Immediate and delayed postoperative morbidity in functional and non-functioning pituitary adenomas.

Neurosurgery is the most widely used definite treatment for pituitary tumors, while medical treatments are a good option to improve symptoms, which tend to recur when drugs are stopped. The aim of this study was to assess postsurgical morbidity of secreting pituitary adenomas (adrenocorticotropin hormone -ACTH- and growth hormone -GH- secreting) and non-functioning (NF) adenomas, operated between January 2002 and May 2009. We retrospectively reviewed the data of 94 patients who were operated by the same neurosurgeons and compared the immediate (1st month) and delayed (1st year) complications between the three groups of adenomas. Forty had immediate post-operative complications (42% of NF, 37% of GH-secreting and 48% of ACTH-secreting adenomas). The most frequent complications were transient diabetes insipidus (23%), cerebrospinal fluid leaks (7%), sinusitis and meningitis (2%). Patients with Cushing's disease showed a tendency to have more transient diabetes insipidus and sinusitis compared to NF adenomas (P = 0.071). Ten patients had delayed complications during the first post-operative year (7% of NF, 11% of GH-secreting and 15% of ACTH-secreting), with a greater incidence of arthromyalgias and acute carpal tunnel syndrome in ACTH-secreting adenomas, compared with the other groups (P < 0.05). We conclude, that although ACTH-secreting adenomas are mostly microadenomas (78%) and affect younger patients, they are associated with a greater number of immediate and delayed complications during the first postoperative year (mainly invalidating arthromyalgias and acute carpal tunnel syndrome) compared with larger GH-secreting and NF adenomas, probably related to acute glucocorticoid deprivation after successful surgery.

Evolution of lipid profiles after bariatric surgery.

BACKGROUND: The most commonly encountered dyslipidemia in obese individuals is characterized by a cluster of interrelated plasma lipid and lipoprotein abnormalities including hypertriglyceridemia, low HDL cholesterol values, and increased small, dense LDL cholesterol particles. The aim of this study was to assess the changes in lipid profiles at baseline (pre-operatively) and at follow-up (6, 12, and 18 months) after a laparoscopic Roux-en-Y gastric bypass (LRYGBP). A retrospective observational study was performed involving all patients who consecutively underwent a LRYGBP between January 1, 2007 and December 31, 2009. Fasting lipids sub-fractions (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) were measured and HOMA-IR calculated pre-operatively and at follow-up post-LRYGBP. Pearson's correlation coefficients were used to assess the relationship between excess weight loss (EWL) and lipid sub-fractions. ANOVA was used to assess the differences between each lipid sub-fraction at various time-points. METHODS: One hundred twenty eight (N = 128) medical charts were reviewed, and those containing data on lipid fractions at the three follow-up time-points were analyzed. One hundred fourteen patients (N = 114), 84 of whom were women (73.7%), were finally included in the study. RESULTS: Total cholesterol, LDL cholesterol, triglycerides, and HOMA-IR were significantly reduced after LRYGBP (P < 0.0005 for all). Inversely, HDL cholesterol disclosed a significant rise (P < 0.0005). Noteworthy significant associations between lipid subfractions and EWL were detected overall (P < 0.0005 for all). A gender effect was found since female patients displayed a milder association than male patients (P < 0.0005). CONCLUSIONS: LRYGBP-induced weight loss improves the lipid profile while reducing insulin resistance, with male patients showing a better profile than female patients.

Relationship between adiponectin and left atrium size in uncomplicated obese patients: adiponectin, a link between fat and heart.

BACKGROUND: It is well known that obesity is a risk factor for severe cardiovascular complications, such as coronary heart disease, heart failure, stroke, venous thromboembolic disease, and atrial fibrillation. Left ventricle (LV) and left atrium (LA) enlargement is a characteristic feature of these patients with the consequent cardiovascular risk. Factors other than hemodynamic may influence LA remodeling. The aim of the study is to evaluate the relationship between adiponectin and LA size in uncomplicated obese patients. METHODS: Seventy-four asymptomatic obese patients and an age- and sex-matched control group (N = 70) were recruited. A detailed clinical, echocardiographic, and analytical study was performed. Insulin resistance was assessed using the homeostasis model assessment for insulin resistance (HOMA-IR) method. Insulin sensitivity was assessed measuring serum total adiponectin concentrations. RESULTS: Adiponectin levels were lower in the obese group (P < 0.001) and particularly so in those obese participants with enlarged LA (32%; P < 0.0005). LA sizes were higher in the obese group (P < 0.0005). Adiponectin displayed significant correlations with body mass index, glucose, insulin, high-density lipoprotein cholesterol, and triglyceride concentrations as well as HOMA-IR (P < 0.001 for all). Adiponectin displayed significant correlations with LV mass and LA size, diastolic and systolic cardiac volumes and diameters, and cardiac output (P < 0.001 for all). Adiponectin correlations with LA size (r = -0.429; P < 0.001) persisted after adjustment for HOMA-IR, age, sex, and LV mass. CONCLUSIONS: A novel inverse relationship between adiponectin and LA size independent of age, sex, insulin resistance, and LV mass appears in our series. Adiponectin could be a link between adipose tissue and the heart, having an influence on cardiac remodeling.

