[Vitamin D and its positive effect on the PTH/vitamin D/calcium-FGF23/klotho/phosphorus axis in kidney transplant recipients]. / Vitamina D y su efecto positivo sobre el eje PTH/vitamina D/calcio-FGF23/klotho/fósforo en pacientes con trasplante renal.

Introduction: Background: hypovitaminosis D is frequent in kidney transplant recipient (KTR) patients and is associated with deleterious effects both at the bone and extraosseous levels. Treatment with cholecalciferol is effective for the normalization of 25(OH)D, demonstrating a beneficial effect on the calcium-tropic axis in other populations; however, its effect on the PTH/vitamin D/calcium and FGF23/klotho/phosphorus axis in RTR has not been reported. The aim of this study was to evaluate the effect of normalization of serum 25(OH)D concentrations on the PTH/vitamin D/calcium-FGF23/klotho/phosphorus axis in KTR treated with cholecalciferol, as well as the association between the components of this axis. Methods: a prospective study in 23 KTR with hypovitaminosis D, with evolution from 1 to 12 months post-transplantation, an estimated glomerular filtration rate > 60 mL/min/1.73 m2 and a history of primary nephropathy treated with cholecalciferol, in whom the PTH/vitamin D/calcium and FGF23/klotho/phosphorus axis was evaluated during the state of hypovitaminosis D and at normalization of 25(OH)D. Results: at the normalization of 25(OH)D, a reduction in PTH [103 (58.5-123.9) vs 45.6 (30.1-65.1) pg/mL; p = 0.002] and an increase in serum phosphorus [3.1 (2.3-3.5) vs 3.3 (3-3.6) mg/dL; p = 0.01] were evident, with no differences in calcium, klotho and FGF23 concentrations. The time to achieve normalization of 25(OH)D was 12 weeks (RIC, 4-12), with a dose of 5000 IU/day (RIC, 4000-6000). A positive association between klotho and PTH was corroborated (r = 0.54; p = 0.008; linear regression, ß = 0.421; B = 0.004; 95 % CI, 0.003-0.007; p = 0.045). Conclusions: treatment with cholecalciferol is effective for the normalization of 25(OH)D, with a beneficial effect on calcium-phosphotropic metabolism characterized by a reduction in PTH concentration, without significant changes in calcemia or calciuria, as well as an increase in phosphatemia, without modifications in FGF23 or klotho concentrations.

Introducción: Introducción: la hipovitaminosis D es frecuente en los receptores de trasplante renal (RTR) y se asocia con efectos deletéreos tanto a nivel óseo como extraóseo. El tratamiento con colecalciferol es eficaz para la normalización de la 25(OH)D, demostrándose un efecto benéfico sobre el eje calciotrópico; sin embargo, su efecto sobre el eje fosfotrópico no se ha reportado. El objetivo de este estudio fue evaluar el efecto de la normalización de las concentraciones séricas de 25(OH)D sobre el eje PTH/vitamina D/calcio-FGF23/klotho/fósforo en RTR tratados con colecalciferol, así como la asociación entre sus componentes. Métodos: estudio prospectivo en 23 RTR con hipovitaminosis D y antecedente de nefropatía primaria tratados con colecalciferol, en quienes se evaluó el eje PTH/vitamina D/calcio y FGF23/klotho/fósforo durante el estado de hipovitaminosis D y a la normalización de la 25(OH)D. Resultados: a la normalización de la 25(OH)D se evidenció una reducción de la PTH [103 (58,5-123,9) vs. 45,6 (30,1-65,1) pg/mL; p = 0,002] y un aumento del fósforo sérico [3,1 (2,3-3,5) vs. 3,3 (3-3,6) mg/dL; p = 0,01], sin diferencias en las concentraciones de calcio, klotho y FGF23. El tiempo para lograr la normalización de la 25(OH)D fue de 12 semanas (4-12), con una dosis de 5000 UI/día (4000-6000). Se corroboró una asociación positiva entre klotho y PTH (r = 0,54; p = 0,008; regresión lineal, ß = 0,421; IC 95 %: 0,003-0,007; p = 0,045). Conclusiones: el tratamiento con colecalciferol es eficaz para la normalización de la 25(OH)D con un efecto benéfico sobre el metabolismo calcio-fosfotrópico caracterizado por una reducción de la PTH y un incremento de la fosfatemia, sin modificaciones de calcemia, calciuria, FGF23 o klotho.

Hypothalamic-pituitary-gonadal axis disturbance and its association with insulin resistance in kidney transplant recipients / Distúrbio do eixo hipotálamo-hipófise-gonadal e sua associação com resistência à insulina em receptores de transplante renal

Abstract Objective: To evaluate hypothalamic-pi- tuitary-gonadal (HPG) axis alterations at 1 and 12 months after kidney transplan- tation (KT) and their association with in- sulin resistance. Methods: A retrospective clinical study was conducted in a tertiary care center in kidney transplantation recipients (KTRs) aged 18- 50 years with primary kidney disease and stable renal graft function. LH, FSH, E2/T, and HOMA-IR were assessed at 1 and 12 months after KT. Results: Twenty-five KTRs were included; 53% were men, and the mean age was 30.6±7.7 years. BMI was 22.3 (20.4-24.6) kg/m2, and 36% had hypogonadism at 1 month vs 8% at 12 months (p=0.001). Re- mission of hypogonadism was observed in all men, while in women, hypogonadotropic hypogonadism persisted in two KTRs at 12 months. A positive correlation between go- nadotrophins and age at 1 and 12 months was evident. Fifty-six percent of patients had insulin resistance (IR) at 1 month and 36% at 12 months (p=0.256). HOMA-IR showed a negative correlation with E2 (r=- 0.60; p=0.050) and T (r=-0.709; p=0.049) at 1 month, with no correlation at 12 months. HOMA-IR at 12 months after KT correlated positively with BMI (r=0.52; p=0.011) and tacrolimus dose (r=0.53; p=0.016). Conclusion: Successful KT restores the HPG axis in the first year. Hypogonadism had a negative correlation with IR in the early pe- riod after KT, but it was not significant at 12 months.

