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Dopamine agonists (DAs) are well recognized as the first-line therapy for prolactinomas due to their efficacy in achieving tumoral shrinkage and normoprolactinemia. However, it remains to be established the best timing to withdraw DAs and in which patients this should be attempted. Studies in the 1980s, mainly using bromocriptine, started to defy the concept that DAs should be regarded as a lifelong therapy considering that sustained normoprolactinemia was attained in a small subset of patients after drug withdrawal. The introduction of the more effective agent cabergoline led to an increase in the percentages of remission. The most recent meta-analysis on the topic stated than remission rates after withdrawal can range from 15% in macroprolactinoma patients treated with bromocriptine to 41% in those with microprolactinomas previously treated with cabergoline. When more stringent criteria were applied before attempting withdrawal, sustained remission ensued in more than 50% of the individuals. Treatment duration for more than 24 months, the achievement of normoprolactinemia, marked reduction (≥ 50%) in tumoral size and DAs tapering till a low maintenance dose (e.g. cabergoline 0.5 mg/week) have been the most consistently identified predictors of success. In addition, a growing amount of evidence suggests that the post-pregnancy/breastfeeding period and menopause are reasonable timings to re-access the need for continuing DAs therapy. Considering that the achievement of sustained normoprolactinemia is still far from being universal after the withdrawal, even in highly selected cohorts, future larger prospective studies should continue to address this issue.
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Agonistas de Dopamina/uso terapéutico , Prolactinoma/tratamiento farmacológico , Cabergolina/uso terapéutico , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND/OBJECTIVES: Bariatric surgery leads to type 2 diabetes mellitus (T2DM) remission, but recurrence can ensue afterwards. However, literature provides heterogenous remission/recurrence criteria and there is no consensus on long-term T2DM management after surgery. We aim to assess T2DM remission/recurrence rates using standardized criteria and to identify relapse predictors. We also intend to analyze the management of residual T2DM and the impact of maintaining/withdrawing metformin in avoiding future relapse. SUBJECTS/METHODS: We investigated a cohort of 110 obese patients with T2DM who underwent bariatric surgery and were followed for 5 years (Y0-Y5). Patients who ever attained remission were accounted for cumulate remission, while prevalent remission was considered for individuals who were on remission in a specific visit. RESULTS: A complete prevalent remission of 47.3% was reached at Y1 and it remained stable till Y5 (46.4-48.2%). Complete cumulative rate was of 57.3% at Y5. Five-year T2DM recurrence rate was 15.9% and it was associated with higher pre-operative HbA1c levels (ß = 1.06; p < 0.05) and a milder excess body weight loss (EBWL) (ß = 0.49; p < 0.05). Glucose-lowering agents were fully stopped in 51.4% of the patients till Y1 and in 16.2% of them afterwards. Medication withdrawal was mainly attempted in patients with a lower baseline HbA1c (ß = 0.54; p < 0.01) and higher first-year EBWL (ß = 1.04; p < 0.01). Patients that kept metformin after reaching a HbA1c in the complete remission range (<6.0%) did not have greater odds of avoiding relapse in the next visit (OR = 0.33; p = 0.08). CONCLUSIONS: Baseline HbA1c and EBWL were the main variables driving both T2DM relapse after bariatric surgery and the attempt to withdrawal anti-diabetic medication. In our population keeping metformin once an HbA1c < 6.0% is achieved did not seem to diminish relapse but further studies on this matter are needed.
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Cirugía Bariátrica , Diabetes Mellitus Tipo 2 , Obesidad , Adulto , Peso Corporal/fisiología , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Femenino , Hemoglobina Glucada/análisis , Humanos , Hipoglucemiantes/administración & dosificación , Hipoglucemiantes/uso terapéutico , Masculino , Metformina/administración & dosificación , Metformina/uso terapéutico , Persona de Mediana Edad , Obesidad/complicaciones , Obesidad/cirugía , Inducción de Remisión , Estudios Retrospectivos , Resultado del Tratamiento , Pérdida de Peso/fisiologíaRESUMEN
Thyroid function has an important role on body weight regulation. However, the impact of thyroid function on weight loss after bariatric surgery is still largely unknown. We evaluated the association between preoperative thyroid function and the excess weight loss 1 year after surgery, in 641 patients with morbid obesity who underwent bariatric surgery. Patients with a history of thyroid disease, treatment with thyroid hormone or antithyroid drugs and those with preoperative evaluation consistent with overt hypothyroidism or hyperthyroidism were excluded. The preoperative levels of TSH and FT4 were not associated with weight loss after bariatric surgery. The variation of FT3 within the reference range was also not associated with weight loss. In contrast, the subgroup with FT3 above the reference range (12.3% of patients) had a significantly higher excess weight loss than patients with normal FT3. This difference remained significant after adjustment for age, sex, BMI, type of surgery, TSH and FT4. In conclusion, we observed an association between high FT3 and a greater weight loss after bariatric surgery, highlighting a group of patients with an increased benefit from this intervention. Our results also suggest a novel hypothesis: the pharmacological modulation of thyroid function may be a potential therapeutic target in patients undergoing bariatric surgery.
