The Mediterranean diet, and not dietary inflammatory index, is associated with rheumatoid arthritis disease activity, the impact of disease and functional disability.

PURPOSE: To assess the relationship between adherence to the Mediterranean Diet (MD) /individual Dietary Inflammatory Index (DII) and disease activity, disease impact, and functional status in Rheumatoid Arthritis (RA) patients. METHODS: RA patients followed at a hospital in Lisbon, Portugal, were recruited. DII was calculated using dietary intake data collected with a food frequency questionnaire (FFQ). Adherence to the MD was obtained using the 14-item Mediterranean Diet assessment tool. Disease Activity Score of 28 Joints (DAS28) and the DAS28 calculated with C-Reactive Protein (DAS28-CRP) were used to assess disease activity. Impact of disease and functional status were evaluated using the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire and the Health Assessment Questionnaire (HAQ), respectively. RESULTS: 120 patients (73.3% female, 61.8 ± 10.1 years of age) were included. Patients with higher adherence to the MD had significantly lower DAS28-CRP (median 3.27(2.37) vs 2.77(1.49), p = 0.030), RAID (median 5.65(2.38) vs 3.51(4.51), p = 0.032) and HAQ (median 1.00(0.56) vs 0.56(1.03), p = 0.013) scores. Higher adherence to the MD reduced the odds of having a higher DAS28 by 70% (OR = 0.303, 95%CI = (0.261, 0.347), p = 0.003). Lower adherence to MD was associated with higher DAS28-CRP (ß = - 0.164, p = 0.001), higher RAID (ß = - 0.311, p < 0.0001), and higher HAQ scores (ß = - 0.089, p = 0.001), irrespective of age, gender, BMI and pharmacological therapy. Mean DII of our cohort was not significantly different from the Portuguese population (0.00 ± 0.17 vs - 0.10 ± 1.46, p = 0.578). No associations between macronutrient intake or DII and RA outcomes were found. CONCLUSIONS: Higher adherence to the MD was associated with lower disease activity, lower impact of disease, and lower functional disability in RA patients.

Determinants of skeletal fragility in acromegaly: a systematic review and meta-analysis.

PURPOSE: Vertebral fractures (VFs) are a potential complication in acromegaly. However, the etiology of this skeletal fragility is unknown. This review aimed to evaluate the effect of acromegaly on VFs, bone turnover, areal bone mineral density (aBMD), and bone quality/microarchitecture. The effect of disease activity and gonadal status in these determinants of skeletal fragility was also evaluated. METHODS: Articles published in English until September 6, 2020 on PubMed and Embase that reported at least one determinant of skeletal fragility in acromegalic patients, were included. Odds ratio (OR) to evaluate the risk of VFs and the standardized mean difference (SMD) to evaluate bone turnover, aBMD and bone quality/microarchitecture were calculated. RESULTS: Fifty-eight studies met eligibility criteria, assembling a total of 2412 acromegalic patients. Of these, 49 studies were included in the meta-analysis. Acromegalic patients, when compared to non-acromegalic patients, had higher risk of VFs [OR 7.00; 95% confidence interval (CI) 2.80-17.52; p < 0.0001], higher bone formation (SMD 1.14; 95% CI 0.69-1.59; p < 0.00001), higher bone resorption (SMD 0.60; 95% CI 0.09-1.10; p = 0.02) and higher aBMD at the femoral neck (SMD 0.36; 95% CI 0.15-0.57; p = 0.0009). No significant differences were found regarding aBMD at lumbar spine. Considering the results of the different techniques evaluating bone quality/microarchitecture, the main reported alterations were a decrease in trabecular bone thickness and density, and an increase in trabecular separation. The presence of active disease and/or hypogonadism were associated with worst results. CONCLUSION: Patients with acromegaly are at increased risk of VFs, mainly because of deterioration in bone microarchitecture.

Flash glucose monitoring system in gestational diabetes: a study of accuracy and usability.