Resumo Objetivo: Avaliar as alterações do eixo hipotálamo-hipófise-gonadal (HHG) em 1 e 12 meses após transplante renal (TR) e sua associação com a resistência à insulina. Métodos: Foi realizado um estudo clínico retrospectivo em um centro de cuidados terciários em receptores de transplante renal (RTR) com idade entre 18-50 anos com doença renal primária e função do enxerto renal estável. LH, FSH, E2/T e HOMA-IR foram avaliados em 1 e 12 meses após o TR. Resultados: foram incluídos 25 RTR; 53% eram homens e a média de idade foi de 30,6±7,7 anos. O IMC foi de 22,3 (20,4-24,6) kg/m2 e 36% apresentaram hipogonadismo em 1 mês vs 8% aos 12 meses (p=0,001). A remissão do hipogonadismo foi observada em todos os homens, enquanto nas mulheres, o hipogonadismo hipogonadotrófico persistiu em dois RTR aos 12 meses. Ficou evidente uma correlação positiva entre gonadotrofinas e idade em 1 e 12 meses. Cinquenta e seis por cento dos pacientes apresentaram resistência à insulina (RI) em 1 mês e 36% aos 12 meses (p=0,256). O HOMA-IR mostrou uma correlação negativa com E2 (r=-0,60; p=0,050) e T (r=-0,709; p=0,049) em 1 mês, sem correlação em 12 meses. O HOMA-IR aos 12 meses após TR correlacionou-se positivamente com o IMC (r=0,52; p=0,011) e a dose de tacrolimus (r=0,53; p=0,016). Conclusão: O TR bem-sucedido restaura o eixo HHG no primeiro ano. O hipogonadismo apresentou uma correlação negativa com a RI no período inicial após o TR, mas essa correlação não foi significativa aos 12 meses.

Guía de práctica clínica mexicana para el diagnóstico y tratamiento de las dislipidemias y enfermedad cardiovascular aterosclerótica.

ANTECEDENTES: Las enfermedades cardiovasculares son la principal causa mundial de mortalidad y México no es la excepción. Los datos epidemiológicos obtenidos en 1990 mostraron que los padecimientos cardiovasculares representaron el 19.8% de todas las causas de muerte en nuestro país; esta cifra se incrementó de manera significativa a un 25.5% para 2015. Diversas encuestas nacionales sugieren que más del 60% de la población adulta tiene al menos un factor de riesgo para padecer enfermedades cardiovasculares (obesidad o sobrepeso, hipertensión, tabaquismo, diabetes, dislipidemias). Por otro lado, datos de la Organización Panamericana de la Salud han relacionado el proceso de aterosclerosis como la primer causa de muerte prematura, reduciendo la expectativa de vida de manera sensible, lo que tiene una enorme repercusión social. OBJETIVO: Este documento constituye la guía de práctica clínica (GPC) elaborada por iniciativa de la Sociedad Mexicana de Cardiología en colaboración con la Sociedad Mexicana de Nutrición y Endocrinología, A.C., Asociación Nacional de Cardiólogos de México, A.C., Asociación Mexicana para la Prevención de la Aterosclerosis y sus Complicaciones, A.C., Comité Normativo Nacional de Medicina General, A.C., Colegio Nacional de Medicina Geriátrica, A.C., Colegio de Medicina Interna de México, A.C., Sociedad Mexicana de Angiología y Cirugía Vascular y Endovenosa, A.C., Instituto Mexicano de Investigaciones Nefrológicas, A.C. y la Academia Mexicana de Neurología, A.C.; con el apoyo metodológico de la Agencia Iberoamericana de Desarrollo y Evaluación de Tecnologías en Salud, con la finalidad de establecer recomendaciones basadas en la mejor evidencia disponible y consensuadas por un grupo interdisciplinario de expertos. El objetivo de este documento es el de brindar recomendaciones basadas en evidencia para ayudar a los tomadores de decisión en el diagnóstico y tratamiento de las dislipidemias en nuestro país. MATERIAL Y MÉTODOS: Este documento cumple con estándares internacionales de calidad, como los descritos por el Instituto de Medicina de EE.UU., el Instituto de Excelencia Clínica de Gran Bretaña, la Red Colegiada para el Desarrollo de Guías de Escocia y la Red Internacional de Guías de Práctica Clínica. Se integró un grupo multidisciplinario de expertos clínicos y metodólogos con experiencia en revisiones sistemáticas de la literatura y el desarrollo de guías de práctica clínica. Se consensuó un documento de alcances, se establecieron las preguntas clínicas relevantes, se identificó de manera exhaustiva la mejor evidencia disponible evaluada críticamente en revisiones sistemáticas de la literatura y se desarrollaron las recomendaciones clínicas. Se utilizó la metodología de Panel Delphi modificado para lograr un nivel de consenso adecuado en cada una de las recomendaciones contenidas en esta GPC. RESULTADOS: Se consensuaron 23 preguntas clínicas que dieron origen a sus respectivas recomendaciones clínicas. CONCLUSIONES: Esperamos que este documento contribuya a la mejor toma de decisiones clínicas y se convierta en un punto de referencia para los clínicos y pacientes en el manejo de las dislipidemias y esto contribuya a disminuir la morbilidad y mortalidad derivada de los eventos cardiovasculares ateroscleróticos en nuestro país. BACKGROUND: Cardiovascular diseases are the leading cause of mortality worldwide and Mexico is no exception. The epidemiological data obtained in 1990 showed that cardiovascular diseases represented 19.8% of all causes of death in our country. This figure increased significantly to 25.5% for 2015. Some national surveys suggest that more than 60% of the adult population has at least one risk factor for cardiovascular disease (obesity or overweight, hypertension, smoking, diabetes, dyslipidemias). On the other hand, data from the Pan American Health Organization have linked the process of atherosclerosis as the first cause of premature death, significantly reducing life expectancy, which has enormous social repercussions. OBJECTIVE: This document constitutes the Clinical Practice Guide (CPG) prepared at the initiative of the Mexican Society of Cardiology in collaboration with the Mexican Society of Nutrition and Endocrinology, AC, National Association of Cardiologists of Mexico, AC, Mexican Association for the Prevention of Atherosclerosis and its Complications, AC, National Normative Committee of General Medicine, AC, National College of Geriatric Medicine, AC, College of Internal Medicine of Mexico, AC, Mexican Society of Angiology and Vascular and Endovenous Surgery, AC, Mexican Institute of Research Nephrological, AC and the Mexican Academy of Neurology, A.C.; with the methodological support of the Ibero-American Agency for the Development and Evaluation of Health Technologies, in order to establish recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. The objective of this document is to provide evidence-based recommendations to help decision makers in the diagnosis and treatment of dyslipidemias in our country. MATERIAL AND METHODS: This document complies with international quality standards, such as those described by the Institute of Medicine of the USA, the Institute of Clinical Excellence of Great Britain, the Scottish Intercollegiate Guideline Network and the Guidelines International Network. A multidisciplinary group of clinical experts and methodologists with experience in systematic reviews of the literature and the development of clinical practice guidelines was formed. A scope document was agreed upon, relevant clinical questions were established, the best available evidence critically evaluated in systematic literature reviews was exhaustively identified, and clinical recommendations were developed. The modified Delphi Panel methodology was used to achieve an adequate level of consensus in each of the recommendations contained in this CPG. RESULTS: 23 clinical questions were agreed upon which gave rise to their respective clinical recommendations. CONCLUSIONS: We consider that this document contributes to better clinical decision-making and becomes a point of reference for clinicians and patients in the management of dyslipidemias and this contributes to reducing the morbidity and mortality derived from atherosclerotic cardiovascular events in our country.

