Differentiated thyroid carcinoma in the elderly: influence of age on disease-free and overall survival.

PURPOSE: We investigated whether age at diagnosis of differentiated thyroid carcinoma (DTC) may be a risk factor for structural disease and mortality after primary treatment in aging patients. METHODS: A multicenter, retrospective analysis including patients older than 60 years at DCT diagnosis was designed. All subjects were treated by surgery with or without radioiodine adjuvant therapy and had a minimum follow-up of one year. We compared elderly patients (group 1, 60-74 years) with very old patients (group 2, ≥75 years). RESULTS: The study involved 1668 patients (74.3% women, median age 67 years, 87.6% papillary thyroid cancer, 73.3% treated with radioiodine), including 1397 in group 1 and 271 in group 2. Patients in group 2 had larger tumor size (1.8 [0.8-3.0] vs 1.5 [0.7-2.8] cm; P = 0.005), higher proportions of tumors with vascular invasion (23.8 vs 16.4%; P = 0.006), and lower proportion of lymphocytic thyroiditis (18.6 vs 24.9%; P = 0.013) than subjects in group 1. Kaplan-Meier survival analysis showed that patients in group 2 had significantly lower structural disease-free survival (DFS) and overall survival (OS) than patients in group 1 (P = 0.035 and <0.001, respectively). In multivariate Cox regression analysis, age was a risk factor significantly associated with OS. However, age was significantly associated with DFS in unadjusted analysis and in analysis adjusted by gender and risk classification variables, but not when pathological and therapy-related variables were introduced in the model. On the other hand, patients who received radioiodine had worse DFS (P < 0.001) compared to those who did not. CONCLUSION: Although age is a conditioning factor for OS, very old patients do not have a greater risk of developing structural disease throughout the follow-up than elderly patients with DTC.

Nutrients and Dietary Approaches in Patients with Type 2 Diabetes Mellitus and Cardiovascular Disease: A Narrative Review.

Cardiovascular disease (CVD) is the most common cause of morbidity and mortality in developed countries. The prevalence of CVD is much higher in patients with type 2 diabetes mellitus (T2DM), who may benefit from lifestyle changes, which include adapted diets. In this review, we provide the role of different groups of nutrients in patients with T2DM and CVD, as well as dietary approaches that have been associated with better and worse outcomes in those patients. Many different diets and supplements have proved to be beneficial in T2DM and CVD, but further studies, guidelines, and dietary recommendations are particularly required for patients with both diseases.

Endocrine Complications of Surgical Treatment of Thyroid Cancer: An Update.

Postoperative hypoparathyroidism (HypoPT) and hypothyroidism (HypoT) are the main endocrine complications after the surgical treatment for thyroid cancer. Postsurgical HypoPT can be transient, protracted or permanent. Its frequency varies according to the underlying cervical pathology, surgical technique, and mainly the experience of the surgeon. Risk factors for HypoPT include aggressiveness of the tumor, extent of surgery, the presence of parathyroid gland in the pathologic specimen, and surgeon experience. Clinical manifestations of postsurgical HypoPT can be acute or chronic. An adequate surgical technique that minimizes trauma and preserve the vascularization of the parathyroid glands is the better procedure to reduce the risk of postoperative HypoPT. Acute hypocalcemia may be managed with intravenous or oral calcium supplements, according to the level of serum calcium and the presence of signs and symptoms. Patients with permanent HypoPT require lifelong calcium and vitamin D supplementation. Calcitriol is the vitamin D metabolite of preference because of its high activity and short half-life. Both PTH (1-34) and intact PTH (1-84) have demonstrated to be attractive options in hypoparathyroid patients who cannot maintain stable serum and urinary calcium levels with calcium and vitamin D supplementation. However, the long-term safety of these preparations has not been established. Postsurgical HypoT is an unavoidable consequence of total or near-total thyroidectomy for thyroid cancer. Replacement and suppressive therapy are necessary in these patients. Thyroid hormone suppression therapy has shown to be accompanied by a decreased risk of disease progression and recurrence; however, it may also be associated with increased risk of dysrhythmia and loss of bone mass. Therefore, the intensity of TSH suppression must be established in a personalized way after balancing risk and benefits, according to the severity of the thyroid cancer, the response to therapy, and the individual risk factors for adverse events.