Quality of life in patients with pituitary tumors.

PURPOSE OF REVIEW: Quality of life (QoL) is impaired in patients with pituitary tumors, even after biochemical cure. However, it is not usually assessed in daily practice. The aim of this study is to highlight recent findings on QoL in the different types of pituitary adenomas and hypopituitarism. RECENT FINDINGS: Patients with acromegaly or Cushing's syndrome have the greatest impairment of QoL, and concomitant hypopituitarism worsens it further. The use of disease-generated QoL questionnaires allows dimensions specifically affected in that disease to be addressed and these dimensions are more sensitive to change after successful therapy; in some cases, improvement in patients' sense of well-being has been shown despite no hormonal change, indicating that evaluation of QoL is not such a soft end-point as thought by some. SUMMARY: Systematic evaluation of QoL in patients with pituitary diseases provides information not always contemplated by hormonal and routine clinical evaluation; this allows detection of not often contemplated health problems, which may then be approached and treated, improving the care provided to these patients.

Prevalence of cardiovascular disease and risk factors in a type 2 diabetic population of the North Catalonia diabetes study.

PURPOSE: The purpose of the study was to evaluate the prevalence of cardiovascular disease (CVD), cardiovascular risk factors (CVRFs), and their control in patients with type 2 diabetes mellitus (T2DM) at primary care settings from the North Catalonia Diabetes Study (NCDS). DATA SOURCES: In this multicentre cross-sectional descriptive study, data were collected from a random sample of 307 patients with T2DM. The prevalence of CVD, CVRF, metabolic syndrome (MS), coronary heart disease (CHD) risk at 10 years (Framingham Point Scores), and CVRF control was evaluated. MS and lipid profiles were established according to Adult Treatment Panel III criteria. CONCLUSIONS: CVD prevalence was 22.0% (CHD: 18.9% and peripheral ischemia: 4.5%) and more frequent in men. The prevalence of selected CVRF was: hypertension: 74.5%; dyslipidemia: 77.7%; smoking: 14.9%; obesity 44.9%, and familial CVD: 38.4%. Three or more CVRFs, including T2DM, were observed in 91.3%. MS prevalence was 68.7%. Framingham score was 10.0%, higher in men than in women. CVD prevalence was related to: age, number of CVRFs, duration of diabetes, familial history of CVD, waist circumference, hypertension, lipid profile, kidney disease, and Framingham score, but not to MS by itself. Correct lipid profiles and blood pressure were only observed in 18.9% and 24.0%, respectively, whereas platelet aggregation inhibitors were only recorded in 16.1% of the patient cohort. MS presence was not an independent risk factor of CVD in our study. IMPLICATIONS FOR PRACTICE: The high prevalence of CVD and an inadequate control of CVRF, which were apparent in the NCDS population, would suggest that advanced practice nurses should consider incorporating specific cardiovascular assessment in their routine care of persons with T2DM.

Hypovitaminosis D and morbid obesity.

There is scarce and flawed data regarding vitamin D status in morbidly obese patients. More often than not, vitamin D deficits have been linked with bariatric surgery, not considering that the deficit may well precede surgery. Moreover, several pathophysiologic mechanism might explain, in part, vitamin D deficits. Conversely, the association between vitamin D deficits and secondary hyperparathyroidism in morbidly obese patients has been reported before and after bariatric surgery. Taking into account the elevated prevalence of vitamin D deficits in morbidly obese patients, its associated comorbidity, and the efficacy and low cost of its treatment to restore normal serum values of 25-OH-vitamin D, it seems advisable to recommend routine monitoring of serum calcium, phosphorus, and 25-OH-vitamin D levels in morbidly obese patients and to implement calcium and vitamin D supplementation whenever necessary.

Hypogonadal hypogonadism and osteoporosis in men.

In recent years, osteoporosis in men has become increasingly recognized as an important clinical and public health problem. Many similarities exist in various aspects of osteoporosis in men and women, but this article focuses on the sex difference, bone biology, epidemiology, and consequences of fractures. Although maintenance of bone integrity depends on the action of sex hormones in both sexes, menopause is a much more obvious indicator of estrogen deficiency than is the subtle decrease of testosterone in aging men. This often leads to delay and neglect of diagnosis. The need to identify and screen men at a particular risk for osteoporosis, as when hypogonadism is induced for treatment of prostate cancer, has become important.

