Venous thromboembolism in Cushing syndrome: results from an EuRRECa and Endo-ERN survey.

Background: Patients with Cushing syndrome (CS) are at increased risk of venous thromboembolism (VTE). Objective: The aim was to evaluate the current management of new cases of CS with a focus on VTE and thromboprophylaxis. Design and methods: A survey was conducted within those that report in the electronic reporting tool (e-REC) of the European Registries for Rare Endocrine Conditions (EuRRECa) and the involved main thematic groups (MTG's) of the European Reference Networks for Rare Endocrine Disorders (Endo-ERN) on new patients with CS from January 2021 to July 2022. Results: Of 222 patients (mean age 44 years, 165 females), 141 patients had Cushing disease (64%), 69 adrenal CS (31%), and 12 patients with ectopic CS (5.4%). The mean follow-up period post-CS diagnosis was 15 months (range 3-30). Cortisol-lowering medications were initiated in 38% of patients. One hundred fifty-four patients (69%) received thromboprophylaxis (including patients on chronic anticoagulant treatment), of which low-molecular-weight heparins were used in 96% of cases. VTE was reported in six patients (2.7%), of which one was fatal: two long before CS diagnosis, two between diagnosis and surgery, and two postoperatively. Three patients were using thromboprophylaxis at time of the VTE diagnosis. The incidence rate of VTE in patients after Cushing syndrome diagnosis in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Conclusion: Thirty percent of patients with CS did not receive preoperative thromboprophylaxis during their active disease stage, and half of the VTE cases even occurred during this stage despite thromboprophylaxis. Prospective trials to establish the optimal thromboprophylaxis strategy in CS patients are highly needed. Significance statement: The incidence rate of venous thromboembolism in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Notably, this survey showed that there is great heterogeneity regarding time of initiation and duration of thromboprophylaxis in expert centers throughout Europe.

Réplica a la carta al director: «Terminología y comunicación entre niveles asistenciales» / Reply to letter to the editor: «Terminology and communication between healthcare levels»

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Affective alterations in patients with Cushing's syndrome in remission are associated with decreased BDNF and cortisone levels.

OBJECTIVE: Affective alterations and poorer quality of life often persist in patients with Cushing's syndrome (CS) in remission. Brain-derived neurotrophic factor (BDNF) regulates the hypothalamic-pituitary-adrenal axis (HPA) and is highly expressed in brain areas controlling mood and response to stress. Our aims were to assess affective alterations after long-term remission of CS and evaluate whether they are associated with serum BDNF, salivary cortisol (SalF) and/or cortisone (SalE) concentrations. SUBJECTS AND METHODS: Thirty-six CS patients in remission (32 females/4 males; mean age (±s.d.), 48.8 ± 11.8 years; median duration of remission, 72 months) and 36 gender-, age- and BMI-matched controls were included. Beck Depression Inventory-II (BDI-II), Center for Epidemiological Studies Depression Scale (CES-D), Positive Affect Negative Affect Scale (PANAS), State-Trait Anxiety Inventory (STAI), Perceived Stress Scale (PSS) and EuroQoL and CushingQoL questionnaires were completed and measured to evaluate anxiety, depression, stress perception and quality of life (QoL) respectively. Salivary cortisol was measured using liquid chromatography/tandem mass spectrometry (LC/TMS). BDNF was measured in serum using an ELISA. RESULTS: Remitted CS patients showed worse scores in all questionnaires than controls: STAI (P < 0.001), BDI (P < 0.001), CES-D (P < 0.001), PANAS (P < 0.01), PSS (P < 0.01) and EuroQoL (P < 0.01). A decrease in BDNF was observed in CS vs controls (P = 0.038), and low BDNF was associated with more anxiety (r = -0.247, P = 0.037), depression (r = -0.249, P = 0.035), stress (r = -0.277, P = 0.019) and affective balance (r = 0.243, P = 0.04). Morning salivary cortisone was inversely associated with trait anxiety (r = -0.377, P = 0.040) and depressed affect (r = -0.392, P = 0.032) in CS patients. Delay to diagnosis was associated with depressive symptoms (BDI-II: r = 0.398, P = 0.036 and CES-D: r = 0.449, P = 0.017) and CushingQoL scoring (r = -0.460, P < 0.01). CONCLUSIONS: Low BDNF levels are associated with affective alterations in 'cured' CS patients, including depression, anxiety and impaired stress perception. Elevated levels of SalE might also be related to poor affective status in these patients.

Smoking affects the oral glucose tolerance test profile and the relationship between glucose and HbA1c in gestational diabetes mellitus.

