Protocolo de diagnóstico y manejo de hipocalcemia en postoperatorio de tiroides / Postoperative thyroid hypocalcemia diagnosis andmanagement protocol

OBJETIVO: La hipocalcemia transitoria por hipoparatiroidismo es la complicación más frecuente de la cirugía cervical (tiroidea y paratiroidea) y también de las reintervenciones. La hipocalcemia por hipoparatiroidismo se asocia a pocos síntomas, si es leve, o a síntomas graves como convulsiones, insuficiencia cardiaca o laringoespasmo, en los casos graves. Tanto el hipoparatiroidismo transitorio como el permanente pueden tener importantes repercusiones sobre la salud de los pacientes, y es necesario establecer protocolos apropiados para su prevención, evaluación y tratamiento. MATERIAL Y MÉTODOS: Se realizó una búsqueda sistemática en Pubmed.gov de la evidencia disponible de artículos en inglés y español con fecha de inclusión hasta mayo del 2019. Se realizaron las recomendaciones mediante sistema GRADE (Grading of Recommendations, Assessment, Development and Evaluation). RESULTADO Y CONCLUSIONES: Proponemos un consenso de manejo del paciente que va a ser sometido a cirugía tiroidea o paratiroidea, con apartados diferenciados para las distintas etapas del proceso, que ayude a la toma de decisiones clínicas y que sirva de ayuda en el proceso de alta y derivación a consultas externas, y, por tanto, la optimización de recursos

OBJETIVE: Transient hypocalcaemia due to hypoparathyroidism is the most frequent complication of cervical surgery (thyroid and parathyroid) and also of reoperations. If mild, hypocalcaemia attributed to hypoparathyroidism is associated with few symptoms or with severe symptoms such as seizures, heart failure, or laryngospasm, in severe cases. Both transient and permanent hypoparathyroidism can have important repercussions on the health of patients. Establishing appropriate protocols are required to prevent, assess and treat these conditions. MATERIAL AND METHODS: A systematic bibliographic search was carried out in Pubmed.gov of available evidence from articles in English and Spanish with inclusion dates until May 2019. Recommendations were made based on the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation). RESULTS AND CONCLUSIONS: We propose a consensus for patient management of those who are going to undergo thyroid or parathyroid surgery, with different sections for the different stages of the process. This is intended to help clinical decision-making, assist in the discharge process and make referrals to outpatient consultations, thus optimizing resources

Osteomalacia en un adulto joven / Osteomalacia in a young adult

Los cuadros de osteomalacia hipofosfatémica responden a diversas causas genéticas y adquiridas. Algunas variantes de tumores mesenquimales producen cantidades inapropiadas de factor de crecimiento fibroblástico 23 (FGF-23), un mediador que induce una pérdida renal de fosfatos. El cuadro bioquímico se caracteriza por hipofosfatemia, disminución de la reabsorción tubular de fosfatos, niveles bajos o inapropiadamente normales de calcitriol sérico y niveles altos o inapropiadamente normales de FGF-23 plasmático. Este síndrome paraneoplásico es denominado osteomalacia tumoral u oncogénica. Existen limitadas series de casos publicadas, pero su reconocimiento es creciente en los últimos años. El diagnóstico puede ser complejo por su baja incidencia, la dificultosa localización de los tumores y la heterogeneidad en la interpretación histopatológica. La exéresis quirúrgica completa es curativa, pero puede haber recidivas y los suplementos orales de fósforo y calcitriol son alternativas de tratamiento médico (AU)

