Long-term remission following antithyroid drug withdrawal in patients with Graves' hyperthyroidism: parameters with prognostic value.

OBJECTIVE: To assess the predictive value of some clinical and biochemical parameters, and of the +49 A/G polymorphism of the CTLA-4 gene, for long-term remission following the withdrawal of antithyroid drugs before starting antithyroid drug therapy. STUDY DESIGN: Observational, prospective and longitudinal study. METHODS: Seventy-two patients (11 of whom were men) with newly diagnosed Graves' hyperthyroidism who had been attended consecutively at a University Clinic in a population with sufficient iodine intake were included in the study. EXCLUSION CRITERIA: patients under the age of 18, pregnant women and non-Caucasian patients. All subjects were treated following a well-defined protocol. Long-term remission was calculated at 12 and 36 months following withdrawal of the antithyroid drug. RESULTS: Thirty-six of the 72 study subjects experienced a remission of at least 12 months following withdrawal of methimazole, with no differences according to their age or sex. A comparison made between the remission rates seen in both groups yielded significant differences regarding the presence of Graves' orbitopathy, the duration of the treatment with methimazole and the absence of the CTLA-4 G/G genotype. In the univariate and multivariate analyses performed, only lower frequencies of Graves' orbitopathy and an absence of the CTLA-4 G/G genotype were considered independent predictors of long-term remission. CONCLUSIONS: The absence of Graves' orbitopathy and of the CTLA-4 G/G genotype are independent predictors of long-term remission following a first course of antithyroid drugs.

Long-term outcome of multimodal therapy for giant prolactinomas.

Giant prolactinomas are rare tumors characterized by their large size, compressive symptoms, and extremely high prolactin secretion. The aim of this study is to describe our experience with a series of 16 giant prolactinomas cases in terms of clinical presentation, therapeutic decisions, and final outcomes. Retrospective analysis of adult patients diagnosed with giant prolactinomas at the endocrine departments of three university tertiary hospitals. We included 16 patients (43.7 % women); mean age at diagnosis: 42.1 ± 21 years. The most frequent presentation was compressive symptoms. The delay in diagnosis was higher in women (median of 150 months vs. 12 in men; p = 0.09). The mean maximum tumor diameter at diagnosis was 56.9 ± 15.5 mm, and mean prolactin levels were 10,995.9 ± 12,157.8 ng/mL. Dopamine agonists were the first-line treatment in 11 patients (mean maximum dose: 3.9 ± 3.2 mg/week). Surgery was the initial treatment in five patients and the second-line treatment in six. Radiotherapy was used in four cases. All patients but one, are still with dopamine agonists. After a mean follow-up of 9 years, prolactin normalized in 7/16 patients (43.7 %) and 13 patients (81 %) reached prolactin levels lower than twice the upper limit of normal. Mean prolactin level at last visit: 79.5 ± 143 ng/mL. Tumor volume was decreased by 93.8 ± 11.3 %, and final maximum tumor diameter was 18.4 ± 18.8 mm. Three patients are actually tumor free. Giant prolactinomas are characterized by a large tumor volume and extreme prolactin hypersecretion. Multimodal treatment is frequently required to obtain biochemical and tumor control.

[Malnutrition in patients with cancer; four years experience]. / Desnutrición en pacientes con cáncer; una experiencia de cuatro años.

OBJECTIVE: To analyze the prevalence and degree of malnutrition among patients with cancer who were sent to an Oncological Nutrition visit. MATERIAL AND METHODS: It is an observational crosssectional descriptive study. First nutrition visit data of all patientes aged ≥ 18 with cancer who were evaluated from march of 2008 to february of 2012 were used. A total of 997 patients were studied using the Patient-Generated Subjective Global Assessment. RESULTS: 69% of the patients had lost more than 5% of their usual weight within the previous 3 months, the patients with the highest frequency of weight loss were those with digestive cancer. Eating problems were encountered by the 81.2% of the patients, the most frequent problem being anorexia (53.3%) and the median number of symptoms was 3. Patient-Generated Subjective Global Assessment shows a malnutrition prevalence of 72.9% (29.9% with moderate malnutrition and 43% with severe malnutrition). Malnutrition was related to the type of cancer and the stage of the disease and was not related to age, gender neither usual body mass index. CONCLUSIONS: Malnutrition prevalence among patients who were evaluated in our consulting-room is high. Nutritional evaluation is very important to detect patients at risk of malnutrition or with malnutrition and helps to choose the nutritional treatment.