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Cirugía Bariátrica/estadística & datos numéricos , Obesidad Mórbida/cirugía , Hormonas Tiroideas/sangre , Pérdida de Peso/fisiología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Periodo Preoperatorio , Estudios RetrospectivosRESUMEN
PURPOSE: Guidelines on pituitary incidentalomas evaluation and management are limited to adults since there are no data on this matter in the paediatric population. We aim to analyse the morphologic characteristics, hormonal profile and follow-up of these lesions in children. METHODS: We have searched for pituitary incidentalomas in the neuroimaging reports and electronic medical records of the Paediatric Endocrinology Clinic of our centre. Patients with 18 years-old or less were included. RESULTS: Forty-one incidentalomas were identified, 25 of them (62.4%) in females. The mean age at diagnosis was 12.0 ± 4.96 years-old. Headaches were the main reason that led to image acquisition (51.2%) and MRI was the imaging method that detected the majority of the incidentalomas (70.7%). The most prevalent lesion was pituitary hypertrophy (29.3%), which was mainly diagnosed in female adolescents (91.7%), followed by arachnoid cysts (17.1%), pituitary adenomas (14.6%) and Rathke's cleft cysts (12.2%). Most patients (90.2%) did not present clinical or laboratorial findings of hypopituitarism or hormonal hypersecretion. Four patients presented endocrine dysfunction: three had growth hormone deficiency and one had a central precocious puberty. Twenty-three patients (56.1%) underwent imagiological revaluation during a median follow-up time of 24.6 months (interquartile range 5.07). None of them presented dimensional progression. CONCLUSIONS: To the best of our knowledge, this is the first series of pituitary incidentalomas in pediatric age. Comparing our series with those conducted in adults, we have observed a higher preponderance of pituitary hypertrophy over adenomas, a lower prevalence of hormonal hyper/hyposecretion and lower risk of dimensional progression during follow-up.
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Neuroimagen/métodos , Hipófisis/diagnóstico por imagen , Neoplasias Hipofisarias/diagnóstico por imagen , Adolescente , Niño , Femenino , Humanos , Masculino , Pediatría/métodos , Estudios RetrospectivosRESUMEN
AIM: We aimed to evaluate the impact of bariatric surgery (BS) on maternal and fetal outcomes. METHODS: A retrospective, descriptive, observational study of 39 pregnant women who underwent BS in our institution between 2010 and 2014 was carried out. A sample of women who became pregnant after BS was evaluated, based on data concerning pregnancy, childbirth, and newborns. RESULTS: Of the 1182 patients who underwent BS at our institution during the study period, 1016 (85.9%) were women. Thirty-nine of these women (with an average age of 31 ± 4.8 years) became pregnant (one twin pregnancy) and 29 of the 39 had undergone a gastric bypass. The mean time interval between BS and pregnancy was 16.6 ± 4.8 months; however, 16 (41%) women became pregnant less than a year after BS. The pre-BS body mass index (BMI) of the 39 women was 44.5 ± 6.2 kg/m2 . The women had a mean BMI of 30.2 ± 3.8 kg/m2 when they got pregnant and they gained 13.2 ± 7.3 kg during pregnancy. Iron deficiency was observed in 18 (46.1%) women, 16 (45.7%) had vitamin B12 deficiency, 12 (66.8%) had zinc deficiency, and 20 (60.6%) had vitamin D deficiency. Three women developed gestational diabetes mellitus. Premature rupture of membranes occurred in two pregnancies, preterm delivery in five, and there was one spontaneous abortion. Cesarean section was performed in seven cases. The average newborn weight was 3002 ± 587 g, five were small for gestational age, and one had macrosomia. Three infants had to be admitted to an intensive care unit. CONCLUSION: Although pregnancy after BS is safe and well tolerated, close monitoring by a multidisciplinary team is required to evaluate complications resulting from BS, especially a deficit of micronutrients.
