Postgraduate Program

Belo Horizonte, Brazil

Postgraduate Program

Belo Horizonte, Brazil

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Rosario P.W.,Postgraduate Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2013

Background: By consensus, a thyrotropin (TSH) level persistently >10 mIU/L is an indication for the treatment of subclinical hypothyroidism (SCH). Controversy exists regarding patients whose TSH level is elevated but <10 mIU/L. Recently, the American Thyroid Association (ATA) and the American Association of Clinical Endocrinologists (AACE) published their position about factors that should be considered in the decision on treating SCH. This study evaluated the frequency of these factors among adult (non-pregnant) women with SCH whose TSH levels are ≤10 mIU/L. Methods: The presence of the conditions that should be considered for the treatment of SCH according to ATA and AACE was evaluated in 252 women who were diagnosed with SCH and had TSH levels ≤10 mIU/L. Pregnant women were excluded. Results: Antithyroperoxidase antibodies (TPOAbs) were detected in 137 (54.3%) women. A high cardiovascular risk was observed in 43 (17%) women. Eighty (31.7%) women who were not at high cardiovascular risk presented at least one classical risk factor (arterial hypertension, elevated level of low-density lipoprotein-cholesterol or low level of high-density lipoprotein-cholesterol, smoking, or first-degree family history of premature coronary artery disease). At least one symptom or sign of hypothyroidism that could not be explained by another condition was observed in 180 (71.4%) women. Two hundred thirty-two (92%) women had positive TPOAbs, or at least one classical cardiovascular risk factor, or at least one symptom or sign of hypothyroidism. Conclusions: According to the new ATA and AACE guidelines, L-T4 therapy would be considered for 92% of women with SCH and TSH ≤10 mIU/L. © 2013, Mary Ann Liebert, Inc.


Rosario P.W.,Postgraduate Program | Mineiro Filho A.F.C.,Postgraduate Program | Prates B.S.S.,Postgraduate Program | Silva L.C.O.,Postgraduate Program | And 2 more authors.
Thyroid | Year: 2012

Background: Epidemiological studies have shown a higher risk of thyroid cancer among individuals who have a relative with papillary thyroid cancer (PTC) compared to those without a family history. This study evaluated the prevalence of thyroid cancer among subjects with only one first-degree relative (sibling) with PTC who had no palpable nodules, factors predictive of this malignancy, and the characteristics of tumors discovered during ultrasonographic screening. Methods: A total of 757 siblings of 447 patients with apparently sporadic PTC were examined. Nodules were palpable in 34 subjects (excluded). The 723 individuals without palpable abnormalities were submitted to thyroid ultrasonography and comprised the study group. The control group, consisting of 241 volunteers without a family history of thyroid cancer matched for gender and age to the study group, was also submitted to thyroid ultrasonography. All nodules ≥5 mm were examined by fine-needle aspiration cytology. Subjects with benign cytology were not submitted to surgery, whereas the subjects having malignant, suspicious for a malignancy, indeterminate, or inadequate cytology were referred for thyroidectomy. Results: Ultrasonography detected nodules in 303 (41.9%) study subjects. PTC was observed in 5.94% of the 723 subjects studied (8% women and 3.75% men, p=0.017) and in 14.2% of the 303 subjects with nonpalpable nodular disease. In the control group, 80 (33.2%) of the volunteers had nodules. PTC was observed in 1.2% of them and in 3.8% of those with nodular disease. In addition, 7.17% of the 447 patients had siblings with PTC detected only by ultrasonography. Multicentricity of the tumor was the main predictor of the presence of malignancy in siblings of patients with PTC. Twenty-two subjects (3% of those screened) had tumors that were not intrathyroid microcarcinomas (whereas all three tumors detected in controls were intrathyroid microcarcinomas). Screening permitted an earlier diagnosis of the disease when compared to siblings with a spontaneous diagnosis. Conclusions: The present results favor ultrasonographic screening of first-degree relatives of patients with apparently sporadic multicentric PTC, especially among women. © Copyright 2012, Mary Ann Liebert, Inc.


