[Diabetic neuroarthropathy in acute phase: a diagnostic dilemma. Two cases and bibliographic review]. / Neuroartropatía diabética en fase aguda: un dilema diagnóstico. A propósito de dos casos y revisión de la bibliografía.

INTRODUCTION: Charcot's neuroarthropathy is a progressive deterioration of bones and joints, mainly the ankle and foot of the diabetic patients suffering severe neuropathy. Its pathogeny is not well known, although mechanical, vascular and neurological factors are thought to be involved, generally with a precipitating minor traumatic even. Charcot's foot acute phase is inflammatory, and it is often confused with other diseases such as arthritis, cellulitis and deep venous thrombosis (DVT). This leads to delays or errors in the diagnosis, the patient coming to the hospital too late with severe foot deformation. OBJECTIVE: Thus, it must always be posed as differential diagnosis in a diabetic patient who comes with a warm and inflamed foot, generally without fever, even more if he has a severe autonomic or somatic neuropathy. In the acute onset, the only treatment has been complete and long term off-loading with a total contact cast that should be initiated immediately after diagnosis. More recent studies show promising results with biphosphonates to decrease bone turnover in acute phase. CONCLUSION: We present two cases of acute Charcot's foot and we briefly review the bibliography.

Neuroartropatía diabética en fase aguda: un dilema diagnóstico. A propósito de dos casos y revisión de la bibliografía / Diabetic neuroarthropathy in acute phase: a diagnostic dilemma. Two cases and bibliographic review

Introducción. La neuroartropatía de Charcot consiste en un progresivo deterioro de los huesos y articulaciones, principalmente del tobillo y pie, de pacientes diabéticos afectos de una neuropatía grave. Su patogenia no es bien conocida, aunque se consideran implicados factores mecánicos, vasculares y neurológicos, precipitados generalmente por un traumatismo. La fase inflamatoria aguda pasa a menudo inadvertida o se confunde con patologías como artritis, celulitis o trombosis venosa profunda (TVP), lo que determina retraso o errores en el diagnóstico, presentándose el paciente en la consulta ya con deformidad en el pie. Objetivo. Así, ha de plantearse siempre como diagnóstico diferencial ante un paciente diabético que acude con un pie caliente e inflamado habitualmente sin fiebre, sobre una neuropatía grave somática y/o autonómica. En esta fase precoz el único tratamiento que ha demostrado una clara ventaja es la descarga completa y prolongada del pie mediante prótesis que debería iniciarse inmediatamente después del diagnóstico. Estudios más recientes muestran resultados positivos con la administración de bifosfonatos que logran frenar la reacción inflamatoria propia de esta fase aguda. Conclusión. A continuación se describen dos casos de neuroartropatía de Charcot en fase aguda y se realiza una revisión de la bibliografía

Introduction. Charcot's neuroarthropathy is a progressive deterioration of bones and joints, mainly the ankle and foot of the diabetic patients suffering severe neuropathy. Its pathogeny is not well known, although mechanical, vascular and neurological factors are thought to be involved, generally with a precipitating minor traumatic even. Charcot's foot acute phase is inflammatory, and it is often confused with other diseases such as arthritis, cellulitis and deep venous thrombosis (DVT). This leads to delays or errors in the diagnosis, the patient coming to the hospital too late with severe foot deformation. Objective. Thus, it must always be posed as differential diagnosis in a diabetic patient who comes with a warm and inflamed foot, generally without fever, even more if he has a severe autonomic or somatic neuropathy. In the acute onset, the only treatment has been complete and long term off-loading with a total contact cast that should be initiated immediately after diagnosis. More recent studies show promising results with biphosphonates to decrease bone turnover in acute phase

Fundamentos, objetivos del tratamiento, factores pronósticos y criterios de control / Basic principles, treatment objectives, prognostic factors and criteria for control

