[Diabetic ketoacidosis secondary to immunotherapy]. / Cetoacidosis diabética secundaria a inmunoterapia.

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that are increasingly used in cancer treatments. As experience in the use of immunotherapy increases, more is known about its safety profile and immune-mediated adverse effects. Among them is diabetic ketoacidosis (DKA), a rare but serious fatal complication of treatment. In this paper we describe the cases of three patients who presented with episodes of DKA during treatment with ICIs, two of which manifested with fulminant forms, leading to an acute course with initially normal glycosylated hemoglobin values. In addition, we conducted a review of the literature on DKA associated with ICIs in order to highlight the importance of noticing these potentially fatal complications and promptly establishing appropriate therapy.

Los inhibidores de puntos de control inmune (ICIs) son anticuerpos monoclonales cada vez más utilizados en tratamientos oncológicos. A medida que aumenta la experiencia en el uso de inmunoterapia, se conoce cada vez más su perfil de seguridad y los efectos adversos inmunomediados. Entre ellos se encuentra la cetoacidosis diabética (CAD), complicación infrecuente, grave y potencialmente mortal. En este trabajo describimos los casos de tres pacientes que se presentaron con episodios de CAD durante el tratamiento con ICIs, dos de los cuales manifestaron con formas fulminantes, llevando un curso agudo con valores de hemoglobina glicosilada inicialmente normales. Asimismo, realizamos una revisión de la literatura sobre la CAD asociada a ICIs a fines de resaltar la importancia de advertir estas complicaciones potencialmente fatales e instaurar rápidamente la terapéutica apropiada.

Laparoscopic adrenalectomy for adrenal metastases of solid tumors.

INTRODUCTION: In patients with history of cancer adrenal metastases can be found in up to 70% of adrenal tumors detected during follow-up. Currently, laparoscopic adrenalectomy (LA) is considered the gold standard approach for benign adrenal tumors but is still controversial in malignant disease. Depending on the patient's oncological status, adrenalectomy might be a possible treatment option. Our objective was to analyze the results of LA for adrenal metastasis from solid tumors in two referral centers. METHODS: Retrospective analysis of 17 patients with non-primary adrenal malignancy treated with LA between 2007 and 2019 was performed. Demographic and primary tumor data, type of metastasis, morbidity, disease recurrence and evolution were evaluated. Patients were compared according to type of metastases: synchronous (< 6 months) vs metachronous (≥ 6 months). RESULTS: 17 patients were included. Median metastatic adrenal tumor size was 4 cm (IQR, 3-5.4). We had one conversion to open surgery. Recurrence was found in 6 patients with one recurring in the adrenal bed. The median OS was 24 (IQR, 10.5-60.5) months and 5-year OS was 61.4% (95%CI: 36.7%-81.4%). Patients with metachronous metastases had better overall survival vs. patients with synchronous metastases (87% vs. 14%, p = 0.0037). CONCLUSION: LA for adrenal metastases is a procedure associated with low morbidity and acceptable oncologic outcomes. Based on our results, seems reasonable to offer this procedure to carefully selected patients, mainly those with metachronous presentation. Indication of LA must be done on a case by case evaluation in the context of a multidisciplinary tumor board.

Bilateral adrenalectomy in the context of primary adrenal insufficiency due to colorectal cancer metastasis.

Introduction: Adrenal glands are a common site of metastasis for several types of malignancies. Nevertheless, bilateral metastasis leading to adrenal insufficiency is a very rare presentation. Presentation of case: We present a 62-year-old woman with previous history of colorectal cancer and bilateral adrenal metastasis associated with primary adrenal insufficiency. The patient underwent bilateral open adrenalectomy after a multidisciplinary tumour board evaluation. Conclusion: The incidence of adrenal insufficiency may be underestimated in patients with a history of cancer. Adrenal function must be evaluated in those patients presenting with bilateral adrenal masses and hormonal replacement therapy should be considered, if appropriate. In selected cases, bilateral adrenalectomy can give a possible therapeutic option for patients with confined disease to the adrenal glands.

Outcomes after laparoscopic adrenalectomy for unilateral primary aldosteronism.

Unilateral primary aldosteronism (PA) is the most common surgically correctable cause of hypertension. Determination of success after laparoscopic adrenalectomy (LA) is limited by the lack of standardized criteria. We sought to evaluate the surgical recurrence and functional outcomes of LA in patients with Conn's syndrome applying the primary aldosteronism surgical outcome (PASO) Criteria. Descriptive observational analysis of patients treated with LA due to confirmed u nilateral Conn's syndrome between May 2007 and August 2020: Twenty patients were included in the cohort; 16 patients had TLA and other four PLA [58% male, median age 47 (IQR: 44-59.5) years and median follow-up of 64 (IQR: 2-156) ] months. Median tumor size was 1.2 (0.8-1.8) cm. No conversions to open surgery were recorded and the overall morbidity of the series was 1/20. No surgical or biochemical recurrence was observed. Five patients were excluded from the analysis of functional results due to lack of follow-up. According to the PASO criteria, complete, partial, and no success were observed in 8/15, 6/15, and 1/15, respectively. The surgical treatment of the disease is supported by the literature, and we were able to reproduce the results of other series. The use of standardized and reproducible criteria to assess its functional results would be essential for a more complete and integrated evaluation of adrenal surgery.

