Parálisis periódica tirotóxica: complicación inusual de una enfermedad frecuente / Thyrotoxic periodic paralysis: un uncommon complication of a common disease

La parálisis periódica tirotóxica es una entidad infrecuente incluida en el grupo de las parálisis periódicas hipopotasémicas. La mayoría de los casos descritos en la bibliografía corresponden a pacientes de raza oriental, y es excepcional la aparición en nuestro medio. Presentamos un caso de un varón de raza blanca de 27 años de edad, con diagnóstico reciente de hipertiroidismo por enfermedad de Graves-Basedow. Revisamos los hallazgos clínicos y de laboratorio, los factores desencadenantes, la fisiopatología y el tratamiento de esta rara complicación del hipertiroidismo (AU)

Thyrotoxic periodic paralysis is an uncommon disorder included in the group of hypokalemic periodic paralyses. Most of the cases described in the literature have occurred in Asian patients and it is extremely rare in our environment. We report a case of thyrotoxic periodic paralysis in a 27-year-old white man with a recent diagnosis of hyperthyroidism due to Graves' disease. We review the clinical and biochemical features, the precipitating factors, the pathophysiology and the treatment of this rare complication of hyperthyroidism (AU)

Child-onset growth hormone deficiency in adulthood. Transfer of patients from pediatric to adult endocrinology units.

Treatment with growth hormone (GH) in adult-onset GH deficiency (AO-GHD) reverses its many metabolic alterations, modifying body composition, bone mass, several cardiovascular risk factors, and improving quality of life. In adult patients with a previous diagnosis of child-onset GH deficiency (CO-GHD), the lack of treatment also produces similar alterations, reversed by GH treatment. In patients with multiple pituitary hormone deficiency, the lack of GH is considered definitive, but in isolated GHD, the need for re-evaluation of the deficit is mandatory. The 'gold standard' test is insulin-induced hypoglycemia, after a wash-out period, and the criterion for GH therapy should be a GH (polyclonal-RIA assay) response less than 3 ng/ml. The initial recommended GH dose is lover than in children, and the dosage must be adjusted to maintain IGF-I levels in the normal range. We propose that decisions about patient recruitment, assessment, confirmation or reevaluation, information about new perspectives, disadvantages and benefits of GH therapy, and the beginning of treatment should be made in cooperation by pediatric and adult endocrinologists, so the patient receives all information from both medical teams, before being transferred to the adult endocrinology department.

Metabolismo en el ayuno / Fasting metabolism

El ayuno es la situación metabólica existente por la mañana después de una noche sin comer. Ante la falta de ingreso de nutrientes, el organismo pone en marcha unos mecanismos conducentes a la producción de sustratos energéticos que aseguren el metabolismo cerebral y otros órganos vitales, y disminuye simultáneamente el consumo periférico, con el objetivo teleológico de la supervivencia. Si el ayuno se prolonga en el tiempo, los procesos metabólicos van cambiando en sus características cualitativas y cuantitativas, de manera que se modifican los productos energéticos consumidos (glucosa, ácidos grasos libres y cuerpos cetónicos), disminuye globalmente su oxidación y tras la depleción inicial de glucógeno hepático y muscular y el catabolismo proteínico, la fuente principal de glucosa es el hígado mediante la gluconeogénesis. Los sustratos provienen inicialmente del catabolismo proteínico y la lipólisis, pero más adelante la destrucción proteínica se ralentiza, maximizándose la lipólisis. En los últimos años se han producido avances en el conocimiento de los mecanismos implicados. Así, se conoce mejor el umbral de glucemia necesario para comenzar la cascada de eventos. Pero, sobre todo, el descubrimiento de la leptina, la implicación del neuropéptido Y, los amplios y diversos cambios hormonales, así como sus repercusiones sobre variados aspectos del metabolismo, están ayudando a comprender los mecanismos íntimos del ayuno (AU)

Deficiencia de GH, de origen infantil, en la edad adulta (COGHD). Transferencia de los pacientes desde endocrinología pediátrica a endocrinología de adultos / No disponible

No disponible

Adrenal failure due to metastasis both to the hypothalamic-pituitary area and the adrenals.

A 61-year-old white male was admitted to our hospital with a big-cell bronchogenic carcinoma whose first clinical manifestation was diabetes insipidus (DI) secondary to metastasis to the hypothalamic-pituitary area (MHP). In three months, and progressively, he developed anterior pituitary failure, as well as primary adrenal insufficiency (PAI) due to metastasis in both adrenals. Panhypopituitarism or PAI due to both MHP and adrenals has been rarely reported in the literature. A thorough examination of the oncologic patient led us to diagnose hormone insufficiency properly. The absence of reported cases might be due to the fact that the symptoms resulting from hormone insufficiency are veiled by the severe condition of the patients suffering from disseminated cancer.

[Nutritional status and plasma amino acid levels in hemodialysis]. / Estado nutricional y niveles plasmáticos de aminoácidos en hemodiálisis.

