Successful outpatient conservative management of chyle leak after laparoscopic left hemicolectomy / Éxito de tratamiento conservador ambulatorio de paciente con ascitis quilosa tras hemicolectomía izquierda laparoscópica

Chyle leak is a pathological extravasation of chyle into the peritoneal cavity after a surgical injury. It is an uncom-mon complication in colorectal surgery. In most cases, conservative treatment is effective, although it often entails prolonged hospital stays.We present the case of a 60-year-old female with chyle leak after laparoscopic left hemicolectomy with complete mesocolic excision who underwent successful outpatient conservative management. We found no other cases of suc-cessful conservative outpatient treatment in the consulted literature. Adequate outpatient management may provide significant benefits by reducing hospital costs and improv-ing patient’s quality of life, while maintaining the possibility of starting adjuvant treatment if indicated (AU)

La ascitis quilosa es una acumulación patológica de quilo en la cavidad peritoneal tras una lesión quirúrgica. Es una complicación infrecuente de la cirugía colorrectal. En la mayoría de los casos, el tratamiento conservador suele ser eficaz, aunque conlleva estancias hospitalarias prolongadas.Se presenta el caso de una paciente de 60 años que de-sarrolló ascitis quilosa trasuna hemicolectomía izquierda laparoscópica, con escisión completa del mesocolon, que se resolvió con éxito mediante manejo conservador ambu-latorio. No se han encontrado casos exitosos de tratamien-to conservador ambulatorio en la bibliografía consultada. Un manejo ambulatorio como el propuesto puede aportar importantes beneficios en términos de reducción de costes hospitalarios y mejora de la calidad de vida del paciente, manteniendo la posibilidad de iniciar un tratamiento adyu-vante si está indicado (AU)

Successful outpatient conservative management of chyle leak after laparoscopic left hemicolectomy.

Chyle leak is a pathological extravasation of chyle into the peritoneal cavity after a surgical injury. It is an uncommon complication in colorectal surgery. In most cases, conservative treatment is effective, although it often entails prolonged hospital stays. We present the case of a 60-year-old female with chyle leak after laparoscopic left hemicolectomy with complete mesocolic excision who underwent successful outpatient conservative management. We found no other cases of successful conservative outpatient treatment in the consulted literature. Adequate outpatient management may provide significant benefits by reducing hospital costs and improving patient´s quality of life, while maintaining the possibility of starting adjuvant treatment if indicated.

Effectiveness and Tolerability of the Intensification of Canagliflozin Dose from 100 mg to 300 mg Daily in Patients with Type 2 Diabetes in Real Life: The INTENSIFY Study.

Aim: This study aimed to evaluate the effectiveness and tolerability of intensifying the dose of canagliflozin from 100 mg/day (CANA100) to 300 mg/day (CANA300) in patients with type 2 diabetes (T2DM) and suboptimal metabolic control in a real-world setting. Methods: A multicenter observational study was conducted on adult patients with T2DM who initiated treatment with CANA100 and subsequently required intensification to CANA300. The primary outcome measures were changes in HbA1c and weight at 6 months after the switch and at the end of the follow-up period. Results: A total of 317 patients met the inclusion criteria (59.6% male, mean age 62.2 years, baseline HbA1c 7.55%, weight 88.6 kg, median duration of treatment with CANA100 9.9 months). Switching to CANA300 resulted in a significant reduction in HbA1c (6 months: -0.33%; last visit: -0.47%, both p < 0.0001) and weight (6 months: -1.8 kg; last visit: -2.9 kg, both p < 0.0001) over a median follow-up period of 20.8 months. The proportion of patients that achieved HbA1c < 7% increased from 26.7% with CANA100 to 51.6% with CANA300 (p < 0.0001). Among individuals with poor baseline glycemic control (HbA1c > 8%, mean 9.0%), HbA1c was significantly reduced by -1.24% (p < 0.0001). Furthermore, significant improvements were observed in fasting plasma glucose (FPG), blood pressure (BP), liver enzymes, and albuminuria. No unexpected adverse events were reported. Conclusions: Intensifying the treatment to CANA300 in a real-world setting resulted in further significant and clinically relevant reductions in FPG, HbA1c, weight, and BP in patients with T2DM. The switch was particularly effective in patients with higher baseline HbA1c levels.

Predictive Factors of Renal Function Decline in Patients with Type 2 Diabetes Treated with Canagliflozin in the Real-Wecan Study.

