Diferenciais regionais da mortalidade no Brasil: contribuição dos grupos etários e de causas de óbito sobre a variação da esperança de vida e da dispersão da idade à morte entre 2008 e 2018 / Regional inequalities in mortality in Brazil: contributions of age and cause of death to changes in life expectancy and lifespan variation between 2008 and 2018 / Diferenciales regionales de mortalidad en Brasil: contribución de los grupos de edad y las causas de muerte en la variación de la esperanza de vida y la dispersión de la edad al morir entre 2008 y 2018

Resumo O Brasil é um país marcado por forte desigualdade socioeconômica entre as regiões, que, por sua vez, se traduz em diferenciais regionais de mortalidade. Para um bom monitoramento desses diferenciais, é importante uma análise não apenas dos níveis médios de mortalidade, mas também da variação da idade à morte na população. Esse artigo analisa a contribuição das causas de óbito sobre as mudanças na esperança de vida e na dispersão da idade à morte no Brasil e grandes regiões entre 2008 e 2018. Os resultados sugerem aumento dos diferenciais regionais na esperança de vida ao longo da década analisada. No entanto, as diferenças regionais na dispersão da idade à morte se mantiveram praticamente constantes. As mudanças na mortalidade por causa impactam de maneiras diferentes a dispersão da idade à morte em cada região: a redução da mortalidade por causas externas contribui substantivamente para diminuir a variação da idade à morte nas regiões Sul e Sudeste, enquanto a contribuição das mortes por afecções originadas no período perinatal foi substantiva apenas na região Nordeste. Por fim, reafirmamos a importância dos indicadores de dispersão da idade à morte para se ter uma visão mais ampla dos diferenciais regionais de mortalidade no Brasil.

Abstract Brazil is a country marked by substantial socioeconomic inequality among regions, which translates into regional differentials in mortality. For better monitoring these differentials, it is important to analyze not only population average mortality levels, but also the age at death variation. This article analyzes cause-of-death contributions to changes in life expectancy and age-at-death variation in Brazil and its regions between 2008 and 2018. Our results suggest an increase in regional inequalities in life expectancy over the decade. However, regional differences in age-at-death variation remained nearly constant. Changes in mortality by cause impact the age-at-death variation differently in each region: the reduction in mortality from external causes substantially contributed to decreasing the variation in age at death in the South and Southeast regions, whereas the contribution of deaths from conditions originating in the perinatal period was substantive only in the Northeast region. Finally, we reaffirm the importance of age-at-death dispersion indicators to have a broader view of Brazil's regional differentials in mortality.

Resumen Brasil es un país marcado por fuertes desigualdades socioeconómicas entre sus regiones, lo que traduce a su vez se en diferencias regionales en la mortalidad. Para un buen seguimiento de estos diferenciales es importante analizar no solo los niveles medios de mortalidad, sino también la variación de la edad de la muerte en la población. Este artículo analiza la contribución de los grupos de causas de defunción sobre los cambios en la esperanza de vida al nacer y la dispersión de la edad al morir en Brasil y las grandes regiones entre 2008 y 2018. Nuestros resultados sugieren un aumento de las diferencias regionales en la esperanza de vida a lo largo de la década. Sin embargo, las diferencias regionales en la dispersión de la edad al morir se mantuvieron prácticamente constantes. Los cambios en la mortalidad por causas repercuten de forma diferente en la dispersión de la edad al fallecer en cada región: la reducción de la mortalidad por causas externas contribuyó de forma sustantiva a disminuir la variación de la edad al morir en las regiones Sur y Sureste, mientras que la contribución de las muertes por afecciones originadas en el período perinatal fue sustantiva en la región Noreste. Por último, reafirmamos la importancia de los indicadores de dispersión de la edad al morir para tener una visión más general de los diferenciales regionales de mortalidad en Brasil.

Ultrasonographic aspects of the gallbladder mucocele in 30 dogs: retrospective study / Aspectos ultrassonográficos da mucocele biliar em 30 cães: estudo retrospectivo

Gallbladder mucocele is characterized by hyperplasia of the gallbladder epithelium, increased mucus production, accumulation, and densification of the bile content, which can lead to biliary obstruction, necrosis, and rupture of the gallbladder wall. Its finding may be accidental or related to symptoms. A retrospective study (2016-2019) was carried out based on abdominal ultrasound examinations in dogs, correlating aspects of the gallbladder and biliary system in the mucocele with existing comorbidities. Thirty dogs diagnosed with biliary mucocele were evaluated, of which 46.66% had the disease at an early stage, and 53.33% showed a more advanced stage. Of these, 66.66% were related to endocrinopathies and hyperadrenocorticism. Signs of extrahepatic bile duct obstruction and biliary peritonitis were observed in two animals. Due to their potential risk of complications, follow-up ultrasound assessments are indicated in cases that opt for clinical treatment, not excluding the need for surgical intervention.(AU)