Background: One of the adverse effects of radioactive iodine ( 131I) treatment in patients with thyroid cancer is damage to the salivary and lacrimal glands. In almost all studies evaluating salivary and lacrimal gland dysfunction, the patients received 131I after levothyroxine (L-T4) withdrawal. Since the biokinetics of 131I after recombinant human thyrotropin (rhTSH) is not the same as in hypothyroidism, studies need to evaluate 131I-induced salivary and lacrimal toxicity after preparation with rhTSH. This prospective study investigated the occurrence of salivary and lacrimal damage after ablation with 131I using this preparation. Methods: One hundred forty-eight patients who had a total thyroidectomy were included in the study. The subjects were evaluated after thyroidectomy during L-T4 use to exclude those who already showed symptoms or had a history of ocular or oral disease. Symptoms were investigated 12 and 18 months after ablation. In patients who had persistent symptoms, specific tests were performed to confirm glandular dysfunction and to rule out other causes. Results: Twelve months after ablation, symptoms of salivary or lacrimal dysfunction were observed in 10 (6.7%) patients, including oral symptoms in 8 (5.4%) and ocular symptoms in 6 (4%). Eighteen months after 131I, symptoms persisted in eight (5.4%) patients, including oral symptoms in seven (4.7%) and ocular symptoms in five (3.4%). In all of the patients, glandular dysfunction was confirmed by specific tests and other causes were ruled out. No symptoms were seen in the patients who received a low 131I dose (30 mCi). In the patients who received high 131I doses (100 or 150 mCi), symptoms were noted 12 months after 131I in 10 patients (9.2%), and 18 months after 131I in 8 patients (7.4%). Conclusions: Apparently, the rates of salivary and lacrimal damage were lower than those reported in prospective studies that used similar 131I activities, but these studies were performed in patients who were hypothyroid at the time of 131I ablation. Further studies are needed to compare radiotoxicity between patients prepared for 131I ablation with rhTSH and those prepared for 131I ablation with L-T4 withdrawal. © 2013, Mary Ann Liebert, Inc.


Rosario P.W.,Postgraduate Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2014

Background: Little is known about the medium- and long-term outcomes of thyroid ablation with 1.1GBq (30mCi) 131I in patients with papillary thyroid carcinoma who have a tumor >4cm or accompanied by extrathyroid invasion or clinically detected lymph node metastases (cN1). The objective of this study was to evaluate the efficacy of ablation with 30mCi 131I in this subgroup of patients and to report the medium-term outcomes. Methods: We studied 152 patients with papillary thyroid carcinoma submitted to total thyroidectomy with apparently complete tumor resection, who had a tumor >4cm or 2-4cm accompanied by extrathyroid invasion or lymph node metastases, or ≤2cm accompanied by both extrathyroid invasion and lymph node metastases. Patients with extensive extrathyroid invasion by the primary tumor were excluded. Lymph node involvement was detected by ultrasonography or palpation (cN1). Results: Forty-two patients were prepared by administration of recombinant human thyrotropin and 110 by levothyroxine withdrawal. Posttherapy whole-body scanning revealed unequivocal ectopic uptake in three patients. When evaluated 9-12 months after ablation, 123 patients had achieved complete ablation (stimulated thyroglobulin [Tg] <1ng/mL, negative anti-Tg antibodies, and neck ultrasonography); a new posttherapy whole-body scanning revealed persistent disease in 2 patients whose initial posttherapy whole-body scanning (obtained at the time of ablation) had already shown ectopic uptake; 12 patients presented with a Tg >1ng/mL and 14 had positive anti-Tg antibodies without apparent metastases; 1 patient had metastases not detected at the time of ablation. Recurrence was observed in an additional 6 patients during follow-up (median 76 months). There was no case of death related to the disease. Therefore, an activity of 30mCi failed in only 9 (6%) patients with persistent disease or recurrence after ablation. None of the variables analyzed (sex, age, tumor size, multicentricity, extrathyroid invasion, lymph node metastases, preparation [recombinant human thyrotropin or levothyroxine withdrawal]) was a predictor of ablation failure. Conclusions: An activity of 30mCi 131I is effective in thyroid ablation in patients with stage T3 and/or N1papillary thyroid carcinoma. © Mary Ann Liebert, Inc.


Rosario P.W.,Postgraduate Program | Mourao G.F.,Postgraduate Program | Siman T.L.,Postgraduate Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2015

Background: Follow-up consisting of the measurement of nonstimulated serum thyroglobulin (Tg) combined with neck ultrasonography is recommended for patients with papillary thyroid carcinoma without indication for radioiodine ablation. There is no recommendation of thyrotropin suppression during this follow-up. New-generation Tg assays have been increasingly used, but few studies involve patients submitted only to thyroidectomy and they have several limitations. The objective of this prospective study was to define expected concentrations of nonstimulated Tg measured with a second-generation assay after total thyroidectomy in the absence of tumor. Methods: Serum Tg was measured using a second-generation assay in 69 patients without tumor and serum thyrotropin between 0.5 and 2 mIU/L, 3, 6, 12, and 24 months after total thyroidectomy. All patients had undetectable anti-Tg antibodies. Results: Serum Tg was undetectable in 44.4%, 57%, 62.5%, and 62.1% of the patients 3, 6, 12, and 24 months after thyroidectomy, respectively, and was ≤0.5 ng/mL in 60.3%, 80%, 90.6%, and 90.9% of patients. All patients had a Tg≤2 ng/mL 6 months after thyroidectomy, and 97% had a Tg≤1 ng/mL 24 months after surgery. There was no case of Tg conversion from undetectable to detectable and none of the patients presented an increase in Tg. Conclusions: An important decline in serum Tg occurred between 3 and 6 months after total thyroidectomy. One year after surgery, Tg was undetectable in approximately 60% of the patients and was ≤2 ng/mL in all of them. © 2015, Mary Ann Liebert, Inc.