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Cirugía Bariátrica/estadística & datos numéricos , Enfermedades del Recién Nacido/epidemiología , Obesidad Mórbida/epidemiología , Complicaciones del Embarazo/epidemiología , Resultado del Embarazo/epidemiología , Deficiencia de Vitamina B 12/epidemiología , Deficiencia de Vitamina D/epidemiología , Zinc/deficiencia , Adulto , Diabetes Gestacional/epidemiología , Femenino , Humanos , Recién Nacido , Masculino , Obesidad Mórbida/cirugía , Embarazo , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: Prolactinomas are the most common functional pituitary tumour. Dopamine agonists (DA) are its principal treatment. The criteria that should guide therapy withdrawal and the factors that influence disease remission or relapse are not yet fully established. Our purpose is to evaluate the proportion of patients who attempted DA withdrawal, and to identify the factors that influence clinicians to try it. In addition, we aim to study the factors that are involved in prolactinoma remission/relapse after therapy withdrawal. METHODS: We retrospectively evaluated 142 patients with prolactinoma diagnosis who had been treated exclusively with DA. Firstly, the patients were divided in two groups, according to whether DA withdrawal had been attempted, or not, and the factors that might predict clinicians' decision to discontinue the therapy were then analysed. Secondly, patients who attempted withdrawal were further divided into two subgroups, based on their remission or relapse status and predictors of remission were evaluated. RESULTS: DA withdrawal was attempted in 35.2% of our patients. Females, subjects with lower initial serum prolactin (PRL) levels, those with microadenomas and those with longer treatment duration all had a higher probability of seeing their therapy discontinued. In the withdrawal group, the remission rate was 72%. Macroprolactinomas relapse more often than microprolactinomas (p < 0.05). The recurrence group had higher median initial serum PRL levels and a lower mean duration of therapy, however these variables did not reach statistical significance. CONCLUSION: We found a low percentage of attempt of withdrawal of DA therapy in the subjects with prolactinoma. Our data confirms that DA therapy can be discontinued with a high remission rate. Tumour size was the main variable that affected the withdrawal outcome in our patients.
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Agonistas de Dopamina/uso terapéutico , Prolactinoma/tratamiento farmacológico , Adolescente , Adulto , Bromocriptina/uso terapéutico , Cabergolina , Ergolinas/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prolactina/sangre , Prolactinoma/sangre , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: The prevalence of hypogonadism in HIV-infected patients is still a matter of debate as there is no standardized consensual diagnostic method. In addition, the etiology and endocrine/metabolic implications of hypogonadism in this population remain controversial. This study aims to determine the prevalence of testosterone deficiency in a single-site hospital and to evaluate its association with potential risk factors, lipodystrophy, metabolic syndrome, and cardiovascular risk. METHODS: This study analyzed 245 HIV-infected men on combined antiretroviral therapy. Patients with low total testosterone (TT) levels (<2.8 ng/mL) and/or low calculated free testosterone (FT) levels (<6.5 ng/dL) were considered testosterone deficient. According to their LH and FSH levels, patients were classified as having hypogonadotropic or hypergonadotropic dysfunction. Other clinical, anthropometric, and analytic parameters were also collected and analyzed. RESULTS: The prevalence of testosterone deficiency in our population was 29.4 %. Among them, 56.9 % had hypogonadotropic dysfunction and 43.1 % presented with hypergonadotropic dysfunction. Patients with testosterone deficiency were older (p < 0.001), had higher HbA1c levels (p = 0.016) and higher systolic blood pressure (p = 0.007). Patients with lower testosterone levels had higher prevalence of isolated central fat accumulation (p = 0.015) and had higher median cardiovascular risk at 10 years as measured by the Framingham Risk Score (p = 0.004) and 10-Year ASCVD risk (p = 0.002). CONCLUSIONS: The prevalence of testosterone deficiency in this HIV population is high, with hypogonadotropic dysfunction being responsible for the majority of cases. Testosterone deficiency might predispose to, or be involved, in the pathogenesis of HIV-associated lipodystrophy. Patients with low testosterone levels have higher cardiovascular risk, highlighting the importance of early diagnosis of this condition.
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Antirretrovirales/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Hipogonadismo/epidemiología , Testosterona/sangre , Adulto , Presión Sanguínea , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/epidemiología , Hormona Folículo Estimulante/sangre , Hemoglobina Glucada/metabolismo , Infecciones por VIH/epidemiología , Síndrome de Lipodistrofia Asociada a VIH , Humanos , Hipogonadismo/sangre , Hormona Luteinizante/sangre , Masculino , Síndrome Metabólico/sangre , Síndrome Metabólico/epidemiología , Persona de Mediana Edad , Portugal/epidemiología , Prevalencia , Factores de RiesgoRESUMEN
BACKGROUND: Catechol-O-methyltransferase (COMT) activity is increased in patients with mild/moderate psoriasis. Narrowband ultraviolet B (nbUVB) phototherapy decreases COMT activity. However, the effect of psoralen plus ultraviolet A (PUVA) on this enzyme activity is unknown, and it remains to be clarified if the nbUVB-induced effect in COMT activity is related to clinical response. The aim of this study is to evaluate COMT activity in moderate/severe psoriasis and assess whether PUVA therapy modifies this activity. METHODS: An observational study was conducted on 18 patients with moderate/severe psoriasis and 13 matched controls. Patients were treated with PUVA twice weekly during 6 weeks, and they were evaluated for Psoriasis Area and Severity Index (PASI) and COMT activity before photochemotherapy, at the end of it and 4 weeks after stopping. RESULTS: Before PUVA therapy, S(soluble)-COMT activity was significantly (P < 0.05) higher in psoriasis patients than in controls. After photochemotherapy, no significant differences were found in S-COMT activity at all end points. Photochemotherapy significantly decreased PASI but COMT activity values remained higher than those of control population. CONCLUSION: Psoriasis patients with moderate/severe disease present higher S-COMT activity than controls. Although a good clinical response was observed, PUVA therapy does not change S-COMT activity. This differential COMT effect of PUVA and nbUVB suggests a wavelength-specific regulation.
