Tratamiento del hipoparatiroidismo postquirúrgico permanente, servicio endocrinología, Centro Médico Nacional 20 de noviembre, México 2020 / Permanent post-surgical hypoparathyroidism treatment response, outpatient consultation Endocrinology Service, ISSSTE, 2020

El hipoparatiroidismo postquirúrgico se caracteriza por hipocalcemia, hiperfosfatemia, e hipercalciuria, secundarios a concentraciones bajas de la hormona paratiroidea. La prevalencia en Estados Unidos es 23-37 casos/100.000 años-persona. Tras la cirugía de cuello ocurre como complicación en 78% de los casos; 75% resuelve espontáneamente en los primeros 6 meses y en el 25% restante es permanente. El tratamiento requiere administrar calcio oral y análogos de vitamina D (calcitriol y alfacalcidol) de forma crónica; en casos complicados se puede emplear calcio intravenoso en el postquirúrgico inmediato y mediato; algunos pacientes no responden a la terapia estándar. Objetivo: describir las características clínicas y la respuesta al tratamiento médico en pacientes con hipoparatiroidismo postquirúrgico permanente. Material y métodos: estudio descriptivo, transversal, con componente analítico mediante revisión de expedientes clínicos de pacientes que asistieron a la consulta externa del Servicio de Endocrinología del Centro Médico Nacional 20 de Noviembre; universo 88 expedientes, muestra por conveniencia 55 expedientes. Resultados: 35(63.6%) pacientes alcanzaron control óptimo de tratamiento a dosis de calcio elemental de 5.7-9.79g/24h (p= 0.0001 chi cuadrado), mostrando calcio sérico promedio 8.36 0.55 mg/dl y calcitriol con mediana de 0.5µg/24 h. 15(27.2%) pacientes presentaron efectos secundarios al uso de calcio oral, 3 de ellos requirieron manejo con Hormona Paratiroidea Recombinante Humana para alcanzar control óptimo. Conclusión: el calcio elemental por vía oral continúa siendo la piedra angular en el tratamiento del hipoparatiroidismo post quirúrgico permanente, con pocos efectos adversos. Se recomiendan más estudios aleatorizados para identificar las características de los pacientes candidatos al manejo con Hormona Paratiroidea Recombinante Humana...(AU)

Surgical and Pharmacological Outcomes in Acromegaly: Real-Life Data From the Mexican Acromegaly Registry.

CONTEXT: Acromegaly registries constitute a valuable source of therapeutic outcome information in real-life. OBJECTIVE: The objective of this work is to analyze surgical and pharmacological outcomes in the Mexican Acromegaly Registry (MAR). DESIGN AND METHODS: Data were extracted from the MAR informatic platform. Surgical remission was defined by a postoperative postglucose (GH) of less than 1 ng/mL and an insulin-like growth factor 1 (IGF-1) of less than 1.2 × upper limit of normal (ULN). Pharmacological remission was defined by a basal GH of less than 1 ng/mL and an IGF-1 of less than 1.2 × ULN. RESULTS: A total of 650 surgical outcomes were analyzed (94.6% transsphenoidal). Surgical remission was achieved in 40.15%, whereas 44.15% remained biochemically active. Persistently active disease after surgery was significantly associated with harboring an invasive macroadenoma, a basal GH of greater than 10 ng/mL, and/or an IGF-1 of greater than 2 × ULN at diagnosis on bivariate and multivariate analysis. The outcome of monotherapy with first-generation somatostatin analogs (SSAs) was evaluated in 267 patients (adjunctive in 65%), of whom 28.4% achieved remission. Persistently active disease was significantly associated with harboring an invasive macroadenoma as well as with pretreatment basal GH and IGF-1 levels of greater than 10 ng/mL and greater than 2 × ULN, respectively, on bivariate and multivariate analysis. Combined therapy with SSA and cabergoline was analyzed in 100 patients, of whom 19% achieved remission and 44% remained active; in this subset of patients, only a pretreatment IGF-1 of greater than 2 × ULN was significantly associated with persistent disease activity. CONCLUSION: Surgical and pharmacological outcomes in acromegaly are highly dependent on tumor size/invasiveness as well as on the degree of hypersomatotropinemia.

Vitamin D deficiency in Mexicans have a high prevalence: a cross-sectional analysis of the patients from the Centro Médico Nacional 20 de Noviembre.

