All-cause mortality and risk factors in patients with type 1 diabetes in Castilla-La Mancha, Spain. DIACAM1 2010-2020 study.

INTRODUCTION: Despite better treatments and care for patients with type 1 diabetes (T1DM), all-cause and cardiovascular mortality still remains higher compared to the general population. We evaluated mortality and risk factors for mortality in a representative cohort of patients with T1DM. METHODS: DIACAM1 was a cross-sectional, multicenter study on adult patients (≥ 16 years old) and diabetes with at least 5 years since diabetes diagnosis conducted between 2009 and 2010. DIACAM1 2010-2020 study was a follow-up study, extension of DIACAM1, where vital status of patients was evaluated between June 2019 and June 2020. RESULTS: 4.03% [CI95%, 2.53-5.62) of the 1465 patients with T1DM included in the cohort of the DIACAM1 in 2010 had died. Survival was lower than in the sex- and age-matched general population in the same region. 40.7% of deaths were due to cardiovascular disease. HbA1c levels < 7% and triglyceride levels < 150 mg/dL were associated with lower mortality, whereas retinopathy and plasma creatinine were associated with increased mortality. CONCLUSIONS: We confirmed a lower survival in people with T1DM, with cardiovascular disease being the main cause of mortality. High HbA1c, high triglycerides, retinopathy, and high creatinine are factors associated with mortality.

Integrative multi-omics analysis identifies a prognostic miRNA signature and a targetable miR-21-3p/TSC2/mTOR axis in metastatic pheochromocytoma/paraganglioma.

Rationale: Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors that present variable outcomes. To date, no effective therapies or reliable prognostic markers are available for patients who develop metastatic PPGL (mPPGL). Our aim was to discover robust prognostic markers validated through in vitro models, and define specific therapeutic options according to tumor genomic features. Methods: We analyzed three PPGL miRNome datasets (n=443), validated candidate markers and assessed them in serum samples (n=36) to find a metastatic miRNA signature. An integrative study of miRNome, transcriptome and proteome was performed to find miRNA targets, which were further characterized in vitro. Results: A signature of six miRNAs (miR-21-3p, miR-183-5p, miR-182-5p, miR-96-5p, miR-551b-3p, and miR-202-5p) was associated with metastatic risk and time to progression. A higher expression of five of these miRNAs was also detected in PPGL patients' liquid biopsies compared with controls. The combined expression of miR-21-3p/miR-183-5p showed the best power to predict metastasis (AUC=0.804, P=4.67·10-18), and was found associated in vitro with pro-metastatic features, such as neuroendocrine-mesenchymal transition phenotype, and increased cell migration rate. A pan-cancer multi-omic integrative study correlated miR-21-3p levels with TSC2 expression, mTOR pathway activation, and a predictive signature for mTOR inhibitor-sensitivity in PPGLs and other cancers. Likewise, we demonstrated in vitro a TSC2 repression and an enhanced rapamycin sensitivity upon miR-21-3p expression. Conclusions: Our findings support the assessment of miR-21-3p/miR-183-5p, in tumors and liquid biopsies, as biomarkers for risk stratification to improve the PPGL patients' management. We propose miR-21-3p to select mPPGL patients who may benefit from mTOR inhibitors.

Follow-up and results in patients with differentiated thyroid carcinoma in Castilla-La Mancha (2001-2015). The CADIT-CAM study. / Resultados del seguimiento de pacientes con carcinoma diferenciado de tiroides en Castilla-La Mancha (2001-2015). Estudio CADIT-CAM.

OBJECTIVE: The CADIT-CAM study was designed to retrospectively analyze the clinical characteristics, treatments, and outcomes of patients with differentiated thyroid carcinoma (DTC) in Castilla La Mancha. PATIENTS AND METHODS: A total of 1434 patients from 7 hospitals in Castilla La Mancha were enrolled into the study from 2001 to 2015. RESULTS: Seventy-seven percent of patients were female, with a mean age at diagnosis of 48 years. Papillary thyroid carcinoma accounted for 93% of cases. Mean tumor size was significantly smaller at final follow-up (P<.05). Radioiodine ablation (RA) was performed in 84% of patients, and its use decreased during the study, especially in tumors with low recurrence risk. Recurrence occurred in 22% of patients and was associated to male gender, greater tumor size, multifocality, lymph node metastases, extrathyroid involvement, distant metastases and increasing thyroglobulin antibody titers. At the end of follow-up 76.2% of patients were alive and free of disease, 2.4% had died from DTC. Overall survival of the cohort was 95.1% at 15 years of follow-up. CONCLUSIONS: Characteristics of DTC in this Spanish cohort are similar to those reported in other studies in our country. Final results were excellent and use of treatment (RA) was consistent with risk-stratified recommendations.