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Catecol O-Metiltransferasa/metabolismo , Terapia PUVA , Psoriasis/tratamiento farmacológico , Psoriasis/enzimología , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Psoriasis/patologíaRESUMEN
Composite pheochromocytoma (CP) is a rare adrenal tumor, composed of ordinary pheochromocytoma and neuroblastic components. There is a paucity of information in the literature regarding this entity. We report the case of a 56-year-old woman with a CP of the left adrenal gland with a ganglioneuroma component. A review of the published literature found 110 cases of CP. The median age was 51.5 (5.86) years, and 59/110 (53.6%) were female. Association with genetic predisposition syndromes was found in 22/110 (20%), the most common of which was neurofibromatosis type 1, in 15/110 (13.6%). The most common histologic type of the neuroblastic component was ganglioneuroma in 83/110 (75.5%). Twenty-seven cases reported SDHB immunohistochemistry results; none of which was positive. Nine patients (8.2%) presented/developed metastatic disease, and 9 patients (8.2%) died from disease. To our knowledge, this is the largest review describing clinical, histopathological, molecular, and prognostic features of CP.
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Neoplasias de las Glándulas Suprarrenales , Ganglioneuroma , Neurofibromatosis 1 , Feocromocitoma , Humanos , Femenino , Persona de Mediana Edad , Masculino , Feocromocitoma/genética , Feocromocitoma/patología , Ganglioneuroma/complicaciones , Ganglioneuroma/patología , Neoplasias de las Glándulas Suprarrenales/genética , Neoplasias de las Glándulas Suprarrenales/patología , Glándulas Suprarrenales/patología , Neurofibromatosis 1/complicacionesRESUMEN
Objectives: Therapeutic options for pancreatic neuroendocrine neoplasia (Pan-NEN) have increased over the last decade. We aim to understand the evolution of the prognosis of patients with diagnosis of Pan-NEN within a 12-year period, considering the implementation of new treatments. Methods: This study is a retrospective cohort study of patients diagnosed with Pan-NENs between 2006 and 2017. Survival outcome estimates were calculated by Kaplan-Meier method. The impact of baseline clinicopathological characteristics on survival was explored with the use of Cox proportional hazard model. Results: Of the 97 patients, 77 (79.9%) had well-differentiated neuroendocrine tumor (NET) according to WHO 2010 classification, and 52 (53.6%) had localized or locoregional disease. There were no differences between clinicopathological characteristics and survival outcomes when comparing patients diagnosed between 2006-2011 and 2012-2017. Neuroendocrine carcinoma - HR 2.76, 95% CI 1.17-6.55 - and stages III and IV at diagnosis were independent poor prognostic factors - HR 6.02, 95% CI 2.22-16.33 and HR 6.93, 95% CI 2.94-16.32, respectively. Conclusions: The new therapeutic approaches did not induce better survival outcomes on Pan-NEN in recent years. This is possibly due to the indolent nature of NET grades 1 and 2, even metastatic, allowing patients to be submitted to new target therapies along their disease course.
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PURPOSE: Due to the low incidence and heterogeneous behaviour of medullary thyroid carcinoma (MTC), its prognostic factors are still not well stablished. While several large studies have investigated the impact of gender in differentiated thyroid cancer (DTC), its role in MTC outcomes remains controversial. We aim to identify MTC prognostic features, specially focusing on the role of gender. METHODS: Retrospective analysis of 76 patients diagnosed with MTC between 1984 and 2018 at a Portuguese Comprehensive Cancer Center. RESULTS: Patients presented a median age at diagnosis of 49 years and multiple endocrine neoplasia type 2 (MEN2) was identified in 27.6% of them, with those individuals being significantly younger (P<0.001). Most cases were diagnosed as stage IV disease (46.9%), except for the subgroup detected through pre-symptomatic genetic screening (55.6% at stage I). The 5- and 10-year survival rates were 87.6% and 75.6%, respectively. Univariate analysis identified male gender (P=0.010), age ≥45 years (P=0.007), presence of distant metastasis at diagnosis (P<0.01), capsule invasion (P=0.004), extrathyroidal invasion (P=0.003) and absence of biochemical cure after surgery (P=0.042) as having a negative impact on prognosis. On multivariate analysis, male gender (P=0.046) remained an independent predictor of mortality, as well as an older age (P<0.001) and the presence of distant metastases (P=0.012). CONCLUSIONS: Male gender independently predicted worse survival in MTC patients even after adjusting for age and disease stage. The few older studies on the topic pointed to a behavioural explanation regarding medical care seeking patterns by men, but our study and newer genetic and basic-science oriented publications raise the possibility of a true biological difference between genders in the tumourigenesis of MTC that should me further investigated.