Objetivo: Analizar la prevalencia y el grado de desnutrición de los pacientes con cáncer remitidos a una consulta específica de Nutrición Oncológica. Material y métodos: Se trata de un estudio transversal, observacional y descriptivo basado en los datos recogidos en la primera consulta de nutrición de todos los pacientes mayores de edad con cáncer evaluados en el período comprendido entre el 1 de marzo de 2008 y el 29 de febrero de 2012. Se incluyeron 997 pacientes, a los que se les realizó la Valoración Global Subjetiva Generada por el Paciente. Resultados: El 69% de los pacientes habían perdido más de un 5% de su peso habitual en los 3 meses previos, siendo esto más frecuente entre los portadores de tumores digestivos. El 81,2% de los pacientes tenían dificultades para alimentarse, el síntoma más frecuente era la anorexia (53,3%) y la mediana de síntomas por paciente 3. La Valoración Global Subjetiva Generada por el Paciente muestra una prevalencia de desnutrición del 72,9% (29,9% desnutrición moderada y 43% desnutrición severa). La desnutrición se relacionó con el tipo de tumor y con el estadío, pero no con la edad, el sexo ni con el Índice de Masa Corporal habitual. Conclusiones: La prevalencia de desnutrición en los pacientes con cáncer evaluados en nuestra consulta es elevada. La valoración nutricional es básica para identificar a aquellos pacientes con desnutrición o riesgo de desnutrición y orientar la necesidad de tratamiento nutricional.

Desnutrición en pacientes con cáncer; una experiencia de cuatro años / Malnutrition in patients with cancer; four years experience

Objetivo: Analizar la prevalencia y el grado de desnutrición de los pacientes con cáncer remitidos a una consulta específica de Nutrición Oncológica. Material y métodos: Se trata de un estudio transversal, observacional y descriptivo basado en los datos recogidos en la primera consulta de nutrición de todos los pacientes mayores de edad con cáncer evaluados en el período comprendido entre el 1 de marzo de 2008 y el 29 de febrero de 2012. Se incluyeron 997 pacientes, a los que se les realizó la Valoración Global Subjetiva Generada por el Paciente. Resultados: El 69% de los pacientes habían perdido más de un 5% de su peso habitual en los 3 meses previos, siendo esto más frecuente entre los portadores de tumores digestivos. El 81,2% de los pacientes tenían dificultades para alimentarse, el síntoma más frecuente era la anorexia (53,3%) y la mediana de síntomas por paciente 3. La Valoración Global Subjetiva Generada por el Paciente muestra una prevalencia de desnutrición del 72,9% (29,9% desnutrición moderada y 43% desnutrición severa). La desnutrición se relacionó con el tipo de tumor y con el estadío, pero no con la edad, el sexo ni con el Índice de Masa Corporal habitual. Conclusiones: La prevalencia de desnutrición en los pacientes con cáncer evaluados en nuestra consulta es elevada. La valoración nutricional es básica para identificar a aquellos pacientes con desnutrición o riesgo de desnutrición y orientar la necesidad de tratamiento nutricional (AU)

Objective: To analyze the prevalence and degree of malnutrition among patients with cancer who were sent to an Oncological Nutrition visit. Material and methods: It's an observational cross-sectional descriptive study. First nutrition visit data of all patientes aged > 18 with cancer who were evaluated from march of 2008 to february of 2012 were used. A total of 997 patients were studied using the Patient-Generated Subjective Global Assessment. Results: 69% of the patients had lost more than 5% of their usual weight within the previous 3 months, the patients with the highest frequency of weight loss were those with digestive cancer. Eating problems were encountered by the 81.2% of the patients, the most frequent problem being anorexia (53.3%) and the median number of symptoms was 3. Patient-Generated Subjective Global Assessment shows a malnutrition prevalence of 72.9% (29.9% with moderate malnutrition and 43% with severe malnutrition). Malnutrition was related to the type of cancer and the stage of the disease and wasn't related to age, gender neither usual body mass index. Conclusions: Malnutrition prevalence among patients who were evaluated in our consulting-room is high. Nutritional evaluation is very important to detect patients at risk of malnutrition or with malnutrition and helps to choose the nutritional treatment (AU)

Acromegaloidism with normal growth hormone secretion associated with X-tetrasomy.

We reported a case of a 26-year-old female who was referred to our clinic with the diagnosis of possible acromegaly. She was born from a term pregnancy by forceps delivery. The patient was diagnosed as having hip luxation at one month and spoke her first word at 15 months. She had been diagnosed at the age of 9 years old as having perinatal encephalopathy with intellectual and motor affectation. Since this period of time she has undergone an insidious change in her appearance, mainly comprising progressive coarsening of the face. For this reason she was submitted to our clinic with presumed acromegaly. Dynamic tests of growth hormone secretion ruled out such a diagnosis. The Patient was considered as having "acromegaloidism", a term used for patients whom manifest clinical features of acromegaly but do not present a demonstrable growth hormone hypersecretion. Subsequently cytogenetic evaluation revealed an infrequent chromosome pattern: X-Tetrasomy. In the present article a differential diagnosis of acromegaloidism and the potential role of genes present on X-chromosome involved in human growth such as SHOX gene are discussed. Overdosification of SHOX gene might explain tall stature of girls with X-tetrasomy. Our observation suggested that X-tetrasomy should be considered in the differential diagnosis of acromegaloidism. Furthermore, this may lead to the identification of new genes in the X-chromosome that are important for growth of facial structures.