PURPOSE: Studies of flash glucose monitoring systems (FGMSs) in pregnancy are insufficient, especially in gestational diabetes (GD). Our aim was to evaluate Freestyle Libre's usability and accuracy (compared to self-monitoring of blood glucose [SMBG]) for GD patients in real-life conditions. METHODS: This is a prospective study with pregnant women diagnosed with GD (n = 24 for the usability analysis; n = 19 for the accuracy analysis). The study duration was up to 28 days (lifetime of two sensors). Participants executed a minimum of four daily FGMS readings obtained immediately after capillary SMBG. Analytical accuracy was assessed with mean absolute relative difference (MARD) and mean absolute difference (MAD); clinical accuracy was assessed with Surveillance Error Grid (SEG). Usability was evaluated with a user acceptability questionnaire. RESULTS: The mean pregestational BMI was 25.21 ± 5.15 kg/m2 (mean ± SD), the mean gestational age was 30.31 ± 2.02 weeks, and the mean glucose values were 76.63 ± 7.49 mg/dL. A total of 1339 SMBG-FGMS pairs of values were obtained. Analytical accuracy was good with an overall MARD of 14.07% and an in-target MARD of 13.79%. The number of SMBG-FMGS pairs for above-target values was low (122 of 1339) with an associated MARD of 17.95%. Clinical accuracy of the FGMS was demonstrated, with 94.4% of values in the no-risk or slight, lower risk zones of the SEG. FGMS accuracy was unaffected by pregestational BMI or gestational age. The user acceptability questionnaire showed high levels of satisfaction, with 95.8-100% preferring FGMS to SMBG. No unexpected or severe adverse effects occurred. CONCLUSION: FGMS showed good performance in GD regarding accuracy and usability. Larger studies are needed to corroborate our results, verify the analytical accuracy of above-target values as this glucose range might lead to initiation or adjustment of pharmacological therapy, and ultimately establish definitive recommendations regarding prescription of FGMS for GD patients.

Safety of intra-articular glucocorticoid injections - state of the art.

Intra-articular glucocorticoid injection (IAGCI) is frequently used to treat joint pain and inflammation. While its efficacy has been extensively studied, there are not as many detailed descriptions regarding safety. This review aimed to describe the immediate-, short- and long-term complications of IAGCI and their predictors. Most studies mainly report mild and self-limited adverse events with an incidence similar to placebo. However, the reported incidences vary significantly and are mostly inferred from retrospective data. Septic arthritis is the most feared adverse event due to its association with high mortality. Other short-term local complications include injection site pain, post-injection flare, skin hypopigmentation and atrophy, and tendon rupture. Systemic side effects are common, including vasovagal reactions, flushing, increased appetite and mood changes, hyperglycemia in diabetic patients, and bleeding in high-risk patients. Few predictors of complications have been systematically evaluated. However, male gender, advanced age, and pre-existing joint disease have been suggested in retrospective studies to correlate with infection risk. Overall, in most studies, only severe adverse event rates are reported, with no systematic prospective evaluations of safety and no report of predictors of complications. Therefore, since IAGCI is a routinely used treatment, more detailed knowledge of adverse events and complications is warranted.

Postpartum reclassification test in gestational diabetes: can the test be reduced to 1 hour?

PURPOSE: In gestational diabetes mellitus (GDM), a postpartum oral glucose tolerance test (OGTT) is recommended. However, poor adherence to this procedure has been described, and the time required is one of the reasons. Our aims were to identify predictive factors for abnormal 2-h reclassification OGTT values, including OGTT 1-h glucose, and, if it was a factor, to determine the 1-h cutoff point that best identifies abnormal values at 2 h. METHODS: This was a retrospective study of 769 patients diagnosed with GDM between 2014 and 2019 in a tertiary center. The sample was divided into two groups according to the presence/absence of abnormal 2-h reclassification values, and predictive factors were studied. To determine the 1-h glycemia cutoff point capable of identifying 2-h changes, a ROC curve was drawn and the Youden index was used. RESULTS: The mean age of included women was 33.6 ± 4.95 years: 70 of them (9.1%) had an abnormal 2-h test result. Women with a history of GDM (OR = 3.41, p = .012) and higher 1-h glycemia value (OR = 1.05, p < .001) had a higher risk of developing an abnormal 2-h test result. One-hour glycemia ≥ 142 mg/dL had a sensitivity of 91.4% and specificity of 75.1% to identify changes in the test at 2 h; area under the curve to predict 2-h changes was 0.90 (CI 95%: 0.86 - 0.93). CONCLUSION: Glucose measurement at 1 h predicts alterations at 2 h in the reclassification test with excellent diagnostic accuracy, and the cutoff point of  ≥ 142 mg/dL presents high sensitivity. These findings could serve as a foundation for a possible future redefinition of the OGTT procedure, but further investigation is required.

