Celiac disease and primary hyperparathyroidism.

OBJECTIVE: Primary hyperparathyroidism (PHPT) and celiac disease (CD) are two distinct medical conditions that can affect bone health. While PHPT leads to excessive calcium levels and bone abnormalities, CD impairs calcium and vitamin D absorption due to small intestine damage. CASE REPORT: We present a case of a 49-year-old woman diagnosed with osteoporosis who was found to have both PHPT and CD. The patient underwent a successful minimally invasive parathyroidectomy, which resulted in decreased parathyroid hormone levels. CONCLUSION: This case highlights the rare coexistence of PHPT and CD and emphasizes the importance of considering secondary causes of osteoporosis in patients with low bone mass. Further studies are needed to explore the underlying mechanisms and potential links between PHPT and CD.

Papillary thyroid carcinoma with desmoid fibromatosis: a case report and review of literature.

Desmoid-type fibromatosis (DF) is a rare monoclonal, fibroblastic proliferation characterized by an unpredictable and variable clinical course. We present the case of a 56-year-old woman who underwent total thyroidectomy for papillary thyroid carcinoma in 2012 and who developed a cervical mass at the left laterocervical level during follow-up, raising the diagnosis of tumor recurrence. Computed tomography of the neck showed solid formations with heterogeneous contrast uptake in the right lateral region of the neck. At the level of the thoracic operculum, a second 26-mm formation was observed that medially contacted the left lateral wall of the trachea. Lateral lymphadenectomy was performed, which was incomplete. Histology showed findings consistent with desmoid-type fibromatosis. DF are slowly proliferating, non-metastatic tumors with a highly invasive capacity that are usually present in familial adenomatous polyposis (FAP)-Gardner syndrome. Our case had a history of massive colonic polyposis and first-degree relatives of colorectal cancer.

La fibromatosis de tipo desmoide (FD) es una rara proliferación fibroblástica monoclonal caracterizada por un curso clínico impredecible y variable. Presentamos el caso de una mujer de 56 años intervenida de tiroidectomía total por carcinoma papilar de tiroides en 2012 y que durante el seguimiento desarrolla una masa cervical a nivel laterocervical izquierdo, planteando el diagnóstico de recidiva tumoral. La tomografía computarizada de cuello demostró formaciones sólidas con captación heterogénea de contraste en la región lateral derecha del cuello. A nivel del opérculo torácico se observó una segunda formación de 26 mm que contactaba medialmente con la pared lateral izquierda de la tráquea. Se realizó una linfadenectomía lateral, que resultó incompleta. La histología mostró hallazgos compatibles con FD. La FD son tumores de proliferación lenta, no metastásicos y con una capacidad altamente invasiva que suelen estar presentes en la poliposis adenomatosa familiar (PAF)-síndrome de Gardner. Nuestro caso tenía antecedentes de poliposis colónica masiva y familiares de primer grado de cáncer colorrectal.

Bone effects of epidural and intra-articular glucocorticoids: a systematic literature review / Efectos óseos de los glucocorticoides epidurales e intraarticulares: revisión sistemática de la literatura

Osteoporosis and vertebral and non-vertebral fractures are common in glucocorticoids (GC) treated patients. Oral GC treatment leads to bone loss, particularly of trabecular bone. The benefits of GC used in rheumatological and traumatological disorders are known but they would have possible negative effects on bone. This systematic review aimed to evaluate the effects of epidural steroid injections (ESI), and intra-articular and intramuscular GC administration on bone mineral density (BMD) and fragility fractures. A systematic review of Medline/PubMed, Cochrane, and LILACS up to November 2020 was conducted. Meta-analyses, systematic reviews, randomized and non-randomized controlled trials, and prospective and retrospective studies comparing the effect of ESI, intra-articular or intramuscular GC used compared to a control group or baseline measurements were included. Results: A total of 8272 individuals were included among the 13 selected articles (10 about ESI and 3 about intra-articular GC; no article was found evaluating intramuscular GC). Only a few studies showed a negative effect of ESI on bone in the qualitative analysis considering osteopenia and osteoporosis in lumbar spine, femoral neck and total hip and BMD as surrogate outcomes. On the other hand, the qualitative analysis showed that most studies found an increased risk of fragility fracture. However, only two studies could be included in the quantitative analysis, in which there were no differences between patients exposed to ESI versus controls in all evaluated regions. In conclusion, there was insufficient evidence to suggest that ESI and intra-articular GC, unlike oral GC, negatively affect bone mass. Longitudinal studies are needed to obtain more knowledge regarding the effect of ESI or intra-articular GC on BMD and fragility fractures. (AU)

La osteoporosis y las fracturas vertebrales y no vertebrales son comunes en pacientes tratados con glucocorticoides (GC). El tratamiento oral con GC conduce a la pérdida ósea, particularmente del hueso trabecular. Los beneficios de los GC utilizados en patologías reumatológicas y traumatológicas son conocidos, pero tendrían posibles efectos negativos sobre el hueso. Esta revisión sistemática tuvo como objetivo evaluar los efectos de las inyecciones epidurales de esteroides (ESI), GC intraarticulares e intramusculares sobre la densidad mineral ósea (DMO) y las fracturas por fragilidad. Se realizó una revisión sistemática de Medline/PubMed, Cochrane y LILACS hasta noviembre de 2020. Se incluyeron metanálisis, revisiones sistemáticas, ensayos controlados aleatorizados y no aleatorizados, estudios prospectivos y retrospectivos que compararon el efecto de ESI, GC intraarticular o intramuscular utilizado en comparación con un grupo de control o mediciones iniciales. Resultados: Se incluyeron un total de 8272 individuos entre los 13 artículos seleccionados (10 sobre ESI y 3 sobre GC intraarticular; no se encontró ningún artículo que evaluara GC intramuscular). Solo unos pocos estudios mostraron un efecto negativo del ESI sobre el hueso en el análisis cualitativo considerando la osteopenia y la osteoporosis en la columna lumbar, el cuello femoral y la cadera total y la DMO como un resultado indirecto. Por otro lado, el análisis cualitativo mostró que la mayoría de los estudios encontraron un mayor riesgo de fractura por fragilidad. Sin embargo, solo dos estudios pudieron incluirse en el análisis cuantitativo, en los que no hubo diferencias entre los pacientes expuestos a ESI versus los controles en todas las regiones evaluadas. En conclusión, no hallamos datos suficientes para sugerir que la ESI y los GC intraarticulares, a diferencia de los GC orales, afectan negativamente a la pérdida ósea. Se necesitan estudios longitudinales para obtener más conocimiento sobre el efecto de ESI o GC intraarticular en la DMO y las fracturas por fragilidad. (AU)