Cases of hypophosphatemic osteomalacia respond to various causes, both genetic and acquired. Some variants of mesenchymal tumors produce inappropriate amounts of fibroblast growth factor 23 (FGF-23), a mediator which induces renal phosphate loss. The biochemical picture is characterized by hypophosphatemia, decreased tubular reabsorption of phosphates, low or inappropriately normal serum calcitriol and high or unusually normal levels of FGF-23 plasma. This paraneoplastic syndrome is called tumorinduced or oncogenic osteomalacia. There are a limited series of published cases, although it has been increasingly accepted in recent years. Diagnosis may be complex given its low incidence, the difficulties in localizing the tumors and heterogeneity in histopathologic interpretation. Complete surgical removal has healed, but there may be recurrences whereas phosphorus and calcitriol oral supplements offer alternative medical treatment (AU)

Actualización de las recomendaciones para la evaluación y tratamiento de la osteoporosis asociada a enfermedades endocrinas y nutricionales. Grupo de trabajo de osteoporosis y metabolismo mineral de la SEEN / Update of recommendations for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions. Working Group on Osteoporosis and Mineral Metabolism of the Spanish Society of Endocrinology

Objetivo: Actualizar las recomendaciones previas formuladas por el Grupo de trabajo de osteoporosis y metabolismo mineral de la Sociedad Española de Endocrinología y Nutrición (SEEN) para la evaluación y el tratamiento de la osteoporosis asociada a diferentes enfermedades endocrinas y alteraciones nutricionales. Participantes: Miembros del Grupo de trabajo de osteoporosis y metabolismo mineral de la SEEN. Métodos: Las recomendaciones se formularon de acuerdo al sistema Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) para establecer tanto la fuerza de las recomendaciones como el grado de evidencia. Se realizó una búsqueda sistemática en PubMed de las nuevas acerca de cada enfermedad usando las siguientes palabras clave asociadas al nombre de cada proceso patológico: AND osteoporosis, fractures, bone mineral density, bone markers y treatment. Se revisaron artículos escritos en inglés con fechas de inclusión comprendidas entre el 18 de octubre de 2011 y el 30 de octubre de 2014. Tras la formulación de las recomendaciones estas se discutieron de forma conjunta por el Grupo de trabajo.Conclusiones: Esta actualización resume los nuevos datos acerca de la evaluación y tratamiento de la osteoporosis en las enfermedades endocrinas y nutricionales que se asocian a baja masa ósea o a un aumento del riesgo de fractura.(AU)

Objective: To update previous recommendations developed by the Working Group on Osteoporosis and Mineral Metabolism of the Spanish Society of Endocrinology and Nutrition for the evaluation and treatment of osteoporosis associated to different endocrine and nutritional diseases. Participants: Members of the Working Group on Osteoporosis and Mineral Metabolism of the Spanish Society of Endocrinology and Nutrition. Methods: Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed) using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date between 18 October 2011 and 30 October 2014 were included. The recommendations were discussed and approved by all members of the Working Group. Conclusions: This update summarizes the new data regarding evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions.(AU)

Vitamina D: presente y futuro / Vitamin D: present and future

En los últimos años se ha producido un creciente interés por la vitamina D, no solo por su importante papel en el metabolismo mineral óseo, sino también por sus efectos extraóseos. La mayoría de las sociedades científicas consideran que los depósitos son suficientes si la concentración plasmática de 25-OH vitamina D está por encima de 30ng/ml y deficientes si están por debajo de 20ng/ml. La mayoría de los estudios encuentran que los suplementos de calcio más vitamina D tienen un efecto positivo en la reducción del riesgo de fractura en un 20% aproximadamente y del riesgo de caída en los ancianos, y las dosis deberían ser de 700-1.000 UI diarias. El tratamiento del déficit se puede realizar con vitamina D2, D3 o sus metabolitos activos como el calcidiol o el calcitriol. En ciertas patologías también puede utilizarse los activadores selectivos del receptor de la vitamina D (AU)

In recent years has been a growing interest by vitamin D, not only for its important role in the bone mineral metabolism, but also by the extra-osseous effects. Most of the scientific societies consider that deposits are sufficient if the serum concentration of 25-OH vitamin D is above 30ng/ml and are considered deficient if levels are below 20ng/ml. The majority of studies found that supplements of calcium plus vitamin D have a positive effect in reducing the risk of fracture and the risk of falls in the elderly, although several specifies that doses should be 700-1.000 IU daily. The treatment of the deficit can be performed with vitamin D2, D3 as well as calcidiol or the active metabolite calcitriol. In certain pathologies also selective vitamin D receptor activators can be used (AU)

Vitamin D: present and future. / Vitamina D: presente y futuro.