The objective of this work is to study the relation between the variations of the plasmatic aminogram, and the nutritional state of the patient with chronic kidney failure on hemodialysis. We studied 79 patients with chronic kidney failure undergoing hemodialysis treatment, with and evolution of 46 +/- 37 months. They were subjected to a dietary questionnaire, and anthropometric study after dialysis (body mass index, triceps skin fold, muscular circumference of the arm), and determination of the levels of serum amino acids after a pre-dialysis nocturnal fast half way through the week, and finally a record is made of the number of times each patient was hospitalized in the 6 months prior to the study. In the amino acids with a pyruvate origin, there is a significant reduction of alanine (p: 0.002), serine (p: 0.004), and methionine (p: 0.001), and a significant increase of glycine, cystathionine, and cystine (p: 0.0001), with the Glycine/Serine coefficient being elevated (p: 0.001). All amino acids with a ketoglutarate origin are increased significantly (p < 0.007), except glutamine which is decreased (p: 0.0009), and arginine which does not show any significant differences. The essential amino acids are decreased in relation to the non-essential ones (p: 0.0001), although if they are compared with the normal values, only threonine is decreased (p: 0.001). Of the rest, histidine, isoleucine (p: 0.0001) and phenylalanine (p: 0.001) are significantly increased. The tyrosine/phenylalanine coefficient is decreased (p: 0.001). The daily ingestion of protein is correlated negatively with alanine, proline, hydroxyproline, and aspartic acid. The anthropometric parameters are correlated positively with the branched amino acids, alanine and proline. Finally, the number of hospital admissions in the last 6 months, is correlated positively with valine, leucine, phenylalanine, and glutamic acid. In conclusion, we consider that the increase of the glycine/serine, phenylalanine/serine and non essential/essential coefficients, is related to alterations of the metabolism, intrinsic to the condition of uremia, while the alterations of the levels of branched amino acids is related to the nutritional condition of the patients.

[Flocculation of NPH insulin]. / Floculación de la insulina NPH.

In the past decade, human insulins have been substituting animal insulins, offering the advantage of its lesser antigenic capacity. One of the most clinically important problems with human NPH insulins is its tendency to flocculate. We present four diabetic patients who, after using flocculated human NPH insulin, encountered a deterioration in the metabolic control of their diabetes, and in two of them, there were bouts of diabetic Ketoacidosis "without any other apparent causal factors". Among those causes favoring flocculation are movement during transport, high temperatures, and probably leaving the vial open for an excessively long period of time, as with the extraction of multiple doses. Physicians, educators, diabetics, and their relatives should be informed of this phenomenon. Diabetics, especially those who carry insulin with them, should carefully inspect their vials before each injection to detect signs of flocculation.

[Metabolic improvement of diabetes mellitus through pamphlets on the norms of self-monitoring control measures]. / Mejoría metabólica de la diabetes mellitus mediante el seguimiento de normas escritas de autocontrol.

OBJECTIVE: To assess whether giving a leaflet containing norms of self-control to diabetics receiving insulin treatment results in a metabolic improvement. The HbA1c was established prior and subsequent to giving out the leaflet. The written norms contained in the leaflet were highlighted from the wider range of instructions obtained from diabetes education. DESIGN: A longitudinal intervention study with no random allocation. SETTING: Hospital care in a specialised Endocrinology clinic. PATIENTS AND OTHER PARTICIPANTS: 122 types 1 and 2 diabetics, treated with various insulin diets, who had received prior diabetes education and carried out blood self-controls. Cases of meta-diabetic syndrome, serious illnesses and those without apparent hypoglycaemia symptoms were excluded. INTERVENTIONS: Giving out of a leaflet with written norms of self-control. MEASUREMENTS AND MAIN RESULTS: The averages, standard deviations and 95% confidence intervals of the basal HbA1c and of those at four-monthly check-ups were calculated. Basal 8.07 (CI 7.75 - 8.39); 4th month 6.88 (CI 6.74 - 7.17); 8th month 6.59 CI 6.29 - 6.90); 12th month 6.60 (CI 6.23 - 6.94); 16th month 6.06 (CI 5.63 - 6.49); 20th month 5.40 (CI 3.04 - 7.75). Averages were compared by the Student T test and all values had p < 0.005 against the basal. CONCLUSIONS: Following the written norms produced a clear metabolic improvement, represented by the significant fall of HbA1c. Therefore, though without ignoring the overall context of treatment and diabetes education, it is proposed that the relationship of the most practical features of insulin dosing to written norms of self-control should be emphasised.

[Does goiter constitute basically a surgical process?]. / Constituye el bocio un proceso fundamentalmente quirúrgico?

Goiter is usually a clinical manifestation present almost in all the thyroid processes. The over-simple idea of a thyroid tumoration demanding surgical resection is, unfortunately, deeply implanted in many medical and, above all, surgical environments. We tried to estimate the incidence of goiter in a series of thyroid processes and how many of them required surgery. We reviewed the surgical indications in several thyroid entities. In a series of 377 thyroidopathies, goiter was present in 345 (91.5%), 50 of which underwent surgery (12.26% of the total and 14.49 of goiters). Some of the patients were operated in other hospitals without adjusting to the aforementioned criteria and, in theory, just 36 of then should had undergone surgery (9.54% of the total and 10.43% of goiters). In conclusion, surgery has a very secondary role in the treatment of goiter.