El hiperaldosteronismo primario es la causa más frecuente de hipertensión secundaria pasible de tratamiento quirúrgico. La determinación del éxito de la adrenalectomía laparoscópica (AL), actualmente, está limitada por la falta de criterios estandarizados. Buscamos evaluar la tasa de recurrencia quirúrgica y los resultados funcionales de la AL en pacientes con Síndrome de Conn aplicando los criterios PASO (primary aldosteronism surgical outcome). Análisis descriptivo y observacional de pacientes tratados con AL en contexto de síndrome de Conn unilateral confirmado, entre Mayo-2007 y Agosto-2020. Se incluyeron 20 pacientes en el estudio; 16 pacientes tratados mediante AL total y 4 con AL parcial (55% hombres, edad mediana de 47 (IQR: 44-59.5) años y mediana de seguimiento 64 (IQR: 2-156) meses. La mediana de tamaño tumoral fue de 1.2 (0.8-1.8) cm. No se registraron conversiones a cirugía abierta y la morbilidad global de la serie: 1/20. No se observó recurrencia quirúrgica o bioquímica. Se excluyeron 5 pacientes en el análisis de resultados funcionales por falta de seguimiento. Según los criterios PASO, se observó un éxito completo, parcial y ausente en 8/15, 6/15 y 1/15, respectivamente. El tratamiento quirúrgico de la enfermedad es avalado por la literatura y pudimos reproducir los resultados de otras series. El uso estandarizado y reproducible de criterios para valorar sus resultados funcionales sería fundamental para una evaluación más completa e integrada de la cirugía suprarrenal.

Outcomes after laparoscopic adrenalectomy for unilateral primary aldosteronism / Resultados luego de adrenalectomía laparoscópica en hiperaldosteronismo primario unilateral

Abstract Unilateral primary aldosteronism (PA) is the most common surgically correctable cause of hypertension. Determination of success after laparoscopic adrenalectomy (LA) is limited by the lack of standardized criteria. We sought to evaluate the surgical recurrence and functional outcomes of LA in patients with Conn's syndrome applying the primary aldosteronism surgical outcome (PASO) Criteria. Descriptive obser vational analysis of patients treated with LA due to confirmed u nilateral Conn's syndrome between May 2007 and August 2020: Twenty patients were included in the cohort; 16 patients had TLA and other four PLA [58% male, median age 47 (IQR: 44-59.5) years and median follow-up of 64 (IQR: 2-156) ] months. Median tumor size was 1.2 (0.8-1.8) cm. No conversions to open surgery were recorded and the overall morbidity of the series was 1/20. No surgical or biochemical recurrence was observed. Five patients were excluded from the analysis of functional results due to lack of follow-up. According to the PASO criteria, complete, partial, and no success were observed in 8/15, 6/15, and 1/15, respectively. The surgical treatment of the disease is supported by the literature, and we were able to reproduce the results of other series. The use of standardized and reproducible criteria to assess its functional results would be essential for a more complete and integrated evaluation of adrenal surgery.

Resumen El hiperaldosteronismo primario es la causa más frecuente de hipertensión secundaria pasible de tratamiento quirúrgico. La determinación del éxito de la adrenalectomía laparoscópica (AL), actualmente, está limitada por la falta de criterios estandarizados. Buscamos evaluar la tasa de recurrencia quirúrgica y los resultados funcionales de la AL en pacientes con Síndrome de Conn aplicando los criterios PASO (primary aldosteronism surgical outcome). Análisis descriptivo y observacional de pacientes tratados con AL en contexto de síndrome de Conn unilateral confirmado, entre Mayo-2007 y Agosto-2020. Se incluyeron 20 pacientes en el estudio; 16 pacientes tratados mediante AL total y 4 con AL parcial (55% hombres, edad mediana de 47 (IQR: 44-59.5) años y mediana de seguimiento 64 (IQR: 2-156) meses. La mediana de tamaño tumoral fue de 1.2 (0.8-1.8) cm. No se registraron conversiones a cirugía abierta y la morbilidad global de la serie: 1/20. No se observó recurrencia quirúrgica o bioquímica. Se excluyeron 5 pacientes en el análisis de resultados funcionales por falta de seguimiento. Según los criterios PASO, se observó un éxito completo, parcial y ausente en 8/15, 6/15 y 1/15, respectivamente. El tratamiento quirúrgico de la enfermedad es avalado por la literatura y pudimos reproducir los resultados de otras series. El uso estandarizado y reproducible de criterios para valorar sus resul tados funcionales sería fundamental para una evaluación más completa e integrada de la cirugía suprarrenal.