Expression of obesity- and type-2 diabetes-associated genes in omental adipose tissue of individuals with obesity.

AIMS: Obesity and type 2 diabetes mellitus are two pathologies that share metabolic abnormalities in most of the cases; however, there are differences as well. Some studies have reported that approximately 30% of obese patients have normal glucose and lipid levels in blood despite an accumulation of abdominal adipose tissue. Here, we compare the gene expression in adipose tissue of several genes associated with obesity and/or diabetes between obese patients without T2D and obese patients with T2D. METHODS: Omental adipose tissue was collected during the patients elective bariatric surgery. Gene expression was determined by real-time PCR. Phenotypic variables were correlated with gene expression and 2^-ΔΔCt relative expression analysis between groups was performed. RESULTS: The stronger correlations in the obese without T2D or reference group was between ICAM1 and HbA1c; HP and TC and LDL while in the obese with diabetes or case group the correlation occurred between CSF1 and BMI. A correlation between HP and TC was found in the case group as well. The expression of VEGFA, CCND2, IL1R1 and PTEN was downregulated in the obese with T2D group. CONCLUSIONS: This study identified genes whose expression is different between obese subjects with and without diabetes. Those genes are related to inflammation, cholesterol transport, adipocyte differentiation/expansion and browning.

Guía de práctica clínica mexicana para el diagnóstico y tratamiento de las dislipidemias y enfermedad cardiovascular aterosclerótica / Mexican clinical practice guideline for the diagnosis and treatment of dyslipidemias and atherosclerotic cardiovascular disease

resumen está disponible en el texto completo

Abstract Background: Cardiovascular diseases are the leading cause of mortality worldwide and Mexico is no exception. The epidemiological data obtained in 1990 showed that cardiovascular diseases represented 19.8% of all causes of death in our country. This figure increased significantly to 25.5% for 2015. Some national surveys suggest that more than 60% of the adult population has at least one risk factor for cardiovascular disease (obesity or overweight, hypertension, smoking, diabetes, dyslipidemias). On the other hand, data from the Pan American Health Organization have linked the process of atherosclerosis as the first cause of premature death, significantly reducing life expectancy, which has enormous social repercussions. Objective: This document constitutes the Clinical Practice Guide (CPG) prepared at the initiative of the Mexican Society of Cardiology in collaboration with the Mexican Society of Nutrition and Endocrinology, AC, National Association of Cardiologists of Mexico, AC, Mexican Association for the Prevention of Atherosclerosis and its Complications, AC, National Normative Committee of General Medicine, AC, National College of Geriatric Medicine, AC, College of Internal Medicine of Mexico, AC, Mexican Society of Angiology and Vascular and Endovenous Surgery, AC, Mexican Institute of Research Nephrological, AC and the Mexican Academy of Neurology, A.C.; with the methodological support of the Ibero-American Agency for the Development and Evaluation of Health Technologies, in order to establish recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. The objective of this document is to provide evidence-based recommendations to help decision makers in the diagnosis and treatment of dyslipidemias in our country. Material and methods: This document complies with international quality standards, such as those described by the Institute of Medicine of the USA, the Institute of Clinical Excellence of Great Britain, the Scottish Intercollegiate Guideline Network and the Guidelines International Network. A multidisciplinary group of clinical experts and methodologists with experience in systematic reviews of the literature and the development of clinical practice guidelines was formed. A scope document was agreed upon, relevant clinical questions were established, the best available evidence critically evaluated in systematic literature reviews was exhaustively identified, and clinical recommendations were developed. The modified Delphi Panel methodology was used to achieve an adequate level of consensus in each of the recommendations contained in this CPG. Results: 23 clinical questions were agreed upon which gave rise to their respective clinical recommendations. Conclusions: We consider that this document contributes to better clinical decision-making and becomes a point of reference for clinicians and patients in the management of dyslipidemias and this contributes to reducing the morbidity and mortality derived from atherosclerotic cardiovascular events in our country.

Quality of life evaluation in Mexican patients with severe obesity before and after bariatric surgery.

INTRODUCTION: In Mexico, neither the 36-item Short Form Health Survey (SF-36) nor the Bariatric Analysis and Reporting Outcome System (BAROS) instruments have been used to assess quality of life (QoL) before and after bariatric surgery (BS). OBJECTIVE: To describe changes in QoL using the SF-36 and BAROS questionnaires in patients with severe obesity before and after BS. METHODS: Clinical and anthropometric data of patients undergoing bariatric surgery between 2015 and 2016 were collected. Statistical significance was considered with a p-value < 0.05. RESULTS: 230 patients were analyzed, 98 before and 132 and after BS; most were females (81 %). Initial body mass index was 48 kg/m2 (44-53). SF-36-measured QoL showed an increase in the physical component score from 43 to 54.2 points (p < 0.001), and in the mental component, from 53.3 to 56.6 points after BS. With BAROS, 98.5 % showed good to excellent QoL results within the first three months after BS. CONCLUSION: When measured with the SF-36 and BAROS questionnaires, QoL of Mexican patients with severe obesity was found to improve after BS.

INTRODUCCIÓN: En México no se han utilizado los instrumentos Shorth Form 36 Items (SF-36) ni Baryatric Assesment Reporting Outcomes System (BAROS) para evaluar la calidad de vida (CV) antes y después de la cirugía bariátrica (CB). OBJETIVO: Describir los cambios en la CV con los cuestionarios SF-36 y BAROS, en pacientes con obesidad severa antes y después de la CB. MÉTODOS: Se recolectaron los datos clínicos y antropométricos de pacientes sometidos a cirugía baríatrica entre 2015 y 2016. Se consideró con significación estadística una p < 0.05. RESULTADOS: Se analizaron 230 pacientes, 98 y 132 antes y después de la CB; la mayoría fue del sexo femenino (81 %). El índice de masa corporal inicial fue de 48 kg/m2 (44-53). La CV medida con el SF-36 demostró un incremento en la puntuación del componente físico de 43 a 54.2 (p < 0.001) y en el componente mental, de 53.3 a 56.6 después de la CB. Con BAROS, en 98.5 % se registraron resultados buenos a excelentes en la CV en los primeros tres meses. CONCLUSIÓN: Al ser medida con los cuestionarios SF-36 y BAROS se definió que la CV de los pacientes mexicanos con obesidad severa mejora después de la CB.