The role of neck ultrasound in the follow-up of low- and intermediate- risk papillary thyroid cancer.

Introduction: The optimal time for a neck ultrasound (US) in the follow-up of papillary thyroid cancer (PTC) after the first year is undetermined. We aimed to verify the utility of routine neck US in the surveillance of patients diagnosed with low- and intermediate-risk PTC with no evidence of disease at the one-year assessment. Subjects and methods: We conducted a retrospective longitudinal study of patients with low- and intermediate-risk PTC with normal neck US, unstimulated serum thyroglobulin (Tg) < 1 ng/mL and negative anti-Tg antibodies at the one-year follow-up. Patients were divided into group 1 [undetectable Tg (<0.20 ng/mL)] and group 2 [detectable Tg but < 1 ng/mL]. The negative predictive value (NPV) of the one-year unstimulated Tg at the five-year and last follow-up visits was calculated. Results: We included n = 88 patients in group 1 and n = 8 patients in group 2. No patient from group 1 presented suspicious US findings at the five-year evaluation [NPV: 100.0% (95% confidence interval (CI): 95.5%-100.0%)], and at the last visit, only one patient had developed a lymph node classified as suspicious [NPV: 98.8% (95% CI: 93.2%-100.0%); mean follow-up: 6.7 years]. In group 2, two patients' USs presented suspicious findings at the five-year evaluation [NPV: 75.0% (95% CI: 34.9%-96.8%)]. At the last visit, only one patient persisted with suspicious findings in the US [NPV: 87.5% (95% CI: 47.4%-99.7%); mean follow-up: 6.5 years]. Conclusion: Low- and intermediaterisk PTC with an excellent response to treatment at the one-year assessment can be safely monitored with regular unstimulated Tg assessments. Conclusions should not be drawn for Tg levels between 0.20-0.99 ng/mL.

Effectiveness and safety of original and biosimilar etanercept (Enbrel® vs Benepali®) in bDMARD-naïve patients in a real-world cohort of Portugal.

OBJECTIVE: To compare the effectiveness and safety of original (Enbrel®) and biosimilar (Benepali®) etanercept in Biologic Disease-modifying Antirheumatic Drug (bDMARD)-naïve patients, measured by persistence rates over 36 months of follow-up. METHODS: A retrospective multicentre observational study using data collected prospectively from The Rheumatic Diseases Portuguese Registry (Reuma.pt) was performed, including patients with: age ≥ 18 years old; diagnosis of Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Spondyloarthritis (SpA) (axial or peripheral) with active disease and biologic-naïve who initiated treatment with etanercept as the first line biological treatment after 2010. Kaplan-Meyer and Cox regression were used to calculate the persistence rate in treatment. Disease activity at baseline and follow-up data at 6, 12, 18 and 24 months of treatment were compared. Causes for discontinuing therapy were summarized using descriptive statistics. Statistical significance was assumed for 2-sided p-values <0.05. RESULTS: We included 1693 patients (413 on Benepali® and 1280 on Enbrel®): 864 diagnosed with RA, 335 with PsA and 494 with SpA. The 3-year persistence rates were not significantly different between both treatment groups in RA, PsA and SpA patients. In the adjusted Cox model, hazard ratios of discontinuation were not statistically different (p>0.05). The proportion of subjects in remission or low disease activity in each disease was similar in both groups. Overall, 535 (31.6%) patients discontinued etanercept (428 patients on Enbrel® and 107 patients on Benepali®). The major cause of discontinuation was inefficacy (57.8%). No differences for the occurrence of inefficacy or adverse effects were found between treatment groups. CONCLUSIONS: Benepali® and Enbrel® demonstrated similar effectiveness and safety in RA, PsA and SpA in our cohort of patients. These data corroborate that the original and biosimilar drugs have similar quality characteristics and biological activity.

