Preoperative thyroid function and weight loss after bariatric surgery.

Thyroid function has an important role on body weight regulation. However, the impact of thyroid function on weight loss after bariatric surgery is still largely unknown. We evaluated the association between preoperative thyroid function and the excess weight loss 1 year after surgery, in 641 patients with morbid obesity who underwent bariatric surgery. Patients with a history of thyroid disease, treatment with thyroid hormone or antithyroid drugs and those with preoperative evaluation consistent with overt hypothyroidism or hyperthyroidism were excluded. The preoperative levels of TSH and FT4 were not associated with weight loss after bariatric surgery. The variation of FT3 within the reference range was also not associated with weight loss. In contrast, the subgroup with FT3 above the reference range (12.3% of patients) had a significantly higher excess weight loss than patients with normal FT3. This difference remained significant after adjustment for age, sex, BMI, type of surgery, TSH and FT4. In conclusion, we observed an association between high FT3 and a greater weight loss after bariatric surgery, highlighting a group of patients with an increased benefit from this intervention. Our results also suggest a novel hypothesis: the pharmacological modulation of thyroid function may be a potential therapeutic target in patients undergoing bariatric surgery.

Pregnancy after bariatric surgery: Maternal and fetal outcomes of 39 pregnancies and a literature review.

AIM: We aimed to evaluate the impact of bariatric surgery (BS) on maternal and fetal outcomes. METHODS: A retrospective, descriptive, observational study of 39 pregnant women who underwent BS in our institution between 2010 and 2014 was carried out. A sample of women who became pregnant after BS was evaluated, based on data concerning pregnancy, childbirth, and newborns. RESULTS: Of the 1182 patients who underwent BS at our institution during the study period, 1016 (85.9%) were women. Thirty-nine of these women (with an average age of 31 ± 4.8 years) became pregnant (one twin pregnancy) and 29 of the 39 had undergone a gastric bypass. The mean time interval between BS and pregnancy was 16.6 ± 4.8 months; however, 16 (41%) women became pregnant less than a year after BS. The pre-BS body mass index (BMI) of the 39 women was 44.5 ± 6.2 kg/m2 . The women had a mean BMI of 30.2 ± 3.8 kg/m2 when they got pregnant and they gained 13.2 ± 7.3 kg during pregnancy. Iron deficiency was observed in 18 (46.1%) women, 16 (45.7%) had vitamin B12 deficiency, 12 (66.8%) had zinc deficiency, and 20 (60.6%) had vitamin D deficiency. Three women developed gestational diabetes mellitus. Premature rupture of membranes occurred in two pregnancies, preterm delivery in five, and there was one spontaneous abortion. Cesarean section was performed in seven cases. The average newborn weight was 3002 ± 587 g, five were small for gestational age, and one had macrosomia. Three infants had to be admitted to an intensive care unit. CONCLUSION: Although pregnancy after BS is safe and well tolerated, close monitoring by a multidisciplinary team is required to evaluate complications resulting from BS, especially a deficit of micronutrients.

Acute suppurative thyroiditis with Graves disease - A very rare association.

Acute suppurative thyroiditis is an uncommon disorder caused by a bacterial infection, usually presenting with normal thyroid function. It is a serious condition that requires a prompt diagnosis and treatment with antibiotics and supportive measures. A 62 years-old female presented with a painful cervical induration and odynophagia a week after a fish bone had been removed from her pharynx. She was febrile, and tachycardic and, on physical examination, a painful thyroid mass was detected. High inflammatory parameters and thyrotoxicosis were confirmed: thyroid stimulating hormone (TSH) < 0.01 mIU/L (normal range [NR] 0.27-4.2); free thyroxine (FT4) 3.86 ng/dL (NR 0.9-1.7) and anti-TSH receptor antibodies (TRABs) 5.3 U/L (NR < 1.5). Thyroid scintigraphy showed a diffuse uptake of the thyroid parenchyma suggesting Graves disease. Cervical ultrasonography revealed an abscess of the left thyroid lobe of 36 × 36 mm and fine needle aspiration biopsy (FNAB) with partial drainage was performed. Staphylococcus aureus and Streptococcus viridans were isolated, and directed antibiotic therapy was started. Clinical improvement was observed as well as a decrease of inflammatory parameters and the patient was discharged after 9 days of hospitalization. Eighteen days after discharge, thiamazole was initiated due to persistent thyrotoxicosis. Complete resolution of the abscess was documented within 6 months and the patient became euthyroid under thiamazole one year after initial presentation. To our knowledge, this is the third case reporting an association between acute thyroiditis and Graves disease. Furthermore, this is the first case detailing the simultaneous diagnosis of acute suppurative thyroiditis caused by a foreign body and Graves disease.

