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- ItemSomente MetadadadosAbsolute and relative adrenal insufficiency in children with septic shock(Lippincott Williams & Wilkins, 2005-04-01) Pizarro, C. F.; Troster, E. J.; Damiani, D.; Carcillo, J. A.; Universidade Federal de São Paulo (UNIFESP)Objective: Corticosteroid replacement improves outcome in adults with relative adrenal insufficiency and catecholamine-resistant septic shock. We evaluated the relationship of absolute and relative adrenal insufficiency to catecholamine-resistant septic shock in children.Design. Prospective cohort study.Setting. University hospital pediatric intensive care unit in Brazil.Patients. Fifty-seven children with septic shock. Children with HIV infection, those with a history of adrenal insufficiency, and those submitted to any steroid therapy or etomidate within the week before diagnosis of septic shock were excluded.Interventions: None.Measurements and Main Results., A short corticotropin test (250 mu g) was performed, and cortisol levels were measured at baseline and 30 and 60 mins posttest. Adrenal insufficiency was defined by a response <= 9 mu g/dL. Absolute adrenal insufficiency was further defined by a baseline cortisol < 20 mu g/dL and relative adrenal insufficiency by a baseline cortisol > 20 mu g/dL. Absolute adrenal insufficiency was observed in 18% of children, all of whom had catecholamine-resistant shock. Relative adrenal insufficiency was observed in 26% of children, of whom 80% had catecholamine-resistant and 20% had dopamine/dobutamine-responsive shock. All children with fluid-responsive shock had a cortisol response > 9 mu g/dL. Children with adrenal insufficiency had an increased risk of catecholamine-resistant shock (relative risk, 1.88; 95% confidence interval, 1.26-2.79). However, mortality was independently predicted by chronic illness or multiple organ failure (p <.05), not adrenal insufficiency.Conclusions: Absolute and relative adrenal insufficiency is common in children with catecholamine-resistant shock and absent in children with fluid-responsive shock. Studies are warranted to determine whether corticosterold therapy has a survival benefit in children with relative adrenal insufficiency and catecholamine-resistant septic shock.
- ItemSomente MetadadadosCorticosteroids (inhaled and/or intranasal) in the treatment of respiratory allergy in children: safety vs. efficacy(Elsevier B.V., 2007-09-01) Rizzo, Maria Candida Faria Varanda [UNIFESP]; Solé, Dirceu [UNIFESP]; Naspitz, Charles Kirov [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Background: Topical administration of Corticosteroids (CS) can reduce the total dose of CS required to treat the patient and minimize side effects. Topical CS is extremely effective and has an excellent safety profile. Nonetheless, care must be taken when multiple sites such as lungs, nose and skin are being treated. CS mechanisms of action on the inflammatory process are complex. The aim of this study is to review such mechanisms and the adverse events secondary to it.Methods: Review English database (Embase, Pub-Med, Scielo) searching words: CS, adverse events, inhaled CS, intranasal CS, and children.Results: There is a classic mechanism involving a genomic effect of CS and a non-genomic effect, independently of gene transcription process. This mechanism acts by reducing mucosal blood flow in the asthmatic airways. Second-generation topical CS is the treatment of choice in allergic diseases control because of their good anti-inflammatory activity, poor absorption and first-pass hepatic metabolism. When comparing different CS, it is important to compare therapeutically equivalent doses. Although topical CS reduces systemic side effects, local and even systemic side effects can occur. Many factors affect the amount of drug that reaches the lung, including inhaler technique and inhaler type, fine particle dose and particle distribution.Conclusion: Most patients with allergic diseases respond to CS treatment, but there is a small subset of them whose response is unsatisfactory even with high doses of CS. They are classified as corticosteroid-resistant asthmatics. Pro-inflammatory cytokines appear to up regulate the expression of GR beta that has been associated with CS resistance.