[Insufficient elevation of TSH before therapy with I131 in a patient with metastatic differentiated thyroid carcinoma] / Elevación insuficiente de TSH antes de la terapia con I131 en paciente con carcinoma diferenciado de tiroides metastásico.

Guidelines suggest a thyrotropin (TSH) stimulation level ≥30 mIU/l for the administration of 131-iodine (I131) in patients with differentiated thyroid carcinoma (DTC). We present a patient with follicular thyroid carcinoma (FTC), with spinal metastasis as the initial manifestation, who after 6 weeks without levothyroxine did not present an elevation of ≥30 mIU/l of TSH. This situation was interpreted as secondary to the presence of functioning metastases and it was decided, regardless of the TSH level, to administer a therapeutic dose of I131, with iodine-uptake lesions in the liver and spine being confirmed.

Las guías sugieren un nivel de estimulación de tirotrofina (TSH) ≥30 mUI/l para la administración de yodo 131 (I131) en pacientes con carcinoma diferenciado de tiroides (CDT). Presentamos una paciente con carcinoma folicular de tiroides (CFT), con metástasis vertebral como manifestación inicial, que tras 6 semanas sin levotiroxina no presentó una elevación ≥30 mUI/l de TSH. Esta situación fue interpretada como secundaria a la presencia de metástasis funcionantes y se decidió, independientemente del valor de TSH, la administración de una dosis terapéutica de I131 constatándose lesiones captantes de I131 en hígado y columna vertebral.

Threshold based on bone mineral density for therapeutic decision-making in postmenopausal women and men over 50 years old under glucocorticoid therapy.

INTRODUCTION AND AIM: T-score bone mineral density (BMD) thresholds may influence guidance for treatment in patients under glucocorticoid (GC) therapy. Different BMD thresholds have been described but there is no international consensus. The aim of this study was to find a threshold to help in treatment decision-making in the population under GC therapy. METHODS: A working group representing three scientific societies from Argentina was convened. The first team was formed by specialists with expertise in glucocorticoid-induced osteoporosis (GIO) who voted according to summary of evidence. The second team was constituted by a methodology group who coordinated and supervised each stage. We conducted two systematic reviews to synthesize the evidence. The first included trials of drugs used in GIO to analyze the BMD cut-off used as inclusion criteria. In the second, we analyzed the evidence regarding the densitometric thresholds to discriminate between fractured and non-fractured patients under GC treatment. RESULTS: In the first review, 31 articles were included for qualitative synthesis and more than 90% of the trials included patients regardless of their densitometric T-score or range of osteopenia. In the second review, 4 articles were included and more than 80% of the T-scores were in the range -1.6 to -2.0. The summary of findings was analyzed and put to a vote. CONCLUSIONS: With more than 80% agreement of the voting expert panel, a T-score≤-1.7 was considered the most appropriate for treatment in postmenopausal women and men over 50 years of age under GC therapy. This study could help in treatment decision-making in patients under GC therapy without fractures but other fracture risk factors should certainly be considered.

Threshold based on bone mineral density for therapeutic decision-making in postmenopausal women and men over 50 years old under glucocorticoid therapy / Umbral densitométrico de densidad mineral ósea para considerar tratamiento en pacientes mujeres posmenopáusicas y hombres mayores de 50 años en tratamiento con glucocorticoids

Introduction and aim: T-score bone mineral density (BMD) thresholds may influence guidance for treatment in patients under glucocorticoid (GC) therapy. Different BMD thresholds have been described but there is no international consensus. The aim of this study was to find a threshold to help in treatment decision-making in the population under GC therapy. Methods: A working group representing three scientific societies from Argentina was convened. The first team was formed by specialists with expertise in glucocorticoid-induced osteoporosis (GIO) who voted according to summary of evidence. The second team was constituted by a methodology group who coordinated and supervised each stage. We conducted two systematic reviews to synthesize the evidence. The first included trials of drugs used in GIO to analyze the BMD cut-off used as inclusion criteria. In the second, we analyzed the evidence regarding the densitometric thresholds to discriminate between fractured and non-fractured patients under GC treatment. Results: In the first review, 31 articles were included for qualitative synthesis and more than 90% of the trials included patients regardless of their densitometric T-score or range of osteopenia. In the second review, 4 articles were included and more than 80% of the T-scores were in the range −1.6 to −2.0. The summary of findings was analyzed and put to a vote. Conclusions: With more than 80% agreement of the voting expert panel, a T-score≤−1.7 was considered the most appropriate for treatment in postmenopausal women and men over 50 years of age under GC therapy. This study could help in treatment decision-making in patients under GC therapy without fractures but other fracture risk factors should certainly be considered.(AU)