Analyzing the Impact of Bariatric Surgery in Kidney Function: a 2-Year Observational Study.

BACKGROUND: Obesity is an independent risk factor for chronic kidney disease (CKD). Our aims were: (1) to evaluate the impact of bariatric surgery (BS) on kidney function, (2) clarify the factors determining postoperative evolution of glomerular filtration rate (ΔGFR) and urinary albumin-to-creatinine ratio (ΔUACR), and (3) access the occurrence of oxalate-mediated renal complications. METHODS: We investigated a cohort of 1448 obese patients who underwent BS. Those with baseline-estimated GFR (eGFR0) < 30 mL/min or without information about the 2-year post-surgical eGFR (eGFR2) were excluded. RESULTS: A total of 725 patients were included. At baseline, 38(5.2%) had hyperfiltration with eGFR0 ≥ 125 mL/min/1.73m2 (G0), 492 (67.9%) had eGFR0 90-124 mL/min/1.73m2 (G1), 178 (24.6%) had eGFR0 60-89 mL/min/1.73m2 (G2), and 17 (2.3%) had eGFR0 < 60 mL/min/1.73m2 (G3). ΔGFR significantly increased in 96.6% (ΔGFR = 23.8 (IQR 15.9-29.8)) and 82.4% (ΔGFR = 18.6 (IQR 3.6-44.0)) of the subjects with G2 and G3 CKD, respectively (p < 0.001). The variables independently associated with ΔGFR were baseline body mass index (BMI) (positively), high blood pressure (HBP) (negatively), and fasting plasma glucose (FPG) (negatively), as well as FPG variation (positively). An overall prevalence of high UACR (≥ 30 mg/g-1) of 17.9% was found, with 81.5% of these subjects presenting A2(30-300 mg/g-1) and 18.5% A3(> 300 mg/g-1) UACR. UACR significantly decreased after BS (p < 0.001). Significant predictors of ΔUACR were BMI, systolic blood pressure, and HbA1c. Urinary excretion of calcium oxalate crystals was found in 77(11.1%) patients, with only 1 presenting oxalate-mediated renal complications. CONCLUSIONS: ΔGFR seems to be influenced by the initial kidney function, as it decreases in subjects with hyperfiltration but tends to increase in those with kidney dysfunction. These results suggest that BS is associated with improvement of kidney outcomes, without a significant increase in renal complications.

Acute suppurative thyroiditis with Graves disease - A very rare association

SUMMARY Acute suppurative thyroiditis is an uncommon disorder caused by a bacterial infection, usually presenting with normal thyroid function. It is a serious condition that requires a prompt diagnosis and treatment with antibiotics and supportive measures. A 62 years-old female presented with a painful cervical induration and odynophagia a week after a fish bone had been removed from her pharynx. She was febrile, and tachycardic and, on physical examination, a painful thyroid mass was detected. High inflammatory parameters and thyrotoxicosis were confirmed: thyroid stimulating hormone (TSH) < 0.01 mIU/L (normal range [NR] 0.27-4.2); free thyroxine (FT4) 3.86 ng/dL (NR 0.9-1.7) and anti-TSH receptor antibodies (TRABs) 5.3 U/L (NR < 1.5). Thyroid scintigraphy showed a diffuse uptake of the thyroid parenchyma suggesting Graves disease. Cervical ultrasonography revealed an abscess of the left thyroid lobe of 36 × 36 mm and fine needle aspiration biopsy (FNAB) with partial drainage was performed. Staphylococcus aureus and Streptococcus viridans were isolated, and directed antibiotic therapy was started. Clinical improvement was observed as well as a decrease of inflammatory parameters and the patient was discharged after 9 days of hospitalization. Eighteen days after discharge, thiamazole was initiated due to persistent thyrotoxicosis. Complete resolution of the abscess was documented within 6 months and the patient became euthyroid under thiamazole one year after initial presentation. To our knowledge, this is the third case reporting an association between acute thyroiditis and Graves disease. Furthermore, this is the first case detailing the simultaneous diagnosis of acute suppurative thyroiditis caused by a foreign body and Graves disease.

A challenging coexistence of central diabetes insipidus and cerebral salt wasting syndrome: a case report.