Evaluación de la calidad de vida en pacientes mexicanos con obesidad severa antes y después de cirugía bariátrica / Quality of life evaluation in Mexican patients with severe obesity before and after bariatric surgery

Resumen Introducción: En México no se han utilizado los instrumentos Shorth Form 36 Items (SF-36) ni Baryatric Assesment Reporting Outcomes System (BAROS) para evaluar la calidad de vida (CV) antes y después de la cirugía bariátrica (CB). Objetivo: Describir los cambios en la CV con los cuestionarios SF-36 y BAROS, en pacientes con obesidad severa antes y después de la CB. Métodos: Se recolectaron los datos clínicos y antropométricos de pacientes sometidos a cirugía baríatrica entre 2015 y 2016. Se consideró con significación estadística una p < 0.05. Resultados: Se analizaron 230 pacientes, 98 y 132 antes y después de la CB; la mayoría fue del sexo femenino (81 %). El índice de masa corporal inicial fue de 48 kg/m2 (44-53). La CV medida con el SF-36 demostró un incremento en la puntuación del componente físico de 43 a 54.2 (p < 0.001) y en el componente mental, de 53.3 a 56.6 después de la CB. Con BAROS, en 98.5 % se registraron resultados buenos a excelentes en la CV en los primeros tres meses. Conclusión: Al ser medida con los cuestionarios SF-36 y BAROS se definió que la CV de los pacientes mexicanos con obesidad severa mejora después de la CB.

Abstract Introduction: In Mexico, neither the 36-item Short Form Health Survey (SF-36) nor the Bariatric Analysis and Reporting Outcome System (BAROS) instruments have been used to assess quality of life (QoL) before and after bariatric surgery (BS). Objective: To describe changes in QoL using the SF-36 and BAROS questionnaires in patients with severe obesity before and after BS. Methods: Clinical and anthropometric data of patients undergoing bariatric surgery between 2015 and 2016 were collected. Statistical significance was considered with a p-value < 0.05. Results: 230 patients were analyzed, 98 before and 132 and after BS; most were females (81 %). Initial body mass index was 48 kg/m2 (44-53). SF-36-measured QoL showed an increase in the physical component score from 43 to 54.2 points (p < 0.001), and in the mental component, from 53.3 to 56.6 points after BS. With BAROS, 98.5 % showed good to excellent QoL results within the first three months after BS. Conclusion: When measured with the SF-36 and BAROS questionnaires, QoL of Mexican patients with severe obesity was found to improve after BS.

Familial hypercholesterolemia in Mexico: Initial insights from the national registry.

BACKGROUND: Familial hypercholesterolemia (FH) remains underdiagnosed and undertreated. OBJECTIVE: Report the results of the first years (2017-2019) of the Mexican FH registry. METHODS: There are 60 investigators, representing 28 federal states, participating in the registry. The variables included are in accordance with the European Atherosclerosis Society (EAS) FH recommendations. RESULTS: To date, 709 patients have been registered, only 336 patients with complete data fields are presented. The mean age is 50 (36-62) years and the average time since diagnosis is 4 (IQR: 2-16) years. Genetic testing is recorded in 26.9%. Tendon xanthomas are present in 43.2%. The prevalence of type 2 diabetes is 11.3% and that of premature CAD is 9.8%. Index cases, male gender, hypertension and smoking were associated with premature CAD. The median lipoprotein (a) level is 30.5 (IQR 10.8-80.7) mg/dl. Statins and co-administration with ezetimibe were recorded in 88.1% and 35.7% respectively. A combined treatment target (50% reduction in LDL-C and an LDL-C <100 mg/dl) was achieved by 13.7%. Associated factors were index case (OR 3.6, 95%CI 1.69-8.73, P = .002), combination therapy (OR 2.4, 95%CI 1.23-4.90, P = .011), type 2 diabetes (OR 2.8, 95%CI 1.03-7.59, P = .036) and age (OR 1.023, 95%CI 1.01-1.05, P = .033). CONCLUSION: The results confirm late diagnosis, a lower than expected prevalence and risk of ASCVD, a higher than expected prevalence of type 2 diabetes and undertreatment, with relatively few patients reaching goals. Recommendations include, the use of combination lipid lowering therapy, control of comorbid conditions and more frequent genetic testing in the future.

High biochemical recurrence rate after withdrawal of cabergoline in prolactinomas: is it necessary to restart treatment?

PURPOSE: Treatment with dopamine agonists (DA) is highly effective in patients with prolactinomas. In selected patients, discontinuation of DA after several years of successful treatment is possible, however, hyperprolactinemia recurs in 60-80% of them. It is unclear what is the clinical significance of these recurrences and hence, whether or not reinitiation of therapy is necessary. OBJECTIVES: To evaluate the recurrence rate in prolactinoma patients after DA withdrawal and the necessity to restart treatment. METHODS: Patients with >2 years of treatment with cabergoline (CBG) who achieved normoprolactinemia and a > 50% reduction in tumor size were included. DA dose was down titrated until withdrawal. Basal tumor size, as well as PRL and gonadal steroid levels were recorded at diagnosis, at withdrawal of DA and every 3-6 months for 1-3 years. RESULTS: Fifty patients were included (38 women, 34 macroprolactinomas). After withdrawal, 34 (68%) presented recurrence of hyperprolactinemia. PRL levels <5 ng/mL at the time of withdrawal predicted remission (sensitivity 76%, specificity of 63%). CBG was restarted in eight patients (23%) because of the presence of hypogonadism. CBG was withheld in the remaining 26, based on the following arguments: (1) premenopausal women without biochemical hypogonadism, (54%); (2) asymptomatic men under 65 without biochemical hypogonadism (19%); (3) asymptomatic postmenopausal women (19%); (4) asymptomatic men over 65 (8%). After a median follow-up of 30 months, no increase in PRL levels or tumor growth was documented. CONCLUSIONS: Biochemical recurrence in prolactinomas is very frequent, however, in only a few of these patients reinitiation of DA is necessary.

Efficacy of the treatment with dapagliflozin and metformin compared to metformin monotherapy for weight loss in patients with class III obesity: a randomized controlled trial.