Clinical Performance of Flash Glucose Monitoring System in Patients with Liver Cirrhosis and Diabetes Mellitus.

Flash glucose monitoring system (FGMS) is an improved subset of continuous glucose monitoring with a recognized effectiveness on glycemic control, though validation in patients with Liver Cirrhosis (LC) is lacking. To evaluate the accuracy of FGMS in patients with Type 2 Diabetes Mellitus (DM) and LC, a prospective, case-control study was performed in 61 ambulatory patients with LC and DM (LC group, n = 31) or DM (Control group, n = 30). During 14 days, patients performed 4 assessments per day of self-monitoring of blood glucose (SMBG, reference value) followed by FGMS scanning. There were 2567 paired SMBG and FGMS values used in the accuracy analysis, with an overall mean absolute relative difference (MARD) of 12.68% in the LC group and 10.55% in the control group (p < 0,001). In patients with LC, the percentage of readings within Consensus Consensus Error Grid analysis Zone A and A + B were 80.36% and 99,26%, respectively. Sensor clinical accuracy was not affected by factors such as body mass index, age, gender, Child-Pugh score or edematoascitic decompensation. This is the first study to approach FGMS clinical accuracy in LC, revealing a potential usability of this system to monitor glycemic control in this population.

Microbes, helminths, and rheumatic diseases.

There has been a progressive interest on modifications of the human defense system following insults occurring in the interface between our body and the external environment, as they may provoke or worsen disease states. Studies suggest that billions of germs, which compose the gut microbiota influence one's innate and adaptive immune responses at the intestinal level, but these microorganisms may also impact rheumatic diseases. The microbiota of the skin, respiratory, and urinary tracts may also be relevant in rheumatology. Evidence indicates that changes in the gut microbiome alter the pathogenesis of immune-mediated diseases such as rheumatoid arthritis and ankylosing spondylitis but also of other disorders like atherosclerosis and osteoarthritis. Therapeutic strategies to modify the microbiota, including probiotics and fecal microbiota transplantation, have been received with skepticism, which, in turn, has drawn attention back to previously developed interventions such as antibiotics. Helminths adapted to humans over the evolution process, but their role in disease modulation, particularly immune-mediated diseases, remains to be understood. The present review focuses on data concerning modifications of the immune system induced by interactions with microbes and pluricellular organisms, namely helminths, and their impact on rheumatic diseases. Practical aspects, including specific microbiota-targeted therapies, are also discussed.

Universal vs. risk-factor-based screening for gestational diabetes-an analysis from a 5-Year Portuguese Cohort.

PURPOSE: The criteria to screen for Gestational Diabetes Mellitus are not internationally consensual. In opposition to the universal screening performed in Portugal, certain countries advocate a risk-factor-based screening. We aim to compare obstetric and neonatal outcomes in pregnant women with and without risk factors treated for Gestational Diabetes Mellitus. METHODS: Retrospective and multicentric study of 12,006 pregnant women diagnosed with Gestational Diabetes Mellitus between 2011 and 2015, in Portugal. Gestational Diabetes Mellitus was diagnosed according to the International Association of the Diabetes and Pregnancy Study Groups criteria. RISK FACTORS: body mass index > 30kg/m2, history of Gestational Diabetes Mellitus, history of macrossomic newborn (birth weight > 4000 g) or first-degree relatives with Type 2 Diabetes Mellitus. EXCLUSION CRITERIA: lack of data concerning risk factors (n = 1563). RESULTS: At least one risk factor was found in 68.2% (n = 7123) pregnant women. Pregnant women with risk factors were more frequently medicated with insulin (p < 0.001), caesarean section was more commonly performed (p < 0.001), their newborns were more frequently large-for-gestational-age (p < 0.001) and neonatal morbidity was higher (p = 0.040) in comparison to pregnant women without risk factors. The Diabetes Mellitus reclassification test showed an increased frequency of intermediate hyperglycaemia and Diabetes Mellitus in women with risk factors (p < 0.001). CONCLUSION: Almost one-third of pregnant women would have remained undiagnosed if risk-based-factor screening were implemented in Portugal. Women without risk factors presented fewer obstetric and neonatal complications. However, more than one third required insulin therapy.

