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Fernandes Taboada G, Barbosa Moraes A, Vieira L. Evaluation of screening practices for primary hyperaldosteronism by specialists and general practitioners: an observational, cross-sectional study. Arch Endocrinol Metab 2024; 68:e230211. [PMID: 38530960 PMCID: PMC11081042 DOI: 10.20945/2359-4292-2023-0211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/17/2023] [Indexed: 03/28/2024]
Abstract
Objective Despite its recognized importance, primary hyperaldosteronism (PHA) remains an underdiagnosed condition in clinical practice. The objective of the present study was to evaluate PHA screening practices by general practitioners and specialists in endocrinology and cardiology. Subjects and methods This cross-sectional, observational study invited physicians to respond voluntarily to an online survey. The survey collected the respondents' sociodemographic data and answers to five hypothetical clinical cases meeting Endocrine Society criteria for PHA screening. Results In all, 126 physicians responded to the online survey. Endocrinologists were the specialists who most often chose PHA screening, although the screening rates were overall low, ranging from 36.5% to 92.9%, depending on the case and the respondents' specialty. The survey also assessed the reasons for not choosing PHA screening, which included limited availability of tests within the public health services, interference of antihypertensive medications on hormone levels, and failure to identify the screening indication. Being an endocrinologist was an independent predictor for choosing PHA screening for the patients in Cases #1 and #5 (p = 0.001 and p = 0.002, respectively). Conclusion Endocrinologists were the specialists who most often chose PHA screening, although the screening rates were overall low among all specialists. These findings highlight a need for continuing medical education programs addressing PHA screening and making the diagnosis of PHA more present in the daily clinical practice of physicians treating patients with hypertension.
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Affiliation(s)
- Giselle Fernandes Taboada
- Universidade Federal Fluminense, Departamento de Clínica Médica, Hospital Universitário Antônio Pedro, Niterói, RJ, Brasil,
- Disciplina de Clínica Médica, Universidade Estácio de Sá/ IDOMED, Rio de Janeiro, RJ, Brasil
| | - Aline Barbosa Moraes
- Universidade Federal Fluminense, Departamento de Clínica Médica, Hospital Universitário Antônio Pedro, Niterói, RJ, Brasil
| | - Leonardo Vieira
- Universidade Federal do Rio de Janeiro, Departamento de Clínica Médica, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, Brasil
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Fragoso Perozo AFD, Fontes R, Lopes FP, Araújo PB, Scrank Y, Gomes DMV, Moraes AB, Vieira Neto L. Morning serum cortisol role in the adrenal insufficiency diagnosis with modern cortisol assays. J Endocrinol Invest 2023; 46:2115-2124. [PMID: 36966469 DOI: 10.1007/s40618-023-02062-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/07/2023] [Indexed: 03/27/2023]
Abstract
PURPOSE To investigate the accuracy of cutoff values of the morning serum cortisol (MSC) using the cortisol stimulus test (CST) insulin tolerance test (ITT) and 250 mcg short Synacthen test (SST) as the reference standard tests, to better define its clinical role as a tool in the diagnostic investigation of adrenal insufficiency (AI) AI. METHODS An observational study was conducted with a retrospective analysis of MSC in adult patients who had been submitted to a CST to investigate AI between January 2014 and December 2020. The normal cortisol response (NR) to stimulation was defined based on the cortisol assay. RESULTS 371 patients underwent CST for suspected AI, 121/371 patients (32.6%) were diagnosed with AI. ROC curve analysis showed an area under the curve (AUC) for MSC of 0.75 (95% CI 0.69 - 0.80). The best MSC cutoff values to confirm AI were < 3.65, < 2.35 and < 1.5 mcg/dL with specificity of 98%, 99%, and 100%, respectively. MSC > 12.35, > 14.2 and > 14.5 mcg/dL had sensitivity of 98%, 99%, and 100%, respectively, being the best cutoff values to exclude AI. Almost 25% of patients undergoing CST for possible AI had MSC values between < 3.65 mcg/dL (6.7% of patients) and > 12.35 mcg/dL (17.5% of patients), making the formal CST testing unnecessary if we consider these cutoff values. CONCLUSION With the most modern cortisol assays, MSC could be used as a diagnostic tool, with high accuracy to confirm or exclude AI, avoiding unnecessary CST; thus, reducing expenses and safety risks during AI investigation.
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Affiliation(s)
- A F D Fragoso Perozo
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, 255 Professor Rodolpho Paulo Rocco Street, ground floor, University City, Rio de Janeiro, RJ, ZC 21941-617, Brazil.
- Diagnósticos da América SA (DASA), Rio de Janeiro, RJ, Brazil.
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rio de Janeiro, Brazil.