BACKGROUND: Mexico has one of the highest prevalence rates of obesity worldwide. New pharmacological strategies that focus on people with class III obesity are required. Metformin and dapagliflozin are two drugs approved for the treatment of diabetes. Beyond its effects on glucose, metformin has been suggested by some studies to result in weight loss. Therapy with dapagliflozin is associated with a mild but sustained weight loss in patients with diabetes. The primary outcome of the study is to determine if the combined treatment with dapagliflozin and metformin is more effective than monotherapy with metformin for weight loss in patients with class III obesity and prediabetes or diabetes who are awaiting bariatric surgery (including those patients who do have surgery). We also aimed to assess the effect of this combined treatment on waist circumference, triglycerides, blood pressure, and inflammatory cytokines. METHODS: This randomized phase IV clinical trial will include patients with diabetes or prediabetes who are between the ages of 18 and 60 years and exhibit grade III obesity (defined as body mass index ≥ 40 kg/m2). Patients using insulin will be excluded. Subjects will be randomized to one of two groups as follows: 1) metformin tablets 850 mg PO bid or 2) metformin tablets 850 mg PO bid plus dapagliflozin tablets 10 mg PO qd. The sample size required is 108 patients, which allows for a 20% dropout rate: 54 patients in the metformin group and 54 in the metformin/dapagliflozin group. All participants will receive personalized nutritional advice during the study. A run-in period of one month will be used to assess tolerance and adherence to treatment regimens. Anthropometric and biochemical variables will be recorded at baseline and at 1, 3, 6, and 12 months. A serum sample to determine glucagon, ghrelin, adiponectin, resistin, interleukin 6, and interleukin 10 will be collected at baseline and before surgery, or at 12 months (whatever happens first). Adherence to treatment and adverse and secondary events will be recorded throughout the study. An intention-to-treat analysis will be used. DISCUSSION: Forty-six percent of the patients in our Obesity Clinic have been diagnosed with prediabetes (32%) or diabetes (14%). The use of dapagliflozin in this population could improve weight loss and other cardiovascular factors. This effect could be translated into less time before undergoing bariatric surgery and better control of associated comorbidities. TRIAL REGISTRATION: Clinicaltrials.gov, ID: NCT03968224. Retrospectively registered on May 29, 2019.

Detection of polyps in the small bowel of patients with acromegaly via capsule endoscopy.

BACKGROUND: the prevalence of small bowel (SB) polyps is unknown in acromegaly patients. OBJECTIVE: to evaluate the prevalence of polyps/tumors in SB of acromegaly patients. MATERIAL: this was a prospective and observational study that compared the prevalence of polyps/tumors using capsule endoscopy with a standard protocol in asymptomatic acromegaly patients and non-acromegaly patients, with abdominal pain, diarrhea or anemia. RESULTS: one hundred and eighty-three cases were included (61 acromegaly and 122 non-acromegaly). Polyps were found in six (9.8%) and three (2.5%) patients, respectively (RR: 4 [95% CI, 1.03-15.45; p = 0.038]). There were no differences in the tumors (n = 4, 6.6% vs n = 7, 5.7%). CONCLUSIONS: acromegaly may be associated with more polyps in SB.

The Testosterone Effect on Metabolic and Urologic Outcomes in Patients with Nonfunctioning Pituitary Macroadenomas and Hypogonadotropic Hypogonadism.

OBJECTIVE: To evaluate cardiovascular risk, metabolic profile, low urinary tract symptoms (LUTS), and sexual function in patients with nonfunctional pituitary macroadenoma (NFPMA) and hypogonadotropic hypogonadism with testosterone therapy (TTh). METHODS: A retrospective clinical study at a tertiary care center was performed in 101 men with NFPMA, HH, and TTh; metabolic profile, cardiovascular risk, International Prostate Symptoms Score (IPSS), and International Index of Erectile Function 5 (IIEF-5) scores were evaluated before initiation of TTh and at the last checkup with TTh. RESULTS: Age was 49.3 ± 8.8 years; T before TTh was 195 ng/mL (101-259) vs. 574 (423-774) at the last checkup. The time of TTh administration was 34 months (12-72). An increase in triglyceride levels (200 (153-294) vs. 174 (134-233) mg/dL; p=0.03), dyslipidemia (40% vs. 52%; p=0.03), and MetS (25% vs. 34%; p=0.05) was corroborated. A statistical difference in the Globorisk score and cardiovascular (CV) risk stratification was not found. IIEF-5 score was 15.5 ± 6.5 vs. 17.8 ± 5.3 (p=0.11). An improvement in penetration quality (2.0 ± 1.5 vs. 2.6 ± 1.3; p=0.05), erection after penetration (1.8 ± 1.2 vs. 2.5 ± 1.6; p=0.02), completion of intercourse (1.8 ± 1.2 vs. 2.4 ± 1.3; p=0.03), and satisfaction of sexual intercourse (1.8 ± 1.3 vs. 2.5 ± 1.5; p=0.01) was evidenced. IPSS score was 6 (IQR 2-10) vs. 7 (IQR 4-12); p=0.30. A lower rate of intermittency (14% vs. 3%; p=0.02), urgency (39% vs. 16%; p=0.01), and episodes of nocturia (18% vs. 4%; p=0.02) was found. An increase of hematocrit (44.1 ± 4.4 vs. 47.3 ± 4.4%; p=0.001), hemoglobin (14.9 ± 1.4 vs. 15.9 ± 1.4 g/dL; p=0.001), and prostatic specific antigen (0.59 (0.43-1.19) vs. 0.82 (0.45-1.4) ng/mL; p=0.02) was evidenced during TTh. CONCLUSION: TTh in young men with NFPMA improves LUTS, sexual function, and some metabolic parameters, and it is relatively safe in the prostatic context.

Silent pituitary plurihormonal adenoma: clinical relevance of immunohistochemical analysis / Adenoma hipofisario silente plurihormonal: relevancia clínica de la inmunohistoquímica

Background: Non-functional pituitary adenomas (NFPAs) present low growth rates; however, some are aggressive and invasive. In 2017 the World Health Organization recognized clinically aggressive adenomas as "high-risk pituitary adenomas". These include the sparsely granulated somatotroph adenoma, the Crooke's cell adenoma, the silent corticotroph adenoma and the plurihormonal Pit-1-positive adenoma (subtype 3). Clinical case: 25-year-old woman who presented oligomenorrhea, increased weight, decreased visual acuity and chronic headache. Biochemical and imaging evaluation showed a NFPA. Transsphenoidal surgery was performed with complete resection of lesion, and during short-term follow-up it was observed recurrence, which is why the patient needed two more interventions. The immunohistochemistry reported: ACTH ++ 90%, prolactin ++ 20%, GH ++ 5%, CKAE1-AE3 +++ 90%, Ki-67 10%. The final diagnosis was plurihormonal adenoma, since the immunohistochemical analysis was positive for more than one pituitary hormone and suggested two distinct cell lineages: Pit-1 and Tpit, both recognized as aggressive adenomas. Conclusions: This case report highlights the significance of a comprehensive immunohistochemical study, which includes transcriptional factors to classify cell lineage, in order to predict aggressiveness and provide personalized treatment.