Iatrogenic water intoxication in a female adolescent with hypopituitarism.

The authors report a case of a 15-year-old girl with hypopituitarism due to pituitary stalk interruption syndrome diagnosed in the neonatal period. The patient was admitted to the emergency room with impaired consciousness and hypoglycaemia. The day before, she increased her water intake to about 1.5 L to perform a pelvic ultrasound. In the following hours, she developed vomiting and food refusal. Blood analysis revealed hypoglycaemia, hyponatraemia, decreased serum osmolality and normal urinary density. Hyponatraemia and adrenal crisis were managed with a gradual but slow resolution of consciousness and electrolytic balance. This case describes an episode of iatrogenic water intoxication in a patient under desmopressin treatment. Although uncommon, dilutional hyponatraemia is the main complication of desmopressin treatment. We reinforce the importance of patients and caregivers' long-life education for the potential complications of an increase in fluid intake in patients treated with desmopressin.

Iron Deficiency and Obesity - Are we Diagnosing with Appropriate Indicators?

INTRODUCTION: We aim to define the iron deficiency prevalence and eventual differences between obese patients with and without metabolic syndrome. MATERIAL AND METHODS: Analysis of patients evaluated at multidisciplinary consultation of obesity in our institution between 2013 and 2015 (n = 260). Iron deficiency: ferritin levels < 15 ng/mL. EXCLUSION CRITERIA: prior bariatric surgery; lack of ferritin or hemoglobin determinations. RESULTS: We analyzed data from 215 patients (84.2% female) with a mean age of 42.0 ± 10.3 years. The median body mass index was 42.5 (40.0 - 46.8) kg/m2 and 52.1% had metabolic syndrome. Iron deficiency was present in 7.0%, with no differences between genders or between patients with or without metabolic syndrome. Hypertension was associated with lower prevalence of iron deficiency. Type 2 diabetes and hypertension patients had higher levels of ferritin. The multivariate analysis showed that metabolic syndrome and increasing body mass index were predictive of higher risk of iron deficiency while hypertension predicted lower odds of iron deficiency. DISCUSSION: The prevalence of iron deficiency was similar in other published studies. Iron deficiency may be underdiagnosed if based only on ferritin concentrations. In our study, diabetes and hypertension appear to contribute to the increase in ferritin levels described in obesity. CONCLUSION: Ferritin may not be a reliable index for evaluating iron stores in obese patients, particularly when associated with comorbidities such as type 2 diabetes and hypertension. Further studies are needed to guide the diagnosis and iron supplementation in these patients.

Introdução: Os objetivos foram a determinação da prevalência de défice de ferro e de eventuais diferenças entre os doentes obesos com e sem síndrome metabólica. Material e Métodos: Análise dos doentes observados na consulta multidisciplinar de obesidade na nossa instituição entre 2013 e 2015 (n = 260). Défice de ferro: ferritina < 15 ng/mL. Critérios de exclusão: cirurgia bariátrica prévia, ausência de doseamentos de ferritina e de hemoglobina. Resultados: Avaliaram-se 215 doentes (84,2% mulheres) com uma idade média de 42,0 ± 10,3 anos. O índice de massa corporal mediano foi 42,5 (40,0 - 46,8) kg/m2 e 52,1% apresentavam síndrome metabólica. O défice de ferro estava presente em 7,0% sem diferenças entre os géneros e entre os doentes com e sem síndrome metabólica. A hipertensão associou-se a menor prevalência de défice de ferro. Doentes com diabetes tipo 2 e hipertensão apresentaram valores mais elevados de ferritina. Na análise multivariada, a síndrome metabólica e o índice de massa corporal constituíram fatores preditivos de défice de ferro, enquanto a hipertensão se associou a um menor risco. Discussão: A prevalência de défice de ferro foi similar a estudos previamente publicados. O défice de ferro pode ser subdiagnosticado se baseado apenas nas concentrações de ferritina. No nosso estudo, a diabetes e a hipertensão parecem contribuir para os níveis elevados de ferritina descritos na obesidade. Conclusão: A ferritina poderá não ser um índice fiável para avaliação de reservas de ferro na obesidade, particularmente quando associada a diabetes tipo 2 e hipertensão. São necessários mais estudos de forma a orientar o diagnóstico e a suplementação com ferro nestes doentes.