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INTRODUCTION: Current guidelines specify controversial areas in adrenocortical carcinomas (ACC), such as optimal follow-up time after remission and identification of prognostic markers. We aim to address these topics by analyzing four reference centers in our country. METHODS: Cross-sectional multicentric study of 69 patients (mean age: 51.7 ± 16.7 years-old; women, 72.5%). Kaplan-Meier survival curves and Cox regression analysis were used to calculate overall survival and its predictors. RESULTS: Thirty-eight individuals (55.0%) had hormonal autonomous production, and 40.6% of the patients presented with metastasis. Surgery was performed in 84.1% of them. Most of these patients (72.4%) were then assigned to adjuvant therapy, while 27.6% were actively surveilled. Among patients undergoing surgery, those who achieved transient remission presented a longer survival time (66 months) than those who never reached the disease-free status (21 months) (p = 0.021). One patient presented with recurrence more than 7 years after complete tumor resection. The lowest overall survival was observed in patients (n = 11) assigned to palliative care since diagnosis (9 months). Tumor stage was identified as the only independent predictor of survival in our cohort (p = 0.006). Five-year survival was 67% for tumors confined to the adrenal space (stage I/II), 56% for locally advanced disease (stage III), and 0% for metastatic disease (stage IV). CONCLUSION: This study reinforces the dismal prognosis of ACC, the need for long-term follow-up, and tumor stage as the most important survival predictor. Reviewing medical records in such rare conditions is an opportunity to identify insufficiencies and to improve medical care.
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Neoplasias de la Corteza Suprarrenal , Carcinoma Corticosuprarrenal , Recurrencia Local de Neoplasia , Evaluación de Resultado en la Atención de Salud , Neoplasias de la Corteza Suprarrenal/diagnóstico , Neoplasias de la Corteza Suprarrenal/mortalidad , Neoplasias de la Corteza Suprarrenal/patología , Neoplasias de la Corteza Suprarrenal/terapia , Carcinoma Corticosuprarrenal/diagnóstico , Carcinoma Corticosuprarrenal/mortalidad , Carcinoma Corticosuprarrenal/patología , Carcinoma Corticosuprarrenal/terapia , Adulto , Cuidados Posteriores , Anciano , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia/diagnóstico , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/terapia , Estadificación de Neoplasias , Cuidados Paliativos , Pronóstico , Inducción de Remisión , Análisis de SupervivenciaRESUMEN
OBJECTIVE: Metastatic disease is common in medullary thyroid carcinoma (MTC) and it is usually detected by raising calcitonin and carcinoembryonic antigen (CEA) levels. Nuclear medicine imaging has an important role in lesion identification/characterisation. We aim to compare 68Ga-DOTANOC PET/CT and 18F-FDG PET/CT performance and to explore the correlations between tumoral markers and functional imaging. METHODS: This a retrospective cross-sectional study including 13 patients with MTC and high calcitonin/CEA levels that underwent both 68Ga-DOTANOC PET/CT and 18F-FDG PET/CT. RESULTS: 68Ga-DOTANOC PET/CT identified MTC metastases in 2twopatients that were 18F-FDG-negative (sensitivity of 69.2% vs. 53.9%, respectively). 68Ga-DOTANOC PET/CT also detected a higher number of lesions than 18F-FDG PET/CT in seven patients, with only one patient showing the opposite pattern. Both differences lacked statistical significance (p = 0.50 and p = 0.86, respectively) but 68Ga-DOTANOC PET/CT better performance allowed changes in patients' management. 68Ga-positive/18F-FDG-negative patients were the ones with the lowest calcitonin doubling time and presented a CEA doubling time >24 months, while the patient with more 18F-FDG-positive lesions was the one with the highest CEA/calcitonin ratio. The number of lesions found in 68Ga-DOTANOC PET/CT were correlated with calcitonin levels (r = 0.73; p < 0.01) but not with CEA ones (r = 0.42; p = 0.15). The number of 18F-FDG hypermetabolic focus were correlated with CEA levels (r = 0.60; p < 0.05) but not with calcitonin (r = 0.48; p = 0.09). CONCLUSIONS: This is the first study to describe a positive correlation between 68Ga-positive lesions and calcitonin levels and between 18F-FDG-positivity and CEA levels. Tumoral markers pattern in metastatic MTC could help clinicians to decide which exam to perform first.