A mucocele biliar caracteriza-se pela hiperplasia do epitélio da vesícula biliar, aumento da produção de muco, acúmulo e densificação do conteúdo biliar, podendo levar à obstrução, necrose e ruptura da parede da vesícula biliar. Seu achado pode ser acidental ou estar relacionado à sintomatologia. Foi realizado um estudo retrospectivo (2016-2019) a partir de exames ultrassonográficos abdominais em cães, correlacionando os aspectos da vesícula biliar na mucocele, com comorbidades existentes. Foram avaliados 30 cães com diagnóstico de mucocele biliar, dos quais 46,66% apresentaram a doença em estágio inicial e 53,33% demonstraram estágio mais avançado. Destes, 66,66% tinham endocrinopatias, principalmente hiperadrenocorticismo. Sinais de obstrução de vias biliares extra-hepáticas e peritonite biliar foram observados em dois animais. Por seu potencial risco de complicação, avaliações ultrassonográficas de seguimento são indicadas nos casos de tratamento clínico, não se descartando a necessidade de intervenção cirúrgica.(AU)

Desde la pérdida de la fuerza hasta el compromiso sistémico: serie de casos del síndrome POEMS / From limb weakness to a systemic involvement: Poems syndrome case two report and review of the literature

El síndrome POEMS es un trastorno paraneoplásico raro y poco frecuente, que se presenta principalmente en la sexta década de la vida, caracterizado por el compromiso multisistémico con predominio de neuropatía desmielinizante. Abarca diversas y heterogéneas manifestaciones clínicas y su diagnóstico requiere un alto índice de sospecha. Se presentan dos casos de pacientes que consultaron por cuadros poco frecuentes en los que la pérdida de la fuerza orientó al acercamiento de una afectación multisistémica que concluyó con el diagnóstico de esta enfermedad(AU)

POEMS syndrome is a rare and infrequent paraneoplastic syndrome, which occurs mainly in the sixth decade of life, characterized by multisystem involvement with a predominance of demyelinating neuropathy, which encompasses diverse and heterogeneous clinical manifestations and whose diagnosis requires a high index of suspicion. We present two cases of patients who consulted due to unusual symptoms and whose loss of strength led to an approach due to multisystem involvement that concluded with the diagnosis of this disease(AU)

Características clínicas y resultados quirúrgicos de pacientes pediátricos intervenidos por cirugía robótica / Clinical characteristics and surgical outcomes of pediatric patients who underwent robotic surgery

INTRODUCCIÓN. La cirugía robótica se realiza gracias al sistema telemanipulado, alcanzando tareas repetitivas, precisas y mínimamente invasivas. En Ecuador inició en el año 2016, incluyendo este procedimiento a pediatría en el 2021. OBJETIVO. Describir las características clínicas y resultados quirúrgicos de pacientes pediátricos intervenidos por cirugía robótica. MATERIALES Y MÉTODOS. Estudio transversal analítico. Población de 278 y muestra de 40 datos de historias clínicas electrónicas de pacientes pediátricos intervenidos por cirugía robótica de agosto del 2021 a marzo del 2022 en el Hospital Carlos Andrade Marín. Criterios de inclusión: pacientes pediátricos intervenidos por cirugía robótica en el Hospital de Especialidades Carlos Andrade Marín. Criterios de exclusión: pacientes adultos, haber sido intervenidos quirúrgicamente por técnicas abiertas o laparoscópica. La información se obtuvo del sistema AS400; se creó una base de datos anonimizando a los pacientes. Se aplicó un análisis univariado y para determinar significancia estadística se utilizó la prueba de Chi-2. La información recolectada fue analizada en el programa estadístico International Business Machines Statistical Package for the Social Sciences. RESULTADOS: De los pacientes del estudio: 45,00% (18; 40) era adolescente. El 52,50% (21; 40) no presentó comorbilidades. 50,00% (20; 40) de las intervenciones fueron colecistectomía. 55% (22; 40) fué por diagnóstico prequirúrgico y posquirúrgico gastrointestinal y hepático. El 95,00% (38; 40) no presentó complicaciones. El 100% (40; 40) presentó sangrado G1. El 97,50% (39; 40) no presentó eventos, y el 72,5% (29; 40) no presentó dolor. El promedio de peso de los pacientes fue 41 kilogramos, con una media de 3 días de estancia hospitalaria, un promedio de 65 minutos de cirugía total y 15 minutos de docking, los cuales son estadísticamente significativos con una p= 0,001. CONCLUSIONES. Se registró las características clínicas y resultados quirúrgicos de pacientes pediátricos intervenidos por cirugía robótica. La cirugía robótica se aplicó con seguridad en pacientes pediátricos del Hospital Carlos Andrade Marín.

