Macroprolactinoma clival ectópico: una forma rara de presentación de adenoma hipofisario / Ectopic clival macroprolactinoma: a rare presentation of pituitary adenoma

Los adenomas pituitarios son los tumores hipofisarios más frecuentes siendo una entidad rara cuando se trata de adenomas ectópicos, es decir, sin conexión con la glándula pituitaria. Se cree que derivan de células residuales del tracto de migración embriológico desde la bolsa de Rathke. Su presentación clínica es muy variable porque depende de la producción hormonal y del efecto masa en estructuras adyacentes. Generalmente suponen un reto diagnóstico debido a su baja frecuencia, la clínica variable de presentación y que no presentan características específicas en las pruebas de imagen. Generalmente el diagnóstico se realiza de manera retrospectiva tras la resección quirúrgica. Presentamos el caso de un varón de 56 años que se presentó con unos valores de prolactina de 6647.5 ng/ml (2.2-17.7) con clínica de hipogonadismo aislada que se resolvió con tratamiento médico sin precisar resección quirúrgica, con una disminución de la densidad radiológica y estabilización del tamaño y sin clínica compresiva ni alteración visual.

Pituitary adenomas are the most common hypophyseal tumors being a rare entity when they are ectopic, without connection to the pituitary gland. They are thought to arise from residual cells in the migration tract from Rathke´s pouch. Its clinical presentation is variable depending on the hormonal production and the pressure effect on adjacent structures. They usually are a diagnostic challenge due to their low frequency, wide range of clinical presentation and not showing specific features on imaging techniques. The diagnosis is made usually retrospectively after surgical resection. We report the case of a 56 years old male that presented with a prolactine value of 6647.5 ng/ml (2.2-17.7) and isolated hypogonadism symptoms that resolved with medical treatment without surgery, diminishing the radiological density and stabilizing the size without having compresive symptoms nor visual disturbances.

Utilidad para médicos no radiólogos de la clasificación tirads y las características ecográficas de los nódulos tiroideos / Usefulness for non radiologist physicians of tirad classification and ecographic characteristics of thyroid nodules

Dada la mayor accesibilidad a la ecografía tiroidea, se diagnostican más nódulos de forma incidental aumentando su prevalencia al 65% en las tres últimas décadas. Todo ello ha supuesto un aumento de punciones innecesarias. El objetivo de nuestro estudio es identificar la utilidad de la clasificación TIRADS y de las características ecográficas de los nódulos tiroideos para establecer la probabilidad de malignidad de los mismos y seleccionar aquellos sospechosos para realizar la punción y aspiración con aguja fina (PAAF). Se encontró una relación estadísticamente significativa entre la malignidad y nódulo sólido, hipoecogenicidad, márgenes irregulares y microcalcificaciones. Sin embargo, no se encontró relación estadísticamente significativa entre malignidad y número de nódulos, tamaño nodular, diámetro craneocaudal y vascularización central. Asimismo, un 26.1% de los nódulos TIRADS-2 (todos ellos microcarcinomas), un 30% de los TIRADS-3 y un 54 % de los TIRADS-4 fueron malignos (p 0.027). Tanto el TIRADS como las características ecográficas aisladas son útiles para identificar nódulos sugerentes de malignidad.

Owed to the easier accessibility to thyroid ecography, more incidental nodules are discovered reaching their prevalence the 65 % of population in the last three decades. All of it has resulted in a growth of unnecessary fine needle aspirations (FNA). Our study objective is to identify the TIRADS classification utility and the nodules sonographic characteristics to establish their probability of malignancy and to select those suspicious susceptible of FNA. We found a statistically significant relationship between malignancy and solid nodule, hypoechogenicity, irregular margins and microcalcifications. However we didn´t find a relation between malignancy and number, size, shape (taller than wide) and central vascularity. With respect to TIRADS classification, 26,1% of TIRADS-2 (all of them microcarcinomas), 30% of TIRADS-3 and 54% of TIRADS-4 were malignant (p: 0,027). Both of them, TIRADS and individual sonographic characteristics are useful to identify nodules suspicious of malignancy.