The Real-WECAN study evaluated the real-life effectiveness and safety of canagliflozin 100 mg daily (initiated in SGLT-2 inhibitors naïve patients) and canagliflozin 300 mg daily (switching from canagliflozin 100 mg or other SGLT-2 inhibitors) in individuals with type 2 diabetes. The objectives of this sub-analysis were to estimate the eGFR slope over the follow-up period and to identify predictive factors of eGFR decline in a multiple linear regression analysis. A total of 583 patients (279 on canagliflozin 100 mg and 304 on canagliflozin 300 mg) were included, with median follow-up at 13 months. The patients had a mean age of 60.4 years, HbA1c of 7.76%, BMI of 34.7 kg/m2, eGFR below 60 mL/min/1.73 m2 8.6%, and urine albumin-to-creatinine ratio (UACR) above 30 mg/g 22.8%. eGFR decreased by −1.9 mL/min/1.73 m2 (p < 0.0001) by the end of the study. The mean eGFR slope during the maintenance phase was −0.16 mL/min/1.73 m2 per year. There were no significant differences between both doses of canagliflozin in the eGFR reduction or in the eGFR slope. The best predictive multivariate model of eGFR decline after canagliflozin therapy included age, hypertension, combined hyperlipidemia, heart failure, eGFR and severely increased albuminuria. All these variables except hypertension were independently associated with the outcome. In conclusion, in this real-world study, individuals with older age, combined hyperlipidemia, heart failure, higher eGFR and UACR > 300 mg/g showed a greater decline in their eGFR after canagliflozin treatment.

Real-World Clinical Outcomes Associated with Canagliflozin in Patients with Type 2 Diabetes Mellitus in Spain: The Real-Wecan Study.

The aims of this multicentric retrospective study were to assess in a real-world setting the effectiveness and safety of canagliflozin 100 mg/d (CANA100) as an add-on to the background antihyperglycemic therapy, and to evaluate the intensification of prior sodium-glucose co-transporter type 2 inhibitor (SGLT-2i) therapy by switching to canagliflozin 300 mg/d (CANA300) in patients with T2DM. One cohort of SGLT2i-naïve patients with T2DM who were initiated on CANA100 and a second cohort of patients with prior background SGLT-2i therapy who switched to CANA300 were included in the study. The primary outcome of the study was the mean change in HbA1c over the follow-up time. In total, 583 patients were included-279 in the cohort of CANA100 (HbA1c 8.05%, weight 94.9 kg) and 304 in the cohort of CANA300 (HbA1c 7.51%, weight 92.0 kg). Median follow-up periods in both cohorts were 9.1 and 15.4 months respectively. CANA100 was associated to significant reductions in HbA1c (-0.90%) and weight (-4.1 kg) at the end of the follow-up. In those patients with baseline HbA1c > 8% (mean 9.25%), CANA100 lowered HbA1c levels by 1.51%. In the second cohort, patients switching to CANA300 experienced a significant decrease in HbA1c (-0.35%) and weight (-2.1 kg). In those patients with baseline HbA1c > 8% (mean 8.94%), CANA300 lowered HbA1c levels by 1.12%. There were significant improvements in blood pressure in both cohorts. No unexpected adverse events were reported. In summary, CANA100 (as an add-on therapy) and CANA300 (switching from prior SGLT-2i therapy) significantly improved several cardiometabolic parameters in patients with T2DM.

Utilidad de la tiroglobulina en lavado de aguja del aspirado de 16 lesiones cervicales en pacientes con cáncer de tiroides / The value of thyroglobulin in washout of fine needle aspirate from 16 cervical lesions in patients with thyroid cancer

Antecedentes y objetivo La tiroglobulina del lavado de aguja (Tg-PAAF) junto con la citología de la punción-aspiración con aguja fina (cito-PAAF) son procedimientos recomendados para el diagnóstico de metástasis ganglionares cervicales y recurrencias del cáncer diferenciado de tiroides. El objetivo de este estudio fue valorar la utilidad de estas técnicas en 16 lesiones cervicales de pacientes con cáncer de tiroides del epitelio folicular (CT).Pacientes y método Se incluyeron 6 pacientes con CT y adenopatías laterocervicales evaluadas antes de la cirugía tiroidea inicial y 10 pacientes en seguimiento por CT ya operado y lesiones cervicales ecográficamente sospechosas y/o persistentes. Las 16 lesiones fueron sometidas a PAAF. Los resultados de la Tg-PAAF, cito-PAAF y de la combinación de ambas se compararon con el diagnóstico definitivo asignado a cada lesión. Resultados En 10 lesiones comprobadamente malignas tras extirpación quirúrgica (9 metástasis ganglionares y una recurrencia en lecho), la cito-PAAF, la Tg-PAAF y la combinación de ambas técnicas permitieron llegar al diagnóstico correcto en 7, 9 y 10 casos respectivamente. En 6 lesiones consideradas benignas, la cito-PAAF pudo confirmar la benignidad de la lesión en 4, resultó no diagnóstica en una y falsamente positiva en otra, mientras que la Tg-PAAF se halló por debajo del valor de corte establecido (para considerar malignidad) en todos los casos. Conclusiones En pacientes con CT y lesiones cervicales sospechosas, la Tg-PAAF mejora la rentabilidad diagnóstica de la cito-PAAF aislada justificándose así su recomendación sistemática al realizar la PAAF. Quedan sin embargo por definir una estandarización universal de la técnica y unos valores de corte válidos de Tg-PAAF (de acuerdo al inmunoanálisis empleado) por encima de los cuales considerar la lesión maligna (AU)