Introducción y objetivo: Los umbrales del T-score de densidad mineral ósea (DMO) podrían influir en el tratamiento de pacientes bajo terapia con glucocorticoides (GC). Se han descrito diferentes umbrales, pero no existe un consenso internacional. El objetivo de este trabajo fue encontrar un umbral que ayude en la decisión terapéutica en la población bajo tratamiento con GC. Métodos: Se convocó un grupo de trabajo en representación de tres sociedades científicas de Argentina. El primer equipo estuvo formado por especialistas con experiencia en osteoporosis inducida por glucocorticoides (OIG), quienes estuvieron a cargo de la votación basada en la evidencia. El segundo equipo estuvo a cargo de la metodología coordinando y supervisando cada etapa. Realizamos dos revisiones sistemáticas: la primera incluyó ensayos de fármacos utilizados en OIG para analizar el T-score considerado como criterio de inclusión. En la segunda, analizamos la evidencia sobre umbrales densitométricos para la discriminación de pacientes fracturados y no fracturados bajo tratamiento con GC. Resultados: En la primera revisión se incluyeron 31 artículos donde se halló que más de 90% de los ensayos incluyeron pacientes independientemente del T-score o en el rango de osteopenia. En la segunda revisión se incluyeron cuatro artículos donde observamos que más de 80% de los valores de T-score se encontraban entre -1,6 y -2,0. Conclusiones: Con un acuerdo superior a 80% del panel de expertos, un T-score ≤ -1,7 se consideró el más adecuado para el tratamiento en mujeres posmenopáusicas y hombres mayores de 50 años bajo tratamiento con GC. Este estudio podría ayudar en la decisión terapéutica en pacientes bajo tratamiento con GC sin fracturas, pero ciertamente deberían considerarse otros factores de riesgos de fracturas complementarios.(AU)

Optimal levothyroxine dose to achieve euthyroidism in patients with primary hypothyroidism: analysis according to etiology.

INTRODUCTION: Levothyroxine (LT4) has been considered the standard of care for treatment of hypothyroidism. Current recommendations suggest a LT4 dose between 1.6-1.8 µg/kg/day. The aim of this study was to evaluate the LT4 dose for adult patients with primary hypothyroidism of different etiologies who reached euthyroidism. METHODS: A cross-sectional study was performed from the retrospective review of the charts of patients with primary hypothyroidism in treatment with LT4. Subjects were classified according to TSH level in overtreated (TSH < 0.4 µIU/ml), euthyroid (TSH 0.40-4.20), and undertreated (TSH >4.2) and according to the etiology of hypothyroidism. A stepwise logistic regression model was performed to evaluate the variables associated with TSH<0.4 µIU/ml. RESULTS: 955 patients were included. 75.13% of the patients had an adequate LT4 replacement. LT4 dose to achieve euthyroidism was higher in patients with a history of radioiodine therapy (1.92 µg/kg) and thyroid surgery (1.52 µg/kg), while the LT4 dose required to achieve euthyroidism in patients with Hashimoto's thyroiditis and atrophic thyroiditis was lower than that reported in previous studies (1.25 and 1.08 µg/kg, respectively). The variables that were associated with a higher probability of TSH<0.4 µIU/ml were male gender, Hashimoto's thyroiditis, radioiodine therapy, and thyroid surgery. MAJOR CONCLUSION: LT4 dose required to achieve euthyroidism in patients with hypothyroidism varies according to the etiology, being higher in patients with hypothyroidism due to radioiodine therapy and thyroid surgery. Patients with hypothyroidism due to Hashimoto's thyroiditis and atrophic thyroiditis require a lower dose than current recommendations.

Introducción: La levotiroxina (LT4) se considera el estándar de tratamiento del hipotiroidismo. Las recomendaciones actuales sugieren una dosis de LT4 entre 1,6-1,8 µg/kg/día. El objetivo de este estudio fue evaluar la dosis de LT4 en pacientes adultos con hipotiroidismo primario de diferentes etiologías que alcanzaron el eutiroidismo. Métodos: Estudio transversal a partir de la revisión retrospectiva de historias clínicas de pacientes con hipotiroidismo primario en tratamiento con LT4. Los sujetos se clasificaron según el nivel de TSH en sobretratados (TSH<0,4 µUI/ml), eutiroideos (TSH 0,40-4,20) y subtratados (TSH>4,2) y según la etiología del hipotiroidismo. Se realizó un modelo de regresión logística escalonada para evaluar las variables asociadas con TSH <0,4 µUI/ml. Resultados: Se incluyeron 955 pacientes. El 75,13% tuvo un reemplazo adecuado de LT4. La dosis de LT4 para lograr el eutiroidismo fue mayor en pacientes con antecedentes de terapia con yodo radiactivo (1,92 µg/kg) y cirugía de tiroides (1,52 µg/kg), mientras que la dosis de LT4 para lograr el eutiroidismo en pacientes con tiroiditis de Hashimoto y tiroiditis atrófica fue menor que el reportado en estudios previos (1,25 y 1,08 µg/kg, respectivamente). Las variables que se asociaron con una mayor probabilidad de TSH<0,4 µUI/ml fueron el sexo masculino, tiroiditis de Hashimoto, terapia con yodo radiactivo y cirugía de tiroides. Conclusión principal: La dosis de LT4 necesaria para alcanzar el eutiroidismo en pacientes con hipotiroidismo varía según la etiología, siendo mayor en pacientes con hipotiroidismo por tratamiento con yodo radiactivo y cirugía tiroidea. Los pacientes con hipotiroidismo debido a tiroiditis de Hashimoto y tiroiditis atrófica requieren una dosis más baja que las recomendaciones actuales.