| | - R Fontes
- Diagnósticos da América SA (DASA), Rio de Janeiro, RJ, Brazil
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rio de Janeiro, Brazil
| | - F P Lopes
- Diagnósticos da América SA (DASA), Rio de Janeiro, RJ, Brazil
| | - P B Araújo
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, 255 Professor Rodolpho Paulo Rocco Street, ground floor, University City, Rio de Janeiro, RJ, ZC 21941-617, Brazil
- Diagnósticos da América SA (DASA), Rio de Janeiro, RJ, Brazil
| | - Y Scrank
- Diagnósticos da América SA (DASA), Rio de Janeiro, RJ, Brazil
| | - D M V Gomes
- Diagnósticos da América SA (DASA), Rio de Janeiro, RJ, Brazil
| | - A B Moraes
- Department of Clinical Medicine and Endocrine Unit, Federal Fluminense University, School of Medicine, Antônio Pedro University Hospital, Niterói, RJ, Brazil
| | - L Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, 255 Professor Rodolpho Paulo Rocco Street, ground floor, University City, Rio de Janeiro, RJ, ZC 21941-617, Brazil
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Rebelo JFD, Costa JM, Junqueira FD, Fonseca ADO, de Almeida ABABS, Moraes AB, Vieira Neto L. Adrenal incidentaloma: Do patients with apparently nonfunctioning mass or autonomous cortisol secretion have similar or different clinical and metabolic features? Clin Endocrinol (Oxf) 2022; 98:662-669. [PMID: 36514987 DOI: 10.1111/cen.14861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/17/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Although there is growing evidence associating nonfunctioning adrenal incidentalomas (NFAI) with cardiovascular risk factors, there are limited data whether NFAI and autonomous cortisol secretion (ACS) groups have similar or different clinical and metabolic features. The aim of this study is to compare cardiometabolic clinic parameters among patients with ACS and NFAI, as well as controls. DESIGN Cross-sectional study. PATIENTS Eighty nine NFAI, 58 ACS and 64 controls were evaluated. MEASUREMENTS Diagnosis of NFAI (1 mg dexamethasone suppression test [1 mg-DST] ≤50 nmol/L [≤1.8 μg/dl]) and ACS (1 mg-DST > 50 nmol/L [> 1.8 μg/dl]) was established according to current guidelines. The control group was selected based on a normal adrenal imaging exam. RESULTS There were no differences between groups regarding age, gender, ethnicity, menopause or body mass index. Patients with adrenal incidentaloma presented higher frequency of hypertension (74.1 vs. 57.8%; p = .02), resistant hypertension (45.4 vs. 9.4%; p < .001), dyslipidemia (80.1 vs. 63.9%; p = .01), as well as metabolic syndrome (84.2 vs. 61.7%; p = .001) compared to the controls, respectively. NFAI and ACS patients presented similar frequency of arterial hypertension (70.8 vs. 79.3%) and resistant hypertension (41.3 vs. 51.1%), dyslipidemia (79.3 vs. 81.5%) and metabolic syndrome (83.3 vs. 85.7%); also, levels of HbA1c were similar between the groups. Binary logistic regression showed that NFAI (p = .004) and ACS (p = .001) were independent predictors for resistant hypertension (p = .003); also, ACS was an independent predictor for metabolic syndrome (p = .04). CONCLUSIONS NFAI and ACS presented a higher frequency of cardiometabolic morbidities in comparison with individuals with normal adrenal glands. Additionally, we demonstrated that both ACS and NFAI groups have similar cardiometabolic conditions.
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Affiliation(s)
- João Felipe Dickson Rebelo
- Department of Internal Medicine and Endocrine Unit, School of Medicine, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Julia Magarão Costa
- Department of Internal Medicine and Endocrine Unit, School of Medicine, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernanda Damasceno Junqueira
- Department of Internal Medicine and Endocrine Unit, School of Medicine, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Aline Barbosa Moraes
- Department of Internal Medicine and Endocrine Unit, School of Medicine, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Department of Internal Medicine and Endocrine Unit, School of Medicine, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Brabo EP, Viana M, Caroli-Bottino A, Pannain VLN, Eiras A, Moraes AB, Vieira Neto L. Colonic tuberculosis presenting as intestinal subocclusion in a patient with neuroendocrine tumor: a case report. AME Case Rep 2021; 5:36. [PMID: 34805755 DOI: 10.21037/acr-21-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/13/2021] [Indexed: 11/06/2022]
Abstract
Extra-pulmonary tuberculosis (EPT) is responsible for approximately 14% of all tuberculosis cases in Brazil. The incidence of EPT is increasing slightly and is often associated with human immunodeficiency virus infection and other causes of immunosuppression. The association of EPT and cancer is poorly documented. Here we present a rare case of intestinal subocclusion that was supposed to be caused by cancer and was caused by colonic tuberculosis (CT) in a patient with metastatic neuroendocrine tumor (NET). A 61-year-old woman presented with one-year history of abdominal pain, diarrhea and weight loss. An abdominal CT scan (ACTS) showed liver, peritoneal and lymph nodes metastasis. Colonoscopy revealed a subocclusive lesion in the descendent colon. She underwent an urgent laparoscopy and transverse colostomy. The liver biopsy revealed a well differentiated grade 2 NET and the mycobacterial culture confirmed tuberculosis in the colonic lesion. Anti-tuberculosis was prescribed, and somatostatin analogue therapy was introduced one month later. The tuberculosis treatment was finished, and the patient remained on somatostatin analogue for 21 months. During this time the symptoms of abdominal pain and diarrhea disappeared and her body weight increased 35% over her baseline weight. Then, diarrhea, flushing and abdominal pain returned, and a new ACTS confirmed progressive disease. Interferon was added to her treatment with satisfactory control of symptoms. She was forwarded to another hospital to be treated with 177Lu-DOTATOC. The symptoms improved and the patient remained symptom free for more than a year, and now she has a new disease progression. The patient will be evaluated for retreatment with 177Lu-DOTATOC. Advanced NET may be a devastating disease enough to predispose the patient to EPT. We must keep this hypothesis in the differential diagnosis of our patients since symptoms of CT are usually nonspecific. At colonoscopy, radiological features are strictures, colitis and polypoidal lesions and complications such as bowel perforation or fistula must be in mind. It is particularly important those with advanced disease in endemic areas of tuberculosis.
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Affiliation(s)
- Eloá Pereira Brabo
- Oncology Service and Neuroendocrine Section, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcos Viana
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Adriana Caroli-Bottino
- Department of Pathology, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vera Lucia Nunes Pannain
- Department of Pathology, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antonio Eiras
- Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aline Barbosa Moraes
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Rodrigues MO, Moraes AB, de Paula MP, Pereira VA, Leão ATT, Vieira Neto L. Adrenal incidentaloma as a novel independent predictive factor for periodontitis. J Endocrinol Invest 2021; 44:2455-2463. [PMID: 33788166 DOI: 10.1007/s40618-021-01557-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/22/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE There are no data regarding periodontal derangements in patients with adrenal incidentalomas (AI). We assessed the frequency and severity of periodontitis in patients with AI [non-functioning adrenal incidentaloma (NFAI) and possible autonomous cortisol secretion (ACS)] and compared with individuals with normal adrenal. METHODS A cross-sectional study evaluated thirty-five individuals with AI and 26 controls. NFAI and possible ACS diagnosis was based on the current guidelines: NFAI [cortisol levels after 1 mg dexamethasone suppression test (1 mg-DST) ≤ 1.8 µg/dL (≤ 50 nmol/L)]; possible ACS [cortisol levels after 1 mg-DST 1.9-5.0 µg/dL (51-138 nmol/L)]. Sociodemographic data were collected, and a full-mouth periodontal evaluation was performed. RESULTS There was no significant difference between groups regarding age, sex, income, ethnicity, education level, smoking, body mass index, dysglycemia, and arterial hypertension. Patients with AI exhibited worse periodontal conditions than controls for the following periodontal clinical parameters: mean percentage of probing pocket depth (PPD) and clinical attachment level (CAL) ≥ 5 mm (p < 0.001 and p = 0.006, respectively). Patients with NFAI and possible ACS showed higher gingival bleeding index (p = 0.014), bleeding on probing (p < 0.001), and CAL (p < 0.001) means compared to controls. The frequencies of periodontitis were 72.7% in patients with NFAI, 84.6% in possible ACS, and 30.8% in controls (p = 0.001). Periodontitis was more severe in patients with possible ACS than NFAI and controls. Patients with NFAI and possible ACS exhibited odds ratio for periodontitis of 4.9 (p = 0.016) and 8.6 (p = 0.02), respectively. CONCLUSION Patients with AI have higher frequency and severity of periodontitis than controls. The presence of AI was an independent predictive factor for periodontitis.