Background and objective Thyroglobulin in the needle washout (Tg-FNA) and cytology of fine needle aspiration (cyto-FNA) are recommended for diagnosis of metastatic lymphadenopathies and recurrence of differentiated thyroid cancer. The objective of this study was to assess the value of these procedures in 16 cervical masses from patients with thyroid cancer of the follicular epithelium (TC).Patients and methods The study included six patients with TC and cervical lymphadenopathies evaluated before initial thyroid surgery and 10 patients followed up after TC surgery with cervical lumps discovered. FNA was performed in all 16 masses. Results of cyto-FNA, Tg-FNA and of the combined tests were compared to the final diagnosis of each lesion. Results Among 10 lesions proven to be malignant at surgery, cyto-FNA, Tg-FNA and the combination of both allowed for adequate diagnosis in 7, 9, and 10 cases respectively. Among 6 lesions considered to be benign, cyto-FNA was able to confirm diagnosis in 4, was non-diagnostic in one, and was falsely negative in the remaining case, while Tg-FNA was below the established cut-off value (to consider malignancy) in all cases. ConclusionsIn patients with TC and suspect cervical masses, Tg-FNA improved the diagnostic yield of cyto-FNA alone, thus warranting its routine recommendation when FNA is performed. However, universal standardization of the technique and definition of valid cut-off thyroglobulin values (depending on the immunoassay used) above which the lesion should be considered to be malignant are still pending (AU)

The value of thyroglobulin in washout of fine needle aspirate from 16 cervical lesions in patients with thyroid cancer.

BACKGROUND AND OBJECTIVE: Thyroglobulin in the needle washout (Tg-FNA) and cytology of fine needle aspiration (cyto-FNA) are recommended for diagnosis of metastatic lymphadenopathies and recurrence of differentiated thyroid cancer. The objective of this study was to assess the value of these procedures in 16 cervical masses from patients with thyroid cancer of the follicular epithelium (TC). PATIENTS AND METHODS: The study included six patients with TC and cervical lymphadenopathies evaluated before initial thyroid surgery and 10 patients followed up after TC surgery with cervical lumps discovered. FNA was performed in all 16 masses. Results of cyto-FNA, Tg-FNA and of the combined tests were compared to the final diagnosis of each lesion. RESULTS: Among 10 lesions proven to be malignant at surgery, cyto-FNA, Tg-FNA and the combination of both allowed for adequate diagnosis in 7, 9, and 10 cases respectively. Among 6 lesions considered to be benign, cyto-FNA was able to confirm diagnosis in 4, was non-diagnostic in one, and was falsely negative in the remaining case, while Tg-FNA was below the established cut-off value (to consider malignancy) in all cases. CONCLUSIONS: In patients with TC and suspect cervical masses, Tg-FNA improved the diagnostic yield of cyto-FNA alone, thus warranting its routine recommendation when FNA is performed. However, universal standardization of the technique and definition of valid cut-off thyroglobulin values (depending on the immunoassay used) above which the lesion should be considered to be malignant are still pending.

[Osteitis fibrosa cystica as the initial manifestation of primary hyperparathyroidism]. / Osteítis fibrosa quística como manifestación inicial de hiperparatiroidismo primario.

Primary hyperparathyroidism is a common endocrinological disease and most cases are asymptomatic. We report the case of a patient with primary hyperparathyroidism and symptomatic bone lesions. The possibility of different etiologies (adenoma vs carcinoma) according to the clinical manifestations and treatment are also discussed.