Slightly elevated thyrotropin levels in pregnancy in our clinical practice / Tirotropina discretamente elevada en la gestación en nuestra práctica clínica

Objective: The aim of this study was to assess the incidence of obstetric and neonatal complications in pregnant women with "normal" thyroid-stimulating hormone (TSH) levels in the first trimester (group A) and to compare them with those with "slightly elevated" TSH (SET) levels treated with levothyroxine (group B2) or not treated (group B1). Methods: A total of 2375 women who had been performed laboratory tests in their first trimester of pregnancy were detected at our hospital between April 2015 and August 2017. Of these, 469 patients with SET were prospectively detected and randomized to groups B1 (227) and B2 (242). They were monitored prospectively until 6 months after delivery. Data of the control group (n = 1906, group A) were retrospectively reviewed. A total of 1745 women were analyzed. Variables assessed included demographic and clinical characteristics and complications of pregnancy and delivery. Results: A, B1, and B2 had similar clinical characteristics. There were no statistically significant differences in complications between the three groups during pregnancy, except in that natural deliveries were more common in group A as compared to group B1 (76.8% vs. 68.7%, p 0.017) and group B2 (66.3%), p < 0.002). There were more induced deliveries in groups B1 (35.8%), and B2 (36.2%) than in group A (18.4%), p < 0.01. Although the recommended TSH level was achieved in the second and third trimesters, no benefit could be found of treatment of SET. Conclusion: Although there were less natural deliveries and more induced deliveries in patients with SET, treatment with levothyroxine could not reverse this situation, despite achievement of levels considered appropriate in the second and third trimester

Objetivo: El propósito de este estudio fue investigar la incidencia de complicaciones obstétricas y neonatales en mujeres embarazadas con una tirotropina (TSH) «normal» en el primer trimestre (grupo A) y compararlas con aquellas con una TSH «discretamente elevada» (SET) tratadas con levotiroxina (grupo B2) o no (grupo B1). Métodos: Dos mil trescientos setenta y cinco gestantes con analítica en el primer trimestre fueron detectadas en nuestro hospital entre abril de 2015 y agosto de 2017. Cuatrocientos sesenta y nueve pacientes con SET se detectaron prospectivamente y randomizaron a los grupos B1 (227) y B2 (242). Se siguieron prospectivamente hasta 6 meses posparto. Los datos del grupo control (n = 1.906, grupo A) se revisaron retrospectivamente. Se analizaron 1.745 pacientes. Las variables incluyeron características demográficas, clínicas y complicaciones de la gestación y el parto. Resultados: A, B1 y B2 eran comparables en sus características clínicas. Los partos eutócicos fueron más frecuentes en el grupo A que en el B1 (76,8 vs. 68,7%, p0,017) y B2 (66,3%, p < 0,002). Hubo más partos inducidos en los grupos B1 (35,8%) y B2 (36,2%) que en A (18,4%), p < 0,01. Aunque se alcanzó el nivel de TSH recomendado en el segundo y tercer trimestres, no pudimos encontrar ningún beneficio en el tratamiento de SET. Conclusión: Aunque hemos encontrado menos partos eutócicos y más partos inducidos en las gestantes con SET, el tratamiento con levotiroxina no pudo revertirlo, pese a alcanzar un valor considerado apropiado en el segundo y tercer trimestre

Slightly elevated thyrotropin levels in pregnancy in our clinical practice.

OBJECTIVE: The aim of this study was to assess the incidence of obstetric and neonatal complications in pregnant women with "normal" thyroid-stimulating hormone (TSH) levels in the first trimester (group A) and to compare them with those with "slightly elevated" TSH (SET) levels treated with levothyroxine (group B2) or not treated (group B1). METHODS: A total of 2375 women who had been performed laboratory tests in their first trimester of pregnancy were detected at our hospital between April 2015 and August 2017. Of these, 469 patients with SET were prospectively detected and randomized to groups B1 (227) and B2 (242). They were monitored prospectively until 6 months after delivery. Data of the control group (n=1906, group A) were retrospectively reviewed. A total of 1745 women were analyzed. Variables assessed included demographic and clinical characteristics and complications of pregnancy and delivery. RESULTS: A, B1, and B2 had similar clinical characteristics. There were no statistically significant differences in complications between the three groups during pregnancy, except in that natural deliveries were more common in group A as compared to group B1 (76.8% vs. 68.7%, p 0.017) and group B2 (66.3%), p<0.002). There were more induced deliveries in groups B1 (35.8%), and B2 (36.2%) than in group A (18.4%), p<0.01. Although the recommended TSH level was achieved in the second and third trimesters, no benefit could be found of treatment of SET. CONCLUSION: Although there were less natural deliveries and more induced deliveries in patients with SET, treatment with levothyroxine could not reverse this situation, despite achievement of levels considered appropriate in the second and third trimester.