BACKGROUND: Combined central diabetes insipidus and cerebral salt wasting syndrome is a rare clinical finding. However, when this happens, mortality is high due to delayed diagnosis and/or inadequate treatment. CASE PRESENTATION: A 42-year-old white man was referred to neurosurgery due to a non-functional pituitary macroadenoma. He underwent a partial resection of the tumor on July 2, 2015. On the day following surgery he presented polyuria with sodium 149 mEq/L, plasma osmolality 301 mOsm/kg, and urine osmolality 293 mOsm/kg. He started nasal desmopressin 0.05 mg/day with good response. He was already on dexamethasone 4 mg and levothyroxine 75 mcg due to hypopituitarism after surgery. On July 9 he became confused. Cerebral computed tomography was performed with no significant changes. His natremia dropped to 128 mEq/L with development of polyuria despite maintenance of desmopressin dose. His hemoglobin and hematocrit rose from 9.1 g/L to 11.6 g/L and 27.5 to 32.5, respectively. His thyroid function was normal and he was on hydrocortisone 30 mg/day. At 12 p.m. 150 mg/hydrocortisone infusion was initiated, but sodium did not increase. Plasma and urine osmolality were 264 mOsm/kg and 679 mOsm/kg, respectively. At 4 p.m. hydrocortisone was increased and hypertonic saline replacement started. Two hours later he was dehydrated with polyuria and vomiting, and natremia of 124 mEq/L. Hyponatremia was very resistant to treatment despite hypertonic saline replacement, hence desmopressin was suspended. The following day, urine spot analysis showed that natriuresis was 63 mEq/L with serum sodium 132 mEq/L. This was interpreted as a cerebral salt wasting syndrome and control was achieved with aggressive hypertonic saline replacements and fludrocortisone 0.1 mg/three times a day. CONCLUSIONS: We present a rare case of a patient with diabetes insipidus and cerebral salt wasting syndrome, who was successfully treated. Hyponatremia in a patient with diabetes insipidus may erroneously be interpreted as inadequate diabetes insipidus control or as syndrome of inappropriate antidiuretic hormone secretion, leading to therapeutic errors. Thus, all clinical and analytical data should be evaluated together for early and correct diagnosis.

The Effect of the Bariatric Surgery Type on the Levothyroxine Dose of Morbidly Obese Hypothyroid Patients.

BACKGROUND: Doubts exist about the effect of different bariatric surgery (BS) types on levothyroxine (Lt4) absorption. We compared Lt4 doses and their variation (ΔLt4) in patients with hypothyroidism that underwent malabsorptive (MS) or restrictive (RS) surgery and studied predictors of Lt4 dose change. METHODS: Retrospective study of morbidly obese hypothyroid patients submitted to BS. We compared RS ("sleeve" gastrectomy or adjustable gastric banding) with MS (Roux-en-Y gastric bypass) patients. We built a multivariable logistic regression and a linear regression model to study predictors of Lt4 dose changes and ΔLt4, respectively. RESULTS: Fifty-seven patients: 35 MS and 22 RS. Mean age 47 years; 7% men. Patients submitted to MS had lower BMI at 1 year than those submitted to RS. Lt4 dose remained unchanged in 61.4%, increased in 12.3%, and decreased in 26.3% of patients. Initial and 1-year Lt4 dose were not different between surgical groups. Relative Lt4 dose, but not absolute (p = 0.07), increased at 1 year (p < 0.001). Neither BS nor BMI variation were predictors of Lt4 dose variation. BMI variation was associated with relative Lt4 dose change independently of initial BMI and BS type: ß (95%CI) - 0.03 (- 0.05; 0.00); p = 0.03. CONCLUSIONS: There were no differences in Lt4 dose and its variation between restrictive and malabsorptive techniques 1 year after surgery. Malabsorptive procedures may not affect Lt4 absorption differently from restrictive ones. Bariatric surgery type was not predictive of Lt4 dose changes. BMI variation is associated with relative Lt4 dose (dose per weight) variation and its association was independent of bariatric surgery type.

Effect of Weight Loss after Bariatric Surgery on Thyroid-Stimulating Hormone Levels in Patients with Morbid Obesity and Normal Thyroid Function.

BACKGROUND: Several studies have reported that morbid obesity is associated with increased thyroid-stimulating hormone (TSH) levels. However, it is not clear what is the impact of bariatric surgery on postoperative thyroid function. The aim of this study was to evaluate the effect of weight loss after bariatric surgery on TSH levels in euthyroid patients with morbid obesity. METHODS: We performed a retrospective observational study of 949 euthyroid patients (86.1% female; age 42.0 ± 10.3 years, BMI 44.3 ± 5.7 kg/m2) with morbid obesity submitted to bariatric surgery (laparoscopic adjustable gastric band, Roux-en-Y gastric bypass, or sleeve gastrectomy). Patients were subdivided in two groups: normal TSH group (TSH <2.5 mU/L) and high-normal TSH group (TSH ≥2.5 mU/L). The impact of anthropometric parameters, comorbidities, TSH, free thyroxine (FT4), free triiodothyronine (FT3), type of surgery, and excessive body weight loss (EBWL) on TSH variation 12 months after surgery was evaluated. RESULTS: The high-normal TSH group (24.3% of patients) included more women, presented a higher BMI, higher systolic blood pressure, and higher FT3 levels. There was a significant decrease of TSH 12 months after surgery that was more marked in the high-normal TSH group (normal TSH group: 1.57 ± 0.49 to 1.53 ± 0.69 mIU/L, p = 0.063; high-normal TSH group: 3.23 ± 0.59 to 2.38 ± 0.86 mIU/L, p < 0.001). In a multivariate analysis, after adjusting for relevant covariates, EBWL, baseline BMI, and baseline FT3 were significantly associated with TSH decrease 12 months after bariatric surgery. CONCLUSION: Bariatric surgery promotes a decrease of TSH that is significantly greater in patients with high-normal TSH and is independently associated with EBWL after surgery.