Rosario P.W.,Postgraduate Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2015

Background: Traditionally, repetition of fine-needle aspiration (FNA) is indicated for thyroid nodules with initially benign cytology if they exhibit growth. The importance of a repetition has also been demonstrated in the case of suspicious ultrasonography (US) findings. Some authors even consider routine repetition of FNA. The objective of this study was to evaluate the best criterion for FNA repetition in thyroid nodules with initially benign cytology. Methods: This was a prospective study. Patients with solid nodules that initially showed a benign cytology were selected. The first group was formed by nodules exhibiting suspicious features on initial US (group A, n=55). The other group consisted of growing nodules without suspicious US features (group B, n=82). Nongrowing nodules without suspicious features on initial US were divided into two groups: nodules that became suspicious on US (group C.1, n=18) and those that continued to be unsuspicious (group C.2, n=398). Results: In group A, the second FNA resulted in the diagnosis of malignancy in 10 cases (18.2%). In group B, malignancy was confirmed in two cases (2.4%). In group C.1, two nodules were confirmed to be malignant (11.1%). No case of carcinoma was observed in group C.2. Considering the sensitivity and number of FNA biopsies necessary for the detection of each false-negative case of the first FNA, the best criterion to repeat FNA was a suspicious initial or subsequent US. The growth of nodules with unsuspicious US findings was of poorly specificity and required a larger number of FNA biopsies to detect one case of malignancy. Conclusions: Ultrasonographic features of the nodule are the best parameter for the indication of FNA repetition in nodules with initially benign cytology, while the growth of nodules with unsuspicious US findings has a poor positive predictive value for malignancy. © Mary Ann Liebert, Inc. 2015.


Rosario P.W.,Postgraduate Program | Mineiro Filho A.F.C.,Postgraduate Program | Lacerda R.X.,Postgraduate Program | Dos Santos D.A.,Postgraduate Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2012

Background: In the presence of anti-thyroglobulin antibodies (TgAb), serum thyroglobulin (Tg) might be underestimated. Therefore, the American Thyroid Association does not recommend serum Tg after thyroid hormone withdrawal or recombinant human thyrotropin administration (stimulated Tg) and diagnostic whole-body scanning (DxWBS) in TgAb-positive patients who have serum Tg values while on thyroxine (Tg-on-T4) of <1 ng/mL. The objective of this study was to determine, in patients with differentiated thyroid cancer (DTC) who appeared to be free of disease after surgery and ablative treatment, but who had positive serum TgAb, the value of performing DxWBS and obtaining serum Tg under stimulated Tg conditions. Methods: There were 121 women and 15 men in the study. By selection criteria, all of them had total thyroidectomy with apparent complete tumor resection, remnant ablation with 131I (1.1-5.5 GBq), and a post- 131I therapy WBS that were negative for ectopic 131I uptake. On assessment 8-12 months after 131I ablation, their clinical exam needed to be normal, their Tg-on-T4 needed to be <1 ng/mL, and the test for TgAb needed to be positive. Stimulated Tg, neck ultrasound (US), and DxWBS were obtained from all patients. Patients with stimulated Tg >1 ng/mL without disease on US and DxWBS were evaluated by other imaging methods. Results: In 10 (7.3%) patients, stimulated Tg was >1 ng/mL. The DxWBS revealed metastases in two of these patients, and other imaging methods showed disease in three others. Stimulated Tg was <1 ng/mL in 126 patients. DxWBS revealed metastases in three of these patients, and US detected lymph node metastases in four with a negative DxWBS. Tg stimulation combined with DxWBS revealed evidence for disease in 13 (9.5%) patients. When excluding patients with a positive US, DxWBS revealed metastases in four patients, and stimulated Tg of >1 ng/mL led to detection of persistent disease by other imaging methods in two more patients. Conclusions: Performing stimulated Tg and DxWBS at the same time seems to be useful after initial therapy in DTC patients with TgAb who do not otherwise appear to have persistent disease, even when US is negative. © 2012, Mary Ann Liebert, Inc.