Glucemia basal en el primer trimestre como acercamiento inicial al diagnóstico de la diabetes en el embarazo / Fasting glucose in the first trimester: An initial approach to diagnosis of gestational diabetes

Objetivos: 1) Determinar si una glucemia basal en el primer trimestre (GBPT) del embarazo ≥ 92 mg/dl anticipa la aparición de complicaciones materno-fetales de diabetes mellitus gestacional (DMG). 2) Valorar si la GBPT puede sustituir al diagnóstico clásico de DMG mediante sobrecarga oral de glucosa (SOG). Métodos: Estudio retrospectivo de 1.425 embarazos con GBPT y test de ÓSullivan (TOS) en el segundo trimestre más SOG según resultado del TOS. Valoración de la sensibilidad y especificidad de la GBPT respecto al diagnóstico clásico de DMG. Relación de las complicaciones materno-fetales con la GBPT en el grupo total y tras excluir a las madres que realizaron tratamiento médico específico de DMG. Resultados: La sensibilidad y la especificidad de la GBPT ≥ 92mg/dl respecto al diagnóstico de DMG en el segundo trimestre, usando los criterios clásicos basados en la SOG de Carpenter y Coustan, fueron respectivamente del 46,4 y el 88,8%. Respecto a las gestantes con GBPT <92 mg/dl, las gestantes con GBPT ≥ 92 mg/dl tienen mayor peso del recién nacido (3.228±86 versus 3.123±31g; p <0,05) y mayor porcentaje de macrosomía (6,9% versus 3,5%; p <0,05). Esta relación se mantuvo tras excluir a las pacientes diagnosticadas y tratadas por DMG (peso: 3.235 ± 98 versus 3.128 ± 31 g; p < 0,05; porcentaje de macrosomía: 7,2% versus 3,4%; p < 0,05). Conclusiones: 1) La GBPT no es un buen sustituto del diagnóstico clásico de DMG en el segundo trimestre. 2) Las gestantes con GBPT ≥ 92 mg/dl, aun sin diagnóstico posterior de DMG, constituyen un grupo de riesgo de macrosomía fetal y podrían beneficiarse de la instauración de tratamiento nutricional y ejercicio físico

Objectives: To establish whether fasting glucose levels in the first trimester (FGFT)of pregnancy ≥ 92 mg/dL (5.1 mmol/L) (FGFT) anticipate the occurrence of maternal-fetal complications of gestational diabetes mellitus. To assess whether FGFT can replace diagnosis of GDM using the classical two-step oral glucose tolerance test (OGTT). Methods: A retrospective study of 1425 pregnancies with FGFT and O'Sullivan Test (OST) and/or OGTT according to OST results in the second trimester. FGFT sensitivity and specificity were assessed as compared to the conventional diagnosis of GDM. The relationship between maternal-fetal complications and FGFT was assessed in the total group and after excluding mothers who received specific medical treatment for GDM. Results: Sensitivity and specificity of FGFT levels ≥ 92mg/dL were 46.4% and 88.8% as compared to diagnosis of GDM using Carpenter and Coustan criteria. In the total group, a statistically significant relationship was found between FGFT levels ≥ 92 mg/dL and newborn weight (3228±86 versus 3123±31g; P<.05), as well as a higher rate of macrosomia (6.9% versus 3.5%; P<.05). This association persisted after excluding patients diagnosed with and treated for GDM (weight: 3235±98 versus 3128±31 g; P<.05; percentage of macrosomia: 7.2% versus 3.4%; P<.05). Conclusions: FGFT is not a good substitute for conventional diagnosis of GDM in the second trimester. Pregnant women with FGFT levels ≥ 92 mg/dL, even with no subsequent diagnosis of GDM, are a risk group for fetal macrosomia and could benefit from dietary measures and physical exercise

Fasting glucose in the first trimester: An initial approach to diagnosis of gestational diabetes. / Glucemia basal en el primer trimestre como acercamiento inicial al diagnóstico de la diabetes en el embarazo.