Hypovitaminosis D in patients with type 2 diabetes: risk factors and association with glycemic control and established microvascular complications

Introduction: Several studies reported than vitamin D deficiency increases the risk of macrovascular and microvascular disease in patients with type 2 diabetes (T2DM). We investigated the plasma levels of 25OHD in adult patients T2DM, risk factors for 25OHD deficiency and the relationship between 25OHD, glycemic control and chronic complications of T2DM. Methods: A cross-sectional study was carried out, in which 25OHD levels were evaluated in adult patients (over 18 years) with T2DM. Correlation analyses were performed to evaluate the interdependence of the 25OHD with other continuous variables. A receiver operating characteristic analysis was also performed to identify cutoff values for diagnosing vitamin D deficiency. Logistic regression was performed to identify the independent association between vitamin D deficiency and the variables associated with lower 25OHD. Results: 208 patients were analyzed. The mean age of the patients was 62 years.  The 25OHD level was 19 ng/ml (IQR 13.28-24.43), 59.78% had vitamin D deficiency, and 10.33% had severe deficiency. Glycemia, HbA1c, and BMI were negatively correlated with 25OHD. Cutoff point for vitamin D deficiency was 33.39 kg/m2 for body mass index (BMI), 123 mg/dl for glycemia, and 6.65% for HbA1c. In multivariate logistic regression, BMI>33.39 kg/m2, glycemia >123.5 mg/dl, and albuminuria presented higher odds of vitamin D deficiency. Conclusion: Vitamin D deficiency was highly prevalent among patients with T2DM. Low levels were related to higher fasting plasma glucose, higher BMI, and diabetic nephropathy.

Introducción: Varios estudios reportaron que la deficiencia de vitamina D aumenta el riesgo de enfermedad macrovascular y microvascular en pacientes con diabetes tipo 2 (DM2). Investigamos los niveles de 25OHD en adultos con DM2, factores de riesgo de deficiencia de 25OHD y relación entre 25OHD, control glucémico y complicaciones crónicas de la DM2. Métodos: Se realizó un estudio transversal en el que se evaluaron los niveles de 25OHD en adultos (mayores de 18 años) con DM2. Se realizaron análisis de correlación para evaluar la interdependencia de la 25OHD con otras variables continuas. Se realizó un análisis de las características operativas del receptor para identificar valores de corte para diagnóstico de deficiencia de vitamina D. Se realizó una regresión logística para identificar asociación independiente entre deficiencia de 25OHD y variables asociadas con una menor 25OHD. Resultados: Se analizaron 208 pacientes. La edad media fue 62 años. El nivel de 25OHD fue 19 ng/ml (IQR 13.28-24.43), 59.78% tenía deficiencia de vitamina D y 10.33% tenía deficiencia severa. Glucemia, HbA1c y IMC correlacionaron negativamente con 25OHD. El punto de corte para deficiencia de vitamina D fue 33,39 kg/m2 para índice de masa corporal (IMC), 123 mg/dl para glucemia y 6,65% para HbA1c. En la regresión logística multivariada, IMC >33,39 kg/m2, glucemia >123,5 mg/dl y albuminuria presentaron mayores probabilidades de deficiencia de vitamina D. Conclusión principal: La deficiencia de vitamina D fue altamente prevalente en los pacientes con DM2. Niveles bajos de 25OHD se relacionaron con mayor glucemia, mayor IMC y nefropatía diabética.

Analysis of the variables involved in the time to resolution of metabolic parameters in adults with diabetic ketoacidosis / [Análisis de las variables involucradas en el tiempo de resolución de los parámetros metabólicos en adultos con cetoacidosis diabética.]

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening complication characterized by hyperglycemia, metabolic acidosis, and ketonemia. Although the time to resolution of DKA has been estimated at 12 to 18 hours, the factors that could prolong it have not been fully studied. Methods: Retrospective study of medical records of adult patients admitted to the general ward with a diagnosis of DKA. They were classified according to severity as mild, moderate and severe. The time to resolution of crisis (TRC) was defined as that necessary until normalization of metabolic parameters. A logistic regression analysis was performed to evaluate the association between TRC>12 hours and continuous variables. ROC analysis and survival analysis were performed using a Cox regression model. Results: 85 patients were studied. 48.23% presented severe DKA. The TRC was 14 hours, being higher in severe DKA. Patients with TRC>12 hours had a lower pH and HCO3-, and a higher anion gap, white blood cells, and volume of crystalloids used. Logistic regression analysis showed that pH and crystalloid volume correlated with TRC>12 hours. ROC analysis determined a pH cutoff value of 7.13 for TRC>12 hours (sensitivity 77%, specificity 88%). The Cox regression showed that a pH<7.13 on admission is associated with a higher TRC (HR 3.30). Conclusion: A pH lower than 7.13 at the time of hospital admission identifies patients with DKA who will need a longer time to resolve their metabolic parameters.

Introducción: La cetoacidosis diabética (CAD) es una complicación potencialmente mortal caracterizada por hiperglucemia, acidosis metabólica y cetonemia. Aunque el tiempo para la resolución de la CAD se ha estimado en 12 a 18 horas, los factores que podrían prolongarlo no se han estudiado con exhaustividad. Métodos: Estudio retrospectivo de historias clínicas de pacientes adultos admitidos a sala general con diagnóstico de CAD. Se clasificaron según la severidad en leve, moderada y severa. El tiempo de resolución de la crisis (TRC) se definió como aquel necesario hasta normalización de parámetros metabólicos. Se realizó un análisis de regresión logística para evaluar la asociación entre TRC>12 horas y variables continuas. Se realizó un análisis ROC y un análisis de supervivencia utilizando un modelo de regresión de Cox. Resultados: Se estudiaron 85 pacientes. El 48.23% presentó CAD severa. El TRC fue de 14 horas, siendo mayor en CAD severa. Los pacientes con TRC>12 horas presentaron menor pH y HCO3, y mayor anión gap, glóbulos blancos y volumen de cristaloides utilizados. El análisis de regresión logística demostró que el pH y el volumen de cristaloides correlacionaron con TRC>12 horas. El análisis ROC determinó un valor de corte de pH de 7.13 para TRC>12 horas (sensibilidad 77%, especificidad 88%). La regresión de Cox demostró que un pH <7.13 al ingreso se asocia a mayor TRC (HR 3.30). Conclusión: Un pH menor a 7.13 al momento de admisión hospitalaria identifica a pacientes con CAD que necesitarán un mayor tiempo para resolver sus parámetros metabólicos.