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Calcitonina/sangre , Antígeno Carcinoembrionario/sangre , Carcinoma Medular/diagnóstico por imagen , Tomografía Computarizada por Tomografía de Emisión de Positrones , Neoplasias de la Tiroides/diagnóstico por imagen , Adulto , Anciano , Biomarcadores de Tumor/sangre , Carcinoma Medular/sangre , Carcinoma Medular/secundario , Estudios Transversales , Femenino , Fluorodesoxiglucosa F18 , Radioisótopos de Galio , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Neoplasias de la Tiroides/sangre , Neoplasias de la Tiroides/patologíaRESUMEN
INTRODUCTION: Adrenocorticotropic hormone (ACTH) ectopic production is a rare cause of Cushing syndrome (CS). The most commonly associated tumours are small-cell lung carcinoma along with bronchial and thymic carcinoids. To date, only 5 cases have been published in the literature featuring ectopic ACTH secretion from metastatic acinic cell carcinoma (ACC) of the parotid gland. We hereby describe a very uncommon case of ectopic CS (ECS) unveiling a metastatic parotid ACC. CASE PRESENTATION: A 46-year-old man with hypertension and dyslipidemia diagnosed 4-months before, as well as new-onset diabetes mellitus unveiled 1-month earlier, was referred to emergency department for hypokalemia. Hormonal study and dynamic biochemical tests performed indicated ECS. Imaging and cytological findings pointed toward a likely primary right parotid malignancy with liver metastases. Somatostatin receptor scintigraphy has shown an increased uptake in the parotid gland and mild expression in liver metastasis. The patient underwent right parotidectomy, and histopathologic examination confirmed ACC. Meanwhile, hypercortisolism was managed with metyrapone, ketoconazole, and lanreotide. Despite chemotherapy onset, a rapid disease progression and clinical course deterioration was observed. CONCLUSION: The present report highlights a rare ECS, exposing a metastatic parotid ACC, with an aggressive and challenging clinical course, representing the first case whose diagnosis of ECS came prior to ACC.
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PURPOSE: Obesity and gestational diabetes mellitus (GDM) have an independent negative impact in pregnancy outcomes. Excessive gestational weight gain (GWG) represents an additional high-risk condition for adverse outcomes. The aims of this study were to evaluate the potential effect of metformin in GWG in overweight or obese women with GDM, to report our experience and to assess metformin's safety in this population. METHODS: Retrospective observational cohort study involving pregnant women with GDM and pregestational overweight or obesity. Demographic, anthropometric, glycemic control data, obstetric, fetal and neonatal outcomes were evaluated. The sample was divided into two groups according to metformin treatment. A propensity score-matched analysis was performed using age, initial body mass index (BMI), trimester at GDM diagnosis and previous history of GDM or macrosomia as covariates. RESULTS: Of the 457 enrolled in the study, 177 (38.7%) were treated with metformin. Two groups of 130 well matched patients were balanced regarding baseline characteristics. Women in metformin group had significantly less excessive GWG (29.23% vs. 42.31%, OR 0.56, 95% CI 0.34-0.94, p = 0.028) and more adequate GWG (36.92% vs. 23.08%, OR 1.95, 95% CI 1.14-3.35, p = 0.015). No significant differences were found between both groups regarding glycemic control, rate of insulinization, and obstetric, fetal, and neonatal outcomes. CONCLUSIONS: This study highlights metformin as an important and safe tool to prevent excessive GWG and promote adequate GWG in overweight or obese women with GDM, regardless of age, BMI, timing of GDM diagnosis, previous history of GDM or macrosomia.