Rosario P.W.,Postgraduate Program | Mourao G.F.,Postgraduate Program | Dos Santos J.B.N.,Postgraduate Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2014

Background: At present, empirical radioactive iodine therapy is recommended for patients with thyroid cancer and elevated thyroglobulin (Tg) after initial therapy when neck ultrasonography (US), chest computed tomography (CT), and 18-fluorodeoxyglucose positron emission tomography (FDG-PET) do not reveal metastases. The objective of this study was to determine whether empirical 131I therapy is indeed useful in these patients. Methods: Patients with papillary thyroid cancer submitted to total thyroidectomy followed by remnant ablation with 131I in whom whole-body scanning at the time of ablation (WBS-ablation) did not reveal metastases and who had elevated Tg after initial therapy were selected. Included in the study were patients with basal Tg >2 ng/mL or Tg >5 ng/mL after stimulation with recombinant human thyrotropin or Tg >10 ng/mL after levothyroxine withdrawal for 4 weeks. All patients were first investigated by neck US and chest CT. FDG-PET/CT was performed in patients with negative US and CT. The final sample of this study consisted of patients with negative US, CT, and FDG-PET/CT. These patients received an activity of 100 mCi 131I and were submitted to posttherapy WBS (RxWBS). Results: Among the 24 patients receiving empirical 131I therapy, no ectopic uptake was seen in 23 and mild uptake in the thyroid bed (<0.5%) in 15. Only one patient presented pulmonary metastases detected by RxWBS. Disease was observed in two other patients during short-term follow-up (mean 22 months), one with lymph node metastases diagnosed by a repeat US and one with bone metastases diagnosed by CT and FDG-PET scans. Conclusions: We conclude that RxWBS rarely reveals disease in patients with elevated Tg after ablation, but with negative findings on WBS-ablation, US, CT, and FDG-PET. In this situation, empirical 131I therapy should be restricted to patients with documented progression of serum Tg. © 2014, Mary Ann Liebert, Inc.


Rosario P.W.,Postgraduate Program | Mourao G.F.,Postgraduate Program | Calsolari M.R.,Postgraduate Program
Hormone and Metabolic Research | Year: 2016

This study screened for asymptomatic primary hyperparathyroidism (PHPT) by measuring calcium (Ca) before thyroid surgery. The study was prospective. A total of 676 patients without a suspicion of PHPT were studied. PHPT was defined as elevated Ca (in 2 measurements) in the presence of PTH>25 pg/ml and in the absence of hypocalciuria. PHPT was diagnosed in 5 patients (0.74%), all of them women. One of the 5 patients with PHPT had no indication for parathyroidectomy (PTx) according to current guidelines. Parathyroid adenoma was easily identified during perioperative assessment of thyroid surgery in 3 patients. In the other 2 patients (0.3%), localization of the adenoma required specific exploration, which was only performed because of the preoperative diagnosis of PHPT. Normalization of Ca and PTH was achieved in all 5 patients. In conclusion, in patients without a clinical or ultrasonographic suspicion of PHPT, approximately 300 individuals should be screened before thyroid surgery to avoid one reoperation (PTx) due to PHPT, which does not seem to be cost-effective. Copyright © 2016, Georg Thieme Verlag KG. All rights reserved.


Background: Self-monitoring of blood glucose (SMBG) has been recommended as a useful tool for improving glycemic control, but is still an underutilized strategy and most diabetic patients are not aware of the actions that must be taken in response to its results and do not adjust their treatment. The purpose of this study was to evaluate the effectiveness and safety of an educational program for insulin self-adjustment based on SMBG in poorly controlled patients with type 2 diabetes (T2DM). Methods: A prospective, randomized, controlled 12-week intervention study was conducted on poorly controlled insulin-requiring patients with T2DM. Twenty-three subjects were randomized to two educational programs: a 2-week basic program with guidance about SMBG and types and techniques of insulin administration (group A, n∈=∈12) and a 6-week program including the basic one and additional instructions about self-titration of insulin doses according to a specific protocol (group B, n∈=∈11). Patients were reviewed after 12 weeks and baseline to endpoint changes in glycated hemoglobin (A1C), insulin doses, body weight and incidence of hypoglycemia were compared by paired and independent Student t-tests. Results: After 12 weeks, there was a significant reduction in A1C only in group B, but group comparison showed no significant difference (p∈=∈0.051). A higher percentage of subjects in group B achieved an A1C near the treatment target (<7.5%) than in group A. Daily insulin dose increased non-significantly in the two groups and there was no significant difference in the incidence of hypoglycemia or body weight changes between groups. Conclusions: Training for self-titrating insulin doses combined with structured SMBG can safely improve glycemic control in poorly controlled insulin-treated T2DM patients. This strategy may facilitate effective insulin therapy in routine medical practice, compensating for any reluctance on the part of physicians to optimize insulin therapy and thus to improve the achievement of recommended targets of diabetes care. © 2015 Silva and Bosco; licensee BioMed Central.

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