[Thyroid dysfunction during pregnancy]. / Disfunción tiroidea y embarazo.

Recent clinical practice guidelines on thyroid dysfunction and pregnancy have changed health care provided to pregnant women, although their recommendations are under constant revision. Trimester- and area-specific reference ranges for serum thyroid-stimulating hormone are required for proper diagnosis of hypothyroidism and hyperthyroidism. There is no doubt on the need of therapy for overt hypothyroidism, while therapy for subclinical hypothyroidism is controversial. Further research is needed to settle adverse effects of isolated hypothyroxinemia and thyroid autoimmunity. Differentiation between hyperthyroidism due to Graves' disease and the usually self-limited gestational transient thyrotoxicosis is critical. It is also important to recognize risk factors for postpartum thyroiditis. Supplementation with iodine is recommended to maintain adequate iodine nutrition during pregnancy and avoid serious consequences in offspring. Controversy remains about universal screening for thyroid disease during pregnancy or case-finding in high-risk women. Opinions of some scientific societies and recent cost-benefit studies favour universal screening. Randomized controlled studies currently under development should reduce the uncertainties that still remain in this area.

[Postoperative radioiodine ablation in patients with low risk differentiated thyroid carcinoma]. / Ablación posquirúrgica con radioyodo en pacientes con carcinoma diferenciado de tiroides de bajo riesgo.

Most patients with newly diagnosed differentiated thyroid carcinoma have tumors with low risk of mortality and recurrence. Standard therapy has been total or near total thyroidectomy followed by postoperative radioiodine remnant ablation (RRA). Although RRA provides benefits, current clinical guidelines do not recommend it universally, since an increase in disease-free survival or a decrease in mortality in low risk patients has not been demonstrated so far. Advancements in our understanding of the biological behavior of thyroid cancer have been translated into the clinic in a personalized approach to the patients based on their individual risk of recurrence and mortality. Current evidence suggests that RRA is not indicated in most low-risk patients, especially those with papillary carcinomas smaller than 1cm, without extrathyroidal extension, unfavorable histology, lymph node involvement or distant metastases. Follow-up of these patients with serial measurements of serum thyroglobulin and neck ultrasound is adequate. Careful evaluation of all risk factors of clinical relevance will allow a more realistic assessment of each individual patient.

Los sistemas mandálicos como herramienta intercultural para organizar la enfermería internacional / Mandalicos como um sistemas de ferramenta multi-cultural para a organização de enfermagem internacional / Mandalicos as a cross-cultural tool systems for organizing the international nursing

Se parte de la hipótesis que la aplicación del modelo mandálico constituye una herramienta útil en la organización y prestación de unos cuidados multiculturales enfermeros. A lo largo de la historia se encuentran multitud de ejemplos de mandalas, en psicología y antropología también han sido empleados. La carta mandálica organiza la diversidad cultural a partir de un círculo dividido en cuatro subsistemas interrelacionados, la salud se obtiene con la armonización de los cuatro subsistemas. El círculo se construye desde un análisis de la historia de vida a partir de las expresiones, valores y necesidades del paciente/cliente, sirviendo además como elemento de comunicación intercultural y organizador de la competencia cultural. Su forma de estructurar el entorno de la persona guarda relación con la teoría del pensamiento complejo de Edgar Morín, además de contener varias similitudes y relaciones con otros modelos y teorías enfermeras. Será empleado como herramienta de autoconocimiento y auto transformación, de búsqueda de la excelencia personal, de respeto a las variables étnico-culturales, considerando su individualidad con una serie de necesidades básicas, espirituales y de autorrealización. Servirá como ejemplo de creativo cultural dotado de un valor transformador de de la civilización actual, con una mentalidad esperanzadora y transición a un mundo renovador