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Diabetes Gestacional/tratamiento farmacológico , Ganancia de Peso Gestacional/efectos de los fármacos , Hipoglucemiantes/uso terapéutico , Metformina/uso terapéutico , Obesidad/complicaciones , Sobrepeso/complicaciones , Adulto , Glucemia , Diabetes Gestacional/sangre , Femenino , Humanos , Hipoglucemiantes/administración & dosificación , Metformina/administración & dosificación , Obesidad/sangre , Sobrepeso/sangre , Embarazo , Resultado del Embarazo , Puntaje de Propensión , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Bariatric surgery is an effective treatment for morbid obesity and its metabolic related comorbidities. However, the literature reports inconsistent results regarding weight loss (WL) and the resolution of comorbidities associated with obesity. OBJECTIVE: We aim to evaluate long-term differences in WL between different surgical techniques and the impact of each surgical technique on metabolic parameters (type 2 diabetes mellitus [T2DM], dyslipidemia,hypertension, and metabolic syndrome). We also aim to evaluate the effect of baseline clinical characteristics in WL and in the evolution of metabolic syndrome (MetS) components. Our hypothesis is that different types of surgery have different effects on WL and the prevalence of comorbidities over time. METHODS: We retrospectively evaluated WL and metabolic parameter remission (T2DM, dyslipidemia, hypertension, and MetS) during 4 years in 1,837 morbidly obese patients (females, 85%; age, 42.5 ± 10.6 years; BMI, 44.0 ± 5.8) who underwent bariatric surgery (Roux-en-Y gastric bypass [RYGB], laparoscopic sleeve gastrectomy [LSG], and laparoscopic adjustable gastric band [LAGB]). RESULTS: The mean percentage of WL for RYGB, LSG, and LAGB was, respectively, 32.9 ± 8.7, 29.8 ± 9.8, and 16.2 ± 9.6 at 12 months and 30.6 ± 9.1, 22.7 ± 10.0, and 15.8 ± 10.8 at 48 months (p < 0.001), even after adjustment for baseline weight, BMI, age, and sex (p < 0.001). Women had more WL during the first 36 months (p = 0.013 and 0.007 at 12 and 36 months, respectively) and older patients had less WL compared to younger ones (p <0.001), except at 48 months. Patients with T2DM had less WL than those without diabetes after adjustment (sex, age, and surgical technique) during the same period. Patients with hypertension had less WL at 12 months (p = 0.009) and MetS at 24 months (p = 0.020) compared to those without these comorbidities. There was no significant difference regarding the presence of dyslipidemia in WL. The RYGB group showed better results for MetS resolution. CONCLUSION: During the 4-year follow-up, RYGB was the surgical procedure that caused the highest WL and MetS resolution.
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Cirugía Bariátrica , Síndrome Metabólico/epidemiología , Síndrome Metabólico/cirugía , Obesidad Mórbida/epidemiología , Obesidad Mórbida/cirugía , Pérdida de Peso/fisiología , Adulto , Factores de Edad , Cirugía Bariátrica/métodos , Cirugía Bariátrica/estadística & datos numéricos , Comorbilidad , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/cirugía , Femenino , Estudios de Seguimiento , Gastrectomía/métodos , Gastrectomía/estadística & datos numéricos , Derivación Gástrica/métodos , Derivación Gástrica/estadística & datos numéricos , Humanos , Laparoscopía/métodos , Laparoscopía/estadística & datos numéricos , Masculino , Síndrome Metabólico/complicaciones , Persona de Mediana Edad , Obesidad Mórbida/complicaciones , Inducción de Remisión , Estudios Retrospectivos , Factores Sexuales , Resultado del TratamientoRESUMEN
BACKGROUND: Super obesity (BMI ≥ 50 kg/m2) is associated with significant morbidity and mortality. The best procedure to treat super obesity is not completely established. Our aim was to compare the effectiveness of bariatric procedures (adjustable gastric band [AGB], Roux-en-Y gastric bypass [RYGB], sleeve gastrectomy [SG]) in super obesity. METHODS: Retrospective observational study of super obese patients who underwent bariatric surgery. Data was assessed preoperatively and in the 1st and 2nd years of follow-up. RESULTS: We evaluated 213 individuals, 77.9% female, age of 43.38 ± 11.49 years, and preoperative BMI of 54.53 ± 4.54 kg/m2; 19 submitted to AGB, 127 to RYGB, and 67 to SG. In the pre-surgical assessment, there were no significant differences in age, anthropometric parameters, blood pressure, glycemic profile, and lipid profile between the three surgical groups. The percentage of excess weight loss (%EWL) in the 1st year was 67.58% in RYGB, 58.74% in SG, and 38.71% in AGB (p < 0.001), and the percentage of total weight loss (%TWL) was 36.29%, 31.59%, and 21.07%, respectively (p < 0.001). Two years after surgery (n = 147; follow-up rate of 69%), the %EWL and %TWL were significantly higher in the RYGB group (p < 0.001). RYGB had a higher success rate (%EWL ≥ 50% and %TWL ≥ 20%) in both years of follow-up (p < 0.001). In multiple linear regression, after adjusting for other covariates, RYGB was the only strong predictive factor of %EWL and %TWL (p < 0.001). CONCLUSION: RYGB proved to be more effective in super obesity. The beneficial effects in weight loss were evident both 1 and 2 years after the procedure, regardless of pre-surgical anthropometric characteristics.