Disorders of vitamin D concentration (deficiency or insufficiency) are a global health problem, which are associated with various chronic diseases. In Latin America, alterations in vitamin D prevalence are different from those shown in previous studies and may be due to differences in geographic location, skin color, and diet type. PURPOSE: To know the prevalence of vitamin D insufficiency (21-29 ng/mL) and deficiency (< 20 ng/mL) in Mexican patients; although it is a risk factor for developing multiple complex diseases, its prevalence in the population is still unknown. METHODS: Cross-sectional study carried out at the endocrinology service of the highly specialized national center November 20. Data on cardiovascular risk factors were obtained and 25-hydroxy vitamin D was measured by chemiluminescence. Prevalence was calculated, and the results were analyzed to categorize the patients according to 25-hydroxy vitamin D deficient or insufficient levels. RESULTS: The mean value of the serum vitamin D concentration was 18.37 ng/mL. Of the 117 patients, 93.2% (n = 109) have decreased vitamin D values; 62.4% (n = 73) of the patients had vitamin D deficiency and 30.8% (n = 36) vitamin D insufficiency. The prevalence of vitamin D deficiency was 62.4% and 30.8% for vitamin D insufficiency. The total prevalence of alterations in vitamin D levels in this population was 93.2%. CONCLUSIONS: This study reports a prevalence of vitamin D deficiency and insufficiency much higher than those described by previous studies, which is of utmost importance for the population due to the morbidities associated with these alterations.

The Mexican Acromegaly Registry: Clinical and Biochemical Characteristics at Diagnosis and Therapeutic Outcomes.

CONTEXT: Acromegaly is a systemic disorder caused by a GH-secreting pituitary adenoma. As with other rare diseases, acromegaly registries developed in various European countries have provided us with important information. OBJECTIVE: The objective of the study was to analyze the epidemiological, clinical, biochemical, and therapeutic data from the Mexican Acromegaly Registry (MAR). SETTING: The setting of the study was a nationwide patient registry. DESIGN AND METHODOLOGY: The MAR was created in 2009. It gathers data from 24 participating centers belonging to three different institutions using a specifically designed on-line platform. Only patients diagnosed after 1990 were included in the program. RESULTS: A total of 2057 patients (51% female, mean age at diagnosis 41.1 ± 24.5 y) have been registered for an estimated prevalence of 18 cases per 1 million inhabitants. Hypertension, glucose intolerance, diabetes, and dyslipidemia were present in 27%, 18.4%, 30%, and 24% of the patients, respectively. The IGF-1 level at diagnosis and the concomitant presence of hypertension were significantly associated with the development of diabetes. Transsphenoidal surgery was the primary treatment in 72% of the patients. Pharmacological treatment, mostly with somatostatin analogs, was administered primarily and adjunctively in 26% and 54% of the patients, respectively. Treatment choice varied among the three participating institutions, with the predominance of pharmacological therapy in two of them and of radiation therapy in the third. Therapeutic outcomes were similar to those reported in the European registries. CONCLUSIONS: The MAR is the largest and first non-European registry of the disease. Our findings highlight important within-country differences in treatment choice due to variations in the availability of resources.

[Reduction in requirements of oral calcium and 1-25 dihydroxy vitamin D in patients with post-surgical hypoparathyroidism treated with teriparatide (PTH1-34)]. / Reducción en los requerimientos de calcio oral y de 1-25 dihidroxi-vitamina D en pacientes con hipoparatiroidismo posquirúrgico tratados con teriparatida (PTH1-34).

The objective of the study is to evaluate the effect of daily administration of recombinant parathyroid hormone (PTH1-34), 20 µg, on serum calcium concentrations (Cas), and the requirements of oral calcium and calcitriol in patients with hypoparathyroidism. It is a prospective, longitudinal study, analytical, with intervention, in patients treated with high doses of calcium (> 7 g/day), with symptoms of hypocalcemia and/or intolerant to treatment. Serum levels of phosphorus (Ps) and Cas, urinary calcium excretion, oral doses of calcitriol and calcium were compared before and after administration of teriparatide, for three months on average, in patients with post-surgical hypoparathyroidism. We studied 16 patients with oral elemental calcium requirements of 22.5 ± 16 g/day of calcitriol 0.79 ± 0.4 µg/day. Cas at baseline was 7.6 ± 1.2 and Ps 5.4 ± 0.76 mg/dl. After administration of teriparatide, Cas was 9.0 ± 0.69 mg/dl (p = 0.007) and Ps of 4.5 ± 0.87 mg/dl (p = 0.003). Doses of calcium and calcitriol showed a statistically significant reduction (p = 0.0001 and 0.001, respectively). We conclude that use of recombinant parathyroid hormone can normalize Cas and Ps, with reduction in oral calcium and calcitriol requirements.