In recent years has been a growing interest by vitamin D, not only for its important role in the bone mineral metabolism, but also by the extra-osseous effects. Most of the scientific societies consider that deposits are sufficient if the serum concentration of 25-OH vitamin D is above 30ng/ml and are considered deficient if levels are below 20ng/ml. The majority of studies found that supplements of calcium plus vitamin D have a positive effect in reducing the risk of fracture and the risk of falls in the elderly, although several specifies that doses should be 700-1.000 IU daily. The treatment of the deficit can be performed with vitamin D2, D3 as well as calcidiol or the active metabolite calcitriol. In certain pathologies also selective vitamin D receptor activators can be used.

Sclerostin serum levels in prostate cancer patients and their relationship with sex steroids.

UNLABELLED: The role of sclerostin on bone metabolism and its relation to sex steroids in patients with prostate cancer (PC) is not well known. We found that sclerostin levels are significantly increased in PC patients, particularly in those with androgen deprivation therapy (ADT), and there is an inverse relationship between sclerostin levels and testosterone. INTRODUCTION: Recent studies have evaluated sclerostin levels in bone diseases as osteoporosis. However, there are few data in PC patients, particularly in patients with hypogonadism related to ADT. The aim of the present study was to compare serum sclerostin levels in ADT/non-ADT-treated PC patients and healthy controls and to evaluate their relationship with sex steroids and bone metabolism. METHODS: We performed a cross-sectional study involving 81 subjects: 25 ADT-treated PC patients, 34 PC patients without ADT treatment, and 22 healthy controls. We measured serum sclerostin levels, bone turnover markers, bone mineral density (BMD) in all individuals, and sex steroids levels in PC patients. RESULTS: Serum sclerostin levels were significantly higher in PC patients compared to those in control subjects. ADT-treated patients had significantly higher sclerostin levels than PC patients without ADT treatment: ADT 64.52 ± 27.21 pmol/L, non-ADT 48.24 ± 15.93 pmol/L, healthy controls 38.48 ± 9.19 pmol/L, p < 0.05. In PC patients, we found a negative relationship between serum sclerostin levels and androgens after age adjustment (total testosterone: r = -0.309, p = 0.029; bioavailable testosterone: r = -0.280, p = 0.049; free testosterone: r = -0.299, p = 0.035). We did not observe any relationship between sclerostin levels and bone turnover markers or BMD in any group. CONCLUSIONS: Circulating sclerostin levels are significantly increased in patients with PC and particularly in those receiving ADT. The inverse relationship between serum sclerostin and testosterone in these patients suggests that androgens are key regulators of bone metabolism in this population.

SHBG levels are associated with bone loss and vertebral fractures in patients with prostate cancer.