Metabolic Activity in the Visceral and Subcutaneous Adipose Tissues by FDG-PET/CT in Obese Patients.

INTRODUCTION: The emerging role of the 18F-fluorodeoxyglucose-positron emission tomography/computed tomography in the study of the metabolic activity and inflammation in adipose tissue indicates that it might be a reliable tool to complement the risk stratification in obesity. The aims of this study were the evaluation of 18F-fluorodeoxyglucose uptake by visceral adipose tissues and subcutaneous adipose tissues and to determine eventual differences in patients with and without obesity. MATERIAL AND METHODS: Retrospective study of adult patients who underwent whole body 18F-fluorodeoxyglucose-positron emission tomography/ computed tomography scanning between July and August of 2016. STATISTICAL ANALYSIS: SPSS™ software v.20. Statisticalsignificance: p < 0.05. RESULTS: We assessed fluorodeoxyglucose-positron emission tomography/computed tomography scans from 156 patients (58.3% of males) with a mean age of 61.0 ± 14.1 years. Half of the patients had a body mass index ≥ 25.0 kg/m2 and 15.4% (n = 24) were obese. In both groups, the mean 18F-fluorodeoxyglucose uptake was higher in visceral adipose tissues. There were no differences in 18F-fluorodeoxyglucose uptake in visceral adipose tissues between the groups. Obese patients had lower density of adipose tissue,both in subcutaneous adipose tissues and in visceral adipose tissues. Abdominal circumference and density of visceral adipose tissueshad a positive predictive value in the mean 18F-fluorodeoxyglucose uptake in visceral adipose tissues. Discussion: Through a non-invasive test, this study demonstrated a significant higher metabolic activity in visceral adipose tissues in both obese and non-obese patients. According to our results, abdominal circumference was an important determinant in 18F-fluorodeoxyglucose uptake in visceral adipose tissues. We also demonstrated that obese patients had differences in adipose tissue quality. CONCLUSION: Our findings reinforce the importance of the adipose tissue quality and distribution for metabolic risk stratification.

Introdução: O 18F-fluorodesoxiglucose-tomografia por emissão de pósitrons/tomografia computorizada tem sido aplicado ao estudo da atividade metabólica e da inflamação do tecido adiposo, constituindo uma possível ferramenta para complementar a estratificação de risco na obesidade. Os objetivos deste estudo foram a avaliação da captação de 18F-fluorodesoxiglucose pelo tecido adiposo visceral e pelo tecido adiposo subcutâneo e a determinação de eventuais diferenças em doentes com e sem obesidade. Material e Métodos: Estudo retrospetivo de doentes adultos submetidos a 18F-fluorodesoxiglucose-tomografia por emissão de pósitrons/ tomografia computorizada entre julho e agosto de 2016. Análise estatística: software SPSS™ versão 20. Significância estatística: p < 0,05. Resultados: Foram avaliados os exames 18F-fluorodesoxiglucose-tomografia por emissão de pósitrons/tomografia computorizada de 156 doentes (58,3% eram homens) com idade média de 61,0 ± 14,1 anos. Metade dos doentes apresentava índice de massa corporal ≥ 25,0 kg/m2 e 15,4% (n = 24) eram obesos. Em ambos os grupos, a captação média de 18F-fluorodesoxiglucose foi superior no tecido adiposo visceral. Não houve diferenças na captação de 18F-fluorodesoxiglucose no tecido adiposo visceral entre os grupos. Os doentes obesos apresentaram menor densidade do tecido adiposo, quer no tecido adiposo visceral como no tecido adiposo subcutâneo. A circunferência abdominal e a densidade do tecido adiposo visceral tiveram um valor preditivo positivo na captação média de 18F-fluorodesoxiglucose no tecido adiposo visceral. Discussão: Através de um exame não invasivo, demonstrou-se a existência de atividade metabólica significativamente maior no tecido adiposo visceral, comparativamente ao tecido adiposo subcutâneo, em doentes com e sem obesidade. De acordo com os nossos resultados, a circunferência abdominal foi um determinante importante na captação de 18F-fluorodesoxiglucose no tecido adiposo visceral. Demonstramos ainda que os doentes obesos apresentaram diferenças na qualidade do tecido adiposo. Conclusão: Os nossos resultados reforçam a importância da qualidade e da distribuição do tecido adiposo para a estratificação do risco metabólico.