Introducción: los adenomas hipofisarios no funcionantes (AHNF) presentan una baja tasa de crecimiento; sin embargo, algunos son agresivos e invasivos. En 2017 la Organización Mundial de la Salud denominó los adenomas de comportamiento clínico agresivo como "tumores hipofisarios de alto riesgo", incluyendo los adenomas del somatotropo escasamente granulados, los adenomas de células de Crooke, los silentes de corticotropo y los adenomas plurihormonal Pit-1 positivo (subtipo 3). Caso clínico: mujer de 25 años de edad con oligoamenorrea, aumento de peso, disminución del campo visual y cefalea crónica. La evaluación bioquímica y de imagen correspondió a un AHNF. Se realizó cirugía transesfenoidal con resección completa de la lesión y durante el seguimiento a corto plazo se observó recurrencia tumoral, por lo que ameritó dos intervenciones más. La inmunohistoquímica reportó: ACTH ++ 90%, prolactina ++ 20%, GH ++ 5%, CKAE1-AE3 +++ 90%, Ki-67 10%. El diagnóstico definitivo correspondió a un adenoma plurihormonal, debido a que la inmunohistoquímica fue positiva para la expresión de más de una hormona hipofisaria, con sugerencia de contenido celular con dos linajes distintos, tanto de Pit-1 como de Tpit, ambos reportados como adenomas agresivos. Conclusiones: este caso resalta la importancia de una inmunohistoquímica completa que incluya factores de transcripción que permitan clasificar el linaje celular para predecir agresividad y proporcionar un tratamiento individualizado.

Efficacy and safety of fractionated conformal radiation therapy in acromegaly: a long-term follow-up study.

BACKGROUND AND PURPOSE: Conformal, fractionated radiation therapy (XRT) is variably used as a treatment alternative for active acromegaly patients, usually, after failed pituitary surgery. Our objective was to evaluate the long-term efficacy and safety of XRT using strict criteria of biochemical control. SETTING, DESIGN, PATIENTS, AND METHODS: Retrospective cohort study of 94 patients (73 women, mean age at radiation 53.16 ± 12.9 years) attending a specialized multidisciplinary clinic between 1998 and 2014 with a mean duration of follow-up of 12.9 ± 7.3 years. RESULTS: A basal growth hormone < 1 ng/mL and an IGF-1 < 1.2 × the upper limit of normal was achieved by 41% and 50.8%, respectively, at 5 years of follow-up, and by 44% and 66%, respectively, 10 years after XRT. Median tumor volume decreased significantly from 904 mm3 at baseline to 424 mm3 upon last follow-up (p = 0.01). The prevalence of central hypogonadism, central hypocortisolism, and central hypothyroidism increased from 18%, 35%, and 35% at baseline, to 38%, 53%, and 64%, respectively, after 10 years of follow-up. One patient was diagnosed with a meningioma and another one developed optic neuritis. No cerebrovascular events were recorded, and all patients are currently alive. CONCLUSION: XRT is an effective and reasonably safe means of controlling acromegalic activity. Its main disadvantages are the time required to achieve biochemical control and the development of anterior pituitary hormone deficiencies.

Evaluation of endothelial function and diastolic function in patients with primary hyperparathyroidism before and after parathyroidectomy.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is the leading cause of outpatient hypercalcemia associated with increased cardiovascular risk. The flow-mediated vasodilation (FMV) has been proposed as a non-invasive method for assessing endothelial function. OBJECTIVE: To compare the endothelial dysfunction measured by FMV and diastolic dysfunction in patients with PHPT before and after parathyroidectomy. METHOD: We performed a quasi-experimental (before-after) study to evaluate diastolic function and FMV in patients with PHPT before and six months after parathyroidectomy. RESULTS: Fifteen patients completed study: 12 women and 3 men; 73% presented lithiasis, 27% osteoporosis and 53% metabolic syndrome; 73% presented diastolic dysfunction before the surgery and 60% after the surgery (p = 0.09). Post-isquemia brachial diameter improved from 41 mm (before surgery) to 46 mm (after surgery; p = 0.020). After surgery, we also observed an increase in the brachial diameter pre vs. post-ischemia from 41 to 46 mm (p = 0.005). Before surgery, the change in the delta of brachial diameter pre and post-ischemia was 1 mm and up to 4 mm after surgery (p = 0.03). CONCLUSIONS: There is a minor endothelial dysfunction measured by FMV in patients who underwent surgery for PHPT at 6 months after surgery, as well as a trend towards improvement in diastolic dysfunction. Echocardiography can be useful in the preoperative evaluation in patients with asymptomatic PHPT.

INTRODUCCIÓN: El hiperparatiroidismo primario (HPTP) es la principal causa de hipercalcemia ambulatoria y se ha asociado con un riesgo cardiovascular elevado. La vasodilatación mediada por flujo (VMF) es un método no invasivo que evalúa la función endotelial. OBJETIVO: Comparar la disfunción endotelial mediante VMF y la disfunción diastólica en pacientes con HPTP antes y después de la paratiroidectomía. MÉTODO: Mediante un estudio cuasiexperimental (antes-después) se evaluaron la función diastólica y la VMF antes y 6 meses después de realizar una paratiroidectomía. RESULTADOS: Se incluyeron 15 pacientes con HPTP: 12 mujeres (80%) y 3 hombres (20%); el 73% presentaron litiasis, el 27% osteoporosis y el 53% síndrome metabólico; el 73% tenían disfunción diastólica antes de la cirugía y el 60% después de la cirugía (p = 0.09). Los diámetros braquiales post-isquemia mejoraron de 41 mm antes de la cirugía a 46 mm tras la cirugía (p = 0.020). Así mismo, los diámetros braquiales preisquemia vs. post-isquemia después de la cirugía mejoraron de 41 a 46 mm (p = 0.005). Antes de la cirugía, el cambio en la delta del diámetro braquial preisquemia y post-isquemia fue de 1 mm, y subió a 4 mm después de la cirugía (p = 0.03). CONCLUSIONES: Existe una menor disfunción endotelial medida por VMF en pacientes posoperados por HPTP a los 6 meses de la cirugía. El estudio ecocardiográfico puede ser de utilidad en la evaluación preoperatoria de los pacientes con HPTP asintomáticos.

Gastroesophageal reflux disease in patients with long standing type 1 diabetes mellitus: utility of two self-report questionnaires in a multifactorial disease.