SUMMARY: Fractures are increased among prostate cancer patients. No data have been reported in patients with prostate cancer about the relation between serum sex hormone-binding globulin (SHBG) and bone metabolism. We found that SHBG levels were inversely related to bone mass and vertebral fractures in this population. INTRODUCTION: Fractures are increased among prostate cancer patients, especially those on androgen deprivation therapy (ADT), but few data are available on the role of SHBG in their bone status. Our objective was to analyze the relation between serum SHBG and bone metabolism in prostate cancer patients. METHODS: This is a cross-sectional study including 91 subjects with prostate cancer (54 % with ADT). We measured serum levels of SHBG and sex steroids, bone mineral density (BMD) by dual-energy X-ray absorptiometry, and prevalent radiographic vertebral fractures. RESULTS: SHBG levels were inversely related to BMD (femoral neck: r = -0.299, p = 0.00; total hip: r = -0.259, p = 0.019). Subjects with osteoporosis had higher SHBG concentrations than patients without osteoporosis (60.97 ± 39.56 vs 44.45 ± 23.32 nmol/l, p = 0.022). Patients with SHBG levels in the first quartile (>57.6 nmol/l) had an odds ratio (OR) for osteoporosis of 2.59 (95 % CI, 1.30-5.12; p = 0.009) compared with patients with lower SHBG levels. In patients with SHBG >57.6 nmol/l, the OR for vertebral fractures was 2.34 (95 % CI, 1.15-4.78; p = 0.034). The calculated OR was higher after adjustment for age (OR, 5.16; 95 % CI, 1.09-24.49; p = 0.039), estrogens (OR, 6.45; 95 % CI, 1.44-28.95; p = 0.023), and androgens (OR, 5.51; 95 % CI, 1.36-22.37; p = 0.017). CONCLUSIONS: In prostate cancer patients, SHBG levels were inversely related to bone mass and vertebral fractures. Determination of the serum SHBG level may constitute a useful and straightforward marker for predicting the severity of osteoporosis in these patients.

Serum osteoprotegerin: bone or cardiovascular marker in Type 2 diabetes males?

BACKGROUND: The role of osteoprotegerin (OPG) as a marker of cardiovascular disease (CVD) in Type 2 diabetes (T2DM) is not well established. Moreover, the relationship between OPG, osteoporosis, and vertebral fractures in T2DM remains to be elucidated. AIM: To determine the role of serum OPG in the prediction of CVD and bone disease in T2DM males. SUBJECTS AND METHODS: Cross-sectional study with 68 males, 43 with T2DM and 25 subjects without diabetes. We measured: serum OPG by inmunoassay, the presence of CVD (coronary heart disease, cerebrovascular and peripheral artery disease), surrogate markers of CVD [intima- media thickness (IMT) and aortic calcification] and bone disease (bone mineral density and prevalent vertebral fractures). RESULTS: OPG serum levels (in pmol/l) were significantly higher in T2DM males with abnormal IMT (5.12 ± 1.59 vs 3.76 ± 1.98), carotid plaque (5.46 ± 1.67 vs 4.20 ± 1.81), aortic calcification (5.91 ± 1.39 vs 4.07 ± 1.76), hypertension (5.11 ± 1.86 vs 3.81 ± 1.47), and peripheral artery disease (6.24 ± 1.64 vs 4.21 ± 1.63, p < 0.05 for all comparisons). In the logistic regression analysis (after adjustment for age and main cardiovascular risk factors), serum OPG (per 1 pmol/l increase in OPG) was associated with increased risk of abnormal IMT [odds ratio (OR) 1.84, confidence interval (CI) 1.21-2.79, p = 0.004), carotid plaque (OR 1.71, CI 1.13-2.58, p = 0.012), aortic calcification (OR 2.21, CI 1.27-3.84, p = 0.05) and peripheral artery disease (OR 4.02, CI 1.65-9.8 p = 0.002). However, OPG were not related to bone mass or vertebral fractures. CONCLUSIONS: Our results suggest that in T2DM males OPG serum concentrations constitute a marker of CVD, but not a marker of bone disease.

Mielolipomas adrenales bilaterales como hallazgo incidental / Bilateral adrenal myelolipomas as an incidental finding

Los mielolipomas son tumores benignos raros, no funcionantes, compuestos por tejido adiposo maduro y precursores hematopoyéticos que involucran principalmente a las glándulas adrenales aunque pueden presentarse en localizaciones extraadrenales. Las características clínicas son muy variables, con descripciones de mielolipomas gigantes, bilaterales, asociados a síndromes de hipersecreción hormonal o a sangrado retroperitoneal. Con el incremento de la utilización de técnicas de imagen abdominales en la práctica clínica habitual, se ha observado un aumento de detección de incidentalomas adrenales, entre los cuales pueden encontrarse en raras ocasiones mielolipomas. Se describe el caso de una presentación inusual de mielolipomas adrenales bilaterales asintomáticos como hallazgo incidental en radiografías convencionales de abdomen, junto con un revisión de la literatura referida a estos tumores.