La acromegalia es una situación clínica que produce una serie de complicaciones y una mortalidad entre 2 y 4 veces superior a la esperada, sobre todo por motivo vascular. El objetivo del tratamiento, desde el punto de vista funcional, es reducir y normalizar la hipersecreción de la hormona de crecimiento (GH) por debajo de 1 ng/ml tras sobrecarga oral de glucosa, así como el control de las concentraciones del factor de crecimiento tipo insulina I (IGF-I). Desde el punto de vista anatómico, hay que extirpar el adenoma que la causa y preservar lo más posible el resto de la función hipofisaria. No están claros los factores pronósticos de curación de la enfermedad, pero los más aceptados son las concentraciones normales de GH e IGF-I tras la intervención quirúrgica. Los criterios de control tras el tratamiento han ido cambiando y se basan en concentraciones cada vez más bajas de GH tras una sobrecarga oral de glucosa, inferior a 0,1 ng/ml e IGF-I normal; no son criterios definitivos, pero la impresión es que estamos llegando a un consenso que será definitivo (AU)

Acromegaly produces a series of complications and a 2- to 3-fold increase in mortality, especially from vascular causes. From the functional point of view, the aim of treatment is to reduce growth hormone (GH) hypersecretion and return GH values to below 1 ng/ml after oral glucose load, as well as to control concentrations of insulin-like growth factor (IGF-1). From the anatomical point of view, the aim is to remove the causative adenoma while preserving the remaining pituitary function as far as possible. Factors predictive of a favorable outcome are not clearly defined but normal GH and IGF-I concentrations after surgery are the most widely accepted. Criteria for hormonal control after treatment have progressively changed and are based on increasingly lower GH values after oral glucose load, lower than 0.1 ng/ml, and normal IGF-I values. These criteria are not conclusive but a definitive consensus may soon be reached (AU)

[Obesity pharmacological treatment]. / Tratamiento farmacológico de la obesidad.

In this clinical observation, we make a small summary of the current state of pharmacological treatment of obesity. The interest in the use of drugs in the treatment of obesity has grown in recent years, upon our knowledge of the biological basis of obesity having increased, and also because non-pharmacological treatments have not succeeded stopping the constant increase of obesity incidence in western countries. Only two drugs are currently approved by the European Agency of the Drug and the FDA (Food and Drug Administration, United States) for the treatment of long-term obesity: sibutramine and orlistat. Pharmacological treatment of obesity should be considered in obese patients (BMI > 30) or overweight (BMI > 27) in presence of comorbidities as diabetes mellitus, hypertension, dyslipemias (7.8); this must not be used as an isolated treatment but together with other basic therapies: diet, physical exercise and psychological support.

Tratamiento farmacológico de la obesidad / Obesity pharmacological treatment

En este comentario clínico hacemos un pequeño resumen del estado actual en el tratamiento farmacológico de la obesidad. El interés por el uso de fármacos en el tratamiento de la obesidad se ha reavivado en los últimos años al haberse incrementado nuestros conocimientos sobre las bases biológicas de la obesidad y también porque los tratamientos no farmacológicos no han conseguido frenar el aumento constante de la incidencia de obesidad en los países occidentales. Actualmente sólo dos fármacos están autorizados por la Agencia Europea del Medicamento y por la FDA (Food and Drug Administration, Estados Unidos) para el tratamiento de la obesidad a largo plazo: sibutramina y orlistat. El tratamiento farmacológico de la obesidad debe ser considerado en pacientes obesos (IMC > 30) o con sobrepeso (> 27) en presencia de comorbilidades como diabetes mellitus, hipertensión arterial, dislipidemias (7,8), no debiéndose utilizar como tratamiento aislado, sino junto a otras terapias básicas: dieta, ejercicio físico y apoyo psicológico

In this clinical observation, we make a small summary of the current state of pharmacological treatment of obesity. The interest in the use of drugs in the treatment of obesity has grown in recent years, upon our knowledge of the biological basis of obesity having increased, and also because non-pharmacological treatments have not succeeded stopping the constant increase of obesity incidence in western countries. Only two drugs are currently approved by the European Agency of the Drug and the FDA (Food and Drug Administration, United States) for the treatment of long-term obesity: sibutramine and orlistat. Pharmacological treatment of obesity should be considered in obese patients (BMI > 30) or overweight (BMI > 27) in presence of comorbidities as diabetes mellitus, hypertension, dyslipemias (7.8); this must not be used as an isolated treatment but together with other basic therapies: diet, physical exercise and psychological support

[F-18-fluordeoxyglucose positron emission tomography on patients with differentiated thyroid cancer who present elevated human serum thyroglobulin levels and negative I-131 whole body scan]. / PET con 18FDG en pacientes con cáncer diferenciado de tiroides que presentan niveles elevados de tiroglobulina sérica y rastreos con 131I negativos.