INTRODUCTION. Robotic surgery is performed thanks to the telemanipulated system, achieving repetitive, precise and minimally invasive tasks. In Ecuador it started in the Hospital de Especialidades Carlos Andrade Marín in 2016, including this procedure to pediatrics in 2021. OBJECTIVE. To describe the clinical characteristics and surgical outcomes of pediatric patients operated by robotic surgery. MATERIALS and METHODS. Analytical cross-sectional study. Population of 278 and sample of 40 data from electronic medical records of pediatric patients operated by robotic surgery from August 2021 to March 2022 at the Carlos Andrade Marin Hospital. Inclusion criteria: pediatric patients who underwent robotic surgery at the Hospital de Especialidades Carlos Andrade Marín. Exclusion criteria: adult patients, having undergone open or laparoscopic surgery. The information was obtained from the AS400 system; a database was created by anonymizing the patients. Univariate analysis was applied and the Chi-2 test was used to determine statistical significance. The information collected was analyzed in the statistical program International Business Machines Statistical Package for the Social Sciences. RESULTS: Of the patients in the study: 45,00% (18; 40) were adolescents. 52,50% (21; 40) had no comorbidities. 50,00% (20; 40) of the interventions were cholecystectomy. 55% (22; 40) were for preoperative and postoperative gastrointestinal and hepatic diagnosis. 95,00% (38; 40) had no complications. 100% (40; 40) presented G1 bleeding. 97.50% (39; 40) did not present events, and 72,5% (29; 40) did not present pain. The average weight of the patients was 41 kilograms, with a mean hospital stay of 3 days, an average of 65 minutes of total surgery and 15 minutes of docking, which are statistically significant with a p= 0,001. CONCLUSIONS. The clinical characteristics and surgical results of pediatric patients who underwent robotic surgery were recorded. Robotic surgery was safely applied in pediatric patients at the Carlos Andrade Marin Hospital.

Síndrome POEMS: desafios no diagnóstico de um caso atípico / POEMS syndrome: challenges in the diagnosis of an atypical case

Introdução: Síndrome POEMS trata de um raro evento paraneoplásico, sem relato atual na literatura sobre sua real prevalência. A maior parte dos casos ocorre em homens de meia idade; Relato do Caso: Relatamos o caso de um paciente masculino, 65 anos, admitido com queixa edema e parestesia em pernas que evoluiu para plegia, associada a hiporexia e fadiga. Investigação ambulatorial inicial evidenciou polirradiculoneuropatia inflamatória desmielinizante crônica (PIDC) de etiologia indefinida. Excluídos secundarismos para polirradiculoneuropatia inflamatória desmielinizante crônica, o paciente foi a seguir diagnosticado com hipotireoidismo primário, hipogonadismo severo, lesões hipercrômicas em pele, ascite, derrame pleural e trombocitose, além de gamopatia monoclonal IgA Lambda por imunofixação sérica. Sorologias para HIV, Sífilis e Hepatites todas negativas. Excluída a possibilidade de Mieloma Múltiplo e outras gamopatias, foi aventada a hipótese de Síndrome POEMS, sendo realizada dosagem de Fator de Crescimento Endotelial Vascular (VEGF) plasmática (425 pg/mL; VR = <96.2). O paciente passou então a preencher os critérios obrigatórios para diagnóstico, além de um maior (VEGF elevada) e vários outros menores. Trata-se de um caso atípico na medida em que, lesões ósseas, presentes em até 97% dos casos, não foram evidenciadas no paciente em questão, tornando desafiador o diagnóstico e sendo então necessário recorrer à dosagem de VEGF. O diagnóstico de síndromes raras, embora desafiante, traz ao clínico um olhar mais amplo do paciente na medida em que incrementa o raciocínio clínico. Difundir e explorar esse universo é cada vez mais necessário

Introduction: POEMS syndrome is a rare paraneoplastic event, with no current report in the literature about its real prevalence. Most cases occur in middle-aged men; Case Report: We report the case of a male patient, 65 years old, admitted with complaints of edema and paresthesia in the legs that progressed to plegia, associated with hyporexia and fatigue. Initial outpatient investigation revealed Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) of undefined etiology. Excluding secondaries for chronic inflammatory demyelinating polyradiculoneuropathy, the patient was subsequently diagnosed with primary hypothyroidism, severe hypogonadism, hyperchromic skin lesions, ascites, pleural effusion and thrombocytosis, in addition to monoclonal IgA Lambda gammopathy by serum immunofixation. All serologies for HIV, Hepatitis and syphilis were negative. Excluding the possibility of Multiple Myeloma and other gammopathies, the hypothesis of POEMS Syndrome was raised, and plasma Vascular Endotelial Growth Factor (VEGF) measurement was performed (425 pg/mL; RV = <96.2). The patient then started to fulfill the mandatory criteria for diagnosis, in addition to a major (elevated VEGF) and several other minors. This is an atypical case in that bone lesions, present in up to 97% of the cases, were not evidenced in the patient in question, making the diagnosis challenging and therefore requiring the use of VEGF dosage. The diagnosis of rare syndromes, although challenging, brings the clinician a broader view of the patient as it increases clinical reasoning. Spreading and exploring this universe is increasingly necessary