Low-Dose Radioiodine Ablation in Patients with Low-Risk Differentiated Thyroid Cancer.

AIM: Based on the response criteria of the 2015 American Thyroid Associations guidelines, our objectives were to -determine the response rate when using a low dose of -131-I GBq in patients with low-risk differentiated thyroid cancer (LRDTC) and the influence of clinical and analytical variables on the prediction of complete response. METHODS: We performed a multicentre and longitudinal study, including patients who were operated for LRDTC and who underwent radioiodine remnant ablation with a low-dose of 131-I. All patients were assessed at 6-12 months, and their status was classified as complete (excellent response) or incomplete response (structural incomplete, biochemical incomplete or indeterminate response). Various factors including age, gender, histology, tumour focality and size, stage, time from surgery to treatment, type of thyroid-stimulating hormone (TSH) stimulation, preablation serum thyroglobulin (pTg), antiTg antibodies (pAntiTgAb) and TSH (pTSH) levels were also analysed in order to predict the complete response rate. RESULTS: Of 108 patients, 79.6$ achieved complete response and the remaining showed incomplete response (2.9, 5.5 and 12$ due to biochemical incomplete, structural incomplete and indeterminate response respectively). Six patients received a new dose of 131-I. Tumour size and pAntiTgAb were the only factors related to therapeutic response (p = 0.03 and p < 0.01, respectively). However, pAntiTgAb was the only independent factor related to complete -response. Patients with complete response showed lower pTg than those with incomplete response (5.1 ± 12.9 vs. 11.2 ± 25 ng/mL) although without statistical significance (p = 0.14). There was no significant difference in the response rate depending on the thyrotropin stimulation methods. CONCLUSIONS: A low dose of 131-I was sufficient for reaching a complete response at 6-12 months of follow-up in the majority of patients with LRDTC. Tumour size and pAntiTgAb variables were related to therapeutic response.

PheoSeq: A Targeted Next-Generation Sequencing Assay for Pheochromocytoma and Paraganglioma Diagnostics.

Genetic diagnosis is recommended for all pheochromocytoma and paraganglioma (PPGL) cases, as driver mutations are identified in approximately 80% of the cases. As the list of related genes expands, genetic diagnosis becomes more time-consuming, and targeted next-generation sequencing (NGS) has emerged as a cost-effective tool. This study aimed to optimize targeted NGS in PPGL genetic diagnostics. A workflow based on two customized targeted NGS assays was validated to study the 18 main PPGL genes in germline and frozen tumor DNA, with one of them specifically directed toward formalin-fixed paraffin-embedded tissue. The series involved 453 unrelated PPGL patients, of whom 30 had known mutations and were used as controls. Partial screening using Sanger had been performed in 275 patients. NGS results were complemented with the study of gross deletions. NGS assay showed a sensitivity ≥99.4%, regardless of DNA source. We identified 45 variants of unknown significance and 89 pathogenic mutations, the latter being germline in 29 (7.2%) and somatic in 58 (31.7%) of the 183 tumors studied. In 37 patients previously studied by Sanger sequencing, the causal mutation could be identified. We demonstrated that both assays are an efficient and accurate alternative to conventional sequencing. Their application facilitates the study of minor PPGL genes, and enables genetic diagnoses in patients with incongruent or missing clinical data, who would otherwise be missed.

Recommendations for somatic and germline genetic testing of single pheochromocytoma and paraganglioma based on findings from a series of 329 patients.