UNLABELLED: This study aimed to evaluate the role of Fluorine-18-fluorodeoxyglucose positron emission tomography (PET-FDG) in patients with elevated serum thyroglobulin (hTg) levels where thyroid cancer tissue does not concentrate radioiodine, rendering false-negative results on I-131 scanning. MATERIAL AND METHODS: Whole-body PET imaging using FDG was performed in 54 patients (37 female, 17 male) aged 17-88 years: 45 with papillary tumors and 9 with follicular tumors who were suspected of having recurrent thyroid carcinoma due to elevated thyroglobulin levels (hTg > 2 ng/ml) under thyroid-stimulating hormone (TSH > or = 30 microIU/ml) in whom the iodine scan was negative. All whole body scans were obtained with diagnostic doses (185 MBq). Whole body PET imaging was performed in fasting patients following i.v. administration of 370 MBq FDG while the patients were receiving full thyroid hormone replacement. Before PET, 99mTc methoxyisobutylisonitrile scintigraphy (99mTc-MIBI) was done in 14 patients and morphologic imaging in 26 by CT scan. RESULTS: Positive PET results confirmed the presence of hypermetabolic foci in 25/54 patients (46.29 %). Positive findings were found for PET-FDG in patients with hTg levels higher than 10 ng/ml receiving full thyroid hormone replacement. 99mTc-MIBI demonstrated lesions in 7/14 patients (50 %). PET-FDG and 99mTc-MIBI had congruent positive results in 4/7 patients. All the lesions found by CT were detected by PET-FDG, while recurrent disease was found in 12/21 patients with previous negative CT. CONCLUSIONS: These results suggest that PET-FDG seems to be a promising tool in the follow-up of thyroid cancer and should be considered in patients suffering from differentiated thyroid cancer with suspected recurrence and/or metastases by elevated thyroglobulin levels, and negative I-131 whole body scans. PET-FDG might be more useful at hTg levels > 10 ng/ml.

PET con 18FDG en pacientes con cáncer diferenciado de tiroides que presentan niveles elevados de tiroglobulina sérica y rastreos con 131I negativos / F-18-Fluordeoxyglucose positron emission tomography on patients with diferentiated thyroid cancer who present elevated human serum thyroglobulin levels and negative I-131 whole body scan

El objetivo de estudio fue valorar el papel de la tomografía por emisión de positrones con 18F-fluordeoxiglucosa (PET-FDG) en los pacientes con cáncer diferenciado de tiroides, niveles de tiroglobulina sérica (hTg) elevados y rastreo de cuerpo completo con radioyodo negativo (RCC). Material y métodos: Se estudiaron con PET-FDG 54 pacientes (37 mujeres y 17 hombres) con edades comprendidas entre los 17 y los 88 años, 45 con carcinomas papilares y 9 con foliculares de tiroides con sospecha de recurrencia/metástasis de su enfermedad por elevación de los niveles de hTg (hTg > 2 ngr/ml) en presencia de valores estimulantes de la TSH (≥ 30 μIU/ml) y en los que el RCC era negativo. Los RCC se realizaron con dosis diagnósticas (185 MBq). Las PET-FDG se efectuaron tras la administración i.v. en ayunas de 370 MBq de FDG hallándose el paciente bajo su tratamiento hormonal sustitutivo habitual. Previamente a la realización de la PET-FDG, 14 pacientes habían sido estudiados por gammagrafía con 99mTc-metoxi-isobutiril-isonitrilo (MIBI), mientras que a 26 se les había realizado tomografía computerizada (TC). Resultados: Un total de 25 de los 54 PET-FDG mostraron focos patológicos de captación del trazador (46,29 %). Se observó asociación significativa entre la positividad de la PET y los niveles de hTg mayores de 10 ng/ml en el momento de esta exploración (en tratamiento sustitutivo). La gammagrafía con 99mTc-MIBI era positiva en 7 de los 14 pacientes a los que se les realizó, y esta positividad fue congruente con la PET-FDG en 4/7. Todas las lesiones detectadas por la TC fueron visualizadas en la PET-FDG, mientras que 12 de los 21 pacientes con TC negativa tenían evidencia de recurrencia de la enfermedad detectada por la PET-FDG. Conclusiones: Nuestros resultados sugieren que la PET-FDG sería una técnica de gran utilidad en el seguimiento de los pacientes diagnosticados de carcinoma diferenciado de tiroides con niveles de hTg elevados y RCC negativos. Su utilidad sería superior si los valores de hTg fuesen mayores de 10 ng/ml