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Affiliation(s)
- M O Rodrigues
- Department of Dental Clinic, Division of Periodontics, Dental School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A B Moraes
- Department of Internal Medicine and Endocrine Unit, School of Medicine, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255. 9th floor-Endocrinology Unit Rio de Janeiro, Rio de Janeiro, RJ, 21941-913, Brazil
| | - M P de Paula
- Department of Internal Medicine and Endocrine Unit, School of Medicine, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255. 9th floor-Endocrinology Unit Rio de Janeiro, Rio de Janeiro, RJ, 21941-913, Brazil
| | - V A Pereira
- Department of Dental Clinic, Division of Periodontics, Dental School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A T T Leão
- Department of Dental Clinic, Division of Periodontics, Dental School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - L Vieira Neto
- Department of Internal Medicine and Endocrine Unit, School of Medicine, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255. 9th floor-Endocrinology Unit Rio de Janeiro, Rio de Janeiro, RJ, 21941-913, Brazil.
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de Paula MP, Moraes AB, de Souza MDGC, Cavalari EMR, Campbell RC, Fernandes GDS, Farias MLF, Mendonça LMC, Madeira M, Bouskela E, Kraemer-Aguiar LG, Vieira Neto L. Cortisol level after dexamethasone suppression test in patients with non-functioning adrenal incidentaloma is positively associated with the duration of reactive hyperemia response on microvascular bed. J Endocrinol Invest 2021; 44:609-619. [PMID: 32686043 DOI: 10.1007/s40618-020-01360-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/09/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Data on endothelial derangements in patients with non-functioning adrenal incidentaloma (NFAI) are scarce. METHODS We investigated if NFAI patients present clinical, biochemical and endothelial alterations compared to individuals without an adrenal lesion and also the associations among these variables. Forty-two NFAI and 40 controls were evaluated. NFAI diagnosis and controls were defined according to the current guidelines and based on a normal adrenal imaging exam, respectively. Body composition was evaluated by dual emission X-ray absorptiometry. Endothelial reactivity was assessed by two methods: tonometry (Endo-PAT®) and laser speckle contrast imaging (LSCI). RESULTS There were no differences between groups regarding age, gender, ethnicity, smoking status, and statin use. The frequency of metabolic syndrome according to the International Diabetes Federation criteria was 69% and 57.9%, respectively in NFAI and controls (p = 0.36), whereas the atherosclerotic cardiovascular disease (ASCVD) risk was 63.4% and 66.7% (p = 0.81). The clinical, laboratory, and anthropometric characteristics, as well as body composition, were similar between the groups. Additionally, any differences between groups were observed on endothelial reactivity tests. Nevertheless, we noted an association between cortisol levels after 1 mg-dexamethosone suppression test (1 mg-DST) and the duration of post-occlusive reactive hyperemia tested on microcirculation (r = 0.30; p = 0.03). NFAI patients require more antihypertensive drugs to achieve blood pressure control (p = 0.04). The number of antihypertensive drugs used to control blood pressure correlated with cortisol levels after 1 mg-DST (r = 0.29; p = 0.03). CONCLUSIONS Since both groups herein investigated had a high frequency of metabolic syndrome and ASCVD risk, it might explain similarities observed on endothelial reactivity. Nevertheless, prolonged reactive hyperemia response on microcirculation was correlated with cortisol levels under suppression.
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Affiliation(s)
- M P de Paula
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255, 9th Floor, Rio de Janeiro, RJ, Brazil
| | - A B Moraes
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255, 9th Floor, Rio de Janeiro, RJ, Brazil
| | - M das Graças Coelho de Souza
- Laboratory for Clinical and Experimental Research on Vascular Biology, Biomedical Center, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - E M R Cavalari
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255, 9th Floor, Rio de Janeiro, RJ, Brazil
| | - R C Campbell
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255, 9th Floor, Rio de Janeiro, RJ, Brazil
| | - G da Silva Fernandes
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255, 9th Floor, Rio de Janeiro, RJ, Brazil
| | - M L F Farias
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255, 9th Floor, Rio de Janeiro, RJ, Brazil
| | - L M C Mendonça
- Department of Internal Medicine and Rheumatology Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - M Madeira
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255, 9th Floor, Rio de Janeiro, RJ, Brazil
| | - E Bouskela
- Laboratory for Clinical and Experimental Research on Vascular Biology, Biomedical Center, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - L G Kraemer-Aguiar
- Laboratory for Clinical and Experimental Research on Vascular Biology, Biomedical Center, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
- Endocrinology, Department of Internal Medicine, Faculty of Medical Sciences, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - L Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Professor Rodolpho Paulo Rocco Street, 255, 9th Floor, Rio de Janeiro, RJ, Brazil.