Ele parte do pressuposto de que o modelo mandálico aplicativo é uma ferramenta útil na organização e prestação de cuidados de enfermeiros multiculturais. Ao longo da história muitos exemplos de mandalas, em psicologiae antropologia também foram empregadas. O mandálico carta organiza a diversidade cultural de um círculo dividido em quatro subsistemas inter-relacionados, a saúde é conseguida através da harmonização dos quatro subsistemas. O círculo é construído a partir de uma análise da história de vida das expressões, valores e necessidades do cliente / paciente, além-de servir como um organizador de comunicação intercultural e competência cultural. Sua forma de estruturar o ambiente da pessoa está relacionado com a teoria do pensamento complexo de Edgar Morin, e contêm muitas semelhanças e as relações com outros modelos de enfermagem e teorias. Ele será usado como uma ferramenta de auto-conhecimento e auto-transformação, buscando a excelência pessoal, respeito variáveis étnicas e culturais, considerando sua individualidade com uma série de necessidades básicas, espiritual e auto-realização. Ele servirá como um exemplo de transformador cultural criativo fornecido com um valor de civilização moderna, com uma mentalidade de esperança e de transição para um inovador mundo (AU)

It starts from the assumption that the application mandalic model is a useful tool in the organization and delivery of a multicultural care nurses. Throughout history are many examples of mandalas, in psychology and anthropology have also been employed. The letter mandalic organizes cultural diversity from a circle divided into four interrelated subsystems, health is achieved by harmonizing the four subsystems. The circle is constructed from an analysis of the history of life from the expressions, values and needs of the patient /client, besides serving as an organizer of intercultural communication and cultural competence. His way of structuring the environment the person is related to the theory of complex thought of Edgar Morin, and contain many similarities and relationships with other nursing models and theories. It will be used as a tool for self-knowledge and self-transformation, seeking personal excellence, respect for ethnic and cultural variables, considering their individuality with a number of basic needs, spiritual and self-realization. It will serve as an example of creative cultural transformer provided with a value of modern civilization, with a hopeful mindset and transition to a world innovator (AU)

Selenium and kidney disease.

Selenium (Se) is a trace element that participates as a cofactor in several enzymes (selenoproteins) which act in the regulation of thyroid hormone metabolism, enzymatic antioxidant defenses and the immune system. Se deficiency has been linked to atherosclerosis-related cardiovascular disease, increased risk of viral infections and even with an increased risk of mortality. Low serum Se levels are a frequent finding in patients with acute kidney injury or chronic kidney disease. The relationship between hyposelenemia and the comorbidities associated with renal disease has not been extensively evaluated. It has been reported that both low serum Se levels and renal insufficiency are associated with an increased risk of coronary heart disease mortality and an increased risk for all-cause mortality in adults older than 35 years. A recent report has suggested that hyposelenemia may contribute to immune dysfunction, increasing the risk of death from infectious disease in hemodialysis patients. Some studies have reported that Se status and immune function improve after oral and intravenous Se supplementation in renal patients, reducing the products of oxidative stress. In summary, although there are intriguing relationships between Se physiology and several derangements and comorbidities associated with acute and chronic kidney disease, only a few studies have analyzed the clinical consequences of hyposelenemia in these patients to date. Available data are encouraging and stimulate interest in further studies to clarify the real extent of Se deficiency and the need for Se supplementation in patients with kidney disease.

Acute responses of gastrointestinal hormones to both oral and parenteral intradialytic nutrition.

INTRODUCTION: Intradialytic nutrition (IDN) has been used to improve the nutritional status of malnourished hemodialysis (HD) patients. OBJECTIVE: To evaluate the different effects of parenteral IDN (IDPN) and oral IDN (IDON) on nutrition-related gastrointestinal hormones. PATIENTS AND METHODS: Seven clinically stable HD patients with malnutrition were included. All patients were treated for 1 month with either IDPN or IDON, with a 4-week period of no nutritional support between each type of therapy. On the first day of each nutritional support (IDON or IDPN) we analyzed the acute responses of insulin, ghrelin, and glucagon-like peptide 1 (GLP-1). We compared the areas under the secretory curves (AUC) and the maximum peaks of serum glucose, insulin, ghrelin, and GLP-1. A group of 6 clinically stable HD patients without any type of IDN served as the control group. RESULTS: The acute responses of glucose and insulin to IDN were significantly higher with IDPN than with IDON. The AUC of glucose (602 ± 81 vs. 495 ± 81 mg/dl/h, p < 0.01) and insulin (232 ± 103 vs. 73.8 ± 69 µU/ml/h, p < 0.01) as well as the maximum peaks of glucose (228 ± 41 vs. 177 ± 47 mg/dl, p < 0.05) and insulin (104 ± 46 vs. 29 ± 24 µU/ml, p < 0.01) were significantly higher after IDPN than after IDON. Ghrelin decreased after both IDPN and IDON; however, the decrease was significantly higher with IDPN compared to IDON. The ghrelin nadir was significantly lower in IDPN than in IDON (0.77 ± 0.5 vs. 1.5 ± 0.3, p < 0.05) although the AUC of ghrelin was not significantly different. GLP-1 was significantly increased at 1 h after starting both IDPN and IDON with no significant differences between the groups. CONCLUSION: IDPN induces a higher increase in serum glucose and insulin levels and a greater reduction in serum ghrelin concentrations compared with an equivalent orally administered nutritional supplement.