The influence of age and body weight on levothyroxine replacement dosage to achieve euthyroidism in patients with primary hypothyroidism.

INTRODUCTION: Although, it is generally held that the levothyroxine (LT4) dose tends to decrease with age, this theory remains controversial. Our objective was to assess whether the LT4 dose required to achieve euthyroid status varies according to age, body weight (BW), sex, menopausal status, or antibody status. MATERIALS AND METHODS: A cross-sectional study was performed from the retrospective review of the charts of patients with a previous diagnosis of primary hypothyroidism in treatment with LT4 and in a euthyroid state. Sex, age, actual body weight (ABW), TSH, and LT4 dose were recorded. Patients were grouped according to age ranges (18-44, 45-65, and over 65 years). A euthyroid state was defined as a serum TSH within the range of 0.4-4µIU/ml. A multiple linear regression model was performed to assess the LT4 dose and age, gender, antibody status, and ABW. RESULTS: A total of 882 charts of patients were reviewed. 586 patients met the inclusion criteria. The median age was 55 years. There was no correlation between the LT4 dose and age. A positive correlation was observed between the LT4 dose and ABW, but not with the ideal BW. Linear regression analysis showed that positivity antibody and ABW have a significant effect on the LT4 dose. Comparison of the LT4 dose between the different age groups showed no difference. CONCLUSION: Our study demonstrates that the dose of LT4 necessary to achieve euthyroidism is influenced by ABW and the presence of antibodies. Age and menopause did not influence the required daily dose of LT4.

The influence of age and body weight on levothyroxine replacement dosage to achieve euthyroidism in patients with primary hypothyroidism.

INTRODUCTION: Although, it is generally held that the levothyroxine (LT4) dose tends to decrease with age, this theory remains controversial. Our objective was to assess whether the LT4 dose required to achieve euthyroid status varies according to age, body weight (BW), sex, menopausal status, or antibody status. MATERIALS AND METHODS: A cross-sectional study was performed from the retrospective review of the charts of patients with a previous diagnosis of primary hypothyroidism in treatment with LT4 and in a euthyroid state. Sex, age, actual body weight (ABW), TSH, and LT4 dose were recorded. Patients were grouped according to age ranges (18-44, 45-65, and over 65 years). A euthyroid state was defined as a serum TSH within the range of 0.4-4µIU/ml. A multiple linear regression model was performed to assess the LT4 dose and age, gender, antibody status, and ABW. RESULTS: A total of 882 charts of patients were reviewed. 586 patients met the inclusion criteria. The median age was 55 years. There was no correlation between the LT4 dose and age. A positive correlation was observed between the LT4 dose and ABW, but not with the ideal BW. Linear regression analysis showed that positivity antibody and ABW have a significant effect on the LT4 dose. Comparison of the LT4 dose between the different age groups showed no difference. CONCLUSION: Our study demonstrates that the dose of LT4 necessary to achieve euthyroidism is influenced by ABW and the presence of antibodies. Age and menopause did not influence the required daily dose of LT4.

Vertebral fractures in adult women with type 2 diabetes mellitus / Fracturas vertebrales en mujeres adultas con diabetes mellitus tipo 2

Introduction. Diabetes is a chronic disease associated with important comorbidities. Type 2 diabetes (T2DM) is associated with a three times increased risk of hip fracture but reports describing potential associations with vertebral fractures (VF) are contradictory. Our objective was to evaluate the factors involved in the prevalent VF in women with and without T2DM. Materials and methods. A cross-sectional design was used and the relationship between morphometric VF and T2DM in adult women was evaluated. The cases were adult women with morphometric VF and the controls were adult women without VF. Thoracic and spinal radiographs in lateral and antero-posterior projections were obtained. Bone mineral density (BMD) values of the lumbar spine (L-BMD) were measured by DXA. Results. A greater number of women with T2DM were found in the VF group (61% vs 31.5%). Non-T2DM women with VF were significantly older and with lower L-BMD than non-T2DM without VF. We observed a negative correlation between age and L-BMD (r=-0.463) in non-T2DM women, but not in the T2DM with FV group. T2DM was a risk factor for prevalent VF with OR of 3.540 (IC95% 1.750-7.160). Conclusion. Our study showed a higher prevalence of T2DM in the VF group. T2DM women with VF were younger and had higher L-BMD than non-T2DM women, L-BMD did not correlate with age and VF were not distributed according to BMD-L and age. (AU)

Introducción. La diabetes es una enfermedad crónica asociada con comorbilidades importantes. La diabetes tipo 2 (DM2) se asocia con un riesgo tres veces mayor de fractura de cadera pero la asociación con fracturas vertebrales (FV) es contradictoria. Nuestro objetivo fue evaluar los factores involucrados en las FV prevalentes en mujeres adultas con y sin DM2. Materiales y métodos. Se realizó un diseño transversal y se evaluó la relación entre FV morfométrica y DM2 en mujeres adultas. Los casos fueron mujeres adultas con FV morfométricas y los controles fueron mujeres adultas sin FV. Se obtuvieron radiografías torácicas y espinales en proyecciones lateral y anteroposterior. Los valores de densidad mineral ósea (DMO) de la columna lumbar (DMO-L) se midieron por DXA. Resultados. Se observó un mayor número de mujeres con DM2 en el grupo de FV (61% frente a 31.5%). Las mujeres sin DM2 con FV eran significativamente mayores y con una DMO-L más baja que las mujeres sin DM2 sin FV. Observamos una correlación negativa entre la edad y la DMO-L (r= -0.463) en mujeres sin DM2 y FV, pero no en DM2 con FV. La DM2 fue un factor de riesgo para FV prevalente con un OR 3.540 (IC95% 1.750-7.160). Conclusión. Nuestro estudio demostró una mayor prevalencia de DM2 en el grupo de FV. Las mujeres con DM2 y FV eran más jóvenes y tenían mayor DMO-L que las mujeres sin DM2, la DMO-L no correlacionó con la edad y las FV no se distribuyeron de acuerdo a la DMO-L y edad. (AU)