This study aimed to evaluate the role of Fluorine-18-fluorodeoxyglucose positron emission tomography (PET-FDG) in patients with elevated serum thyroglobulin (hTg) levels where thyroid cancer tissue does not concentrate radioiodine, rendering false-negative results on I-131 scanning. Material and methods: Whole-body PET imaging using FDG was performed in 54 patients (37 female, 17 male) aged 17-88 years: 45 with papillary tumors and 9 with follicular tumors who were suspected of having recurrent thyroid carcinoma due to elevated thyroglobulin levels (hTg > 2 ng/ml) under thyroid-stimulating hormone (TSH ≥ 30 μIU/ml) in whom the iodine scan was negative. All whole body scans were obtained with diagnostic doses (185 MBq). Whole body PET imaging was performed in fasting patients following i.v. administration of 370 MBq FDG while the patients were receiving full thyroid hormone replacement. Before PET, 99mTc methoxyisobutylisonitrile scintigraphy (99mTc-MIBI) was done in 14 patients and morphologic imaging in 26 by CT scan. Results: Positive PET results confirmed the presence of hypermetabolic foci in 25/54 patients (46.29 %). Positive findings were found for PET-FDG in patients with hTg levels higher than 10 ng/ml receiving full thyroid hormone replacement. 99mTc-MIBI demonstrated lesions in 7/14 patients (50 %). PET-FDG and 99mTc-MIBI had congruent positive results in 4/7 patients. All the lesions found by CT were detected by PET-FDG, while recurrent disease was found in 12/21 patients with previous negative CT. Conclusions: These results suggest that PET-FDG seems to be a promising tool in the follow-up of thyroid cancer and should be considered in patients suffering from differentiated thyroid cancer with suspected recurrence and/or metastases by elevated thyroglobulin levels, and negative I-131 whole body scans. PET-FDG might be more useful at hTg levels > 10 ng/mlThis study aimed to evaluate the role of Fluorine-18-fluorodeoxyglucose positron emission tomography (PET-FDG) in patients with elevated serum thyroglobulin (hTg) levels where thyroid cancer tissue does not concentrate radioiodine, rendering false-negative results on I-131 scanning. Material and methods: Whole-body PET imaging using FDG was performed in 54 patients (37 female, 17 male) aged 17-88 years: 45 with papillary tumors and 9 with follicular tumors who were suspected of having recurrent thyroid carcinoma due to elevated thyroglobulin levels (hTg > 2 ng/ml) under thyroid-stimulating hormone (TSH ≥ 30 μIU/ml) in whom the iodine scan was negative. All whole body scans were obtained with diagnostic doses (185 MBq). Whole body PET imaging was performed in fasting patients following i.v. administration of 370 MBq FDG while the patients were receiving full thyroid hormone replacement. Before PET, 99mTc methoxyisobutylisonitrile scintigraphy (99mTc-MIBI) was done in 14 patients and morphologic imaging in 26 by CT scan. Results: Positive PET results confirmed the presence of hypermetabolic foci in 25/54 patients (46.29 %). Positive findings were found for PET-FDG in patients with hTg levels higher than 10 ng/ml receiving full thyroid hormone replacement. 99mTc-MIBI demonstrated lesions in 7/14 patients (50 %). PET-FDG and 99mTc-MIBI had congruent positive results in 4/7 patients. All the lesions found by CT were detected by PET-FDG, while recurrent disease was found in 12/21 patients with previous negative CT. Conclusions: These results suggest that PET-FDG seems to be a promising tool in the follow-up of thyroid cancer and should be considered in patients suffering from differentiated thyroid cancer with suspected recurrence and/or metastases by elevated thyroglobulin levels, and negative I-131 whole body scans. PET-FDG might be more useful at hTg levels > 10 ng/ml