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Brabo EP, Moraes AB, Neto LV. The role of immune checkpoint inhibitor therapy in advanced adrenocortical carcinoma revisited: review of literature. J Endocrinol Invest 2020; 43:1531-1542. [PMID: 32468513 DOI: 10.1007/s40618-020-01306-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/21/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Adrenocortical carcinoma (ACC) is a rare disease with few therapeutic options. There is an urgency of new effective therapeutic options for these patients. The role of immune checkpoint inhibitors (ICI) in advanced ACC patients is still unclear. METHODS We conducted a MEDLINE search using the following string: adrenocortical carcinoma and immunotherapy or checkpoint inhibitors. RESULTS We found four case series comprising 10 patients, and four prospective studies totaling 115 patients. The response rate (RR) in the group of 10 patients was 1 complete response, 3 partial response (PR), 4 stable disease (SD), and 2 progressive disease (PD). The median progression-free survival (mPFS) ranged from 2 to 31 months and the median overall survival (mOS) ranged from 4.3 to 31 months. The results in the 115 patients from prospective trials was variable, the PR ranged from 6 to 23%, the SD ranged from 18 to 50% and overall disease control rate ranged from 30 to 64%. The mPFS reported varied from 1.8 to 2.6 months while the mOS varied from 10.6 to 24.9 months. There were five patients with sustained response for more than 24 months. The most common treatment-related adverse event (TRAE) was the increase in liver enzymes. No treatment-related deaths were reported. Better results in terms of RR and survival were observed in studies that used pembrolizumab. No predictive biomarker of response was found up to now. CONCLUSION ICI, mainly pembrolizumab, is a potential therapeutic option, which is safe and associated with prolonged OS benefit, in selected patients with advanced ACC.
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Affiliation(s)
- E P Brabo
- Oncology Unit and Neuroendocrine Section, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, 255 Professor Rodolpho Paulo Rocco Street, ground floor, University City, Rio de Janeiro, RJ, 21941-913, Brazil
| | - A B Moraes
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, 255 Professor Rodolpho Paulo Rocco Street, 9th floor, University City, Rio de Janeiro, RJ, 21941-913, Brazil
| | - L V Neto
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, 255 Professor Rodolpho Paulo Rocco Street, 9th floor, University City, Rio de Janeiro, RJ, 21941-913, Brazil.
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Moraes AB, de Paula MP, de Paula Paranhos-Neto F, Cavalari EMR, de Morais FFC, Curi DSC, Lima LFC, de Mendonça LMC, Farias MLF, Madeira M, Vieira Neto L. Bone Evaluation by High-Resolution Peripheral Quantitative Computed Tomography in Patients With Adrenal Incidentaloma. J Clin Endocrinol Metab 2020; 105:5837655. [PMID: 32413110 DOI: 10.1210/clinem/dgaa263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/08/2020] [Indexed: 12/23/2022]
Abstract
CONTEXT Data regarding high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with adrenal incidentaloma (AI) are unknown. PURPOSE To evaluate the areal bone mineral density (aBMD), microstructure, and fractures in patients with nonfunctioning AI (NFAI) and autonomous cortisol secretion (ACS). METHODS We evaluated 45 patients with NFAI (1 mg dexamethasone suppression test [DST] ≤1.8 µg/dL) and 30 patients with ACS (1 mg DST 1.9-5.0 µg/dL). aBMD was measured using dual-energy X-ray absorptiometry; vertebral fracture by spine X-ray; and bone geometry, volumetric bone mineral density (vBMD), and microstructure by HR-pQCT. RESULTS Patients with ACS showed lower aBMD values at the spine, femoral neck, and radius 33% than those with NFAI. Osteoporosis was frequent in both groups: NFAI (64.9%) and ACS (75%). Parameters at the distal radius by HR-pQCT were decreased in patients with ACS compared to those with NFAI: trabecular vBMD (Tb.vBMD, P = 0.03), inner zone of the trabecular region (Inn.Tb.vBMD, P = 0.01), the bone volume/tissue volume ratio (BV/TV, P = 0.03) and trabecular thickness (P = 0.04). As consequence, a higher ratio of the outer zone of the trabecular region/inner zone vBMD (Meta/Inn.vBMD, P = 0.003) was observed. A correlation between the cortisol levels after 1 mg DST and Meta/Inn.vBMD ratio was found (r = 0.29; P = 0.01). The fracture frequency was 73.7% in patients with ACS vs 55.6% in patients with NFAI (P = 0.24). CONCLUSION Our findings point to an association between trabecular bone microarchitectural derangement at the distal radius and ACS. Our data suggest that AI have a negative impact on bone when assessed by HR-pQCT, probably associated to subclinical hypercortisolism.
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Affiliation(s)
- Aline Barbosa Moraes
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Marcela Pessoa de Paula
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Francisco de Paula Paranhos-Neto
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Emanuela Mello Ribeiro Cavalari
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Felipe Fernandes Cordeiro de Morais
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Daniel Silva Carvalho Curi
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Luis Felipe Cardoso Lima
- Nuclear Instrumentation Laboratory, COPPE-PEN, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Laura Maria Carvalho de Mendonça
- Department of Internal Medicine and Rheumatology Unit, Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Maria Lucia Fleiuss Farias
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
| | - Miguel Madeira
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
- Endocrinology Unit, Bonsucesso Federal Hospital, Rio de Janeiro, RJ, Brazil
| | - Leonardo Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio de Janeiro, RJ, Brazil
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Gama EMF, de Pinho LKJ, Madeira M, Duarte C, Pessoa GC, Moraes AB, Amaral MCAC, Neto FPP, de Farias MLF. SUN-388 Role of QUS and Functional Tests in Evaluating Fracture Risk Based on Frax Tool. J Endocr Soc 2020. [PMCID: PMC7208261 DOI: 10.1210/jendso/bvaa046.1493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Osteoporosis is common among elderly people, and identifying those at high risk for fracture is very important. Aim: To evaluate whether the use of quantitative calcaneal ultrasound (QUS), the Sitting–rising test (SRT) and handgrip test (HT) are additional tools for tracking fragility fracture risk when compared to FRAX and NOGG. Methods: During the national campaign against osteoporosis, held in 2018 in Rio de Janeiro, participants were randomly selected to perform QUS, SRT and HT, besides categorization of the risk of major and hip fractures by FRAX and NOGG. The following adequacy values were used: QUS T-score> -1.05 (adequate) or ≤ -1.05 (inadequate); Sitting – rising test (SRT) (composite score): age-reference values at quartiles 3 and 4 (adequate); quartiles 1 and 2 (inadequate); best result 3 attempts of the dominant arm handgrip test, according to age and gender: percentile ≥50 (adequate) and <50 (inadequate); FRAX tool: suggests high risk for major osteoporotic fractures if > 20% and for hip fractures when > 3%; NOGG (complement to FRAX): patient′s risk for major and for hip fractures considered as low (green zone), medium (yellow zone) or high (red zone). Qui square test was used for associations. Results: We included 162 individuals: 118 females, mean age 66.8 years and 44 males, mean age 71.8 years. High risk of hip fractures by FRAX was observed in 51% of those patients with a QUS T-score ≤-1.05 while it was observed in 28% of those with a QUS T-score> -1.05 (p=0.005). An inadequate QUS T-score was also associated with a higher risk of hip fracture by NOGG (p=0.007). An inadequate SRT and HT were not associated with a high fracture risk. Conclusions: As densitometry, a method established in clinical practice for the diagnosis of osteoporosis, has limitations in its use, other tools are necessary for tracking the risk of fragility fractures in these events. Quantitative calcaneal ultrasound was a good predictor of hip fracture risk, while SRT and HT were not capable of evaluate for fracture risk stratification in our study, reinforcing the need for QUS for screening in large populations. Having strength and functional ability did not eliminate the need for investigation.