[Consensus of diagnosis and treatment of obesity in women in reproductive age and climacterium]. / Consenso de diagnóstico y tratamiento de la obesidad en la mujer en edad reproductiva y en el climaterio.

BACKGROUND: The development of obesity is complex and multifactorial, with genetic, biological, environmental and lifestyle of each individual etiology. The different changes in metabolism of women, amongst other factors, lead to disorganization in the distribution of lipids, which gathered in large quantities within the viscera, increases cardiovascular mortality and it is a major determinant factor of the metabolic syndrome. OBJECTIVE: To homologate and to apply concepts of evidence-based clinical practice in diagnosis and treatment of obesity in women in reproductive age and climacterium. METHOD: The experts' consensus was done by specialized physicians properly endocrinologists, gynecologists, surgeons, psychologists, nutrition specialists, physical activity and public health, according to their expertise and clinical judgment. The recommendations were based in diagnostic criteria aside from the level of evidence of previously established treatment guidelines, controlled clinical trials and standardized guides for women in reproductive age and climacterium with obesity. RESULTS: The establishment of a nutritional intervention amongst other aspects of lifestyle is the first-line in the treatment of obesity. Current pharmacological treatments offer modest results in efficiency and security in weight reduction so these must go along with real changes in lifestyle in order to obtain better results in the short and long term. CONCLUSION: The high prevalence of overweight and obesity in our country, especially in women in reproductive age, compels us to pose and work in prevention strategies as well as diverse therapeutic plans favoring safe weight loss and results in the long term.

Sleep apnea in patients with acromegaly. Frequency, characterization and positive pressure titration.

OBJECTIVES: to describe the frequency of sleep apnea in patients with acromegaly;to identify the proportion of candidates for treatment with positive airway pressure;to report our experience with the positive pressure titration process in acromegaly patients. METHODS: A cross-sectional study that included the acromegaly cohort at the Centro Medico Nacional "20 de Noviembre" in Mexico City (n=44). A standard polysomnography (PSG) was carried out for each patient. A second PSG was done for purposes of CPAP titration. RESULTS: A total of 35 patients were studied (80% of the cohort, 20 [57%] women). Polysomnography results showed that 34 subjects (97%, 95%CI 91-100%) had apnea hypopnea indexes (AHI) ≥ 5. No patient had central apnea. We identified 19 subjects with AHI ≥5 and Epworth ≥10, for a frequency of obstructive sleep apnea syndrome of 54% (95%CI 36-71%). A total of 31 patients (88%; 95%CI 77-99%) were deemed to be candidates for positive pressure treatment, but only 8 of them accepted CPAP. They required pressures that ranged from 10 to 18 cmH(2)O. CONCLUSIONS: Our results confirm a high prevalence of sleep apnea in patients with acromegaly, and provide evidence that the majority of those patients are candidates for treatment with positive pressure. Contrary to what has been reported, we identified no patients with central apnea.

Risk factors and impact on bone mineral density in postmenopausal Mexican mestizo women.

OBJECTIVE: Considering that the Mexican mestizo population seems to be the result of a genetic admixture, we proposed that further research is needed to evaluate the role of ethnicity in conjunction with health-related factors to better understand ethnic differences in bone mineral density (BMD). The aim of this study was to analyze several risk factors related to the development of osteoporosis in postmenopausal Mexican mestizo women. METHODS: We included 567 postmenopausal Mexican mestizo women. A structured questionnaire for risk factors was applied and BMD was measured in total hip and lumbar spine by dual-energy x-ray absorptiometry. Nonconditional logistic regression was used to estimate crude and adjusted odds ratio. RESULTS: Using World Health Organization criteria, 28.7% of postmenopausal women had osteoporosis, 46.4% had osteopenia, and 24.9% had normal BMD. Each clinical risk factor had a different significance for osteopenia/osteoporosis; however, duration of total breast-feeding, body mass index, and number of years since menopause remained significantly associated with osteopenia/osteoporosis after bone density was added to the nonconditional model. Interestingly, extended periods of accumulated breast-feeding for 24 and 36 months were, in both cases, significantly associated with osteopenia/osteoporosis. CONCLUSIONS: Our results confirm the importance of considering the duration of breast-feeding as an important risk factor for osteopenia/osteoporosis. In addition, we find that body mass index is positively associated with BMD. Because of the heterogeneity of the Mexican mestizo population, the risk factor for osteoporosis may not be the same in different ethnic groups.