Hipoparatiroidismo y calcificaciones cerebrales: reporte de caso / Hypoparathyroidism and brain calcifications: a case report

Introducción. El hipoparatiroidismo es una enfermedad caracterizada por la ausencia o concentraciones inadecuadamente bajas de hormona paratiroidea (PTH), que conduce a hipocalcemia, hiperfosfatemia y excreción fraccional elevada de calcio en la orina. Las calcificaciones del sistema nervioso central son un hallazgo frecuente en estos pacientes. Caso clínico. Mujer de 56 años con antecedente de hipotiroidismo, que ingresó por un cuadro de 6 días de evolución caracterizado por astenia, parestesias periorales y movimientos anormales de manos y pies. Las pruebas de laboratorio demostraron hipocalcemia, hiperfosfatemia y niveles bajos de hormona paratiroidea. Se realizó una tomografía computarizada de cráneo que mostró áreas bilaterales y simétricas de calcificaciones en hemisferios cerebelosos, ganglios basales y corona radiata. No se evidenciaron trastornos en el metabolismo del cobre y hierro. Se estableció el diagnóstico del síndrome de Fahr secundario a hipoparatiroidismo y se inició tratamiento con suplementos de calcio y vitamina D con evolución satisfactoria. Discusión. El síndrome de Fahr es un trastorno neurológico caracterizado por el depósito anormal de calcio en áreas del cerebro que controlan la actividad motora. Se asocia a varias enfermedades, especialmente, hipoparatiroidismo. La suplementación con calcio y vitamina D con el objetivo de normalizar los niveles plasmáticos de estos cationes es el tratamiento convencional. (AU)

Introduction. Hypoparathyroidism is a disease characterized by absence or inappropriately low concentrations of circulating parathyroid hormone, leading to hypocalcaemia, hyperphosphataemia and elevated fractional excretion of calcium in the urine. Central nervous system calcifications are a common finding in these patients. Case report. 56-year-old woman with a history of hypothyroidism who was admitted for a 6-day course of illness characterized by asthenia, perioral paresthesias, and abnormal movements of the hands and feet. Laboratory tests showed hypocalcemia, hyperphosphatemia, and low parathyroid hormone levels. A cranial computed tomography was performed. It showed bilateral and symmetrical areas of calcifications in the cerebellar hemispheres, basal ganglia, and radiata crown. No disorders of copper or iron metabolism were evident. The diagnosis of Fahr syndrome secondary to hypoparathyroidism was established and treatment with calcium and vitamin D supplements was started with satisfactory evolution. Discussion. Fahr's syndrome is a neurological disorder associated with abnormal calcium deposition in areas of the brain that control motor activity. It is associated with various diseases, especially hypoparathyroidism. The conventional treatment is supplementation with calcium and vitamin D, with the aim of normalizing their plasma levels. (AU)

Mecanismos involucrados en la fragilidad ósea en diabetes mellitus / Mechanisms involved in the bone fragility in diabetes mellitus

La diabetes es una enfermedad crónica asociada con importantes comorbilidades. El sistema esquelético parece ser un objetivo adicional de daño mediado por diabetes. Se acepta que la diabetes tipo 1 y tipo 2 se asocian con un mayor riesgo de fractura ósea. Varios estudios han demostrado que los cambios metabólicos causados por la diabetes pueden influir en el metabolismo óseo disminuyendo la calidad y la resistencia del hueso. Sin embargo, los mecanismos subyacentes no se conocen por completo pero son multifactoriales y, probablemente, incluyen los efectos de la obesidad, hiperglucemia, estrés oxidativo y acumulación de productos finales de glicosilación avanzada. Estos darían lugar a un desequilibrio de varios procesos y sistemas: formación de hueso, resorción ósea, formación y entrecruzamiento de colágeno. Otros factores adicionales como la hipoglucemia inducida por el tratamiento, ciertos medicamentos antidiabéticos con un efecto directo sobre el metabolismo óseo y mineral, así como una mayor propensión a las caídas, contribuirían al aumento del riesgo de fracturas en pacientes con diabetes mellitus. Esta revisión tiene como objetivo describir los mecanismos fisiopatológicas subyacentes a la fragilidad ósea en pacientes diabéticos. (AU)

Diabetes is a chronic disease associated with important comorbidities. The skeletal system seems to be an additional target of diabetes mediated damage. It is accepted that type 1 and type 2 diabetes are associated with an increased risk of bone fracture. Several studies have shown that metabolic changes caused by diabetes can influence bone metabolism by decreasing bone quality and resistance. However, the underlying mechanisms are not completely known but they are multifactorial and probably include the effects of obesity, hyperglycemia, oxidative stress and accumulation of advanced glycosylation end products. These would lead to an imbalance of several processes and systems: bone formation, bone resorption, formation and collagen crosslinking. Other additional factors such as treatment-induced hypoglycemia, certain antidiabetic medications with a direct effect on bone and mineral metabolism, as well as an increased propensity for falls, would contribute to the increased risk of fractures in patients with diabetes mellitus. This review aims to describe the pathophysiological mechanisms underlying bone fragility in diabetic patients. (AU)