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Paranhos-Neto FP, Vieira Neto L, Madeira M, Moraes AB, Mendonça LMC, Lima ICB, Chagas CLR, Lira DA, Spitz JF, Guimarães JAM, Duarte MEL, Farias MLF. Vitamin D deficiency is associated with cortical bone loss and fractures in the elderly. Eur J Endocrinol 2019; 181:509-517. [PMID: 31484162 DOI: 10.1530/eje-19-0197] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/28/2019] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The role of vitamin D on bone microarchitecture and fragility is not clear. OBJECTIVE To investigate whether vitamin D deficiency (25(OH)D <20 ng/mL) increases cortical bone loss and the severity of fractures. DESIGN Cross-sectional study of 287 elderly women with at least one prevalent low-impact fracture. METHODS Biochemistry, X-rays to identify vertebral fractures (VFs) and to confirm non-vertebral fractures (NonVFs), and high-resolution peripheral quantitative computed tomography (HR-pQCT) to evaluate bone microstructure. RESULTS Serum 25(OH)D levels were associated with body mass index (BMI: r = -0.161, P = 0.006), PTH (r = -0.165; P = 0.005), CTX (r = -0.119; P = 0.043) and vBMD at cortical bone (Dcomp: r = 0.132; P = 0.033) and entire bone (D100: r = 0.162 P = 0.009) at the distal radius, but not at the tibia. Age and PTH levels were potential confounding variables, but in the multiple linear regressions only BMI (95% CI: 0.11-4.16; P < 0.01), 25(OH)D (95% CI: -0.007 to 1.70; P = 0.05) and CTX (95% CI: -149.04 to 21.80; P < 0.01) predicted Dcomp, while BMI (95% CI: 1.13-4.18; P < 0.01) and 25(OH)D (95% CI: 0.24-1.52; P < 0.01) predicted D100. NonVFs predominated in patients with 25(OH)D <20 ng/mL (P = 0.013). Logistic regression analysis showed a decrease in the likelihood of presenting grade 2-3 VFs/NonVFs for every increase in 25(OH)D (OR = 0.962, 95% CI: 0.940-0.984; P = 0.001), BMI (OR = 0.932, 95% CI: 0.885-0.981; P = 0.007) and D100 at radius (OR = 0.994, 95% CI: 0.990-0.998; P = 0.005). CONCLUSION In elderly patients with prevalent fractures, vitamin D deficiency was associated with cortical bone loss and severity of fractures.
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Affiliation(s)
- F P Paranhos-Neto
- Division of Endocrinology, Clementino Fraga Filho University Hospital, UFRJ, Rio de Janeiro, Rio de Janeiro, Brasil
| | - L Vieira Neto
- Division of Endocrinology, Clementino Fraga Filho University Hospital, UFRJ, Rio de Janeiro, Rio de Janeiro, Brasil
| | - M Madeira
- Division of Endocrinology, Clementino Fraga Filho University Hospital, UFRJ, Rio de Janeiro, Rio de Janeiro, Brasil
| | - A B Moraes
- Division of Endocrinology, Clementino Fraga Filho University Hospital, UFRJ, Rio de Janeiro, Rio de Janeiro, Brasil
| | - L M C Mendonça
- Division of Reumathology, Clementino Fraga Filho University Hospital, UFRJ, Rio de Janeiro, Rio de Janeiro, Brasil
| | - I C B Lima
- Program of Nuclear Engineering - COPPE - UFRJ, Rio de Janeiro, Rio de Janeiro, Brasil
| | - C L R Chagas
- Research Division, National Institute of Orthopedics and Traumatology, Rio de Janeiro, Rio de Janeiro, Brazil
| | - D A Lira
- Research Division, National Institute of Orthopedics and Traumatology, Rio de Janeiro, Rio de Janeiro, Brazil
| | - J F Spitz
- Research Division, National Institute of Orthopedics and Traumatology, Rio de Janeiro, Rio de Janeiro, Brazil
| | - J A M Guimarães
- Research Division, National Institute of Orthopedics and Traumatology, Rio de Janeiro, Rio de Janeiro, Brazil
| | - M E L Duarte
- Research Division, National Institute of Orthopedics and Traumatology, Rio de Janeiro, Rio de Janeiro, Brazil
| | - M L F Farias
- Division of Endocrinology, Clementino Fraga Filho University Hospital, UFRJ, Rio de Janeiro, Rio de Janeiro, Brasil
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11
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Moraes AB, Cavalari EMR, de Paula MP, Arruda M, Curi DSC, Leitão RA, de Mendonça LMC, Farias MLF, Madeira M, Vieira Neto L. Evaluation of body composition using dual-energy X-ray absorptiometry in patients with non-functioning adrenal incidentalomas and an intermediate phenotype: Is there an association with metabolic syndrome? J Endocrinol Invest 2019; 42:797-807. [PMID: 30465247 DOI: 10.1007/s40618-018-0985-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/15/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Metabolic syndrome (MS) and sarcopenia are associated with increased cardiovascular risk. No studies using dual-energy x-ray absorptiometry (DXA) have evaluated association between body composition (BC) changes and MS in adrenal incidentaloma (AI). Our aim was to analyse BC in non-functioning AI (NFAI) and intermediate phenotype (IP) relative to controls and to correlate with cortisol levels. METHODS Cross-sectional study with 44 NFAI (serum cortisol ≤ 50 nmol/L after the overnight 1 mg dexamethasone suppression test), 27 IP (cortisol 51-138 nmol/L), and 41 controls (normal adrenal on imaging examination) using DXA. Autonomic cortisol secretion (cortisol > 138 nmol/L) was excluded from the study. BC data were compared using criteria for MS (World Health Organization, National Cholesterol Education Program-Adult Treatment Panel-III, American Association of Clinical Endocrinologists (AACE), and International Diabetes Federation). RESULTS There was no significant difference in clinical data and body mass index (BMI) among the three groups. Waist circumference (WC) was larger in AI vs. controls (p < 0.01). Waist-to-hip ratio was higher in NFAI vs. controls and waist-to-height ratio was higher in IP vs. controls (p = 0.03 and p = 0.02, respectively). The frequency of MS was higher in AI vs. controls. BC was not different among the groups. Patients with AI there was a significant association of MS with both an increase in total fat and body fat index (all criteria), and a significant difference between MS and smaller BMI-adjusted lean mass (AACE, p = 0.036). No correlation of cortisol after 1 mg dexamethasone test with BC or MS. AI and WC were independently associated with MS. CONCLUSIONS AI presented high frequency of MS and was independently associated with MS. Possible deleterious effects of cortisol secretion seem to initially affect the muscular system.