PTEN promoter methylation in sporadic thyroid carcinomas.

The tumor-suppressor gene PTEN/MMAC1, on chromosome 10q23.3, has been implicated in an important number of human tumors, such as thyroid carcinomas. PTEN somatic mutations occur in sporadic tumors of the endometrium, brain, prostate, or melanomas, while germline mutations predispose to development of the multiple hamartoma syndromes (i.e., Cowden's disease and Bannayan-Zonana syndrome). Activation of the two alleles of PTEN is required for its tumor-suppression role. Because the frequency of PTEN suppression in thyroid tumors exceeds that of PTEN mutations or deletions, it is very likely that epigenetic mechanisms, such as promoter hypermethylation, may account for its inactivation in a subset of tumors. The main aim of this study was to assess the frequency of promoter hypermethylation of PTEN in thyroid tumors. We studied frozen tissue samples from 46 papillary carcinomas, 7 follicular carcinomas, 6 follicular adenomas as well as 39 normal thyroid tissue samples. Methylation-specific polymerase-chain reaction (PCR) with three different sets of primers was used. Two of the primer sets were designed to avoid any interference with PTEN pseudogene promoter. PTEN promoter hypermethylation was detected in 21 of 46 (45.7%) papillary carcinomas, 6 of 7 follicular carcinomas, and 5 of 6 follicular adenomas. It was negative in all normal tissues. Negative immunohistochemical staining for PTEN was significantly associated with the presence of promoter hypermethylation (p < 0.001). These results show a high frequency of PTEN promoter hypermethylation, especially in follicular tumors, suggesting its possible role in thyroid tumorigenesis.

Role of pre-operative imaging using 99mTc-MIBI and neck ultrasound in patients with secondary hyperparathyroidism who are candidates for subtotal parathyroidectomy.

PURPOSE: The purpose of this study was to assess whether pre-operative (99m)Tc-methoxyisobutylisonitrile (MIBI) scintigraphy and neck ultrasound (US) are of value in improving the outcome of subtotal parathyroidectomy in patients with secondary hyperparathyroidism. METHODS: Forty-eight consecutive haemodialysis patients with severe secondary hyperparathyroidism prospectively underwent "blinded" subtotal parathyroid surgery, with 1-year follow-up to establish cure or relapse of their secondary hyperparathyroidism. Double-phase (99m)Tc-MIBI scintigraphy and neck US were performed pre-operatively in all patients. When the preserved gland showed (99m)Tc-MIBI uptake or an abnormal size on US, it was considered that "(99m)Tc-MIBI advice" and "US advice", respectively, had not been followed. Pre-operative and follow-up parathyroid hormone (PTH) levels were obtained in all patients. All data were evaluated on a patient by patient basis. RESULTS: Four parathyroid glands were identified in each patient at primary surgery, resulting in an operative success rate of 100%. Their weight ranged from 15 to 7,300 mg (mean 1,120+/-900 mg). Nine of the 48 patients (19%) showed a recurrence of their secondary hyperparathyroidism. The recurrence rate was 2% (1/48) and 10% (5/48), respectively, when (99m)Tc-MIBI and US advice was followed. The sensitivity, specificity, NPV and PPV for pre-operative imaging were 72%, 95%, 97% and 80% respectively for (99m)Tc-MIBI, and 55%, 67%, 87% and 28% for US. CONCLUSION: (99m)Tc-MIBI scintigraphy is a reliable non-invasive exploratory tool and its preoperative use results in a significant reduction in the number of recurrences in haemodialysis patients with secondary hyperparathyroidism who are candidates for subtotal parathyroidectomy. The use of neck US did not significantly improve the results obtained with (99m)Tc-MIBI alone.

Effects of bariatric surgery on vitamin D status and secondary hyperparathyroidism: a prospective study.