Falla autonómica asociada a hipoglucemia / Hypoglycemia associated autonomic failure

La hipoglucemia inadvertida (HI) es una complicación del tratamiento de la diabetes mellitus tipo 1 (DM1) y DM2 tratada con insulina o sulfonilureas, que se caracteriza por una capacidad reducida para percibir el inicio de los episodios de hipoglucemia. En general, coexiste con una insuficiente respuesta hormonal contrarreguladora a la hipoglucemia denominada falla autonómica asociada a la hipoglucemia (FAAH). El desarrollo de HI y de falla contrarreguladora a la hipoglucemia aumentan significativamente el riesgo de hipoglucemias severas. Se han desarrollado escalas de puntuación para identificar, en la consulta clínica, a este grupo de personas con elevado riesgo de hipoglucemias severas. La piedra angular del tratamiento consiste en evitar las hipoglucemias mediante una intervención multifactorial de cuidados clínicos y educación estructurada.

Hypoglycemia unawereness is a complication of type 1 diabetes treatment and of type 2 diabetes treatment treated with insulin or sulfonylureas, characterized by a reduced ability to perceive the onset of episodes of hypoglycemia. In general, it coexists with an insufficient counterregulatory hormonal response to hypoglycemia called: hypoglycemia associated autonomic failure (HAAF). The development of hypoglycemia unawereness and counterregulatory failure to hypoglycemia significantly increase the risk of severe hypoglycemia. Scoring scales have been developed to identify this group of people at high risk of severe hypoglycemia in the clinic. The cornerstone of treatment is to avoid hypoglycemia through a multifactorial intervention of clinical care and structured education.

Características metabólicas de los pacientes con apneas obstructivas del sueño / Metabolic characteristics from patients with obstructive sleep apnea

Introducción: la apnea obstructiva del sueño (AOS) es una patología de alta prevalencia asociada al sobrepeso y la obesidad. La relación entre el síndrome metabólico (SM) y la AOS no ha sido comunicada en nuestro medio. Materiales y métodos: estudio retrospectivo en adultos seleccionados para poligrafía respiratoria y evaluación metabólica clasificados según la presencia de SM. Resultados: incluimos 302 pacientes. La prevalencia de obesidad fue de 66,88% y de SM de 62,58%. El 19% presentó síntomas de somnolencia diurna y el 48,3% mostró cinco o más componentes del cuestionario STOP-BANG. Los pacientes con AOS fueron mayormente del sexo masculino, con mayor edad, peso corporal, circunferencia de cintura y cuello comparados con el grupo sin AOS (57 vs 49 años, p<0,001; 93,89 vs 85 kg, p<0,05; 108 vs 100 cm, p<0,001 respectivamente). Mostraron mayores valores de triglicéridos, presión arterial sistólica, obesidad e índice de desaturación (134 vs 99 mg/dl, p<0,001; 134 vs 128 mmHg, p<0,05; 69,2 vs 52,3%, p<0,05 y 14,6 vs 2 ev/h, p<0,001 respectivamente). La cantidad de componentes de STOP-BANG fue mayor en los pacientes con AOS (5 vs 3; p<0,001). Conclusiones: AOS y SM están frecuentemente relacionados y permanecen subdiagnosticados. La utilización de cuestionarios validados facilita la identificación de candidatos a estudios de sueño. Se necesitan implementar programas de gestión de hábitos saludables para prevenir las complicaciones de ambas patologías

Introduction: the obstructive sleep apnea (OSA) is a pathology of high prevalence associated with overweight and obesity. The relationship between metabolic syndrome (MS) and OSA has not been reported in our environment. Materials and methods: retrospective study in adults selected for respiratory polygraphy and metabolic evaluation classified according to the presence of MS. Results: we included 302 patients. The prevalence of obesity was 66.88% and MS 62.58%. 19% had symptoms of daytime sleepiness and 48.3% showed 5 or more components of the STOP-BANG questionnaire. Patients with OSA were mostly male, older, body weight, waist and neck circumference compared to the group without OSA (57 vs 49 years, p<0.001; 93.89 vs 85kg, p<0.05; 108 vs. 100 cm, p<0.001 respectively). They showed higher values of triglycerides, systolic blood pressure, obesity and desaturation index (134 vs 99 mg/dl, p<0.001; 134 vs 128 mmHg, p<0.05; 69.2 vs. 52.3%, p<0.05 and 14.6 vs 2 ev/h, p<0.001 respectively). The amount of STOP-BANG components was higher in patients with OSA (5 vs 3; p<0.001). Conclusions: AOS and MS are frequently related and remain underdiagnosed. The use of validated questionnaires facilitates the identification of candidates for sleep studies. It is necessary to implement healthy habits management programs to prevent complications of both pathologies