Fisiopatología de la enfermedad COVID-19 / Pathophysiology of COVID-19 / Fisiopatologia da doença COVID-19

La enfermedad por coronavirus es una infección respiratoria causada por el virus SARS-CoV 2, el cual genera una cascada de eventos sistémicos, afectando diferentes órganos y tejidos. El entendimiento de la fisiopatología del COVID-19 es indispensable no solo al momento de brindar tratamiento a los pacientes, sino que también para comprender las causas de las complicaciones que presentan un número importante de pacientes recuperados. El objetivo de este trabajo es presentar una revisión actualizada de los efectos de la infección en diferentes órganos y sistemas principales que sea de utilidad como material de referencia para profesionales y estudiantes de la salud. Para ello se realizó una búsqueda bibliográfica en los portales PubMED, Scielo, Google Scholar, Cochrane y Springer Link, así como en las bases de repositorios científicos pre-publicación bioRxiv ("bioarchives") y medRxiv ("med-archives") y sobre un total de cerca de 200 mil artículos, se seleccionaron 100 artículos para esta revisión en base a su relevancia o sugerencias de parte de profesionales especializados.

Coronavirus disease is a respiratory infection caused by the SARS-CoV-2 virus, which causes a cascade of systemic events, affecting various organs and tissues. Understanding the pathophysiology of COVID-19 is essential to treat patients and understand the causes of the complications in a significant number of recovered patients. This article presents a review of the effects of infection on various organs and systems that will be useful as reference material for healthcare professionals and medical students. To this end, a literature search was conducted in PubMED, Scielo, Google Scholar, Cochrane, and Springer Link portals, as well as in the pre-publication scientific repositories bioRxiv ("bioarchives") and medRxiv ("med-archives") databases. From about 200,000 papers, 100 articles were selected for this review based on their relevance or suggestions from experts in the field.

A doença coronavírus é uma infecção respiratória causada pelo vírus SARS-CoV-2, que gera uma cascata de eventos sistêmicos, afetando diferentes órgãos e tecidos. Compreender a fisiopatologia da COVID-19 é essencial não apenas no tratamento de pacientes, mas também para compreender as causas das complicações que um número significativo de pacientes recuperados apresenta. O objetivo deste trabalho é apresentar uma revisão atualizada dos efeitos da infecção em diferentes órgãos e principais sistemas que seja útil como material de referência para profissionais de saúde e estudantes. Para isso, foi realizada uma pesquisa bibliográfica nos portais PubMED, Scielo, Google Scholar, Cochrane e Springer Link, bem como nos repositórios científicos de pré-publicação bioRxiv ("bioarquivos") e medRxiv ("arquivos med"). Num total de cerca de 200 mil artigos, 100 artigos foram selecionados para esta revisão por sua relevância ou sugestões de profissionais especializados.

Función tiroidea y embarazo / Thyroid function and pregnancy

La enfermedad tiroidea, junto con la diabetes mellitus, son las dos endocrinopatías más frecuentes en el embarazo. El hipotiroidismo primario en mujeres en edad gestacional tiene una prevalencia del 2%, convirtiendo en un reto su diagnóstico, tratamiento y seguimiento en la práctica clínica

Thyroid disease, along with diabetes mellitus, are the two most common endocrinopathies in pregnancy. Primary hypothyroidism in women of gestational age has a prevalence of 2%, making its diagnosis, treatment and follow-up a challenge in clinical practice

Liver involvement in endocrine diseases / 中华肝脏病杂志

As a secondary endocrine organ, the liver is closely related to the endocrine system. Liver involvement is not uncommon in endocrine diseases, such as hyper/hypothyroidism, diabetes, dysfunction of adrenal and gonadal. It can be manifested in a variety of forms, including hepatocyte injury (elevated transaminase), bile duct injury (cholestasis), hepatocyte steatosis, vascular injury and liver tumor. Direct and indirect liver injury caused by abnormal hormone levels and side effects of drugs for the treatment of endocrine diseases are common pathogenesis. In addition, endocrine diseases can be concomitant with liver diseases, such as autoimmune thyroiditis and autoimmune hepatitis. Systemic diseases can also involve the endocrine system and liver at the same time, such as systemic lupus erythematosus and IgG4 related diseases. For patients with unexplained liver injury, endocrine system diseases should be considered as the differential diagnosis.