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Affiliation(s)
- A B Moraes
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil
| | - E M R Cavalari
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil
| | - M P de Paula
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil
| | - M Arruda
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil
| | - D S C Curi
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil
| | - R A Leitão
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil
| | - L M C de Mendonça
- Department of Internal Medicine and Rheumatology Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rio De Janeiro, RJ, Brazil
| | - M L F Farias
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil
| | - M Madeira
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil
- Endocrinology Unit, Bonsucesso Federal Hospital, Rio de Janeiro, RJ, Brazil
| | - L Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Federal University of Rio de Janeiro, School of Medicine, Clementino Fraga Filho University Hospital, Rua Professor Rodolpho Paulo Rocco, 255. 9 Floor - Endocrine Unit, Rio De Janeiro, RJ, 21941-913, Brazil.
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12
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Moraes AB, Treistman N, Studart MC, Chagas VLA, Brabo EP, Vieira Neto L. Gastrinoma of Cystic Duct: A Rare Association With Multiple Endocrine Neoplasia Type 1. J Clin Med Res 2018; 10:843-847. [PMID: 30344820 PMCID: PMC6188020 DOI: 10.14740/jocmr3541w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/14/2018] [Indexed: 11/29/2022] Open
Abstract
Neuroendocrine tumors (NETs) of cystic duct are extremely rare, accounting for less than 2% of NET cases. The association of biliary tree NET and multiple endocrine neoplasm type 1 (MEN1) are even more rare. In this report, we described a case of a 65-year-old woman who was referred to our neuroendocrine outpatient clinic to investigate MEN1 after an incidental diagnosis of gastrinoma. Her medical history initiated 7 years earlier with severe peptic disease not responsive to proton pump inhibitor therapy. Endoscopic study revealed erosive antral gastritis, erosive duodenitis, bulbar ulcer and pyloric deformity. During follow-up she presented with abdominal pain, chronic diarrhea and weight loss; an ultrasonography was performed and showed only a cholelithiasis. She underwent a video laparoscopic cholecystectomy and all her symptoms were solved. Histopathological study found a 1.0 cm well differentiated NET (Ki-67 labeling index < 2%) located in cystic duct infiltrating the entire wall and subserosa. The MEN1 investigation revealed a primary hyperparathyroidism with a brown tumor in right iliac bone; the patient was referred to a total parathyroidectomy with autotransplantation. No evidence of pituitary tumor was found. The patient remains asymptomatic 24 months after surgery. To conclude, this case highlights an unusual presentation of a cystic duct primary NET gastrinoma in a MEN1 context.
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Affiliation(s)
- Aline Barbosa Moraes
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Natalia Treistman
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana Coutinho Studart
- Pathology Department, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vera Lucia Antunes Chagas
- Pathology Department, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eloa Pereira Brabo
- Oncology Unit and Neuroendocrine Section, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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13
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Arruda M, Coelho MCA, Moraes AB, de Paula Paranhos-Neto F, Madeira M, Farias MLF, Vieira Neto L. Bone Mineral Density and Microarchitecture in Patients With Autosomal Dominant Osteopetrosis: A Report of Two Cases. J Bone Miner Res 2016; 31:657-62. [PMID: 26387875 DOI: 10.1002/jbmr.2715] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/13/2015] [Accepted: 09/16/2015] [Indexed: 01/22/2023]
Abstract
The aim of this case study is to describe changes in areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry (DXA) scan, as well as volumetric bone density and microarchitecture by high-resolution peripheral quantitative computed tomography (HR-pQCT) in two patients with autosomal dominant osteopetrosis (ADO) and compare with 20 healthy subjects. We describe a 44-year-old male patient with six low-impact fractures since he was age 16 years, and a 32-year-old female patient with four low-impact fractures on her past history. Radiographic changes were typical of ADO. Consistent with the much higher aBMD, total volumetric BMD (average bone density of the whole bone, including trabecular and cortical compartments) at distal radius and tibia (HR-pQCT) was more than twice the mean values found in healthy subjects in both patients. Trabecular number and thickness were higher, leading to an evident increase in trabecular bone volume to tissue volume. Also, an enormous increase in cortical thickness was found. Most important, a great heterogeneity in bone microstructure of the affected patients was evident on HR-pQCT images: islets of very dense bone were interposed with areas with apparent normal density. The increase in aBMD, volumetric BMD, and most indices of trabecular and cortical bone, associated with the great heterogeneity on bone tridimensional microarchitecture, reflect the accumulation of old and fragile bone randomly distributed along the skeleton. These alterations in bone microstructure probably compromise bone quality, which might justify the high prevalence of low-impact fractures in patients with ADO, despite abnormally elevated BMD.