BACKGROUND: Nowadays, 65-80% of pheochromocytoma and paraganglioma (PPGL) cases are explained by germline or somatic mutations in one of 22 genes. Several genetic testing algorithms have been proposed, but they usually exclude sporadic-PPGLs (S-PPGLs) and none include somatic testing. We aimed to genetically characterise S-PPGL cases and propose an evidence-based algorithm for genetic testing, prioritising DNA source. METHODS: The study included 329 probands fitting three criteria: single PPGL, no syndromic and no PPGL family history. Germline DNA was tested for point mutations in RET and for both point mutation and gross deletions in VHL, the SDH genes, TMEM127, MAX and FH. 99 tumours from patients negative for germline screening were available and tested for RET, VHL, HRAS, EPAS1, MAX and SDHB. RESULTS: Germline mutations were found in 46 (14.0%) patients, being more prevalent in paragangliomas (PGLs) (28.7%) than in pheochromocytomas (PCCs) (4.5%) (p=6.62×10(-10)). Somatic mutations were found in 43% of those tested, being more prevalent in PCCs (48.5%) than in PGLs (32.3%) (p=0.13). A quarter of S-PPGLs had a somatic mutation, regardless of age at presentation. Head and neck PGLs (HN-PGLs) and thoracic-PGLs (T-PGLs) more commonly had germline mutations (p=2.0×10(-4) and p=0.027, respectively). Five of the 29 metastatic cases harboured a somatic mutation, one in HRAS. CONCLUSIONS: We recommend prioritising testing for germline mutations in patients with HN-PGLs and T-PGLs, and for somatic mutations in those with PCC. Biochemical secretion and SDHB-immunohistochemistry should guide genetic screening in abdominal-PGLs. Paediatric and metastatic cases should not be excluded from somatic screening.

VEGF, VEGFR3, and PDGFRB protein expression is influenced by RAS mutations in medullary thyroid carcinoma.

BACKGROUND: Tyrosine kinase inhibitors (TKIs) have achieved remarkable clinical results in medullary thyroid carcinoma (MTC) patients. However, the considerable variability in patient response to treatment with TKIs remains largely unexplained. There is evidence that it could be due, at least in part, to alterations in genes associated with the disease via their effect on the expression of TKI targets. The objective of this study was to evaluate the influence of RAS mutations on the expression levels in MTC tumors of eight key TKI target proteins. METHODS: We assessed by immunohistochemistry the expression of EGFR, KIT, MET, PDGFRB, VEGF, VEGFR1, VEGFR2, and VEGFR3 in a series of 84 primary MTC tumors that had previously been molecularly characterized, including 14 RAS-positive, 18 RET(M918T)-positive, and 24 RET(C634)-positive tumors, as well as 15 wild-type tumors with no mutations in the RET or RAS genes. RESULTS: In contrast to RET-positive tumors, RAS-positive tumors expressed neither PDGFRB nor MET (p=0.0060 and 0.047, respectively). Similarly, fewer RAS-positive than RET-related tumors expressed VEGFR3 (p=0.00062). Finally, wild-type tumors expressed VEGF more often than both RAS- and RET-positive tumors (p=0.0082 and 0.011, respectively). CONCLUSIONS: This is the first study identifying that the expression of TKI targets differs according to the presence of RAS mutations in MTC. This information could potentially be used to select the most beneficial TKI treatment for these patients.

Metabolic and cardiovascular risk factor control in a diabetic cohort. Four-year results.

OBJECTIVES: To assess control of blood glucose and other cardiovascular risk factors in diabetic patients monitored at an outpatient endocrinology clinic. To ascertain treatment used and its changes over time. PATIENTS AND METHODS: A cohort of 424 randomly selected diabetic patients (both type 1 and type 2) was monitored from 2004 to 2008. Final cohort size was 343 patients. Data were collected about epidemiological characteristics, cardiovascular risk factors, chronic complications, glycemic, lipid and blood pressure control, and treatment at baseline and 4 years. RESULTS: After 4 years, the proportion of patients achieving glycosylated hemoglobin levels less than 7% remained stable (type 1: 18.5% in 2004 vs 21.7% in 2008, type 2: 26.6% vs 26.5%). The degree of achievement of lipid and blood pressure (BP) control levels increased in both groups. The complexity of treatment schemes used to achieve these results significantly increased. CONCLUSIONS: Stabilization of glycemic control after 4 years of follow-up was a positive result, considering the long course of diabetes, progressive pancreatic function impairment, and complexity of our cohort. Treatment optimization significantly improved BP and lipid control in the study group.

[Differentiated thyroid carcinoma: survival and prognostic factors]. / Carcinoma diferenciado de tiroides: supervivencia y factores relacionados.