AIMS: Current smokers in the general population have a lower 2 h plasma glucose after an oral glucose tolerance test (OGTT) and a higher HbA1c than non-smokers, but the relationships between OGTT/HbA1c and smoking status have not been addressed in pregnancy. We analysed glycaemic measurements in women with gestational diabetes mellitus in relation to smoking status. METHODS: We performed a review of the prospectively collected database of the diabetes and pregnancy clinic. We included women with gestational diabetes mellitus and a singleton pregnancy who delivered between 1986 and 2006. Bivariate and multivariate analyses were used to evaluate patient characteristics in relation to smoking status. RESULTS: A total of 2361 women met the inclusion criteria: 556 (23.5%) were active smokers, 266 (11.3%) quit during pregnancy and 1539 (65.2%) were non-smokers. Most baseline characteristics were similar across groups. Diagnostic OGTT was performed at a gestational age of [median (25th, 75(th) centiles)] 29 weeks (26, 33). Women who smoked at the beginning of pregnancy had a higher 1-h plasma glucose than non-smokers [11.8 (11, 12.7), 11.6 (11, 12.6) and 11.5 (10.8, 12.5) mmol/l, for active smokers, those who quit during pregnancy and non-smokers, respectively, P < 0.001] and a lower 3-h plasma glucose [7.3 (5.9, 8.4), 7.6 (6.4, 8.7) and 8.0 (6.8, 9.0) mmol/l, respectively, P < 0.001]. HbA1c was higher in women who smoked at the beginning of pregnancy. Multiple regression analysis confirmed the independent association of smoking status with HbA1c and OGTT plasma glucose. CONCLUSIONS: In women with gestational diabetes mellitus who smoke at the beginning of pregnancy, the shape of the OGTT is consistent with accelerated glucose absorption, and HbA1c is higher than expected for glycaemic values.

Communication between primary care and physician specialist: is it improving? / Comunicación entre la atención primaria y el médico especialista: ¿se está produciendo alguna mejora?

Fundamento y objetivo. En los últimos años se ha intentado mejorar en España la comunicación entre la atención primaria y la atención especializada. El objetivo de este estudio fue analizar el impacto de un cambio en el modelo de comunicación entre ambas áreas, comparando el sistema tradicional con un sistema de consultoría. Se analizó la satisfacción de los médicos de atención primaria y el número de derivaciones realizadas. Métodos. En un centro de atención primaria donde trabajan 20 médicos, se pasó un cuestionario al inicio y a los 18 meses de introducir un sistema de consultoría, para conocer su punto de vista sobre la relación con el equipo de endocrinología. Asimismo se contabilizó el número de derivaciones durante ambos períodos. Resultados. Se analizaron 30 cuestionarios: 13 al inicio y 17 tras el establecimiento del sistema de consultoría. El nuevo sistema se prefirió a otras alternativas como medio de comunicación con los endocrinólogos. Tras la introducción del sistema de consultoría, los médicos tenían más confianza y autonomía en la gestión de la diabetes y el hipotiroidismo. Además disminuyó drásticamente el número de derivaciones a la atención especializada, que pasó de 93,8 a 34,6 pacientes por mes tras la introducción del sistema de consultoría. Conclusiones. El sistema de consultoría resultó más eficaz que el sistema tradicional para la resolución de problemas y la respuesta a los médicos. Los médicos aumentaron la confianza y autonomía en la gestión de la diabetes y el hipotiroidismo. Se observó un descenso importante del número de derivaciones (AU)

Background and objective. Efforts have recently been made in Spain to improve the communication model between primary care and specialized care. The aim of our study was to analyze the impact of a change in the communication model between the two areas when comparing a traditional system to a consulting system in terms of satisfaction of general practitioners and the number of patient referrals. Methods. A questionnaire was used to assess the point of view on the relations with the endocrinologist team of 20 general practitioners from one primary care center at baseline and 18 months after the implementation of the new method of communication. In addition, we counted the number of referrals during the two periods. Results. We analyzed 30 questionnaires; 13 before and 17 after the consulting system was established. Consulting system was preferred to other alternatives as a way of communication with endocrinologists. After the consulting system was implemented, general practitioners were more confident in treating hypothyroidism and diabetes. There was a decrease in the number of patient referrals to specialized care from 93.8 to 34.6 per month after implementation of the consultant system. Conclusions. The consultant system was more efficient in resolving problems and responding to general practitioners than the traditional system. General practitioners were more confident in self-management of hypothyroidism and diabetes. A very large decrease in the number of patient referrals was observed after implementation of the consultant system (AU)

Communication between primary care and physician specialist: is it improving?

BACKGROUND AND OBJECTIVE: Efforts have recently been made in Spain to improve the communication model between primary care and specialized care. The aim of our study was to analyze the impact of a change in the communication model between the two areas when comparing a traditional system to a consulting system in terms of satisfaction of general practitioners and the number of patient referrals. METHODS: A questionnaire was used to assess the point of view on the relations with the endocrinologist team of 20 general practitioners from one primary care center at baseline and 18 months after the implementation of the new method of communication. In addition, we counted the number of referrals during the two periods. RESULTS: We analyzed 30 questionnaires; 13 before and 17 after the consulting system was established. Consulting system was preferred to other alternatives as a way of communication with endocrinologists. After the consulting system was implemented, general practitioners were more confident in treating hypothyroidism and diabetes. There was a decrease in the number of patient referrals to specialized care from 93.8 to 34.6 per month after implementation of the consultant system. CONCLUSIONS: The consultant system was more efficient in resolving problems and responding to general practitioners than the traditional system. General practitioners were more confident in self-management of hypothyroidism and diabetes. A very large decrease in the number of patient referrals was observed after implementation of the consultant system.

