tumor reccurrence,and need to be performed by a experienced surgeon in order tominimize the risk.