OBJECTIVES: To establish whether fasting glucose levels in the first trimester (FGFT)of pregnancy ≥ 92 mg/dL (5.1 mmol/L) (FGFT) anticipate the occurrence of maternal-fetal complications of gestational diabetes mellitus. To assess whether FGFT can replace diagnosis of GDM using the classical two-step oral glucose tolerance test (OGTT). METHODS: A retrospective study of 1425 pregnancies with FGFT and O'Sullivan Test (OST) and/or OGTT according to OST results in the second trimester. FGFT sensitivity and specificity were assessed as compared to the conventional diagnosis of GDM. The relationship between maternal-fetal complications and FGFT was assessed in the total group and after excluding mothers who received specific medical treatment for GDM. RESULTS: Sensitivity and specificity of FGFT levels ≥ 92mg/dL were 46.4% and 88.8% as compared to diagnosis of GDM using Carpenter and Coustan criteria. In the total group, a statistically significant relationship was found between FGFT levels ≥ 92 mg/dL and newborn weight (3228±86 versus 3123±31g; P<.05), as well as a higher rate of macrosomia (6.9% versus 3.5%; P<.05). This association persisted after excluding patients diagnosed with and treated for GDM (weight: 3235±98 versus 3128±31 g; P<.05; percentage of macrosomia: 7.2% versus 3.4%; P<.05). CONCLUSIONS: FGFT is not a good substitute for conventional diagnosis of GDM in the second trimester. Pregnant women with FGFT levels ≥ 92 mg/dL, even with no subsequent diagnosis of GDM, are a risk group for fetal macrosomia and could benefit from dietary measures and physical exercise.

Hypoalbuminemia and other prognostic factors of mortality at different time points after ischemic stroke.

OBJECTIVE: The aim of this study was to investigate whether hypoalbuminemia and other risk factors for mortality after stroke have the same or different short (1 month), medium (3 months), long (1 year) or very long term (5 years) prognostic value. SUBJECTS/METHODS: clinical and analytical data from 254 patients admitted to our Hospital with an ischemic stroke and followed up prospectively for 2 years were collected with a prospective standard protocol. Additional data up to 5 years were obtained from Clinical and Laboratory Registries of the Hospital, a mailed questionnaire, a phone call and the Council Registry of Mortality. Risk factors for mortality at different time points were calculated with logistic regression and Cox proportional hazard analyses. RESULTS: The following factors were significantly associated with mortality at one month: cardioembolic mechanism, hypoalbuminemia, glycemia, age, low diastolic arterial pressure and Canadian Scale, at three months: previous stroke and Barthel index at discharge, at one year: previous dementia and Barthel index at three months and at five years: age, Canadian Scale score at discharge and low cholesterol at admission. Cox regression analysis considering survival time showed hypoalbuminemia at admission (hazard ratio (HR) 2; p = 0.03), age (HR 1.06; p < 0.00), previous dementia (HR 2; p < 0.00), cardioembolic mechanism (HR 2; p < 0.00) and severity on the Canadian Neurological Stroke Scale (HR 1.2; p < 0.00) to be independently associated with mortality. CONCLUSION: Mortality after ischemic stroke seems to depend on different factors along time. Hypoalbuminemia at admission is an independent factor for short term (acute) and global mortality. Other risk factors for global mortality were previous dementia, cardioembolic mechanism and severity on the Canadian Neurological Stroke Scale at admittance.

Objetivo: El propósito del estudio era investigar si la hipoalbuminemia y otros factores de riesgo de mortalidad tras un ictus tenían el mismo valor pronóstico tras un ictus a corto (1 mes), medio (3 meses), largo (1 AÑO) o muy largo plazo (5 AÑOs). Métodos: Se estudiaron 254 pacientes ingresados en nuestro hospital con ictus isquémico y seguidos prospectivamente durante dos AÑOs con un procolo estándar de forma prospectiva. Se recogieron datos adicionales hasta 5 AÑOs de las Historias Clínicas, los datos del laboratorio, un cuestionario enviado por correo, una llamada telefónica y la revisión de los Registros de Mortalidad de los ayuntamientos. Los factores de riesgo de mortalidad en cada periodo se calcularon con regresión logistica y el modelo de riesgos proporcionales de Cox. Resultados: Se asociaron de forma significativa con la mortalidad al mes el mecanismo cardioembólico, la hipoalbuminemia, la glucemia al ingreso, la edad, la presión arterial diastólica más baja y la puntuación en la Escala Canadiense. A los tres meses, la existencia de ictus previos y el índice de Barthel al alta. Al AÑO la existencia previa de demencia y el índice de Barthel a los 3 meses y a los cinco AÑOs la edad, la puntuación en la escala Canadiense al alta y un colesterol menor al ingreso. El análisis de regresión de Cox considerando el tiempo de supervivencia, mostró una asociación independiente con la mortalidad de la hipoalbuminemia al ingreso ((HR) 2; p = 0,03), la edad (HR 1,06; p < 0,00), la demencia previa (HR 2; p < 0,00), el mecanismo cardioembólico (HR 2; p < 0,00) y la severidad según la escala Canadiense (HR 1.2; p < 0,00). Conclusión: La mortalidad tras un ictus isquémico parece depender de distintos factores según el tiempo transcurrido.