- ItemSomente MetadadadosThe Effect of Corticosteroid Withdrawal on Glucose Metabolism and Anti-GAD Antibodies in Simultaneous Pancreas-Kidney Transplant Patients(Sage Publications Inc, 2016) Silicani Ribeiro, Rogerio; Cristelli, Marina [UNIFESP]; Amor, Antonio J.; Guerrero, Vanessa; Ferrer, Joana; Jose Ricart, Maria; Esmatjes, EnricContext: Corticosteroid withdrawal may reduce insulin resistance
- ItemAcesso aberto (Open Access)Final height in congenital adrenal hyperplasia: the dilemma of hypercortisolism versus hyperandrogenism(Sociedade Brasileira de Endocrinologia e Metabologia, 2013-03-01) Cordeiro, Giovana Vignoli; Silva, Ivani Novato; Goulart, Eugênio Marcos Andrade; Chagas, Antônio José das; Kater, Claudio Elias [UNIFESP]; Universidade Federal de Minas Gerais Department of Pediatrics; Universidade Federal de São Paulo (UNIFESP)OBJECTIVE: The purpose of this study was to identify factors that might interfere with reaching the final height in patients with 21-hydroxylase deficiency (21-OHD). SUBJECTS AND METHODS: Thirty-one patients with classical 21-OHD who reached their FH in our Institution were evaluated in order to compare the Z score for final height (FHZ) with: (1) the target height, (2) the standard height for the population, and (3) the hydrocortisone treatment schedule. RESULTS: The FHZ of -2.13 ± 1.11 had a significant negative correlation with the hydrocortisone doses used throughout the period of study. Patients who reached FH within the normal population range were those who received lower doses of hydrocortisone, as compared to those whose FH remained below -2 SDS. CONCLUSION: We conclude that careful treatment adjustments have a major influence on growth of children with CAH, and that the dose range for hydrocortisone replacement that does not lead to side effects is relatively narrow. The better height outcome was achieved in 21-OHD patients who received lower doses of hydrocortisone.
- ItemAcesso aberto (Open Access)Growth velocity and weight gain in prepubertal asthmatic children(Assoc Medica Brasileira, 2017) Renosto, Larissa Celiberto [UNIFESP]; Acatauassu, Carla [UNIFESP]; Andrade, Itana [UNIFESP]; Rafael, Marina Neto [UNIFESP]; Paulino, Talita Lemos [UNIFESP]; Suano-Souza, Fabola Isabel [UNIFESP]; Sole, Dirceu [UNIFESP]; Saccardo Sarni, Roseli OselkaObjective: To evaluate the stature growth rate (GR) and the weight gain of prepubertal asthmatic children. Method: A retrospective cohort study evaluating medical records of 85 children diagnosed with asthma, aged less than 9 years, of both sexes, with at least one year of follow-up in the allergy outpatient clinic. The data on the disease, weights and heights were collected through a standardized questionnaire on two occasions, with an interval of one year. The curves proposed by Tanner were applied for the analysis of the GR, and the Z-score of the GR (ZGR) was calculated. Results: Excess weight (risk for overweight, overweight and obesity) was observed in 31.8% (27/85) of the patients, but there was no association with the severity of asthma. Low GR (ZGR < -2) was found in 13.9% (11/79) of patients, most frequently among children with moderate/severe persistent asthma compared to persistent mild and intermittent forms (7/11 - 63.6% vs. 21/68 - 30.2%, respectively, p=0.047). Use of steroids (dose, type and time of use) was not associated with GR. Conclusion: GR was most affected in children with moderate/severe asthma.
- ItemSomente MetadadadosHigh prevalence of vertebral deformity in premenopausal systemic lupus erythematosus patients(Arnold, Hodder Headline Plc, 2005-01-01) Borba, VCZ; Matos, P. G.; Viana, PRD; Fernandes, A.; Sato, E. I.; Lazaretti-Castro, M.; Universidade Federal de São Paulo (UNIFESP); Univ Fed ParanaIn this paper we searched for vertebral deformities in a group of 70 premenopausal systemic lupus erythematosus (SLE) patients (31.8 +/- 8.1 years old) and compared them to a matched control group of 22 healthy women (32.0 +/- 8.9 years old). Patients and controls performed spine X-ray (XR) morphometry and lumbar spine and femoral neck bone mineral density (BMD). Clinical data was obtained by a questionnaire and charts review. Thoracic or lumbar spine fracture was observed in 15 (21.4%) SLE patients, while no deformities were found in the control group (P = 0.018). BMD was not different amongst SLE patients and controls and between SLE patients with or without deformities. Although BMD could not predict what patient have deformity, seven patients (46.6%) with deformity had a lumbar spine or femoral neck Z-score less than - 1 SD [median = - 0.59 (- 3.72 to + 0.88) and - 0.20 (- 4.05 to + 1.87)] respectively. in addition, we found a negative correlation between number of fracture per patient and lumbar spine and femoral neck BMD (R = 0.58, P = 0.04 and R = 0.84, P = < 0.0001 respectively). No significant correlation was found between number of deformities and clinical data. This is the first study to search for vertebral deformities in SLE patients and to demonstrate a high prevalence of deformities in a relative young SLE population. These findings bring up the necessity to look for spine deformities in this group of women regardless the BMD.