Endocrine dysfunction induced by immune checkpoint inhibitors / Disfunción endocrina inducida por inhibidores de los puntos de control inmune

Abstract Since their approval in 2011, immune checkpoint inhibitors (ICPis) are increasingly used to treat several advanced cancers. ICPis target certain cellular molecules that regulate immune response resulting in antitumor activity. The use of these new agents needs careful monitoring since they brought a whole new spectrum of adverse events. In this review, we aim to describe different endocrine dysfunctions induced by ICPis and to underline the importance of diagnosing and managing these adverse effects. Immune-related endocrine toxicities include thyroid dysfunction, hypophysitis and, less frequently, type 1 diabetes, primary ad renal insufficiency and hypoparathyroidism. Diagnosis of endocrine adverse events related to ICPis therapy can be challenging due to nonspecific manifestations in an oncological scenario and difficulties in the biochemical evaluation. Despite the fact that these endocrine adverse events could lead to life-threatening consequences, the availability of effective replacement treatment enables continuing therapy and together with an interdisciplinary approach will impact positively on survival.

Resumen Desde su aprobación en 2011, el uso de los inhibidores de los puntos de control inmunes (ICPis) se ha ex tendido para el tratamiento de diversas neoplasias en estadios avanzados. Los ICPis tienen como blanco ciertas moléculas de las células que regulan la respuesta inmune favoreciendo una actividad antitumoral. El uso de estos nuevos agentes requiere un monitoreo específico, ya que se han vinculado con un amplio y nuevo espectro de efectos adversos. El objetivo de esta revisión es describir las diferentes disfunciones endocrinas inducidas por los ICPis y destacar la importancia del diagnóstico y manejo oportuno de estos efectos adversos. Los efectos adversos inmunes endocrinos incluyen disfunción tiroidea, hipofisitis y con menor frecuencia, diabetes tipo 1, insuficiencia suprarrenal primaria e hipoparatiroidismo. El diagnóstico de eventos adversos endocrinos relacionados con la terapia ICPis es un desafío debido a su presentación clínica inespecífica en un escenario oncológico y a las dificultades en la evaluación bioquímica. Estos eventos adversos endocrinos podrían tener consecuencias potencialmente letales, pero la disponibilidad de un tratamiento de reemplazo eficaz permite continuar la terapia y, junto con un enfoque interdisciplinario, generar un impacto positivo en la supervivencia.

Efectos de los opioides en endocrinología / Opioids effects in endocrinology

El uso de opioides ha aumentado en forma significativa en las últimas décadas, lo que nos ha permitido conocer sus diversos efectos en el sistema endocrino. Estos efectos están sub diagnosticados, en parte porque los síntomas se confunden con los de la misma enfermedad que lleva al uso de opioides y porque no los buscamos de forma dirigida. El hipogonadismo y la insuficiencia suprarrenal son sus efectos más establecidos, sin embargo, otros efectos como los provocados en el tejido óseo requieren de especial atención. La evaluación de los ejes gonadotropo, adrenal y de la salud ósea debe tenerse en consideración en los usuarios crónicos de opioides, particularmente frente a la presencia de síntomas. La suspensión o reducción del uso de opioides es el primer tratamiento del compromiso endocrinológico.

The use of opioids has increased significantly in recent decades, which has allowed us to understand its effects on the endocrine system. These effects are underdiagnosed, the symptoms are confused with those of the same disease that leads to the use of opioids and we do not look for them in a targeted way. Hypogonadism and adrenal insufficiency are its most established effects, however, other effects such as the ones caused on bone tissue require special attention. Evaluation of gonadotropic and adrenal axes as well as bone health should be taken into consideration in chronic opioid users, particularly in the presence of symptoms. Stopping or reducing opioid use is the first treatment for endocrine compromise.

Air pollution and children's health-a review of adverse effects associated with prenatal exposure from fine to ultrafine particulate matter

BACKGROUND@#Particulate matter (PM), a major component of ambient air pollution, accounts for a substantial burden of diseases and fatality worldwide. Maternal exposure to PM during pregnancy is particularly harmful to children's health since this is a phase of rapid human growth and development.@*METHOD@#In this review, we synthesize the scientific evidence on adverse health outcomes in children following prenatal exposure to the smallest toxic components, fine (PM@*RESULTS@#Maternal exposure to fine and ultrafine PM directly and indirectly yields numerous adverse birth outcomes and impacts on children's respiratory systems, immune status, brain development, and cardiometabolic health. The biological mechanisms underlying adverse effects include direct placental translocation of ultrafine particles, placental and systemic maternal oxidative stress and inflammation elicited by both fine and ultrafine PM, epigenetic changes, and potential endocrine effects that influence long-term health.@*CONCLUSION@#Policies to reduce maternal exposure and health consequences in children should be a high priority. PM

Endocrinopatías por inmunoterapia oncológica / Endocrinopathies by oncological immunotherapy