Hypoalbuminemia and other prognostic factors of mortality at different time points after ischemic stroke / Hipoalbuminemia y otros factores pronósticos de mortalidad en distintos periodos tras una trombosis isquémica

Objective: The aim of this study was to investigate whether hypoalbuminemia and other risk factors for mortality after stroke have the same or different short (1 month), medium (3 months), long (1 year) or very long term (5 years) prognostic value. Subjects/methods: clinical and analytical data from 254 patients admitted to our Hospital with an ischemic stroke and followed up prospectively for 2 years were collected with a prospective standard protocol. Additional data up to 5 years were obtained from Clinical and Laboratory Registries of the Hospital, a mailed questionnaire, a phone call and the Council Registry of Mortality. Risk factors for mortality at different time points were calculated with logistic regression and Cox proportional hazard analyses. Results: The following factors were significantly associated with mortality at one month: cardioembolic mechanism, hypoalbuminemia, glycemia, age, low diastolic arterial pressure and Canadian Scale, at three months: previous stroke and Barthel index at discharge, at one year: previous dementia and Barthel index at three months and at five years: age, Canadian Scale score at discharge and low cholesterol at admission. Cox regression analysis considering survival time showed hypoalbuminemia at admission (hazard ratio (HR) 2; p = 0.03), age (HR 1.06; p < 0.00), previous dementia (HR 2; p < 0.00), cardioembolic mechanism (HR 2; p < 0.00) and severity on the Canadian Neurological Stroke Scale (HR 1.2; p < 0.00) to be independently associated with mortality. Conclusion: Mortality after ischemic stroke seems to depend on different factors along time. Hypoalbuminemia at admission is an independent factor for short term (acute) and global mortality. Other risk factors for global mortality were previous dementia, cardioembolic mechanism and severity on the Canadian Neurological Stroke Scale at admittance (AU)

Objetivo: El propósito del estudio era investigar si la hipoalbuminemia y otros factores de riesgo de mortalidad tras un ictus tenían el mismo valor pronóstico tras un ictus a corto (1 mes), medio (3 meses), largo (1 año) o muy largo plazo (5 años). Métodos: Se estudiaron 254 pacientes ingresados en nuestro hospital con ictus isquémico y seguidos prospectivamente durante dos años con un procolo estándar de forma prospectiva. Se recogieron datos adicionales hasta 5 años de las Historias Clínicas, los datos del laboratorio, un cuestionario enviado por correo, una llamada telefónica y la revisión de los Registros de Mortalidad de los ayuntamientos. Los factores de riesgo de mortalidad en cada periodo se calcularon con regresión logistica y el modelo de riesgos proporcionales de Cox. Resultados: Se asociaron de forma significativa con la mortalidad al mes el mecanismo cardioembólico, la hipoalbuminemia, la glucemia al ingreso, la edad, la presión arterial diastólica más baja y la puntuación en la Escala Canadiense. A los tres meses, la existencia de ictus previos y el índice de Barthel al alta. Al año la existencia previa de demencia y el índice de Barthel a los 3 meses y a los cinco años la edad, la puntuación en la escala Canadiense al alta y un colesterol menor al ingreso. El análisis de regresión de Cox considerando el tiempo de supervivencia, mostró una asociación independiente con la mortalidad de la hipoalbuminemia al ingreso ((HR) 2; p = 0,03), la edad (HR 1,06; p < 0,00), la demencia previa (HR 2; p < 0,00), el mecanismo cardioembólico (HR 2; p < 0,00) y la severidad según la escala Canadiense (HR 1.2; p < 0,00). Conclusión: La mortalidad tras un ictus isquémico parece depender de distintos factores según el tiempo transcurrido (AU)