Crisis hipercalcémica causada por adenoma paratiroideo: reporte de un caso clínico / Hypercalcemic crisis due to parathyroid adenoma: report of a clinical case

La hipercalcemia es un trastorno común que representa aproximadamente el 0,6% de todas las admisiones médicas agudas. El hiperparatiroidismo primario (HPTP) y las neoplasias malignas son las dos causas más comunes de elevación de los niveles séricos de calcio; constituyen, en conjunto, alrededor del 90% de todos los casos. La presentación sintomática clásica de la hipercalcemia se observa con relativa poca frecuencia en el mundo desarrollado; la presentación más común es la detección asintomática en las pruebas bioquímicas. Sin embargo, en casos raros, el HPTP puede desarrollar hipercalcemia aguda, grave y sintomática, llamada crisis hipercalcémica (CH). Esta condición se asocia a alteraciones profundas en el estado mental y las funciones cardíaca, renal y gastrointestinal en presencia de concentraciones marcadamente elevadas de calcio sérico y paratohormona (PTH). Mientras que algunas elevaciones en el calcio sérico pueden ser bien toleradas, los síntomas de la CH son severos. Si el tratamiento se retrasa, la CH puede provocar la muerte. Describimos el caso de un paciente masculino que ingresa en la unidad de cuidados críticos por una CH secundaria a un HPTP por adenoma paratiroideo. (AU)

Hypercalcaemia is a most common disorder, accounting for approximately 0,6% of all acute medical admissions. Primary hyperparathyroidism (PHPT) and malignancy are the two most common causes of increased serum calcium levels, together accounting for about 90% of all cases. The classical symptomatic presentation of hypercalcaemia is seen relatively rarely in the developed world, the most common presentation being asymptomatic and detected following on biochemical testing. However, in rare cases HPTP can result in acute, severe and symptomatic hypercalcemia, called hypercalcemic crisis (HC). This condition is associated with profound disturbances in mental status, and cardiac, renal, and gastrointestinal function in the presence of markedly increased serum calcium and parathyroid hormone (PTH) concentrations. While some elevations in serum calcium can be well tolerated, symptoms of HC are severe. If treatment is delayed, HC can result in death. We describe herein a case of a male patient who was admitted to the intensive care unit as a consequence of HC resulting from elevated PTH, secondary to a parathyroid adenoma. We describe the case of a male patient who was admitted to the critical care unit for a HC mediated by PTH secondary to a parathyroid adenoma. (AU)

Niveles de 25(oh)-vitamina D en pacientes con diabetes mellitus tipo 2 con y sin síndrome metabólico / 25(OH)-Vitamin D levels in type 2 diabetes with and without metabolic syndrome

Los bajos niveles de 25-hidroxivitamina D (25OHD) se han vinculado con el desarrollo de enfermedad cardiovascular, diabetes mellitus tipo 2, obesidad, dislipidemia e hipertensión arterial, todos componentes del síndrome metabólico (SM). Además, se ha reportado una asociación inversa entre 25OHD y el SM, resistencia a la insulina, deterioro de la función celular ß e intolerancia a la glucosa. El objetivo de este trabajo fue evaluar los niveles de 25OHD en pacientes diabéticos tipo 2 con y sin SM. Se llevó a cabo un estudio observacional de corte transversal. Se evaluaron 108 pacientes diabéticos tipo 2 (grupo DM2) y 89 pacientes sin DM2 (GC) con y sin SM, en los cuales se determinó la concentración de 25OHD total. Se calculó el cociente de probabilidad (OR) e intervalo de confianza del 95% (IC95) para la deficiencia de 25OHD (<20 ng/ml). Resultados: el grupo DM2 presentó niveles menores de 25OHD (19,8 ng/ml vs. 25,0 ng/ml) y mayor proporción de pacientes con deficiencia de 25OHD respecto del GC (50,9% vs. 28,1%, OR 2,7, IC95%: 1,5-4,8). No se halló una correlación entre 25OHD y HbA1c. Se halló asociación significativa entre deficiencia de 25OHD y presencia de diabetes, obesidad y SM. Sin embargo, en el análisis multivariado solo la presencia del SM presentó asociación negativa significativa con la deficiencia de 25OHD (OR=4,04, IC95% 1,48-11,68). En conclusión, nuestros datos demuestran una elevada prevalencia de hipovitaminosis D en pacientes con diabetes mellitus tipo 2 a expensas, principalmente, del elevado porcentaje de pacientes que padecen SM. El SM incrementa cuatro veces el riesgo de deficiencia de vitamina D independientemente de la presencia de diabetes mellitus tipo 2. (AU)

Low levels of 25-hydroxyvitamin D (25OHD) have been linked to cardiovascular disease, type 2 diabetes mellitus, obesity, dyslipidemia and hypertension, all components of the metabolic syndrome. An inverse association has been observed between 25OHD and metabolic syndrome, insulin resistance, impaired ß-cell function and glucose intolerance. The aim of this study was to evaluate the 25OHD levels in type 2 diabetic patients with and without metabolic syndrome. An observational cross-sectional study was carried out. We included 108 type 2 diabetic patients (DM2 group) and 89 patients without DM2 (CG) with and without metabolic syndrome, in which the total 25OHD levels were measured. The odds ratio (OR) and 95% confidence interval (95%CI) for 25OHD deficiency (<20 ng/ml) were estimated. Results: The DM2 group had lower 25OHD levels (19.8 ng/ml vs 25.0 ng/ml) and higher proportion of patients with a 25OHD deficiency compared to the CG (50.9% vs 28.1%, OR 2.7, 95%CI: 1.5-4.8). No correlation was found between 25OHD and HbA1c. A significant association was found between 25OHD deficiency and the presence of diabetes, obesity, and the presence of metabolic syndrome. However, in the multivariate analysis only the presence of metabolic syndrome had a significant negative association with the 25OHD deficiency (OR=4.04, 95%CI 1.48-11.68). In conclusion, we found a high prevalence of hypovitaminosis D in DM2 and the metabolic syndrome increases the risk of 25OHD deficiency by four times. (AU)