Osteítis fibrosa quística como manifestación inicial de hiperparatiroidismo primario / Osteitis fibrosa cystica as the initial manifestation of primary hyperparathyroidism

El hiperparatirioidismo primario es una enfermedad endocrina muy frecuente y, en la mayoría de los casos, asintomática. Se presenta el caso de un paciente con hiperparatiroidismo primario y lesiones óseas sintomáticas y se discute la etiología en función de los hallazgos clínicos (adenoma frente a carcinoma) y su tratamiento (AU)

Primary hyperparathyroidism is a common endocrinological disease and most cases are asymptomatic. We report the case of a patient with primary hyperparathyroidism and symptomatic bone lesions. The possibility of different etiologies (adenoma vs carcinoma) according to the clinical manifestations and treatment are also discussed (AU)

Disnea y estridor en paciente obesa por bocio multinodular / Dyspnea and stridor due to multinodular goiter

El bocio multinodular intratorácico es una enfermedad frecuente que puede originar síntomas compresivos con riesgo vital para el paciente. A continuación se presenta el caso de una paciente con estenosis traqueal por bocio multinodular y se discuten las diferentes posibilidades terapéuticas (AU)

Substernal multinodular goiter is a common entity that may cause life-threatening pressure symptoms. We report the case of a patient with tracheal stenosis due to multinodular goiter and discuss various treatment options (AU)

Efectos de los traumatismos craneoencefálicos y la hemorragia subaracnoidea en la función hipofisaria anterior / Effects of traumatic brain injury and subarachnoid hemorrhage on anterior pituitary function

Los traumatismos craneoencefálicos (TCE) y las hemorragias subaracnoideas (HSA) son enfermedades frecuentes en nuestro medio. Ambos son causa reconocida de hipopituitarismo anterior y su prevalencia varía entre el 20 y el 80% según las últimas series publicadas. No existe consenso sobre la forma de evaluar los diferentes ejes hormonales, aunque sí está claro que se necesitan revisiones periódicas, puesto que el hipopituitarismo puede aparecer hasta transcurrido 1 año del TCE o la HSA. El tratamiento de las posibles deficiencias hormonales facilita el proceso de rehabilitación y disminuye la morbimortalidad Objective: To assess the safety and efficacy of biphasic insulin aspart 30/70 in patients with type 2 diabetes mellitus (DM2). Material and methods: We performed an observational, multicenter, prospective study in 3,054 DM2 patients from primary care and specialized settings, treated with biphasic insulin aspart 30/70 (started within 15 days prior to inclusion). In all patients, the following information was available before starting insulin treatment: HbA1c levels, fasting plasma glucose (FPG), 4-point glucose profile (before and 90 minutes after breakfast and dinner) and number of hypoglycemic episodes/week. A total of 2,887 patients completed the study (26 ± 1 week). The variables evaluated were rate of adverse events (AE), number of hypoglycemic episodes/week, HbA1c, FPG and 4-point glucose profile. Results: At least one AE occurred in 10.7% of the patients (2.3% related to the study drug and 1.4% severe). There was a significant decrease (end of study vs baseline; p < 0.0001 for all the comparisons) in HbA1c (7.3% and 8.9%, respectively), the mean number of minor (0.3/0.5) and major (0.02/0.07) hypoglycemic episodes/week, FPG (145/207 mg/dl) and postprandial glycemia (162/225 mg/dl). The improvement in metabolic control was achieved both in patients previously treated with oral antidiabetic drugs and in those treated with insulin. The number of hypoglycemic episodes decreased in patients previously treated with insulin. Conclusions: Treatment with biphasic insulin aspart 30/70 in patients with DM2 improves glycemic control, irrespective of previous treatment, with a low rate of AE and fewer hypoglycemic episodes in patients previously treated with insulin (AU)

Traumatic brain injuries and subarachnoid hemorrhage are frequent events in Spain. Both are well recognized causes of anterior hypopituitarism, the prevalence ranging from 20 to 80% according to recent series. Consensus is lacking on how to assess pituitary function after the injury, although periodic assessment is clearly needed because hypopituitarism may appear at any time in the first year after the event. Hormone replacement when necessary helps recovery and reduces morbidity and mortality (AU)

Dyspnea and stridor due to multinodular goiter in an obese woman.

Substernal multinodular goiter is a common entity that may cause life threatening pressure symptoms. We report the case of a patient with tracheal stenosis due to multinodular goiter and discuss various treatment options.

Effects of traumatic brain injury and subarachnoid hemorrhage on anterior pituitary function.