Type 2 Diabetes Decompensation as the Clinical Presentation of Thyroid Storm - Cause or Consequence?

This case study aims to discuss the unusual forms of hyperthyroidism presentation, the nonspecific symptoms and precipitating events. A 70-year-old male was taken to the emergency department for hyperglycaemia, nausea, vomiting and altered mental status with a week of evolution. He had a past medical history of type 2 diabetes, hypertension and dyslipidemia. He had no history of any recent intercurrent illness or infection. At the emergency room, besides hyperglycaemia, ketonemia and slightly elevated C-reactive protein, the basic laboratory panel workup was normal, as was the head computed tomography. He was admitted for metabolic compensation and to study the altered neurological status. During hospitalisation, despite the good glycemic control, he had no improvements in neurological status. At day four of hospitalisation, thyrotoxicosis with thyroid storm criteria was diagnosed. He started on adequate treatment with complete clinical recovery. The associated morbidity and mortality of thyroid storm requires immediate recognition and treatment. Elderly patients are frequently misdiagnosed or diagnosed later due to fewer and less pronounced signs and symptoms.

The role of neck ultrasound in the follow-up of low- and intermediate- risk papillary thyroid cancer

ABSTRACT Objective: The optimal time for a neck ultrasound (US) in the follow-up of papillary thyroid cancer (PTC) after the first year is undetermined. We aimed to verify the utility of routine neck US in the surveillance of patients diagnosed with low- and intermediate-risk PTC with no evidence of disease at the one-year assessment. Materials and methods: We conducted a retrospective longitudinal study of patients with low- and intermediate-risk PTC with normal neck US, unstimulated serum thyroglobulin (Tg) < 1 ng/mL and negative anti-Tg antibodies at the one-year follow-up. Patients were divided into group 1 [undetectable Tg (<0.20 ng/mL)] and group 2 [detectable Tg but < 1 ng/mL]. The negative predictive value (NPV) of the one-year unstimulated Tg at the five-year and last follow-up visits was calculated. Results: We included n = 88 patients in group 1 and n = 8 patients in group 2. No patient from group 1 presented suspicious US findings at the five-year evaluation [NPV: 100.0% (95% confidence interval (CI): 95.5%-100.0%)], and at the last visit, only one patient had developed a lymph node classified as suspicious [NPV: 98.8% (95% CI: 93.2%-100.0%); mean follow-up: 6.7 years]. In group 2, two patients' USs presented suspicious findings at the five-year evaluation [NPV: 75.0% (95% CI: 34.9%-96.8%)]. At the last visit, only one patient persisted with suspicious findings in the US [NPV: 87.5% (95% CI: 47.4%-99.7%); mean follow-up: 6.5 years]. Conclusion: Low- and intermediate-risk PTC with an excellent response to treatment at the one-year assessment can be safely monitored with regular unstimulated Tg assessments. Conclusions should not be drawn for Tg levels between 0.20-0.99 ng/mL.