Patterns of radioiodine use for differentiated thyroid carcinoma in Brazil: insights and a call for action from a 20-year database

OBJECTIVE

This study aimed to explore the patterns of radioactive iodine (RAI) use for differentiated thyroid cancer (DTC) in Brazil over the past 20 years.

METHODS

A retrospective analysis of the DTC-related RAI prescriptions, from 2000 to 2018, retrieved from the Department of Informatics of the Unified Health System (Datasus) and National Supplementary Health Agency (ANS) database was performed. RAI activities prescriptions were re-classified as low (30-50 mCi), intermediate (100 mCi), or high activities (>100 mCi).

RESULTS

The number of DTC-related RAI prescriptions increased from 0.45 to 2.28/100,000 inhabitants from 2000 to 2015, declining onwards, closing 2018 at 1.87/100,000. In 2018, population-adjusted RAI prescriptions by state ranged from 0.07 to 4.74/100,000 inhabitants. Regarding RAI activities, in the 2000 to 2008 period, the proportion of high-activities among all RAI prescriptions increased from 51.2% to 74.1%. From 2009 onwards, there was a progressive reduction in high-activity prescriptions in the country, closing 2018 at 50.1%. In 2018, the practice of requesting high-activities varied from 16% to 82% between Brazilian states. Interestingly, variability of RAI use do not seem to be related to RAI referral center volume nor state socio-economic indicators.

CONCLUSION

In recent years, there has been a trend towards the lower prescription of RAI, and a reduction of high-activity RAI prescriptions for DTC in Brazil. Also, significative inter-state and inter-institutional variability on RAI use was documented. These results suggest that actions to advance DTC healthcare quality surveillance should be prioritized.

Pituitary Macroprolactinoma Apoplexy in a Prepubertal Girl

Background: Prolactinomas are rare in children, with an incidence of 1: 10.000.000 cases, representing less than 2% of all intracranial tumors in this age group (1). Indeed, only a few cases are reported in prepubertal children.

Clinical Case: Eight-year old female prepubertal child, previously healthy, presented a progressive loss of the visual acuity in the last 5 months and was admitted to the emergency department with an intensive headache associated with nauseas, started 48 hours before the admission. At the physical examination, the patient was eutrophic, with an infantile genitalia and no breast development or galactorrhea. No focal neurologic deficits were detected and presented normal pupils reflex and preserved extrinsic eye movements. The Campimetry evidenced bitemporal heteronymous hemianopsia and the nuclear magnetic resonance of the central nervous system identified a suprasellar and intrasellar expansive lesion measuring 3.2 x 2.6 x 2.3 cm, with bleeding signs and compression of the optic chiasm. The hormonal evaluation showed: free T4 0.55 ng/dL (normal value: 0.93-1.70ng/dL), total T4 4.8ng/dL (5.1-14.1ng/dL), TSH 4.06µUI/mL (0.6-5.4µUI/mL), morning serum cortisol 1.80mcg/dL (6.2-2mcg/dL), ACTH 7.0pg/mL (<46pg/mL), prolactin 3.376ng/mL (4.8-23.3ng/mL). The patient initially started glucocorticoid replacement, subsequently levothyroxine and cabergoline. A diagnosis of macroprolactinoma with pituitary apoplexy and optic nerve compression was performed and confirmed by the Immunohistochemical after the transsphenoidal resection. No history of any neoplasms were reported by family members and calcium abnormalities were excluded in the child. A significant improvement of the visual field was suddenly observed and the prolactin substantially decreased to 35ng/mL within 30 days after the intervention. CONCLUSION: We report a rare case of macroprolactinoma in a prepubertal girl associated with pituitary apoplexy. Complete assessment and prompt intervention were essential to recover the visual field and to prevent major sequelae.

Reference: (1) Yang, A., Cho, S. Y., Park, H., Kim, M. S., Kong, D.S., Shin, H.J., & Jin, D.K. (2020). Clinical, Hormonal, and Neuroradiological Characteristics and Therapeutic Outcomes of Prolactinomas in Children and Adolescents at a Single Center. Frontiers in Endocrinology. 2020; 11:527.

Psychiatric disorders in children with enuresis at 6 and 11 years old in a birth cohort

OBJECTIVE

Enuresis may have a negative impact on the self-image in childhood and adolescence. The objective of this study was to evaluate the association between enuresis and psychiatric disorders at 6 and 11 years of age.

METHOD

3,356 children of a birth cohort were evaluated. A standard questionnaire on urinary habits and mental health (Development and Well-Being Assessment [DAWBA]), was used. The prevalence of psychiatric disorders pursuant to the existence of enuresis and its subtypes (monosymptomatic and non-monosymptomatic), stratified by sex, was described. A logistic regression was used for adjusted analysis.

RESULTS

The prevalence of enuresis at age 6 years was of 10.2% (9% non-monosymptomatic) and, at 11 years old, of 5.4% (4.5% non-monosymptomatic). At age 6 years, boys with non-monosymptomatic enuresis showed more hyperactivity disorders than those without enuresis (6.2% vs. 2.7%, p=0.017). At 11 years old, after adjustment, among the boys with non-monosymptomatic enuresis, the prevalence of any psychiatric disorder, hyperactivity disorders, and oppositional disorders was, respectively, 3.2, 3.4, and 2.6 times higher than in boys without enuresis; and, among the girls with non-monosymptomatic enuresis, the prevalence of any psychiatric disorder and oppositional disorders was, respectively, 4 and 5.5 times higher than among girls without enuresis.

CONCLUSION

There is a strong association between non-monosymptomatic enuresis and psychiatric disorders at 6 and 11 years old.

Treatment of Mycobacterium marinum with lymecycline: new therapeutic alternative?

Skin infections by Mycobacterium marinum are quite rare in our environment and, therefore, little studied. The majority of the lesions appear three weeks after traumas in aquariums, beaches and fish tanks. Lymph node drainage and systematization of the disease are rare and most lesions disappear in about three years. This case aims to show the effectiveness of the treatment used (lymecycline 150 mg/orally/day). This medication may be a new therapeutic option for the treatment of Mycobacterium marinum.

Severe and refractory myositis in mixed connective tissue disease: a description of a rare case

Mixed connective tissue disease (MCTD) is a rare disease that includes clinical and laboratorial manifestations of systemic lupus erythematosus, scleroderma and polymyositis that is associated with high titers of anti-U1RNP antibodies. In general, muscle involvement is subclinical, usually appearing as an increase in muscle enzyme levels that tends to be a characteristic of the initial phases of the disease. Severe clinical muscle weakness is not observed in this disease. The objective of this study is to report a rare case of a patient who presented a severe onset of myositis characterized by dysphagia, an increase in myopathy and a weakening of the cervical musculature. While there was no response to the administration of an initial dose of corticosteroids, improvement was observed after increasing the dose of corticosteroids, in addition to the initiation of pulse therapy with methylprednisolone accompanied by methotrexate treatment. The authors emphasize that there is only one previously reported case regarding a child with MCTD and severe clinical myopathy on electromyography and muscle biopsy, and they report in this article one adult female patient who presented severe myositis and was refractive to corticotherapy.