BACKGROUND AND AIMS: Differentiated thyroid carcinoma (DTC) is the most common endocrine tumor. DTC has a good prognosis and survival rates higher than 85%. The aim of our study was to assess our current survival rate and to analyze prognostic factors. PATIENTS AND METHODS: A retrospective analysis was conducted of 308 patients with DTC (93.5% with papillary tumors, 78.8% women). Mean age at diagnosis was 45.4±15.8years, and mean follow-up time was 8.9±6.8years. The whole group was treated and followed up using the same protocol at our hospital. The following data were collected: age at diagnosis, sex, histology, TNM stage, treatments, and date and cause of death. Survival probability was calculated using Kaplan-Meier analyses. Prognostic factors were analyzed using a univariate log rank test and a multivariate Cox regression analysis model. RESULTS: Twenty-six patients died during follow-up, 15 of them (4.9%) from DTC. Thyroid carcinoma-related survival was 92.7% for the whole group. In multivariate analyses, the following parameters were associated to a significantly increased risk of death from DTC: presence of distant metastases, follicular histology, age at diagnosis older than 60years, and extrathyroid invasion. DISCUSSION: Our survival rate is similar to that reported in literature. Assessment of prognostic factors related to an increased risk of death in our patient group, is essential to establish active therapeutic approaches in high risk patients.

[Incidence of postpartum thyroiditis and study of possible associated factors]. / Tiroiditis posparto: incidencia y estudio de los posibles factores asociados en las embarazadas de una zona de salud.

BACKGROUND AND OBJECTIVE: Our objective was to evaluate the presence of postpartum thyroiditis (PPT) in a group of pregnant euthyroid women. MATERIAL AND METHOD: This study was prospective and descriptive in nature and was carried out over the course of three years in an urban Health District in Toledo, Spain. Information recorded included height and weight, tobacco use, previous consumption of oral contraceptives, and numbers of pregnancies and abortions prior to the current gestation. Levels of Thyroid Stimulating Hormone (TSH), free Thyroxin (FT4) and thyroid peroxidase antibodies (TPOAb) were determined during the first trimester and 3 and 6 months postpartum. A urine sample was collected for determination of iodine levels. Thyroid ultrasonography was performed on all pregnant subjects concurrently with analytical sample collection at 3 months of pregnancy and 3 months postpartum. RESULTS: The sample contained 157 pregnant women, of whom 25 (15.9%) developed PPT. Of these, 44.0% were positive for TPO antibodies in the first trimester, compared to 4.5% of the subjects who did not develop PPT (P<.001). At the end of the first year, 5 (20%) were still afflicted with hypothyroidism. The complete study group of pregnant women displayed a median urinary iodine level of 135 microg/L. A minor BMI was found in the PPT subjects when compared with the rest of the study group (21.7 vs 24.5; P=.000). A greater frequency of PPT was found in Rh-negative women (33.3 vs 12.2%; P=.015). CONCLUSIONS: The incidence of PPT exceeded that previously reported. We have only found a significant correlation between PPT and BMI and Rh factor. Based on the high incidence rate detected in our Health District, an active search for cases of PPT might be justified.

Thyroid disorders and iodine nutritional status in the first trimester of pregnancy.

BACKGROUND AND OBJECTIVES: Thyroid alterations are frequent during pregnancy and can be harmful to the development of the newborn. The objective of this study was to assess the prevalence of thyroid disorders as well as iodine nutritional status in pregnant women in the first trimester of pregnancy. PATIENTS AND METHOD: We performed a descriptive observational survey in a health area of Toledo (Spain). Participants consisted of pregnant women in this area and a control group of non-pregnant women of similar age. Both groups underwent thyroid ultrasonography and urinary iodine concentration test. Thyrotropin, free T4 and anti-thyroid peroxidase antibodies (anti-TPO Ab) levels were also measured in pregnant women. RESULTS: A total of 199 expectant women and a control group of 169 non-pregnant women participated. The median urinary iodine concentration was 135 µg/l (IR, 240-65) in pregnant women and 150µg/l (IR, 200-90) in the control group. The mean values for TSH and free T4 in pregnant women were 1.95±1.62 and 1.03±0.15µU/ml, respectively. The prevalence of hypothyroidism in expectant women was 9.5% (95% CI, 6.0-14.7). Thyroid volume was larger in pregnant women (12.2±5.6mL) than in controls (10.7±4.0mL) (p=0.005). Thyroid nodules were found in 38.5% of the women in the control group and in 33.2% of pregnant women (p = 0.290). CONCLUSIONS: Iodine status was deficient in our group of pregnant women. In agreement with the results of other studies performed in Spain, the prevalence of hypothyroidism was high. Thyroid hormones and anti-TPO Ab tests should be evaluated in the first prenatal visit. The prevalence of nodules was similar in pregnant women in the first trimester of pregnancy and in controls. Thyroid ultrasonography should be performed in pregnant women whenever a goiter and/or thyroid nodules are detected during clinical examination.