Myelolipomas are rare, non-functioning, benign tumors composed of mature fat tissue and myeloid hematopoietic precursors that involve mainly the adrenal glands and rarely other extra-adrenal tissues. The clinical features are heterogeneous and there are reports of giant and bilateral myelolipomas. Few tumors have been associated with endocrine dysfunction or retroperitoneal bleeding. With the development and wide-spread use of modern imaging techniques, this adrenal entity is sometimes found incidentally during radiology procedures for other reasons. We describe an unusual clinical presentation of asymptomatic bilateral myelolipomas incidentally discovered in abdominal X-Rays.

Outcome of treating advanced neuroendocrine tumours with radiolabelled somatostatin analogues.

OBJECTIVES: To evaluate the initial response and outcomes (quality of life and presence of side effects) in patients with advanced neuroendocrine tumours (NET) after treatment with radiolabelled somatostatin analogues: (90)Y-DOTATyr3- octreotide ((90)Y-DOTATOC) and (177)Lu-DOTA-Tyr3- octreotate ((177)Lu-DOTATATE). MATERIAL AND METHODS: The study included 5 patients with advanced NET referred to European centres for treatment with (90)Y-DOTATOC and (177)Lu-DOTATATE after lack of response to conventional treatment. The mean age was 45.6 years (29-68 years). Response to therapy was assessed according to: (1) RECIST criteria, as complete response, partial response, stable disease or disease progression, (2) post-treatment survival time and (3) quality of life, using the Karnofsky performance index. RESULTS: All patients survived for >20 months after treatment; mean survival time was 28 months. At the time of writing, three of the patients are alive after 20, 26 and 37 months. Partial response was observed in one patient, stable disease in three and disease progression in the fifth patient. A good-to-excellent post-treatment quality of life was observed in all patients. CONCLUSION: Therapy with radiolabelled somatostatin analogues showed promising results in patients with advanced NET, with a partial response or disease stabilisation in four of the five patients, who have enjoyed an extended survival period and an improved quality of life.

Outcome of treating advanced neuroendocrine tumours with radiolabelled somatostatin analogues

OBJECTIVES: To evaluate the initial response and outcomes (quality of life and presence of side effects) in patients with advanced neuroendocrine tumours (NET) after treatment with radiolabelled somatostatin analogues: (90)Y-DOTATyr3- octreotide ((90)Y-DOTATOC) and (177)Lu-DOTA-Tyr3- octreotate ((177)Lu-DOTATATE). MATERIAL AND METHODS: The study included 5 patients with advanced NET referred to European centres for treatment with (90)Y-DOTATOC and (177)Lu-DOTATATE after lack of response to conventional treatment. The mean age was 45.6 years (29-68 years). Response to therapy was assessed according to: (1) RECIST criteria, as complete response, partial response, stable disease or disease progression, (2) post-treatment survival time and (3) quality of life, using the Karnofsky performance index. RESULTS: All patients survived for >20 months after treatment; mean survival time was 28 months. At the time of writing, three of the patients are alive after 20, 26 and 37 months. Partial response was observed in one patient, stable disease in three and disease progression in the fifth patient. A good-to-excellent post-treatment quality of life was observed in all patients. CONCLUSION: Therapy with radiolabelled somatostatin analogues showed promising results in patients with advanced NET, with a partial response or disease stabilisation in four of the five patients, who have enjoyed an extended survival period and an improved quality of life (AU)

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