Significación clínica de la macroprolactina / Clinical significance of macroprolactin

Introducción: La macroprolactina (maPRL) es una variedad molecular de prolactina (PRL) de alto peso molecular y de actividad biológica cuestionable. El objetivo del presente estudio fue valorar la repercusión clínico-analítica de la presencia de maPRL en pacientes con hiperprolactinemia. Pacientes y método: Seleccionamos las muestras con concentraciones de PRL > 50 ng/ml (1.060 MU/l), tras la realización de la técnica de precipitación con polietilenglicol (PEG) 6000, consideramos que presentaban maPRL aquellas con valores de recuperación 50 ng/ml estudiados en un periodo de 24 meses, 22 presentaron maPRL (9,6%), todas mujeres con edad media de 32 años (12-48). El rango de PRL basal fue de 50,5 a 158 ng/ml. El motivo más frecuente de petición de PRL fueron las alteraciones menstruales (el 45% de los pacientes). Para valorar la repercusión clínica, evaluamos la PRL monomérica en estas pacientes y encontramos que en el 36,4% la maPRL se asociaba a aumento de PRL monomérica (grupo A) y en este grupo presentaba clínica hipogonadal el 87,5%. La maPRL se asociaba con concentraciones fisiológicas de PRL monomérica en el 63,6% (grupo B) y en este grupo presentaba clínica de amenorrea sólo 1 (7,14%) paciente, p < 0,05. De las 6 pacientes a las que se realizó estudio radiológico, 2 presentaron adenomas. Se trató con agonistas dopaminérgicos a 6 pacientes y en todas se normalizaron la clínica y los valores de hiperprolactinemia. Conclusiones: En nuestra serie, la presencia de maPRL sólo se acompañó de clínica de disfunción gonadal cuando se asoció a hiperprolactinemia monomérica. La maPRL aislada carece de significado clínico, pero es importante determinarla para evitar un manejo clínico innecesario

Introduction: Macroprolactin (maPRL) is a high molecular weight variant of prolactin (PRL) with reduced bioactivity. The purpose of the present study was to determine the clinical-laboratory repercussions of the presence of maPRL in patients with hyperprolactinemia. Patients and Method: A polyethylene glycol (PEG) precipitation test was used to detect the presence of maPRL in all consecutive samples with a prolactin concentration of > 50 ng/ml (1.060 MU/l). A recovery 50 ng/ml. All the patients with maPRL were women; the mean age was 32 years (12-48). Serum PRL levels ranged from 50.5-158 ng/ml. The most frequent reason for the initial PRL request was menstrual disturbance (45% patients). To study clinical repercussions, monomeric PRL was determined. The results showed that maPRL was associated with an increase of monomeric PRL levels in 36.4% of the patients (group A) and that 87.5% of patients in this group had hypogonadal symptoms. MaPRL was associated with physiological concentrations of monomeric PRL in 63.6% (group B) and only one patient in this group had amenorrhea (7.14%), p < 0.05. Of 6 patients who underwent neuroimaging, pituitary adenomas were identified in 2. Six patients were treated with dopamine agonists. In all 6 of these patients, symptoms and hyperprolactinemic values were resolved. Conclusions: Our results indicate that patients with maPRL only presented symptomatology suggestive of hyperprolactinemia when the monomeric PRL concentration was elevated. MaPRL has limited clinical repercussions but its determination in routine practice is important to avoid inappropriate management

Tratamiento quirúrgico del bocio endotorácico que produce síndrome compresivo en ancianos con múltiples enfermedades concomitantes / Surgical treatment of endothoracic goiter producing compressive syndromes in elderly patients with multiple comorbidities

El bocio endotorácico produce una potencial morbimortalidad derivada tanto de la compresión de estructuras que atraviesan el estrecho cervicotorácico como de su posible malignización. El tratamiento quirúrgico en el anciano, con enfermedad asociada en la mayoría de los casos, se cuestiona por el alto riesgo anestésico y quirúrgico que conlleva. Se presentan 3 casos intervenidos de bocio endotorácico que producía síndrome compresivo en el mediastino, todos con enfermedades importantes asociadas. Tras la exéresis quirúrgica, realizada sin complicaciones, los pacientes mostraron remisión total de la clínica compresiva y mejoría de su calidad de vida. El desarrollo de las técnicas anestésicas y la habilidad y la experiencia de algunos cirujanos hace que la edad no figure como factor limitante en la indicación de tratamiento quirúrgico de estos pacientes ancianos

Endothoracic goiter produces potential morbidity and mortality due to possible compression of surrounding structures and its potential for malignant transformation. Surgical treatment of this entity in the elderly, who usually have associated diseases, has been questioned due to the high surgical and anesthetic risk it carries. We present three cases of endothoracic goiter that produced mediastinal compression syndrome in patients with significant associated diseases. Surgical excision was performed without complications and the patients showed complete remission of compressive symptoms and improved quality of life. Because of the development of anesthetic techniques and the skill and experience of some surgeons, age is not a limiting factor in the indication for surgical treatment in these elderly patients