BACKGROUND: Morbidly obese patients have been reported to present with vitamin D insufficiency and secondary hyperparathyroidism. Scattered data are available regarding the effects of bariatric surgery on vitamin D status. We studied calcium metabolism and vitamin D status before and after bariatric surgery. METHODS: In this prospective study, 64 patients (M5/F59) fulfilled the inclusion criteria (i.e. 2 calcidiol serum determinations in the winter season) among 457 morbidly obese individuals who underwent Roux-en-Y gastric bypass (RYGBP) a mean of 36 months previously. Laboratory data (serum calcium, phosphorus, creatinine, alkaline phosphatase, albumin, calcidiol, albumin and iPTH) were determined before and after RYGBP. Pre- and postoperative calcidiol levels were categorized as being normal (>50 nmol/L), insufficient (25-50 nmol/L), and deficient (<25 nmol/L). Pre- and postoperative mild secondary hyperparathyroidism was defined as iPTH >7.3 pmol/L with simultaneous normal values for creatinine, calcium and phosphorus. RESULTS: RYGBP produced a significant weight loss coupled with a simultaneous increase in calcidiol (+28%, P<0.0005) and decrements in total alkaline phosphatase (-53%, P<0.0005) and iPTH (-74%, P=0.001). Corrected serum calcium, phosphorus, and creatinine levels were indistinguishable before and after RYGBP. Additionally, 37.5% of the patients maintained their calcidiol category, while 42.2 % improved it and 20.3% lost one category. CONCLUSIONS: RYGBP does not completely correct pre-existing vitamin D deficient states with secondary hyperparathyroidism. Low calcidiol bioavailability and or insufficient sunlight exposure do probably persist after bariatric surgery. While randomized controlled studies are warranted, it seems advisable to support vitamin D supplementation as well as increasing sunlight exposure in the morbidly obese population.

Unchanged hypovitaminosis D and secondary hyperparathyroidism in morbid obesity after bariatric surgery.

BACKGROUND: Morbidly obese patients have been reported to present with vitamin D insufficiency and secondary hyperparathyroidism. We assessed whether bariatric surgery alters the 25-hydroxyvitamin D (calcidiol) and intact parathyroid hormone (iPTH) levels in patients presenting with morbid obesity. METHODS: A cross-sectional survey was conducted on 144 patients of whom 80 had not undergone bariatric surgery, while 64 had bariatric surgery at a mean of 36 months previously. Calcidiol levels were defined as being normal (>50 nmol/L), insufficient (2550 nmol/L) and deficient (<25 nmol/L). Mild secondary hyperparathyroidism was defined as iPTH >7.3 pmol/L with simultaneous normal values for creatinine, calcium and phosphorus. RESULTS: 80% of the patients presented low vitamin D levels and mild secondary hyperparathyroidism. Previous surgery or the presence of diabetes did not influence calcidiol levels. Corrected serum calcium, phosphorus, alkaline phosphatase, iPTH and Calcidiol were similar between subjects with and without surgery. CONCLUSIONS: Vitamin D deficient states with secondary hyperparathyroidism in the morbidly obese precede and are not significantly affected by bariatric surgery. Hypovitaminosis D with secondary hyperparathyroidism due to low calcidiol bio-availability should be added to the crowded list of sequelae of morbid obesity. While further studies are warranted, it seems advisable to support vitamin D supplementation in the morbidly obese population.

Evaluation of nutritional education using concept mapping.

UNLABELLED: The concept mapping method is presented in the current study as a new tool to assess the learning process taking part in the hallmark of a nutritional education program addressed to obese diabetic patients. POPULATION: eight patients were interviewed prior to and after completion of 1-week in-hospital stay during which concept maps were designed. Concept maps quantitative and qualitative analysis disclose both (i) the importance of previous knowledge among patients prior to nutritional education and (ii) the maintenance of misconceptions after it. Nutritional education allows patients to acquire and structure their knowledge while providing them with a certain amount of medical vocabulary. An underlying correlation between concept maps design and the results of psychological tests identifying eating behaviour troubles (EBT), depression or anxiety has not been clearly identified. However, the nutritional education is more beneficial to those patients with a higher degree of self-assertiveness and with a lesser degree of anxiety, depression and eating disorder.

Determination of the maximal tumor:normal bladder ratio after i.p. or bladder administration of 5-aminolevulinic acid in Fischer 344 rats by fluorescence spectroscopy in situ.

The two major steps in our study on the treatment of bladder tumors by photodynamic therapy (PDT) were the development of a new bladder tumor model in Fischer rats by implantation of tumor cells and the use of fluorescence spectroscopy, a semi-quantitative and non-invasive method, in order to determine the time after general or local administration of a photosensitizer when the tumor:normal bladder ratio was at its highest. 5-Aminolevulinic acid (5-ALA) (250 mg/kg body weight) was injected i.p. or instilled directly into the bladder cavity for 1, 2 or 4 h and fluorescence was measured on normal and bladder tumor tissues every 30 min for 8-10 h after administration, with a special miniaturized optical-fiber captor. The better tumor:normal bladder ratios were 2.85+/-1.2 at 3.5 h after i.p. administration and 3.96+/-1.04 after bladder instillation for 4 h, respectively. These results were confirmed by fluorescence microscopy. PDT with the same dose of 5-ALA as in this pharmacokinetic study must also be carried out in order to compare the toxicity of the two administration routes of the photosensitizer and to determine which one is the better for this bladder tumor model.