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Affiliation(s)
- Mariana Arruda
- Department of Internal Medicine and Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Caroline Alves Coelho
- Department of Internal Medicine and Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Endocrinology Section, Hospital Universitário Pedro Ernesto, Rio de Janeiro, Brazil.,Endocrinology Section, Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rio de Janeiro, Brazil
| | - Aline Barbosa Moraes
- Department of Internal Medicine and Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Francisco de Paula Paranhos-Neto
- Department of Internal Medicine and Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Miguel Madeira
- Department of Internal Medicine and Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Endocrinology Section, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Maria Lucia Fleiuss Farias
- Department of Internal Medicine and Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Department of Internal Medicine and Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Endocrinology Section, Hospital Federal da Lagoa, Rio de Janeiro, Brazil
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14
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Lange R, Von Linsingen C, Mata F, Moraes AB, Arruda M, Vieira Neto L. Endocrine abnormalities in ring chromosome 11: a case report and review of the literature. Endocrinol Diabetes Metab Case Rep 2015; 2015:150085. [PMID: 26576288 PMCID: PMC4644930 DOI: 10.1530/edm-15-0085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 10/15/2015] [Indexed: 11/16/2022] Open
Abstract
Ring chromosomes (RCs) are uncommon cytogenetic findings, and RC11 has only been described in 19 cases in the literature. Endocrine abnormalities associated with RC11 were reported for two of these cases. The clinical features of RC11 can result from an alteration in the structure of the genetic material, ring instability, mosaicism, and various extents of genetic material loss. We herein describe a case of RC11 with clinical features of 11q-syndrome and endocrine abnormalities that have not yet been reported. A 20-year-old female patient had facial dysmorphism, short stature, psychomotor developmental delays, a ventricular septal defect, and thrombocytopenia. Karyotyping demonstrated RC11 (46,XX,r(11)(p15q25)). This patient presented with clinical features that may be related to Jacobsen syndrome, which is caused by partial deletion of the long arm of chromosome 11. Regarding endocrine abnormalities, our patient presented with precocious puberty followed by severe hirsutism, androgenic alopecia, clitoromegaly, and amenorrhea, which were associated with overweight, type 2 diabetes mellitus (T2DM), and hyperinsulinemia; therefore, this case meets the diagnostic criteria for polycystic ovary syndrome. Endocrine abnormalities are rare in patients with RC11, and the association of RC11 with precocious puberty, severe clinical hyperandrogenism, insulin resistance, and T2DM has not been reported previously. We speculate that gene(s) located on chromosome 11 might be involved in the pathogenesis of these conditions. Despite the rarity of RCs, studies to correlate the genes located on the chromosomes with the phenotypes observed could lead to major advances in the understanding and treatment of more prevalent diseases.
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Affiliation(s)
- Renata Lange
- Endocrine Section, Hospital Federal da Lagoa , Rio de Janeiro , Brazil
| | | | - Fernanda Mata
- Endocrine Section, Hospital Federal da Lagoa , Rio de Janeiro , Brazil
| | - Aline Barbosa Moraes
- Department of Internal Medicine and Endocrine Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal de Rio de Janeiro , Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundão, Rio de Janeiro, 21941-913 , Brazil
| | - Mariana Arruda
- Department of Internal Medicine and Endocrine Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal de Rio de Janeiro , Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundão, Rio de Janeiro, 21941-913 , Brazil
| | - Leonardo Vieira Neto
- Endocrine Section, Hospital Federal da Lagoa , Rio de Janeiro , Brazil ; Department of Internal Medicine and Endocrine Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal de Rio de Janeiro , Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundão, Rio de Janeiro, 21941-913 , Brazil
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15
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Vieria Neto L, Wildemberg LE, Colli LM, Kasuki L, Marques NV, Moraes AB, Gasparetto EL, Takiya CM, Castro M, Gadelha MR. ZAC1 and SSTR2 are downregulated in non-functioning pituitary adenomas but not in somatotropinomas. PLoS One 2013; 8:e77406. [PMID: 24098585 PMCID: PMC3788723 DOI: 10.1371/journal.pone.0077406] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 09/03/2013] [Indexed: 01/18/2023] Open
Abstract
Introduction There are few data regarding ZAC1 expression in clinically non-functioning pituitary adenomas (NFPA). Because somatotropinomas and NFPA behave differently with respect to tumor shrinkage during somatostatin analogs (SA) therapy, we sought to compare the ZAC1 and somatostatin receptor (sstr) types 1, 2, 3 and 5 mRNA expression in these two pituitary adenoma subtypes and in normal human pituitaries. Methods ZAC1 and SSTR mRNA expression levels were evaluated using real-time RT-PCR (TaqMan) in 20 NFPA and compared with the expression levels in 23 somatotropinomas and five normal pituitaries. The NFPA invasiveness was evaluated using magnetic resonance imaging with Hardy’s modified criteria. Ki-67 and p53 were evaluated using immunohistochemistry. Results A total of 20 patients with NFPA [6 males, median age 56 years (range: 30-78)], 23 with acromegaly [12 males, median age 43 years (range: 24–57)] and five normal pituitaries [4 males, median age 48 years (range: 36–54)] were included. Four of the patients (20%) had Hardy’s grade 2 tumors; all of the others had Hardy’s grade 3 tumors. The Ki-67 median expression was 2.35 (range: 0.2–9.23), and only four of the tumors (20%) were positive for p53. The ZAC1 mRNA expression was significantly lower in NFPA than in somatotropinomas and in normal pituitaries (p<0.001 for both), as well as the SSTR2 (p=0.001 and 0.01, respectively). The SSTR3 expression was higher in the NFPA than in the somatotropinomas and in the normal pituitaries (p=0.03 and 0.02, respectively). No correlation was found between the ZAC1 mRNA expression and the tumor invasiveness, Ki-67 and p53. Conclusion ZAC1 and SSTR2 are underexpressed and SSTR3 is overexpressed in NFPA compared to those in somatotropinomas and in normal pituitaries, which might explain the lack of tumor shrinkage that is observed in response to commercially available SA therapy in patients with NFPA.
