RESUMO
BACKGROUND: Life expectancy in recent decades has increased the prevalence of chronic diseases in the population, requiring an approach to new health topics, such as discussions on quality of life and expectations about death and dying. The concept of advance directives (ADs) gives individuals the opportunity to make known their decisions about the treatments they would like to receive at the end of life. Despite the recognition of relevance in clinical practice, the applicability of the concept presents challenges, including establishing the appropriate prognosis for each patient and the ideal time to approach the patient. Some prognostic tools were developed, such as the surprise question (SQ): "Would you be surprised if your patient died in 12 months?", which is used in some clinical settings to predict patient deaths and to make decisions regarding ADs. The main objective of the present study was to evaluate the behavior of second-year resident physicians (PGY-2) when the SQ was applied. METHOD: In our observational study, from July 1, 2016, to February 28, 2017, (PGY-2) in the Internal Medicine Residency Program (IMRP) applied SQ to all patients with multiple and varied chronic no communicable comorbidities, who were followed up at the general medicine outpatient clinic (GMOC) of a tertiary university hospital in São Paulo- Brazil. The frequency of the outcome (death or non-death within 12 months) was analyzed by correlating it with the clinical data (impact of the studied variables). RESULTS: Eight hundred forty patients entered the study. Fitfty-two of them (6.2%) died within one year. PGY-2 predicted that two hundred and fourteen patients (25.5% of total) would die within a year (answer No to SQ), of which, 32 (14.9%) did so. The correct residents' prognosis for the subgroup of 626 patients (answer "Yes" to SQ) was NPV = 96.8% (CI = 95.4%-98.2%) and PPV = 14.9% (CI 10.1%-19, 6%). Answering "Yes" to SQ correlated negatively to addressing AD while the outcomes death and the answer No to SQ were positively correlated, according to the number of comorbidities. CONCLUSION: The SQ, in addition to care, contributed to health education, communication and care planning shared by the doctor and patient.
Assuntos
Pacientes Ambulatoriais , Cuidados Paliativos , Humanos , Prognóstico , Qualidade de Vida , Estudos Prospectivos , Brasil/epidemiologiaRESUMO
Brain natriuretic peptide (BNP) is used as a marker of cardiac dysfunction to predict heart failure mortality. The significance of the prognostic ability of BNP for liver cirrhosis remains unknown, although the levels of BNP seen in cirrhosis are high. We aimed to determine whether the BNP level is related to the stage of cirrhosis and could serve as a prognostic marker of cirrhosis (predict the 1-year all-cause mortality). We recruited 92 patients at different stages of cirrhosis and 81 controls matched by age and gender for this study. At admission, cardiac physical examination and BNP measurements were performed. Upon discharge, the 89 patients were followed up for 12 months. The median BNP levels of patients with cirrhosis were 167.0 pg/mL, which were significantly higher than those of the control group (167.0 vs 34.8 pg/mL, P = 0.001). Serum BNP levels were positively correlated with the Child score, the grade of esophageal varices, a history of spontaneous bacterial peritonitis, and the presence of ascites and collateral circulation. BNP levels above the median were associated with an increased occurrence of death within 12 months of discharge (log rank P = 0.025), as determined by univariate and multivariate Cox regression analyses. Esophageal varices, large/medium volume ascites, and BNP levels were related to the clinical outcome (P = 0.034, 0.030, and 0.025, respectively). Together, these results suggested that serum BNP levels are significantly correlated with the stage of cirrhosis, suggesting that BNP levels might serve as a significant predictor for 1-year all-cause mortality.