- ItemSomente MetadadadosLysine-vasopressin in the evaluation of the hypothalamic-pituitary-adrenal axis in children with allergic rhinitis treated with intranasal beclomethasone dipropionate or oral prednisone(J R Prous Sa, 1997-01-01) Kokron, C. M.; Castro, A. S.; Sole, D.; Naspitz, C. K.; Universidade Federal de São Paulo (UNIFESP)One of the complications of steroid therapy is the hypothalamic-pituitary-adrenal (HPA) axis suppression, particularly in children where this can lead to growth suppression and other well known complications. Although there are a large number of studies on suppression of the HPA axis with the use of topical steroids, the subject is still controversial. We measured the HPA axis function in 3 groups of allergic children treated with. 1) intranasal beclomethasone dipropionate (BDP) 400 mu g/day for 4 weeks or 2) BDP 800 mu g/day for 4 weeks and 3) oral prednisone, 1 mg/kg/day for 2 weeks. The HPA response was obtained after lysine-vasopressin (LVP) stimulation. LVP acts on the pituitary or hypothalamus level, stimulating the whole axis. Peripheral blood samples through an intravenous line were obtained for serum cortisol measurement at zero, 30, 60, and 90 minutes after the intravenous injection of LVP, before and after the treatment period. Our results showed no suppression of the HPA axis in children medicated with BDP at either 400 mu g/day or 800 mu g/day. On the other hand, there was a suppression of the HPA axis after prednisone treatment (p <0.05). During the LVP test some side effects, possibly due to systemic vasoconstriction, were noted such as abdominal pain, nausea and vomiting, and transient hypertension. in conclusion, intranasal BDP at the dose of 400 or 800 mu g/day during 4 weeks did not induce HPA axis suppression. The LVP test is efficient to demonstrate HPA hypofunction or suppression and it produced only mild to moderate transient side effects. However, due to the side effects observed, a safer test such as urinary free cortisol (24 hours), should be used in the investigation of the HPA axis.
- ItemSomente MetadadadosPostoperative subconjunctival corticosteroid injection to prevent pterygium recurrence(Lippincott Williams & Wilkins, 2008-05-01) Paris, Fabiana dos Santos [UNIFESP]; Farias, Charles Costa de [UNIFESP]; Melo, Gustavo Barreto de [UNIFESP]; Santos, Myrna Serapião dos [UNIFESP]; Batista, Jefferson Luiz Alves [UNIFESP]; Gomes, José Álvaro Pereira [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Purpose: To report the outcome of postoperative subconjunctival injection of triamcinolone in eyes that underwent pterygium surgery and were at risk for recurrence.Methods: Twelve eyes of 11 patients with primary (7 eyes) or recurrent (5 eyes) pterygia underwent excision and conjunctival autografting (4 eyes, 33.3%), an-miotic membrane grafting (6 eyes, 50%), or both (2 eyes, 16.6%). All of these eyes had signs that were considered to be risk factors for recurrence (conjunctival inflammation, hemorrhage, granuloma, and fibrovascular proliferation); accordingly, they also underwent subconjunctival injection of triamcinolone.Results: Among the 11 patients, there were 8 (72.7%) men and 3 (27.3%) women; the mean age was 41 years (range, 20 - 56 years). In 5 (41.7%) eyes, the pterygium was graded as T2 (intermediate) and in 7 (58.3%) eyes was graded as T3 (fleshy). The time between surgery and the first injection ranged from 2 to 5 weeks (mean, 3.4 weeks), and 1 - 3 injections were necessary (mean, 1.7) to achieve the desired effect. After injection, 1 (8.3%) eye developed inflammation, and 2 (16.7%) eyes from another patient developed intraocular hypertension that was controlled with a topical P-blocker. The follow-up after the last injection ranged from 8 to 36 months (mean, 14.5 months); only 1 recurrence (grade 3) occurred during this period.Conclusions: The postoperative use of subconjunctival triamcinclone seems to benefit patients at increased risk of pterygium recurrence. It is relatively safe and is accompanied by few complications, but controlled and prospective studies are necessary to confirm its efficacy.