Primary hyperparathyroidism in pregnancy.

Gestational primary hyperparathyroidism presents with features which, from a physiological and prognostic viewpoint, entail great difficulty in diagnosis and a high risk of complications. These complications occur at rates of 67% and 80% in the mother and fetus, respectively, and can be reduced by up to four times by means of prompt application of effective therapeutic measures. We report a case involving a pregnant woman in the 16th week of gestation who presented with asymptomatic hypercalcemia secondary to a solitary parathyroid adenoma. When the patient did not improve after conservative therapeutic measures, it was decided to employ surgical treatment in the second trimester of pregnancy. The surgery was successful, and the follow-up period was without complications for the mother and neonate. We therefore agree with the growing evidence that surgery in the second trimester of pregnancy constitutes a safe and effective alternative to conservative treatment.

Carbohidratos. Consideraciones nutricionales en el tratamiento de la diabetes mellitus. Estado actual del conocimiento / No disponible

No disponible

Luces y sombras de la cirugía de la obesidad / Pros and cons of bariatric surgery

No disponible

[Recombinant human thyrotropin in the follow-up of patients with differentiated thyroid carcinoma]. / La TSH humana recombinante en el seguimiento de pacientes con cáncer diferenciado de tiroides.

PURPOSE: To determine the value of the use of radio-iodine scanning diagnostic and radio-iodine therapy during the follow-up of advanced differentiated thyroid cancer without stopping thyroid hormone suppression therapy. MATERIAL AND METHODS: We performed 7 radio-iodine scans and 4 radioiodine therapies in 5 men and 1 woman, aged 39 to 79 years. Five patients had papillary thyroid cancer and one follicular thyroid cancer. Human recombinant thyrotropin was given intramuscularly at a dose of 0.9 mg/ml once a day for two days. Twenty-four hours after the second dose, serum thyrotropin, thyroglobulin (Tg) and thyroglobulin autoantibodies were measured and each patient was given 2 mCi of 131I in postsurgery scans and 5 mCi of 131I in patients previously treated with 131I. Whole-body scans were obtained within 54 hours of injection and in the cases of diagnostic uncertainty a second scan was performed 72 hours after the injection. RESULTS: Four scans were positive and two were negative. One positive scan patient was not treated due to a serious clinical condition. An effective increase of serum TSH was observed in all 6 patients. Four patients had an effective increase of serum Tg; the other 2 cases had a decrease of serum Tg: One case was undifferentiated and in the other case the mass was smaller after surgery. CONCLUSIONS: rhTSH is an effective means of stimulating TSH levels and allowing scan and/or radioiodine treatment. rhTSH has no significant adverse effects. The use of rhTSH avoids all the disadvantages of hypothyroidism and maintains quality of life.

La TSH humana recombinante en el seguimiento de pacientes con cáncer diferenciado de tiroides / Recombinant human thyrotropin in the follow-up of patients with differentiated thyroid carcinoma