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Affiliation(s)
- Leonardo Vieria Neto
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Endocrinology Unit, Federal Hospital of Lagoa, Rio de Janeiro, Brazil
| | - Luiz Eduardo Wildemberg
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandro Machado Colli
- Department of Internal Medicine, Medical School of Ribeirão Preto, Universidade de São Paulo, São Paulo, Brazil
| | - Leandro Kasuki
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nelma Veronica Marques
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aline Barbosa Moraes
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Emerson L. Gasparetto
- Radiology Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Christina Maeda Takiya
- Biofísica Carlos Chagas Filho Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Margaret Castro
- Department of Internal Medicine, Medical School of Ribeirão Preto, Universidade de São Paulo, São Paulo, Brazil
| | - Mônica Roberto Gadelha
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- * E-mail:
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Wildemberg LEA, Vieira Neto L, Taboada GF, Moraes AB, Marcondes J, Conceição FL, Chimelli L, Gadelha MR. Sellar and suprasellar mixed germ cell tumor mimicking a pituitary adenoma. Pituitary 2011; 14:345-50. [PMID: 19116786 DOI: 10.1007/s11102-008-0161-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Germ cell tumors (GCT) are a heterogeneous group of lesions whose origin is not well established. Several cases of primary intrasellar germinomas have been reported, however non-germinomatous GCT have rarely been described. We report the case of a young adult male patient with a mixed GCT that presented with a sellar tumor with suprasellar extension. The patient seeked medical attention because of seizures and magnetic resonance imaging evidenced a tumor of the sellar region. Hyperprolactinemia was also present and dopamine agonist therapy was started. As there was a rapid tumor growth and the patient had concomitant central diabetes insipidus and elevated testosterone levels, a GCT was suspected and confirmed by elevated serum concentration of β-human chorionic gonadotrophin. Patient underwent surgical resection of the tumor and histopathological examination confirmed the diagnosis of a mixed GCT. Chemotherapy was initiated, followed by conventional radiotherapy. In conclusion, although pituitary adenomas respond for the vast majority of sellar tumors, concomitant symptoms such as central diabetes insipidus and rapid tumor growth should raise the suspicion of a diverse diagnosis. The present report intend not only to show a rare case of sellar and suprasellar mixed GCT but also to remind clinicians that if laboratory findings do not fit into patient's diagnosis (such as high testosterone levels in our patient), then the diagnosis should be reviewed.
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Affiliation(s)
- Luiz Eduardo Armondi Wildemberg
- Endocrinology Unit, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.
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17
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Pinho LKJD, Vieira Neto L, Wildemberg LEA, Moraes AB, Takiya CM, Frohman LA, Korbonits M, Gadelha MR. Familial isolated pituitary adenomas experience at a single center: clinical importance of AIP mutation screening. ACTA ACUST UNITED AC 2011; 54:698-704. [PMID: 21340155 DOI: 10.1590/s0004-27302010000800006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 10/27/2010] [Indexed: 11/22/2022]
Abstract
We present four FIPA kindred discussing clinical and molecular data and emphasizing the differences regarding AIP status, as well as the importance of genetic screening. Family 1 consists of five patients harboring somatotropinomas with germline E24X mutation in AIP. In one of the patients, acromegaly was diagnosed through active screening, being cured by surgery. Families 2 and 3 are composed of two patients with non-functioning pituitary adenomas. Family 4 comprises patients harboring a prolactinoma and a somatotropinoma. No mutations in AIP were found in these families. No patient in Family 1 was controlled with octreotide treatment, while the acromegalic patient in Family 4 was controlled with octreotide LAR. In conclusion, FIPA is a heterogeneous condition, which may be associated with AIP mutation. Genomic and clinical screening is recommended in families with two or more members harboring pituitary adenomas, allowing early diagnosis and better outcome.
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18
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Moraes AB, Taboada GF, Carneiro MP, Neto LV, Wildemberg LEA, Madi K, Domingues RC, Gadelha MR. Utility of [(18)F] fluoro-2-deoxy-D: -glucose positron emission tomography in the localization of ectopic ACTH-secreting tumors. Pituitary 2009; 12:380-3. [PMID: 18459046 DOI: 10.1007/s11102-008-0125-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Ectopically ACTH producing tumors may be difficult to localize by conventional radiology and functional imaging may be helpful. Case 1: 31-year-old man was diagnosed with ectopic ACTH-dependent Cushing's syndrome (ECS). Thorax CT revealed a 1.3 cm nodular opacity in upper left lobe, suggestive of residual lesion. [(18)F] fluoro-2-deoxy-D: -glucose ([(18)F] FDG) positron emission tomography ([(18)F] FDG PET) scan revealed mild glycolytic metabolic activity. Pathological examination confirmed an ACTH-positive carcinoid tumor. Case 2: 53-year-old woman presented with very rapid onset ECS. Pituitary MRI was normal. Thorax CT revealed no tumoral lesion. Abdominal and pelvic MRI showed images suggestive of hepatic and iliac, femoral and lumbar secondary implants. [(18)F] FDG PET scan revealed intense uptake in uterus, especially cervix, suggesting this to be the primary tumor site. These cases illustrate the role of [(18)F] FDG PET in the investigation of an ECS where conventional imaging studies were not elucidative in the search for a responsible tumor.
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Affiliation(s)
- Aline Barbosa Moraes
- Endocrinology Unit, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rua Nascimento Silva, 555 apt: 101, CEP: 22421-020, Rio de Janeiro, RJ, Brazil
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19
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Rosa MI, Medeiros LR, Bozzetti MC, Fachel J, Wendland E, Zanini RR, Moraes AB, Rosa DD. Accuracy of telomerase in cervical lesions: a systematic review. Int J Gynecol Cancer 2007; 17:1205-14. [PMID: 17506842 DOI: 10.1111/j.1525-1438.2007.00980.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The detection of telomerase activity in cervix may provide information on cervical carcinogenesis and may be a marker to monitor cervical intraepithelial neoplasia transition. A quantitative systematic review was performed to estimate the accuracy of telomerase assay in cervical lesions. Studies that evaluated the telomerase test (telomerase repeated amplification protocol) for the diagnosis of cervix lesions and compared it to paraffin-embedded sections as the diagnostic standard were included. Ten studies were analyzed, which included 1069 women. The diagnostic odds ratio (DOR) for a positive telomerase test for low-grade squamous intraepithelial lesions (Lo-SIL) vs normal or benign lesions was 3.2 (95% CI, 1.9-5.6). The DOR for a positive telomerase test for high-grade squamous intraepithelial lesions (Hi-SIL) vs Lo-SIL, normal or benign lesions was 5.8 (95% CI, 3.1-10). For cervix cancer vs Hi-SIL, the DOR for a positive telomerase test was 8.1 (95% CI, 3.2-20.3) and for cervix cancer vs Lo-SIL, normal or benign lesions, it was 40.9 (95% CI, 18.2-91). Our data support the current hypothesis that telomerase may activate an early event in cervical carcinogenesis that could be associated with the initiation and progression of cervical lesions.
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Affiliation(s)
- M I Rosa
- Postgraduate Program in Epidemiology, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
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