BACKGROUND: Gastroesophageal pathologies are common and multifactorial in patients with type 1 diabetes (T1DM). The evaluation with endoscopy and 24 h pH esophageal monitoring is expensive and not always available in all medical centers, especially in developing countries so more cost-effective algorithms for diagnosis are required. Clinical questionnaires are easy to apply but its utility for gastroesophageal reflux disease screening in patients with long standing T1DM must be analyzed. OBJECTIVE: To evaluate the utility of the FSSG and Carlsson-Dent (CDQ) questionnaires to detect the frequency of gastroesophageal reflux disease in patients with T1DM. METHODS: Analytic cross-sectional study, included 54 randomly selected patients from the T1DM clinic in our hospital. Before their routine evaluation, were asked to answer FSSG and CDQ questionnaires, classifying them as positive with a score >8 or >4, respectively. we associated and compared the clinical and biochemical characteristics between patients with or without gastroesophageal reflux detected through questionnaires. RESULTS: Median age was 29 years (22-35), 67% were female (median of 16 years from diagnosis). In 39% of the patients FSSG was positive, CDQ was positive in 28%. A total of 71% of patients were taking medications to treat non-specific gastric symptoms. The concordance between questionnaires was 65% (p: <0.001). Those patients with tobacco consumption as well as those with poor glycemic control were more likely to score positive in either questionnaire. CONCLUSIONS: Patients T1DM had a high prevalence of gastroesophageal reflux disease. In those patients FSSG questionnaire detected a higher number of patients in comparison with CDQ.

INTRODUCCIÓN: Las patologías gastroesofágicas son comunes y multifactoriales en pacientes con diabetes tipo 1 (DM1). La evaluación por medio de panendoscopia y pHmetría es costosa y difícil de realizar en todos los centros de atención, por lo que se requieren algoritmos rentables para su diagnóstico. Existen cuestionarios sencillos y autoaplicables que pueden ser útiles para el diagnóstico de enfermedad por reflujo gastroesofágico en los pacientes con DM1. OBJETIVO: Evaluar la utilidad de los cuestionarios FSSG y Carlsson-Dent (CDQ) para detectar la enfermedad por reflujo gastroesofágico (ERGE) en pacientes con DM1. MÉTODOS: Estudio transversal, se incluyeron 54 pacientes, elegidos al azar de la clínica de DMT1. Previo a la consulta, se les solicitó contestaran los cuestionarios FSSG y el CDQ, considerándose positivos para diagnóstico de ERGE los puntajes >8 y >4, respectivamente. Se analizaron y compararon las características bioquímicas y clínicas entre los pacientes con y sin síntomas de ERGE detectada por medio de los cuestionarios. RESULTADOS: Los pacientes estudiados tenían edad de 29 años (22-35), 67% fueron mujeres, (mediana de diagnóstico de 16 años). El 39% de los pacientes tenían ERGE detectado mediante FSSG y 28% utilizando el cuestionario CDQ. El 71% de los pacientes reportó uso de medicamentos para reflujo. La concordancia entre ambos cuestionarios fue del 65% (p: <0.001). Pacientes que consumen tabaco y con descontrol glucémico, tenían más probabilidades de positividad en cualquier cuestionario. CONCLUSIONES: Existe una alta prevalencia de ERGE en los pacientes con DM1. En esta población el cuestionario FSSG detectó a un mayor número de pacientes en comparación con el CDQ.

[Evaluation of cardiovascular risk factors in obesity before and after bariatric surgery]. / Evaluación de factores de riesgo cardiovascular antes y después de cirugía bariátrica.

BACKGROUND: Mexico has one of the highest prevalences of severe obesity worldwide. Mortality in those patients may be as high as 90% mainly due to cardiovascular disease. Despite Framingham score has been validated in the Mexican population, it only predicts cardiovascular risk at 10 years. Meanwhile ASCVD10 score could evaluate risk at 10 years and through lifetime. None of these scores have been used for cardiovascular risk assessment in Mexican patients with severe obesity. METHODS: We conducted a quasi-experimental (before/ after) study with 109 patients with severe obesity, assessed prevalence of comorbidities, performed anthropometric and biochemical evaluations before and a year after bariatric surgery. With these results we calculated Framingham and ASCVD10 scores and compared them. RESULTS: Patients had a mean age of 45.3 ± 10.1 years, 70% female, 79% underwent laparoscopic Roux-en-Y gastric bypass. We observed weight decrease at each evaluation point after surgery, independently of the surgical procedure. All biochemical parameters improved. Framingham score decreased from 9.4% to 5.9%, frequency of patients classified as high-risk decreased from 25% to 11%. ASCVD10 score decreased from 4.1% to 2.5%, patients classified as high-risk decreased from 28% to 16%. Tobacco use was the most important factor involved in cardiovascular risk. CONCLUSIONS: Cardiovascular risk at 10-years and lifetime decreased as soon as one year after surgery as assessed through Framingham and ASCVD scores.

INTRODUCCIÓN: México posee una de las más altas prevalencias de obesidad severa en el mundo. La mortalidad por causas cardiovasculares en estos pacientes alcanza el 90%. Existen distintas escalas para valorar el riesgo, como la escala de Framingham que evalúa a 10 años, y la ASCVD10 que evalúa a 10 años y a lo largo de la vida. Ninguna se ha usado para evaluar el riesgo cardiovascular en mexicanos con obesidad severa antes y después de la cirugía bariátrica. MÉTODOS: se efectuó un estudio cuasiexperimental con 109 pacientes con obesidad severa, con evaluación antropométrica y bioquímica, antes y un año después de la cirugía bariátrica. Se obtuvo el puntaje de riesgo con las escalas de Framingham y ASCVD10. RESULTADOS: la mediana de edad fue 45.3 ± 10.1 años, 70% eran mujeres, en 79% se realizó bypass laparoscópico con Y de Roux. Hubo disminución de peso en cada evaluación posterior a la cirugía, independientemente del procedimiento, y mejoría en todos los parámetros bioquímicos. El riesgo evaluado por Framingham disminuyó de 9.4 a 5.9%, el porcentaje de pacientes de "alto riesgo" disminuyó de 25 a 11%; con respecto al riesgo evaluado por ASCVD10 se redujo de 4.1 a 2.5%, con porcentaje de pacientes de alto riesgo que disminuyó de 28 a 16%. El tabaquismo fue el mayor determinante de riesgo cardiovascular. CONCLUSIONES: el riesgo cardiovascular evaluado por ambas escalas disminuyó un año después de la cirugía bariátrica.