La relación entre inmunidad y cáncer es compleja. Las células tumorales desarrollan mecanismos de evasión a las respuestas del sistema inmunitario. Esta capacidad permite su supervivencia y crecimiento. La inmunoterapia ha transformado el tratamiento oncológico mejorando la respuesta inmunitaria contra la célula tumoral. Esta se basa en el bloqueo de los puntos de control inmunitario mediante anticuerpos monoclonales contra la molécula inhibidora CTLA-4 (antígeno 4 del linfocito T citotóxico [CTLA-4]) y la proteína 1 de muerte celular programada y su ligando (PD-1/PD-L1). Aunque los inhibidores de los puntos de control inmunitario (ICIs) son fármacos bien tolerados, tienen un perfil de efectos adversos conocido como eventos adversos inmunorrelacionados (EAI). Estos afectan varios sistemas, incluyendo las glándulas endocrinas. Los eventos adversos endocrinos más frecuentes son la disfunción tiroidea, la insuficiencia hipofisaria, la diabetes mellitus autoinmune y la insuficiencia suprarrenal primaria. El creciente conocimiento de estos efectos adversos endocrinos ha llevado a estrategias de tratamiento efectivo con el reemplazo hormonal correspondiente. El objetivo de esta revisión es reconocer la incidencia de estas nuevas endocrinopatías, la fisiopatología, su valoración clínica y el manejo terapéutico. (AU)

The relationship between immunity and cancer is complex. Tumor cells develop evasion mechanisms to the immune system responses. This ability allows their survival and progression. Immunotherapy has transformed cancer treatment by improving the immune response against tumor cells. This is achieved by blocking immune checkpoints with monoclonal antibodies against cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death protein 1 and its ligand (PD-1 / PD-L1). Although the immune checkpoint inhibitors (ICIs) are well tolerated drugs, they have a profile of adverse effects known as immune-related adverse events (irAES). These involve diverse systems, including the endocrine glands. The most frequent endocrine immune-related adverse events are thyroid and pituitary dysfunction, autoimmune diabetes mellitus and primary adrenal insufficiency. The increasing knowledge of these irAES has led to effective treatment strategies with the corresponding hormonal replacement. The objective of this review is to recognize the incidence of these new endocrinopathies, the physiopathology, their clinical evaluation, and therapeutic management. (AU)

Laminite endocrinopática em equinos com síndrome metabólica: características clínicas, tratamento e evolução em três pacientes ˗ relato de caso / [Endocrinopathic laminitis in horses with metabolic syndrome: clinical characteristics, treatment and evolution in three patients ˗ case report]

Laminite endocrinopática designa os casos de laminite cuja etiologia está associada a uma endocrinopatia. Cavalos com síndrome metabólica equina (SME) apresentam adiposidade regional e obesidade. Existe uma correlação positiva entre obesidade e resistência à insulina. Este relato descreve três casos de laminite endocrinopática em cavalos com SME. Os pacientes apresentaram escore de condição corporal (ECC) variando de 8 a 9 (escala de 1 a 9), sensibilidade ao teste de pinçamento do casco e claudicação de grau 3 ou 4 (escala de 1 a 4). Não havia histórico de cólica recente, trauma ou excesso de exercício. O tratamento incluiu medicação anti-inflamatória não esteroidal, repouso na baia, restrição energética para perda de peso, revestimento e bandagem dos membros, conforme a necessidade de cada paciente. A restrição alimentar ajudou no tratamento da SME e reduziu o ECC. Tratamento medicamentoso, casqueamento e bandagem diminuíram o grau de claudicação. Conclui-se que o tratamento anti-inflamatório não esteroidal, a restrição energética, o repouso em baia, o casqueamento e a bandagem do casco são eficazes no tratamento da laminite endocrinopática em cavalos com síndrome metabólica equina.(AU)

Endocrinopathic laminitis refers to cases of laminitis whose etiology is associated with an endocrinopathy. Horses with Equine Metabolic Syndrome (EMS) have regional adiposity and obesity. There is a positive correlation between obesity and insulin resistance. This report describes three cases of endocrinopathic laminitis in horses with EMS. Patients had body condition score (BCS) ranging from 8 to 9 (scale from 1 to 9), sensitivity to the hoof clamping test and claudication grade 3 or 4 (scale from 1 to 4). There was no history of recent colic, trauma or over exercise. Treatment included non-steroidal anti-inflammatory medication, stall rest, energy restriction for weight loss, hoofing and hoof bandage as needed by each patient. Dietary restriction helped in the treatment of EMS and reduced BCS. Drug treatment, hoofing and hoof bandage decreased the degree of lameness. It is concluded that non-steroidal anti-inflammatory treatment, energy restriction, stall rest, hoofing and hoof bandage are effective in the treatment of endocrinopathic laminitis in horses with equine metabolic syndrome.(AU)

Problemas gastrointestinales, nutricionales, endocrinológicos y de microbiota en el trastorno del espectro autista / Gastrointestinal, nutritional, endocrine, and microbiota conditions in autism spectrum disorder