Assuntos
Cirrose Hepática/sangue , Cirrose Hepática/mortalidade , Peptídeo Natriurético Encefálico/sangue , Prognóstico , Adulto , Idoso , Progressão da Doença , Feminino , Humanos , Cirrose Hepática/terapia , Masculino , Pessoa de Meia-Idade , Fragmentos de Peptídeos/sangue , Fatores de RiscoRESUMO
Ovarian steroid cell tumors are rare neoplasms composed of typical steroid hormone-secreting cells. Most ovarian steroid cell tumors, however, cannot be appropriately classified on a morphological basis, because the neoplastic cells closely resemble adrenal cortical cells. Nevertheless, the true adrenal origin of such tumors has been difficult to demonstrate. Here we report a 3-yr-old girl with isosexual pseudoprecocious puberty due to an ovarian steroid tumor whose adrenal cell origin was determined by the presence of messenger ribonucleic acid (mRNA) of adrenal-specific steroidogenic P450 enzymes (P450c11 and P450c21) and ACTH receptor (ACTHR). Her height was +2.3 SD, and she had Tanner stage III breast development, Tanner stage II pubic hair, and a normal clitoris. Bone age was 5 yr. Basal gonadotropin levels were undetectable (<0.6 U/L for LH and <1.0 U/L for FSH) and remained undetectable after stimulation with 100 microg GnRH, i.v. Basal serum testosterone and 17-hydroxyprogesterone levels were slightly elevated, whereas basal serum androstenedione, estradiol, and dehydroepiandrosterone sulfate levels were clearly elevated. Pelvic ultrasound disclosed an enlarged uterus and an adnexal multicystic mass in the right ovary, and pathological studies disclosed an ovarian steroid cell tumor. To establish the cellular origin of the tumor we determined the presence of mRNA for P450c11, P450c21, and ACTHR in tumor tissue and normal adrenal and ovarian tissue. Detection of ACTHR, P450c21, and P450c11 mRNAs isoforms was achieved in tumoral and adrenal control tissue, but not in the ovary control tissue. The RT-PCR products of P450c11 from adrenal control tissue were composed by both BglI-sensitive and -resistant complementary DNAs, indicating the presence of both P450c11AS and P450c11beta, whereas RT-PCR product from the tumor was resistant to BglI digestion, indicating only the presence of P450c11beta. We conclude that the histological origin of so-called adrenal rest tumor could be reliably determined by assessing the expression of specific genes in the tumor as P450c11beta and P450c21. The use ofthese molecular tools will allow a more precise classification of an important subset of the ovarian steroid cell tumors and can help to identify ectopic adrenal tissue in ovary and testis.
Assuntos
Glândulas Suprarrenais/metabolismo , Neoplasias Ovarianas/patologia , Puberdade Precoce/etiologia , Receptores da Corticotropina/metabolismo , Esteroides/biossíntese , Glândulas Suprarrenais/enzimologia , Pré-Escolar , Feminino , Hormônios Esteroides Gonadais/sangue , Humanos , Neoplasias Ovarianas/complicações , Neoplasias Ovarianas/enzimologia , Puberdade Precoce/enzimologia , RNA Mensageiro/análise , RNA Neoplásico/análise , Reação em Cadeia da Polimerase Via Transcriptase ReversaRESUMO
Histoplasma capsulatum is a universal dimorphic fungus found mainly in soil contaminated with excrement of birds and bats. Bilateral adrenal masses with massive tissue destruction are a rare primary presentation of disseminated histoplasmosis. As it behaves as an opportunistic pathogen there is a higher susceptibility for dissemination on those patients with immunodeficiency or immunosuppression. We report a case in an elderly diabetic patient with bilateral adrenal enlargement, diagnosed as histoplasmosis only after surgical exploration, with symptoms probably occurring at least 60 years after the original infection. She was successfully treated with itraconazole.
Assuntos
Doenças das Glândulas Suprarrenais/etiologia , Histoplasmose/diagnóstico , Doenças das Glândulas Suprarrenais/tratamento farmacológico , Idoso , Antifúngicos/uso terapêutico , Feminino , Histoplasmose/complicações , Histoplasmose/tratamento farmacológico , Humanos , Imunocompetência , Itraconazol/uso terapêuticoRESUMO
GH receptor (GHR) has been reported to express in both normal rat and human adrenals. However, no study examined GHR expression in diseased human adrenal cortex. We quantitated, with RT-PCR, GHR messenger RNA (mRNA) in both normal and diseased human adrenal cortex with the following results: GHR mRNA levels in four histologically normal, not steroid-stimulated, control adrenal cortices was 1.5-11 x 10(4) molecules/microgram total RNA; in three diffusely hyperplastic adrenals (DH): 6.7-17.7 x 10(4); in two nonfunctioning tumors (NF): 0.84-1.9 x 10(4); in five androgen-producing neoplasms (AP): 4.6-34 x 10(4); and in five glucocorticoid-producing neoplasms (GP): 6.7-87 x 10(4). GHR transcript levels among adrenal cortices, DH, NF, AP, and GP reached statistically significant difference (P < 0.03). The GP group exhibited higher GHR mRNA levels than controls (P < 0.006). NF, as well as GP and AP, tumors had less GHR mRNA than their histologically normal adjacent cortex (P < 0.05). A positive correlation between urinary cortisol and GHR messenger RNA (mRNA) levels from GP and DH was observed (r = 0.93, P < 0.003). Our data suggest that GHR is expressed in both normal and diseased adrenal cortex and that GHR mRNA accumulation is less efficient in adrenocortical neoplasm than their adjacent nonneoplastic cortex. GHR expression in adrenal cortex provides an evidence of direct GH action in this tissue.