- ItemAcesso aberto (Open Access)Reduced bone mineral density in men after heart transplantation(Associação Brasileira de Divulgação Científica, 1999-04-01) Anijar, José Ricardo; Szejnfeld, Vera Lucia [UNIFESP]; Almeida, Dirceu Rodrigues de [UNIFESP]; Fernandes, Artur da Rocha Correa [UNIFESP]; Ferraz, Marcos Bosi [UNIFESP]; A01; A02; Universidade Federal de São Paulo (UNIFESP)Heart transplantation is associated with rapid bone loss and an increased prevalence and incidence of fractures. The aim of the present study was to compare the bone mineral density (BMD) of 30 heart transplant (HT) recipients to that of 31 chronic heart failure (CHF) patients waiting for transplantation and to determine their biochemical markers of bone resorption and hormone levels. The BMD of lumbar spine and proximal femur was determined by dual-energy X-ray absorptiometry. Anteroposterior and lateral radiographs of the thoracic and lumbar spine were also obtained. The mean age of the two groups did not differ significantly. Mean time of transplantation was 25.4 ± 21.1 months (6 to 88 months). Except for the albumin levels, which were significantly higher, and magnesium levels, which were significantly lower in HT patients when compared to CHF patients, all other biochemical parameters and hormone levels were within the normal range and similar in the two groups. Both groups had lower BMD of the spine and proximal femur compared to young healthy adults. However, the mean BMD of HT patients was significantly lower than in CHF patients at all sites studied. Bone mass did not correlate with time after transplantation or cumulative dose of cyclosporine A. There was a negative correlation between BMD and the cumulative dose of prednisone. These data suggest that bone loss occurs in HT patients mainly due to the use of corticosteroids and that in 30% of the patients it can be present before transplantation. It seems that cyclosporine A may also play a role in this loss.
- ItemSomente MetadadadosToxicological considerations for intravitreal drugs(Informa Healthcare, 2011-08-01) Penha, Fernando M. [UNIFESP]; Rodrigues, Eduardo B. [UNIFESP]; Furlani, Bruno A. [UNIFESP]; Dib, Eduardo [UNIFESP]; Melo, Gustavo B. [UNIFESP]; Farah, Michel E. [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Introduction: Intravitreal injections are a very common procedure and are the most effective route of drug delivery to the retina. There are currently several drugs available and even more are in development; therefore, safety is a very important concern.Areas covered: the toxicological considerations of the most common drugs used for intravitreal pharmacotherapy such as anti-VEGFs, corticosteroids and antibiotics. Emerging agents such as anti-TNFs, VEGF-trap and kinase inhibitors are also discussed. An assessment of the efficacy and safety issues of the most relevant drugs including bevacizumab, ranibizumab and triamcinolone is presented.Expert opinion: the toxicology and safety profiles are available for several drugs that are either in use or will be available for intravitreal injections. Retinal pharmacotherapy is very effective for different retinal diseases; however safety is a very important issue when intravitreal injections are applied and the possibility of retinal toxicity should always be kept in mind. Bevacizumab and ranibizumab are effective for the therapy of wet-age-related macular degeneration and macular edema, while triamcinolone remains an alternative agent to treat secondary macular edema. It is important, as some of these drugs will be used for extended periods of time, that their long-term toxicological effects are better understood.