Acute and one-year effects of cinacalcet in patients with persistent primary hyperparathyroidism after unsuccessful parathyroidectomy.

OBJECTIVE: We report the acute effects of cinacalcet on calcium and parathyroid hormone (PTH) levels and the effects of 1 year of therapy on calcium and phosphorus metabolism in 4 patients with persistent primary hyperparathyroidism (PHPT) after unsuccessful parathyroidectomy. PATIENTS: Four patients (3 women; age, 24 to 71 years) were studied after 1 to 3 parathyroid operative procedures. All of them had elevated serum total and ionized calcium levels, decreased serum phosphorus, and increased concentrations of intact PTH. METHODS: Calcium and PTH responses to an acute dose of oral cinacalcet (30 mg) were studied at baseline. Effects of cinacalcet (30 mg b.i.d.) on serum calcium, phosphorus, and PTH, and urinary calcium and phosphorus were studied at 1, 3, 6, and 12 months of therapy. RESULTS: PTH concentrations were reduced by 13.0% to 86.7% after acute cinacalcet administration. Chronic therapy with cinacalcet was followed by a decrement in serum total calcium (10.2% at 12 months) and ionized calcium (10.1%) and an increase in serum phosphorus (20.8%), with only a modest decrement in PTH levels (5.1%). All patients had normal serum total and ionized calcium levels at 3 to 12 months of therapy. Urinary calcium decreased by 20.0% at 12 months. CONCLUSIONS: Cinacalcet was effective in normalizing calcium and phosphorus concentrations in patients with persistent PHPT after unsuccessful parathyroidectomy.

Effects of cinacalcet on gastrointestinal hormone release in patients with secondary hyperparathyroidism undergoing dialysis.

UNLABELLED: Objective. Our aim has been evaluating the influence of an acute dose of cinacalcet on the gastrointestinal hormonal responses to a test meal in uraemic patients with secondary hyperparathyroidism undergoing peritoneal dialysis (PD) or haemodialysis (HD). METHODS: Twenty patients (11 PD, 9 HD) on cinacalcet treatment (30-120 mg/day) were studied. Twelve patients (1 PD, 11 HD) who never received cinacalcet were studied as control group. Each patient received a test meal with blood samples at 0, 2 and 4 h. At 0 time, patients in the cinacalcet group received their usual oral dose of this calcimimetic. Plasma concentrations of intact parathyroid hormone (PTH), vasoactive intestinal peptide (VIP), ghrelin, substance P, serotonin, cholecystokinin (CCK) and gastrin were quantified at 0, 2 and 4 h. RESULTS: No significant differences in baseline concentrations of serum VIP, ghrelin, substance P, serotonine, CCK and gastrin were found between controls and cinacalcet-treated patients. In comparison with the control group, cinacalcet administration was followed by a significant decrease in VIP concentration at 4 h and a significant increase in substance P at 4 h. However, the areas under the curves of all studied gut hormones were similar in both groups. CONCLUSION: An acute dose of cinacalcet exerts minimal influence on gut hormone responses to a mixed meal in dialysis patients on chronic therapy with this drug. The small but significant differences between control subjects and patients on cinacalcet in VIP and substance P levels at 4 h should be investigated in symptomatic patients.