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Cirugía Bariátrica/métodos , Índice de Masa Corporal , Peso Corporal/fisiología , Obesidad Mórbida/cirugía , Adulto , Cirugía Bariátrica/efectos adversos , Femenino , Gastrectomía/métodos , Derivación Gástrica/métodos , Humanos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/patología , Estudios Retrospectivos , Resultado del Tratamiento , Pérdida de Peso/fisiologíaRESUMEN
BACKGROUND: Obesity is an independent risk factor for chronic kidney disease (CKD). Our aims were: (1) to evaluate the impact of bariatric surgery (BS) on kidney function, (2) clarify the factors determining postoperative evolution of glomerular filtration rate (ΔGFR) and urinary albumin-to-creatinine ratio (ΔUACR), and (3) access the occurrence of oxalate-mediated renal complications. METHODS: We investigated a cohort of 1448 obese patients who underwent BS. Those with baseline-estimated GFR (eGFR0) < 30 mL/min or without information about the 2-year post-surgical eGFR (eGFR2) were excluded. RESULTS: A total of 725 patients were included. At baseline, 38(5.2%) had hyperfiltration with eGFR0 ≥ 125 mL/min/1.73m2 (G0), 492 (67.9%) had eGFR0 90-124 mL/min/1.73m2 (G1), 178 (24.6%) had eGFR0 60-89 mL/min/1.73m2 (G2), and 17 (2.3%) had eGFR0 < 60 mL/min/1.73m2 (G3). ΔGFR significantly increased in 96.6% (ΔGFR = 23.8 (IQR 15.9-29.8)) and 82.4% (ΔGFR = 18.6 (IQR 3.6-44.0)) of the subjects with G2 and G3 CKD, respectively (p < 0.001). The variables independently associated with ΔGFR were baseline body mass index (BMI) (positively), high blood pressure (HBP) (negatively), and fasting plasma glucose (FPG) (negatively), as well as FPG variation (positively). An overall prevalence of high UACR (≥ 30 mg/g-1) of 17.9% was found, with 81.5% of these subjects presenting A2(30-300 mg/g-1) and 18.5% A3(> 300 mg/g-1) UACR. UACR significantly decreased after BS (p < 0.001). Significant predictors of ΔUACR were BMI, systolic blood pressure, and HbA1c. Urinary excretion of calcium oxalate crystals was found in 77(11.1%) patients, with only 1 presenting oxalate-mediated renal complications. CONCLUSIONS: ΔGFR seems to be influenced by the initial kidney function, as it decreases in subjects with hyperfiltration but tends to increase in those with kidney dysfunction. These results suggest that BS is associated with improvement of kidney outcomes, without a significant increase in renal complications.
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Cirugía Bariátrica , Riñón/fisiopatología , Obesidad Mórbida/cirugía , Adulto , Anciano , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Cirugía Bariátrica/rehabilitación , Índice de Masa Corporal , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Humanos , Hipertensión/complicaciones , Hipertensión/epidemiología , Hipertensión/fisiopatología , Hipertensión/cirugía , Masculino , Persona de Mediana Edad , Obesidad/fisiopatología , Obesidad/cirugía , Obesidad Mórbida/epidemiología , Obesidad Mórbida/fisiopatología , Periodo Posoperatorio , Prevalencia , Insuficiencia Renal/complicaciones , Insuficiencia Renal/epidemiología , Insuficiencia Renal/cirugía , Insuficiencia Renal Crónica/epidemiología , Insuficiencia Renal Crónica/fisiopatología , Insuficiencia Renal Crónica/cirugía , Factores de RiesgoRESUMEN
BACKGROUND: Doubts exist about the effect of different bariatric surgery (BS) types on levothyroxine (Lt4) absorption. We compared Lt4 doses and their variation (ΔLt4) in patients with hypothyroidism that underwent malabsorptive (MS) or restrictive (RS) surgery and studied predictors of Lt4 dose change. METHODS: Retrospective study of morbidly obese hypothyroid patients submitted to BS. We compared RS ("sleeve" gastrectomy or adjustable gastric banding) with MS (Roux-en-Y gastric bypass) patients. We built a multivariable logistic regression and a linear regression model to study predictors of Lt4 dose changes and ΔLt4, respectively. RESULTS: Fifty-seven patients: 35 MS and 22 RS. Mean age 47 years; 7% men. Patients submitted to MS had lower BMI at 1 year than those submitted to RS. Lt4 dose remained unchanged in 61.4%, increased in 12.3%, and decreased in 26.3% of patients. Initial and 1-year Lt4 dose were not different between surgical groups. Relative Lt4 dose, but not absolute (p = 0.07), increased at 1 year (p < 0.001). Neither BS nor BMI variation were predictors of Lt4 dose variation. BMI variation was associated with relative Lt4 dose change independently of initial BMI and BS type: ß (95%CI) - 0.03 (- 0.05; 0.00); p = 0.03. CONCLUSIONS: There were no differences in Lt4 dose and its variation between restrictive and malabsorptive techniques 1 year after surgery. Malabsorptive procedures may not affect Lt4 absorption differently from restrictive ones. Bariatric surgery type was not predictive of Lt4 dose changes. BMI variation is associated with relative Lt4 dose (dose per weight) variation and its association was independent of bariatric surgery type.