Traumatic brain injuries and subarachnoid hemorrhage are frequent events in Spain. Both are well recognized causes of anterior hypopituitarism, the prevalence ranging from 20 to 80% according to recent series. Consensus is lacking on how to assess pituitary function after the injury, although periodic assessment is clearly needed because hypopituitarism may appear at any time in the first year after the event. Hormone replacement when necessary helps recovery and reduces morbidity and mortality.

Pubertad precoz verdadera secundaria a masa supraselar: probable histiocitosis X / Central precocious puberty with inflammatory suprasellar mass: probable histiocytosis x

La pubertad precoz central se debe a la activación prematura del generador de pulsos de gonadotropinas del eje hipotálamo-hipofisariogonadal. En la mayoría de los casos se desconoce la etiología, pero siempre se debe descartar afecciones del sistema nervioso central, como tumores, radioterapia craneal, traumatismos craneoencefálicos y procesos inflamatorios como la histiocitosis X. En la histiocitosis X la afección hipotálamo-hipofisaria es muy frecuente, y la manifestación más común es la diabetes insípida. Presentamos el caso de una niña con pubertad precoz central secundaria a masa supraselar inflamatoria, probablemente, histiocitosis X (AU)

Central precocious puberty is due to premature activation of gonadotropin pulse generator in the hypothalamuspituitary- gonadal axis. The etiology isknown in most cases, but tumors, cranial radiotherapy, traumatic brain injury and inflammatory disorders, such as histiocytosis X, are important options to be considered in the differential diagnosis. Hypothalamic-pituitary involvement is common in histiocytosis X, and in these cases diabetes insipidus is the most common endocrine deficiency at presentation. We report the case of a girl with an inflammatory suprasellar mass, probably histiocytosis X, who presented with central precocious puberty (AU)

Cetoacidosis diabética y distrés respiratorio agudo / Diabetic ketoacidosis and acute respiratory distress

El síndrome de distrés respiratorio del adulto (SDRA) es una complicación infrecuente de la cetoacidosis diabética que aumenta notablemente su mortalidad. Su patogenia es probablemente multifactorial. Se han propuesto como mecanismos el descenso brusco de la presión osmótica y las alteraciones hidroelectrolíticas que ocurren durante el tratamiento, en especial la hipofosfatemia. Presentamos el caso de un varón de mediana edad que desarrolló un SDRA durante el tratamiento de un episodio de cetoacidosis (AU)

Acute respiratory distress (ARDS) is a rare complication of diabetic ketoacidosis that markedly increases mortality. The pathogenesis of this entity is probably multifactorial and includes a rapid decrease of osmotic pressure and electrolyte changes occurring during treatment, especially hypophosphatemia. We describe the case of a middle-aged man with acute respiratory distress complicating diabetic ketoacidosis (AU)

Neuralgia del trigémino como manifestación de un macroadenoma hipofisario / Trigeminal neuralgia as a manifestation of pituitary macroadenoma

Los adenomas hipofisarios son tumores con un comportamiento generalmente benigno aunque en alrededor del 9 al 40% de los casos invaden estructuras vecinas. La extensión hacia los senos cavernosos de los adenomas hipofisarios puede producir una compresión de las estructuras que alberga, como los pares craneales oculomotores (III, IV y VI) y la primera y la segunda rama del trigémino. La cefalea es un síntoma frecuente en los pacientes que presentan un adenoma hipofisario y puede estar producida por múltiples causas. La neuralgia del trigémino como consecuencia de la compresión del nervio en su recorrido por el seno cavernoso es una causa rara de cefalea en estos pacientes, y es todavía más infrecuente que éste sea el único síntoma que produzca un adenoma hipofisario. Presentamos el caso de una paciente con un macroprolactinoma que presentó como síntoma una neuralgia del trigémino con una remisión completa del dolor tras el tratamiento del adenoma con cabergolina (AU)

Pituitary adenomas are generally regarded as benign tumors, although they can invade neighboring structures such as the cavernous sinus in 9-40% of cases. Extension of pituitary adenomas towards the cavernous sinus can compress the cranial nerves in the area, such as cranial nerves III, IV and VI, and the first and second branches of the trigeminal nerve. Headache is frequent in patients with pituitary adenoma and can be caused by multiple entities. Trigeminal neuralgia as a result of trigeminal nerve compression is a rare cause of headache in these patients and is even more unusual as an isolated symptom. We present the case of a patient with a macroprolactinoma causing trigeminal neuralgia. Complete remission of pain was produced after the adenoma was treated with cabergoline (AU)

Pancitopenia y déficit adquirido del factor IX de la coagulación en un caso de síndrome de Sheehan / Pancytopenia and acquired factor IX deficiency in patient with Sheehan’s syndrome

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