Los problemas médicos gastrointestinales, nutricionales, metabólicos, endocrinológicos y de microbiota en los pacientes pediátricos con diagnóstico de trastorno del espectro autista (TEA) son parte de los problemas médicos concomitantes al diagnóstico. La prevalencia alcanza a más del 91 % en el caso de los problemas gastrointestinales, hasta el 89 % para los nutricionales y metabólicos, más del 50 % de disfunción tiroidea y hasta el 100 % para los relacionados con la microbiota.Es urgente actualizar la práctica médica para incluir la evaluación, testeo, diagnóstico y tratamiento de estos problemas médicos concomitantes al diagnóstico de TEA en la población pediátrica, adolescente y adulta. El tratamiento riguroso de dichos problemas genera cambios positivos en la calidad de vida y en la sintomatología bajo la cual el TEA se diagnostica en muchos casos. Debe basarse en evidencia científica de alta calidad, con control y cuidado médico adecuado

Gastrointestinal, nutritional, metabolic, endocrine, and microbiota medical problems in pediatric patients diagnosed with autism spectrum disorder (ASD) are some of the coexisting medical conditions in ASD diagnosis. Their prevalence reaches more than 91 % for gastrointestinal problems, up to 89 % for nutritional and metabolic disorders, more than 50 % for thyroid dysfunction, and up to 100 % for microbiota-related conditions.There is an urgency for medical practice to be updated and to include the assessment, testing, diagnosis, and treatment of these coexisting medical conditions in ASD diagnosis in the pediatric, adolescent, and adult population. A strict management of such conditions results in positive changes in the quality of life and symptoms based on which ASD is diagnosed many times. It should be based on high-quality scientific evidence with an adequate medical care and control

Infecção de trato urinário inferior por Citrobacter sp em cadela com hipoadrenocorticismo / Citrobacter sp lower urinary tract infection in a bitch with hypoadrenocorticism

Citrobacter sp. é um microrganismo frequentemente encontrado em vagina de cadelas, mas corresponde a menos de 3% do total de microrganismos isolados em urocultura. O hipoadrenocorticismo (HA) é uma doença endócrina incomum e que leva a poliúria e hipostenúria. O objetivo deste trabalho é relatar o caso de uma fêmea da espécie canina, da raça Teckel, 11 anos, atendida com queixa de urina de odor alterado há vários dias, além de vômito, diarreia e inapetência há três dias, e poliúria e polidipsia há 2 meses, com histórico de tratamento anterior com mitotano para hiperadrenocorticismo. O diagnóstico foi de ITU por Citrobactersp., além de HA iatrogênico. Como destaques nos exames, relação sódio:potássio de 22,6 foi observada, sugestiva de HA, que foi confirmado por teste de estimulação com ACTH, além de urina inicialmente hipostenúrica (densidade 1,006), o que pode ser atribuído ao washout medular renal devido à hiponatremia causada pelo hipoadrenocorticismo. O tratamento foi feito com amoxicilina associada a ácido clavulânico por 20 dias, além da terapia específica para HA com prednisona e fludrocortisona, que foi continuado. A paciente recuperou-se bem, a densidade urinária aumentou após início do tratamento para HA e não houve recidiva da ITU em período de acompanhamento de 8 meses. Acredita-se que a baixa densidade urinária causada pelo HA tenha sido fator essencial para a ocorrência da ITU por Citrobacter.

Citrobacter sp. is a normal constituent of bitches' vagina, but it is related to less than 3% of total isolated microorganism in uroculture. Hypoadrenocorticism (HA) is an endocrine disease uncommonly diagnosed that leads to polyuria and hypostenuria. The aim of this work is report the case of a Teckel bitch, 11 years old, attended with complaint of altered urinary smell for several days, besides vomiting, diarrhea and inappetence for three days, and polyuria and polydispsia for two months, with previous mitotane treatment for hyperadrenocorticism. The diagnosis was Citrobacter UTI, besides iatrogenic HA. The most important exam results include sodium:potassium ratio of 22.6, suggestive of HA, that was confirmed by ACTH stimulation test. Besides, hypostenuria (urinary specific gravity ­ USG - of 1.006) was noted, attributed to renal medular washout due to hyponatremia seen in HA. Therapy comprised amoxicillin associated with clavulanic acid for 20 days, in addition to specific therapy for AH with prednisone and fludrocortisone. The patient recovery well, USG increased after the beginning of the treatment for HA and there was no UTI reinfection for a 8 month period. It is believed that low USG due to HA was essential for the occurrence of Citrobacter UTI.