Poorer perinatal outcome in male newborns of women with pregestational diabetes mellitus.

AIMS: To assess perinatal outcome in women with pregestational diabetes mellitus according to the sex of the fetus. METHODS: A retrospective review of all singleton pregnancies of women with pregestational diabetes progressing to a gestational age of 22 weeks or more who attended the diabetes and pregnancy clinic from 1981 to 2006 (n=455). We compared maternal characteristics and perinatal outcomes (perinatal mortality, major congenital malformations, small and large for gestational age newborns, preterm birth and a composite of the former) according to the sex of the fetus. A logistic regression analysis was performed using the composite perinatal outcome as the dependent variable and all maternal variables and sex of fetus as potential predictors. RESULTS: Maternal characteristics did not differ in mothers of male and female newborns. In the whole cohort, the composite perinatal outcome was significantly higher in male fetuses; adjusted OR 1.61 (95% CI 1.04-2.50). CONCLUSIONS: In women with pregestational diabetes, perinatal outcome was poorer in male newborns despite similar maternal characteristics.

Cambios en el perfil del paciente diabético hospitalizado en una sala de cirugía vascular y de los procedimientos quirúrgicos utilizados en 1985 y 2007 / Changes of the in-hospital diabetic patient profile in the employed in a vascular surgery department and surgical procedures between 1985 and 2007

Objetivos: 1. Conocer las características de los pacientes con piediabético hospitalizados en cirugía vascular durante los años 1985y 2007, los procedimientos quirúrgicos utilizados, la estancia mediay la mortalidad, y 2. Conocer el grado de control de la diabetes y losfactores de riesgo asociados en los mismos pacientes en 2007.Material y métodos: Se analizaron datos de la diabetes (tipo,tiempo de evolución, tratamiento y complicaciones), factores deriesgo, procedimientos quirúrgicos, estancia media y mortalidad enlos años 1985 y 2007. En 2007 se valoraron además: hemoglobinaglucosilada (HbA1c), perfil lipídico y presión arterial (PA). Resultados:Se evaluaron 162 pacientes (91 en 1985, 71 en 2007). Laprevalencia de complicaciones microangiopáticas, el número de fumadoresy los pacientes en tratamiento con insulina fueron superioresen 1985. La edad y prevalencia de hipertensión y dislipemiafueron mayores en 2007. La distribución por sexos y duración de ladiabetes fueron similares. En 1985 se practicaron más amputaciones,y en 2007 más cirugía conservadora, asociada o no a amputaciónmenor, y menos amputaciones, sobre todo mayores. En 2007no se practicaron simpatectomías lumbares, frecuentes en 1985. Lamortalidad y la estancia media fueron inferiores en 2007, pero sóloun 36% de pacientes tenía una HbA1c <7%, un 24% presentaba PAinferior al objetivo y un 29% cumplía objetivos lipídicos. Conclusiones:Los sujetos ingresados en 2007 presentan menos complicacionesde la diabetes que los de 1985 con el mismo tiempo deevolución. Ya no se realizan simpatectomías lumbares, se han reducidolas amputaciones, sobre todo mayores, y se realiza más cirugíarevascularizadora. En 2007 el grado de control de la diabetes, la PAy los lípidos es subóptimo(AU)

Objectives: To know: 1) The features of patients hospitalised fordiabetic foot in the department of vascular surgery, the years 1985and 2007, surgical procedures used, average stay and mortality.2) Metabolic control and associated cardiovascular risk factors of thesame patients in 2007. Material and methods: Data related todiabetes (type, time evolution, treatment, complications), other riskfactors, surgical procedures, average stay and mortality in the years1985 and 2007, were registered. In 2007 other parameters werealso registered: HbA1c, lipid profile and blood pressure. Results: Atotal of 162 diabetic patients were evaluated (91 in 1985 and 71 in2007). The prevalence of microangiopathic complications, currentsmokers and number of patients treated with insulin were higher in1985. Age, prevalence of hypertension and dyslipidemia were higherin 2007. Sex distribution and diabetes duration were similar. In1985 more amputations were carried out. In 2007 more conservativesurgery associated or not with minor amputation was executed,with less number of amputations (especially major). In 2007, lumbarsympathectomy was not performed, whereas it was frequent in1985. Mortality and average stay were reduced in 2007, but only 36% of subjects presented HbA1c <7%, only 24% presented bloodpressure below goals and only 29% had lipid profile below goals.Conclusions: Patients hospitalised in 1987 had more complicationsof diabetes than those hospitalised in 2007, with the sametime of evolution. Nowadays, lumbar sympathectomy has been abandoned,amputations have been reduced (especially major amputations)and more revascularization surgery is performed. In 2007,control of diabetes, lipids and blood pressure are suboptimal(AU)