Gastroesophageal reflux disease in patients with long standing type 1 diabetes mellitus: utility of two self-report questionnaires in a multifactorial disease / Enfermedad por Reflujo Gastroesofágico en pacientes con Diabetes Mellitus tipo 1: utilidad de dos cuestionarios auto-aplicables

Abstract Background: Gastroesophageal pathologies are common and multifactorial in patients with type 1 diabetes (T1DM). The evaluation with endoscopy and 24 h pH esophageal monitoring is expensive and not always available in all medical centers, especially in developing countries so more cost-effective algorithms for diagnosis are required. Clinical questionnaires are easy to apply but its utility for gastroesophageal reflux disease screening in patients with long standing T1DM must be analyzed. Objective: To evaluate the utility of the FSSG and Carlsson-Dent (CDQ) questionnaires to detect the frequency of gastroesophageal reflux disease in patients with T1DM. Methods: Analytic cross-sectional study, included 54 randomly selected patients from the T1DM clinic in our hospital. Before their routine evaluation, were asked to answer FSSG and CDQ questionnaires, classifying them as positive with a score >8 or >4, respectively. we associated and compared the clinical and biochemical characteristics between patients with or without gastroesophageal reflux detected through questionnaires. Results: Median age was 29 years (22-35), 67% were female (median of 16 years from diagnosis). In 39% of the patients FSSG was positive, CDQ was positive in 28%. A total of 71% of patients were taking medications to treat non-specific gastric symptoms. The concordance between questionnaires was 65% (p: <0.001). Those patients with tobacco consumption as well as those with poor glycemic control were more likely to score positive in either questionnaire. Conclusions: Patients T1DM had a high prevalence of gastroesophageal reflux disease. In those patients FSSG questionnaire detected a higher number of patients in comparison with CDQ.

Resumen Introducción: Las patologías gastroesofágicas son comunes y multifactoriales en pacientes con diabetes tipo 1 (DM1). La evaluación por medio de panendoscopia y pHmetría es costosa y difícil de realizar en todos los centros de atención, por lo que se requieren algoritmos rentables para su diagnóstico. Existen cuestionarios sencillos y autoaplicables que pueden ser útiles para el diagnóstico de enfermedad por reflujo gastroesofágico en los pacientes con DM1. Objetivo: Evaluar la utilidad de los cuestionarios FSSG y Carlsson-Dent (CDQ) para detectar la enfermedad por reflujo gastroesofágico (ERGE) en pacientes con DM1. Métodos: Estudio transversal, se incluyeron 54 pacientes, elegidos al azar de la clínica de DMT1. Previo a la consulta, se les solicitó contestaran los cuestionarios FSSG y el CDQ, considerándose positivos para diagnóstico de ERGE los puntajes >8 y >4, respectivamente. Se analizaron y compararon las características bioquímicas y clínicas entre los pacientes con y sin síntomas de ERGE detectada por medio de los cuestionarios. Resultados: Los pacientes estudiados tenían edad de 29 años (22-35), 67% fueron mujeres, (mediana de diagnóstico de 16 años). El 39% de los pacientes tenían ERGE detectado mediante FSSG y 28% utilizando el cuestionario CDQ. El 71% de los pacientes reportó uso de medicamentos para reflujo. La concordancia entre ambos cuestionarios fue del 65% (p: <0.001). Pacientes que consumen tabaco y con descontrol glucémico, tenían más probabilidades de positividad en cualquier cuestionario. Conclusiones: Existe una alta prevalencia de ERGE en los pacientes con DM1. En esta población el cuestionario FSSG detectó a un mayor número de pacientes en comparación con el CDQ.

Tratamiento multimodal de los adenomas de hipófisis recidivantes clínicamente no funcionales. Reporte de caso y revisión de la literatura / Multimodal treatment of non-functional recidivant hypophyseal adenomas. A case report and literature review

Resumen Antecedentes: Los adenomas hipofisarios no funcionales generalmente tienen un comportamiento benigno y naturaleza no invasiva, sin embargo, pueden mostrar características de agresividad con invasión a tejidos circundantes, alto índice mitótico, un índice de Ki67 > 3%y positividad extensa para la tinción de p53, diferenciándose de los carcinomas hipofisarios por la ausencia de diseminación cerebroespinal o metástasis a distancia. Los adenomas agresivos muestran resistencia al tratamiento guirúrgico, médico y radioterapia, y los agentes guimioterapéuticos como temozolamida son una opción terapéutica prometedora de acuerdo con los reportes de la literatura médica internacional. Caso clínico: Paciente del sexo femenino en la sexta década de la vida con padecimiento caracterizado por síndrome guiasmático progresivo e hipopituitarismo ante la presencia de un macroadenoma hipofisario no funcional, con resistencia a tratamiento neuroguirúrgico inicial, tratamiento médico con un agonista dopaminérgico y análogo de receptor de la somatostatina así como radioterapia convencional fraccionada, y cumple con los criterios de agresividad. Se establece tratamiento guimioterapéutico a base de temozolamida, y durante su vigilancia muestra tanto estabilidad clínica como ausencia de progresión tumoral. Conclusiones: La determinación de agresividad es de crucial importancia para mejorar el tratamiento del paciente y, con ello, ofrecer un mejor pronóstico y efectividad terapéutica. El tratamiento de los adenomas hipofisarios no funcionales con características de agresividad es un reto clínico gue involucra un abordaje multidisciplinario. La resistencia al tratamiento quirúrgico, médico y radioterapéutico han dado lugar a la investigación de opciones terapéuticas con agentes quimioterapéuticos como la temozolamida, con tasas de respuesta prometedoras.

Abstract Background: Non-functional pituitary adenomas generally have a benign and non-invasive nature, however, it may show aggressiveness with invasion of surrounding tissues, high mitotic index, an index of Ki67> 3% and extensive positive staining for the cellular tumor antigen p53, differing from the pituitary carcinomas by the absence of craniospinal dissemination or systemic metastases. Aggressive adenomas show resistance to surgical, medical and radiation therapy, including chemotherapeutic agents such as temozolomide, a promising therapeutic option according to reports in the international literature. Case presentation: This is a woman in her 6th decade of life with a clinical presentation characterized by a progressive chiasm syndrome and hypopituitarism in the presence of non-functional pituitary macroadenoma, with initial resistance of neurosurgical treatment, medical treatment with a dopaminergic agonist plus a somatostatin receptor agonist and conventional fractionated radiotherapy, meeting the criteria of aggressive pituitary adenoma. After the treatment with temozolomide as a chemotherapy regimen, the patient showed clinical stability and absence of tumor progression during her follow-up. Conclusion: Defining aggressiveness is of crucial importance for improving the management of patients by enhancing prognostic predictions and effectiveness of treatment. The treatment of nonfunctioning pituitary adenomas with aggressiveness is a clinical challenge that involves a multidisciplinary approach. Resistance to surgical, medical and radiotherapeutic treatment have resulted in the investigation of therapeutic options with chemotherapeutic agents such as temozolomide, with promising response rates.