Endocrinopatía múltiple autoinmune autoinmune / Autoimmune polyendocrinopathy

Los autoanticuerpos son proteínas producidas en el organismo por la inducción de un antígeno propio del individuo el cual no reconocen y rechazan. Su aparición en sangre puede iniciarse tiempo antes de la presentación de síntomas o signos. El deterioro funcional de dos o más glándulas es una afectación endocrinológica múltiple que puede asociarse con otras patologías autoinmunes no endocrinas, tales como vitiligo, alopecia areata, gastritis autoinmune y anemia perniciosa. Se clasifica en tres síndromes poliendocrinos autoinmunes (SPA). En Europa la incidencia del tipo I es menor a 1:100000 por año y los 2 y 3 varían entre 1­2:100000 por año. Colombia no cuenta con registros que permitan calcularla. Se reporta el caso de un hombre de 18 años diagnosticado con hipotiroidismo autoinmune, a los 15 años de edad debutó con cetoacidosis diabética y a los 17 con posterior aparición de vitiligo. El manejo inicial se realizó con levotiroxina sódica y análogos de insulina. Este caso corresponde a un SPA tipo IIIA, ya que cursa con hipotiroidismo autoinmune, diabetes mellitus y como último hallazgo cronológico la asociación con vitiligo. La detección de una endocrinopatía autoinmune en pacientes jóvenes debe alertar sobre la posible existencia de un SPA

Autoantibodies are blood proteins produced in response to and counteracting a specific antigen. Autoantibodies may be present before signs and symptoms occur. A polyendocrinopathy is characterized by the coexistence of at least two endocrine glands insufficiency and may be associated with another non-endocrine autoimmune illness including vitiligo, alopecia areata, autoimmune gastritis and pernicious anemia. It is classified into three types of autoimmune polyglandular syndromes (APS). In Europe the incidence of APS-1 is less than one new case per 100000 persons per year and the incidence of the other two APS types vary between1 to 2 new cases per 100000 persons per year. APS incidence in Colombia cannot be estimated due to lack of records on this subject. We report the case of an 18-year-old male with autoimmune hypothyroidism diagnosed at 15 years of age, with onset of diabetic ketoacidosis at 17 followed by vitiligo. Therapy with levothyroxine 100 mcg daily and insulin glargine 10 units daily did not yield successful correction of APS in the patient. This patient was affected by APS- IIIA, characterized by the association of autoimmune hypothyroidism, diabetes mellitus and vitiligo, as the last manifestation. Detecting an autoimmune polyendocrinopathy in young patients should raise the suspicion of APS.

Efectos endocrinológicos tardíos del tratamiento oncológico en supervivientes de meduloblastoma / Endocrinological late effects of oncologic treatment on survivors of medulloblastoma

INTRODUCCIÓN: La radioterapia, quimioterapia y la cirugía empleada en el tratamiento de los tumores cerebrales tienen efectos en el eje hipotálamo-hipofisario y pueden resultar en disfunción endocrina hasta en el 96% de los casos. PACIENTES Y MÉTODO: Estudio retrospectivo y descriptivo en pacientes diagnos ticados de meduloblastoma sometidos a tratamiento con quimio y radioterapia en los últimos 20 años en un hospital terciario. Se analizan variables edad, sexo, peso, talla, índice de masa corporal (IMC) al final del seguimiento, estadio de maduración sexual, niveles séricos de TSH y T4 libre, ACTH/cortisol e IGF-1, FSH, LH, estradiol, testosterona, perfil lipídico (colesterol total) y prueba de función dinámica de hormona de crecimiento. RESULTADOS: Muestra total de 23 pacientes. El déficit de hormona de crecimiento es la secuela más frecuente (82 %) seguido de disfunción ti roidea (44,8%) y disfunción puberal (24,1%). Solo se diagnosticó un caso de diabetes insípida y 2 casos de déficit de corticotrofina. CONCLUSIONES: El seguimiento a largo plazo de los supervivientes de meduloblastoma tratados con quimio y radioterapia revela una prevalencia muy alta de disfun ción endocrina, particularmente de deficiencia de hormona del crecimiento y de hipotiroidismo. Creemos oportuna la monitorización y el seguimiento a largo plazo de estos pacientes con el fin de garantizar un manejo terapéutico adecuado de aquellas disfunciones tratables.

INTRODUCTION: Radiation therapy, chemotherapy, and surgery used to treat brain tumors have effects on the hy pothalamic-pituitary-adrenal axis and can result in endocrine dysfunction in up to 96% of cases. PATIENTS Y METHOD: Retrospective and descriptive study in patients diagnosed with medulloblasto ma who underwent treatment with chemo and radiotherapy in the last 20 years in a tertiary hospital. The variables analyzed were age, sex, weight, height, body mass index (BMI) at the end of follow-up, sexual maturity stage, serum levels of TSH and free T4, ACTH/cortisol and IGF-1, FSH, LH, estradiol, testosterone, lipid profile (total cholesterol), and growth hormone dynamic function test. RESULTS: Total sample of 23 patients. Growth hormone deficiency is the most frequent sequelae (82%) fo llowed by thyroid dysfunction (44.8%), and disorders of puberty (24.1%). Only one case of diabetes insipidus and two cases of corticotropin deficiency were diagnosed. CONCLUSIONS: Long-term follow- up of medulloblastoma survivors treated with chemo and radiotherapy reveals a very high prevalence of endocrine dysfunction, especially growth hormone deficiency and hypothyroidism. We believe that monitoring and long-term follow-up of these patients is necessary in order to ensure adequate therapeutic management of those treatable dysfunctions.