- ItemSomente MetadadadosTreatment of Early Rheumatoid Arthritis in a Multinational Inception Cohort of Latin American Patients the GLADAR Experience(Lippincott Williams & Wilkins, 2012-10-01) Cardiel, Mario H.; Pons-Estel, Bernardo A.; Sacnun, Monica P.; Wojdyla, Daniel; Saurit, Veronica; Carlos Marcos, Juan; Pinto, Maria Raquel C.; Cordeiro de Azevedo, Ana Beatriz [UNIFESP]; Silveira, Ines Guimaraes da; Radominski, Sebastiao C.; Ximenes, Antonio C.; Massardo, Loreto; Ballesteros, Francisco; Rojas-Villarraga, Adriana; Valle Onate, Rafael; Portela Hernandez, Margarita; Esquivel-Valerio, Jorge A.; Garcia-De la Torre, Ignacio; Khoury, Vianna J.; Millan, Alberto; Roberto Soriano, Enrique; GLADAR; Hosp Italiano Buenos Aires; Fdn Dr Pedro M Catoggio Progreso Reumatol; Hosp Gen Dr Miguel Silva; Hosp Prov Rosario; Univ Nacl Rosario; Hosp Privado; Hosp San Martin La Plata; Universidade Federal de Minas Gerais (UFMG); Universidade Federal de São Paulo (UNIFESP); Pontificia Univ Catolica Rio Grande do Sul; Univ Fed Parana; Hosp Geral Goiania Dr Alberto Rassi; Pontificia Univ Catolica Chile; Hosp Clin San Borja Arriaran; Clin Univ Bolivariana; Hosp Mil; Hosp Especialidades Ctr Med La Raza; Univ Autonoma Nuevo Leon; Hosp Gen Occidente Secretaria Salud; Hosp Presidente Estrella Urena; Hosp Univ CaracasBackground: Treatment of rheumatoid arthritis (RA) has evolved dramatically in the last decade. However, little is known about the way rheumatologists in Latin America treat their patients in clinical practice, outside the scope of clinical trials.Objective: the objective of this study was to describe treatment patterns at disease onset in early RA with data from a large, multicenter, multinational inception cohort of Latin American patients.Methods: Consecutive patients with early RA (<1 year of disease duration as diagnosed by a rheumatologist) from 46 centers in 14 Latin American countries were enrolled in the study. Clinical data, laboratory assessments, and a detailed registry on type of prescriptions were collected at baseline and at 3, 6, 12, 18, and 24 months of follow-up. Hands and feet x-rays were obtained at baseline and at 12 and 24 months. All data were captured in Arthros 6.1 database. Continuous variables were expressed as means and SDs, and categorical variables were expressed as percentages and 95% confidence intervals (95% CIs). Only therapeutic data at baseline are presented, corresponding to the period between disease onset and second visit (3 months).Results: A total of 1093 patients were included. Eighty-five percent were female, and 76% had a positive rheumatoid factor. Mean age at diagnosis was 46.5 (SD, 14.2) years, and mean disease duration at the first visit was 5.8 (SD, 3.8) months. Between baseline and second visit (3 months), 75% of patients (95% CI, 72%-78%) received disease-modifying antirheumatic drugs. Methotrexate (MTX) alone or in combination was the most frequently used (60.5%), followed by antimalarials (chloroquine or hydroxychloroquine, 32.1%), sulfasalazine (7.1%), and leflunomide (LEF, 4%). in 474 patients (43%), initiation of disease-modifying antirheumatic drugs was within the first month after the first visit. in addition, 290 patients (26%; 95% CI, 23%-29%) received combination therapy as initial treatment. the most frequently used combinations were MTX + chloroquine (45%), MTX + hydroxychloroquine (25%), and MTX + sulfasalazine (16%). Eleven patients (1%; 95% CI, 0.5%-1.8%) received biologics. Sixty-four percent (95% CI, 60%-66%) received corticosteroids. of those, 80% (95% CI, 77%-84%) received 10 mg of oral prednisone or less.Conclusions: in this cohort of Latin American patients with early RA, most patients received MTX very early in their disease course. Combination therapy was used approximately in 1 of every 4 patients as initial therapy. Biologics were rarely used at this early stage, and low-dose prednisone was commonly used.