Objetivo: Estimar el valor del uso de TSH humana recombinante (rhTSH), para el rastreo y tratamiento con I 131 en pacientes con CDT avanzado, en los que se desaconseja la interrupción de toma exógena de hormonas tiroideas.Material y métodos: Se realizan 7 rastreos y 4 tratamientos con I 131, en cinco hombres y una mujer, edad de 39 a 79 años.5 con carcinoma papilar de tiroides y 1 con carcinoma folicular.Pauta de administración de rhTSH: dos inyecciones intramusculares de 0,9 mg/ml, separadas 24 horas, a las 24 horas de la segunda inyección se determina en suero TSH, Tg y AbTg y se administra dosis trazadora de I131 (2 mCi en rastreos postcirugía y 5 mCi en pacientes ya tratados con I131); realizando a las 54 horas en todos los pacientes, y a las 72 horas en caso de duda diagnóstica, rastreo de cuerpo completo e imágenes estáticas de áreas de interés, en una gammacámara de un detector, con colimador de alta energía.Resultados: 4 rastreos positivos ( +) y 2 negativos (-). Hubo 1 rastreo positivo que no recibió tratamiento por situación clínica grave. En los 6 pacientes se elevó eficazmente la TSH, la Tg lo hizo en 4. En los 2 restantes la menor producción a la esperada de Tg tras el estímulo con rhTSH se explica por desdiferenciación del tumor y por disminución de la masa tumoral tras intervención quirúrgica.Conclusiones: La rhTSH eleva eficazmente la TSH, permitiendo el rastreo y/o el tratamiento con I131. Es bien tolerada y no presenta efectos adversos significativos. Evita las molestias de la situación de hipotiroidismo en pacientes de riesgo, manteniendo su calidad de vida (AU)

Resolución de seudoquiste pancreático tras Pancreatitis aguda grave con nutrición enteral continua en el yeyuno / Resolution of pancreatic pseudocysts after acute Pancreatitis with continuous jejunal feeding

Presentamos un caso de Pancreatitis aguda de etiología enólica complicada con seudoquiste pancreático, que evolucionó favorablemente con nutrición enteral con fórmula monomérica administrada a través de sonda nasoyeyunal. Se discuten las indicaciones de soporte nutricional, las vías de administración de la nutrición (nutrición enteral frente a nutrición parenteral), el lugar de infusión y el tipo de fórmula de la nutrición enteral en la Pancreatitis aguda complicada (AU)

Pheochromocytoma in a pregnant woman with multiple endocrine neoplasia type 2a.

Pheochromocytoma is a rare cause of hypertension. Its coexistence with pregnancy is exceptional and laparoscopic removal has rarely been reported. We describe the case of a 34-year-old woman with multiple endocrine neoplasia type 2a (MEN 2a) with adrenal pheochromocytoma diagnosed in the 6th week of pregnancy. After pretreatment with phenoxybenzamine, a successful transperitoneal laparoscopic adrenalectomy was performed in the twentieth week of gestation. The management of pheochromocytoma in pregnancy and the indications for laparoscopic surgery in pregnant patients are discussed.

In vitro short-term effects of SMS 201-995, bromocriptine and TRH on growth hormone cell morphology from human pituitary adenomas.

This study reports, by immunocytochemistry, ultrastructure and morphometry, the in vitro effects of SMS 201-995 (10 nM), bromocriptine (1 microM) and TRH (10 microM) on the morphology of cells from two acromegalic patient adenomas containing immunoreactive growth hormone (GH). By electron microscopy, one tumor presented numerous large secretory granules (densely granulated growth hormone cell adenoma) while they were scarce and small in the other (sparsely granulated growth hormone cell adenoma); fibrous bodies could be seen in the specimen and in vitro. In the sparsely granulated growth hormone cell adenoma, TRH produced an increase in endoplasmic reticulum surface density compared to the other cultures. Bromocriptine increased the number and decreased the secretory granule diameters, while SMS 201-995 produced no significant changes in the same time. In the densely granulated growth hormone cell adenoma, the three substances increased the number of granules. TRH increased the mitochondrial volume density and endoplasmic reticulum surface density (with respect to the other cultures). SMS 201-995 decreased the mitochondrial and lysosome volume densities and endoplasmic reticulum surface density. We conclude that 1) TRH produces in cultured cells of both adenoma types an increase in cellular activity. 2) In cultured sparsely granulated growth hormone adenoma cells, bromocriptine has a stronger inhibitory effect than SMS 201-995. In cultured densely granulated growth hormone cells adenoma, bromocriptine has smaller inhibitory effect than SMS 201-995.