Edema agudo de pulmón neurogénico como complicación de traumatismo encéfalocraneano / Acute neurogenic pulmonary edema as a complication of head trauma

La insuficiencia respiratoria observada tras una injuria cerebral aguda es un fenómeno común que puede debersea múltiples causas, como broncoaspiración, neumonía, atelectasia, embolismo pulmonar y, raramente, edemapulmonar neurogénico. Esta última entidad se encuentra subdiagnosticada y sería un potencial contribuyente dela disfunción pulmonar temprana en pacientes con injurias cerebrales. La misma se ha asociado a convulsiones,accidentes cerebrovasculares, infecciones, traumatismos encéfalocraneanos, entre otros. Se origina por una lesióngrave del sistema nervioso central en ausencia de cardiopatías o neumopatías previas. La gravedad es directamenteproporcional a la lesión cerebral y se produciría por una disfunción del centro vasomotor hipotalámico. Se caracterizapor un incremento en el contenido de agua intersticial pulmonar. Los cambios hemodinámicos son sugestivosde disfunción cardíaca. El análisis temprano del fluido pulmonar revela un cociente de proteínas líquido/suerobajo, compatible con edema hidrostático. El tratamiento incluye oxígenoterapia, asistencia respiratoria mecánicay manejo hemodinámico. Presentamos a una paciente de 20 años, sin antecedentes patológicos, que ingresa portraumatismo encéfalocraneano moderado tras accidente en la vía pública y que posteriormente desarrolla una descompensacióncardiorrespiratoria interpretada como edema pulmonar neurogénico (EPN).

Respiratory distress observed following an acute brain injury is a common phenomenon which could suggest multiplecauses, such as bronchoaspiration, pneumonia, atelectasis, pulmonary embolism and, rarely, neurogenic pulmonary edema(NPE). NPE is usually under-diagnosed and could be a potential contributor to early pulmonary failure in patients whosuffer brain injuries. NPE has been associated, among others, to seizures, strokes, infections, and head trauma. It appearsas a result of a severe injury of the central nervous system (CNS), in absence of previous heart or lung diseases. Its severityis directly proportional to the brain injury and would be a consequence of a failure of the hypothalamic vasomotor center.It is characterized by an increase in the lung interstitial fluid content. The hemodynamic changes suggest heart failure. Theearly assessment of lung fluid reveals a low ratio of liquid/serum proteins compatible with hydrostatic edema. Treatmentinvolves oxygen therapy, mechanical ventilation and hemodynamic monitoring. We present a 20-year old female patient,with no pathologic history, who is admitted due to moderate head trauma after a street accident and who later developscardiopulmonary failure interpreted as a neurogenic pulmonary edema (NPE).

Edema agudo de pulmón neurogénico como complicación de traumatismo encéfalocraneano / Acute neurogenic pulmonary edema as a complication of head trauma

La insuficiencia respiratoria observada tras una injuria cerebral aguda es un fenómeno común que puede debersea múltiples causas, como broncoaspiración, neumonía, atelectasia, embolismo pulmonar y, raramente, edemapulmonar neurogénico. Esta última entidad se encuentra subdiagnosticada y sería un potencial contribuyente dela disfunción pulmonar temprana en pacientes con injurias cerebrales. La misma se ha asociado a convulsiones,accidentes cerebrovasculares, infecciones, traumatismos encéfalocraneanos, entre otros. Se origina por una lesióngrave del sistema nervioso central en ausencia de cardiopatías o neumopatías previas. La gravedad es directamenteproporcional a la lesión cerebral y se produciría por una disfunción del centro vasomotor hipotalámico. Se caracterizapor un incremento en el contenido de agua intersticial pulmonar. Los cambios hemodinámicos son sugestivosde disfunción cardíaca. El análisis temprano del fluido pulmonar revela un cociente de proteínas líquido/suerobajo, compatible con edema hidrostático. El tratamiento incluye oxígenoterapia, asistencia respiratoria mecánicay manejo hemodinámico. Presentamos a una paciente de 20 años, sin antecedentes patológicos, que ingresa portraumatismo encéfalocraneano moderado tras accidente en la vía pública y que posteriormente desarrolla una descompensacióncardiorrespiratoria interpretada como edema pulmonar neurogénico (EPN).(AU)

Respiratory distress observed following an acute brain injury is a common phenomenon which could suggest multiplecauses, such as bronchoaspiration, pneumonia, atelectasis, pulmonary embolism and, rarely, neurogenic pulmonary edema(NPE). NPE is usually under-diagnosed and could be a potential contributor to early pulmonary failure in patients whosuffer brain injuries. NPE has been associated, among others, to seizures, strokes, infections, and head trauma. It appearsas a result of a severe injury of the central nervous system (CNS), in absence of previous heart or lung diseases. Its severityis directly proportional to the brain injury and would be a consequence of a failure of the hypothalamic vasomotor center.It is characterized by an increase in the lung interstitial fluid content. The hemodynamic changes suggest heart failure. Theearly assessment of lung fluid reveals a low ratio of liquid/serum proteins compatible with hydrostatic edema. Treatmentinvolves oxygen therapy, mechanical ventilation and hemodynamic monitoring. We present a 20-year old female patient,with no pathologic history, who is admitted due to moderate head trauma after a street accident and who later developscardiopulmonary failure interpreted as a neurogenic pulmonary edema (NPE).(AU)