Malignant melanoma with synchronous thyroid metastases: case report and literature review.

Thyroid metastases are rare in clinical practice. We describe the case of an 85-year-old woman who was referred to our department due to a multinodular goiter with compressive symptoms and subclinical hyperthyroidism. The patient was also undergoing evaluation for a polyp in her left nasal cavity, which was then diagnosed as a malignant melanoma of the nasal mucosa. A thoracoabdominal magnetic resonance imaging obtained for cancer staging revealed a > 50% tracheal obstruction caused by the goiter. The patient underwent simultaneous total thyroidectomy and melanoma excision. Histological analysis of the thyroid showed the presence of multiple metastatic foci from the melanoma. Due to the patient's age, a decision was made to maintain her under surveillance and administer palliative treatment if necessary. Although metastases to the thyroid are rare, they should be considered in the differential diagnosis of thyroid lesions in patients with a known primary tumor. The thyroidectomy, performed in this patient's case, allowed the diagnosis of the metastases and relief of compressive symptoms caused by the goiter.

Preoperative Beta Cell Function Is Predictive of Diabetes Remission After Bariatric Surgery.

BACKGROUND: Bariatric surgery can improve glucose metabolism in obese patients with diabetes, but the factors that can predict diabetes remission are still under discussion. The present study aims to examine the impact of preoperative beta cell function on diabetes remission following surgery. MATERIALS AND METHODS: We investigated a cohort of 363 obese diabetic patients who underwent bariatric surgery. The impact of several preoperative beta cell function indexes on diabetes remission was explored through bivariate logistic regression models. RESULTS: Postoperative diabetes remission was achieved in 39.9 % of patients. Younger patients (p < 0.001) and those with lower HbA1c (p = 0.001) at the baseline evaluation had higher odds of diabetes remission. Use of oral anti-diabetics and insulin therapy did not reach statistical significance when they were adjusted for age and HbA1c. Among the evaluated indexes of beta cell function, higher values of insulinogenix index, Stumvoll first- and second-phase indexes, fasting C-peptide, C-peptide area under the curve (AUC), C-peptide/glucose AUC, ISR (insulin secretion rate) AUC, and ISR/glucose AUC predicted diabetes remission even after adjustment for age and HbA1c. Among them, C-peptide AUC had the higher discriminative power (AUC 0.76; p < 0.001). CONCLUSIONS: Patients' age and preoperative HbA1c can forecast diabetes remission following surgery. Unlike other studies, our group found that the use of oral anti-diabetics and insulin therapy were not independent predictors of postoperative diabetes status. Preoperative beta cell function, mainly C-peptide AUC, is useful in predicting diabetes remission, and it should be assessed in all obese diabetic patients before bariatric or metabolic surgery.

Malignant melanoma with synchronous thyroid metastases: case report and literature review

SUMMARY Thyroid metastases are rare in clinical practice. We describe the case of an 85-year-old woman who was referred to our department due to a multinodular goiter with compressive symptoms and subclinical hyperthyroidism. The patient was also undergoing evaluation for a polyp in her left nasal cavity, which was then diagnosed as a malignant melanoma of the nasal mucosa. A thoracoabdominal magnetic resonance imaging obtained for cancer staging revealed a > 50% tracheal obstruction caused by the goiter. The patient underwent simultaneous total thyroidectomy and melanoma excision. Histological analysis of the thyroid showed the presence of multiple metastatic foci from the melanoma. Due to the patient’s age, a decision was made to maintain her under surveillance and administer palliative treatment if necessary. Although metastases to the thyroid are rare, they should be considered in the differential diagnosis of thyroid lesions in patients with a known primary tumor. The thyroidectomy, performed in this patient’s case, allowed the diagnosis of the metastases and relief of compressive symptoms caused by the goiter.

Papulose Bowenóide: um caso clinico / Bowenoide papulosis: a clinical case

Descrevemos o caso clínico de um doente com papulose bowenóide localizada na pele da prega inguino-escrotal direita, tendo sido feita comprovaçao histopatológica e identificaçao de Papilomavírus Humano tipo 16 em material de biópsia.