Is a second recombinant human thyrotropin stimulation test useful? The value of postsurgical undetectable stimulated thyroglobulin level at the time of remnant ablation on clinical outcome.

OBJECTIVE: The management of patients with differentiated thyroid cancer (DTC) has changed in recent years, and monitoring depends on the risk of persistent/recurrent disease. The objective was to assess the prognostic value of a single stimulated thyroglobulin (Tg) measured at the time of the first radioiodine therapy (Stim-Tg1), and the utility of a second stimulated Tg measurement performed 6-12 months later (Stim-Tg2). We also examined the role of neck ultrasound (US) in the early diagnosis of recurrence. DESIGN: This was a retrospective observational cohort study conducted in a tertiary referral hospital. Of 213 evaluated patients with DTC, 169 were finally included. METHODS: Measurement of Stim-Tg1, Stim-Tg2 and neck US. RESULTS: Stim-Tg1 was undetectable in 71 of 169 patients (42%). All of them (71/71) continued to have negative Stim-Tg2. Seventy of 71 had an excellent response to the first treatment. Sixty-eight of 71 had no evidence of disease after an average follow-up of 7·2 years. In patients with detectable Stim-Tg1 (98/169; 58%), Stim-Tg2 became negative in 40. The negative predictive value (NPV) of Stim-Tg1 was 0·96. The optimal Stim-Tg1 cut-off level for identifying persistence was 3·65 ng/ml. Recurrence was detected in 14 patients. Neck US was useful for identifying local recurrence (13/14; 92·85%). CONCLUSIONS: Stim-Tg1 is a reliable marker with a high NPV. A second stimulation test should be avoided in patients with negative Stim-Tg1. In patients with biochemical persistence, Stim-Tg2 is useful for confirming/ruling out final status. Neck US plays a valuable role in the early diagnosis of recurrence.

Ultrasound Muscle Evaluation for Predicting the Prognosis of Patients with Head and Neck Cancer: A Large-Scale and Multicenter Prospective Study.

Head and neck cancer (HNC) is a prevalent and aggressive form of cancer with high mortality rates and significant implications for nutritional status. Accurate assessment of malnutrition in patients with HNC is crucial for optimizing treatment outcomes and improving survival rates. This study aimed to evaluate the use of ultrasound techniques for predicting nutritional status, malnutrition, and cancer outcomes in patients with HNC. A total of 494 patients with HNC were included in this cross-sectional observational study. Various tools and body composition measurements, including muscle mass and adipose tissue ultrasound evaluations, were implemented. Using regression models, we mainly found that high levels of RF-CSA (rectus femoris cross-sectional area) were associated with a decreased risk of malnutrition (as defined with GLIM criteria (OR = 0.81, 95% CI: 0.68-0.98); as defined with PG-SGA (OR = 0.78, 95% CI: 0.62-0.98)) and sarcopenia (OR = 0.64, 95% CI: 0.49-0.82) after being adjusted for age, sex, and BMI. To predict the importance of muscle mass ultrasound variables on the risk of mortality, a nomogram, a random forest, and decision tree models were conducted. RF-CSA was the most important variable under the random forest model. The obtained C-index for the nomogram was 0.704, and the Brier score was 16.8. With an RF-CSA < 2.7 (AUC of 0.653 (0.59-0.77)) as a split, the decision tree model classified up to 68% of patients as possessing a high probability of survival. According to the cut-off value of 2.7 cm2, patients with a low RF-CSA value lower than 2.7 cm2 had worse survival rates (p < 0.001). The findings of this study highlight the importance of implementing ultrasound tools, for accurate diagnoses and monitoring of malnutrition in patients with HNC. Adipose tissue ultrasound measurements were only weakly associated with malnutrition and not with sarcopenia, indicating that muscle mass is a more important indicator of overall health and nutritional status. These results have the potential to improve survival rates and quality of life by enabling early intervention and personalized nutritional management.

Improving the nutritional evaluation in head neck cancer patients using bioelectrical impedance analysis: Not only the phase angle matters.

BACKGROUND: Malnutrition and sarcopenia are highly prevalent in patients with head neck cancer (HNC). An accurate early diagnosis is necessary for starting nutritional support, as both are clearly associated with clinical outcomes and mortality. We aimed to evaluate the applicability and accuracy of body composition analysis using electrical bioimpedance vectorial analysis (BIVA) for diagnosing malnutrition and sarcopenia in patients with HNC cancer undergoing systemic treatment with chemotherapy or radiotherapy. METHODS: Cross-sectional, observational study that included 509 HNC patients. A comprehensive nutritional evaluation that included BIVA was performed. RESULTS: The prevalence of malnutrition was higher in patients that received treatment with chemotherapy (59.2% vs. 40.8%, P < 0.001); increased mortality was observed in malnourished patients (33.3% vs. 20.1%; P < 0.001); ECOG status (1-4) was also worse in malnourished patients (59.2% vs. 22.8% P < 0.001). Body cell mass (BCM) and fat mass were the most significantly associated parameters with malnutrition [OR 0.88 (0.84-0.93) and 0.98 (0.95-1.01), respectively]; BCM and fat free mass index (FFMI) were associated with several aspects including (1) the patient-generated subjective global assessment [OR 0.93 (0.84-0.98) and 0.86 (0.76-0.97), respectively], (2) the presence of sarcopenia [OR 0.81 (0.76-0.87) and 0.78 (0.66-0.92), respectively]. A BCM index (BCMI) < 7.8 in combination with other parameters including FFMI and BCM accurately predicted patients with malnutrition [accuracy 95% CI: 0.803 (0.763-0.839); kappa index: 0.486; AUC: 0.618 (P < 0.01)]. A BCMI cutoff of 7.6 was enough for identifying males with malnutrition (P < 0.001), while it should be combined with other parameters in females. CONCLUSIONS: Body composition parameters determined by BIVA accurately identify patients with HNC and malnutrition. Phase angle, but other parameters including BCMI, FFMI and BCM provide significant information about nutritional status in patients with HNC.

Prognostic value of bioelectrical impedance analysis in head and neck cancer patients undergoing radiotherapy: a VALOR® study.

Introduction: Bioelectrical impedance analysis (BIA) serves as a method to estimate body composition. Parameters such as phase angle (PA), standardized phase angle (SPA), body mass cell (BCM), BCM index (BCMI), and fat-free mass (FFM) might significantly impact the prognosis of head and neck cancer (HNC) patients. The present study aimed to investigate whether bioelectrical parameters can be used to predict survival in the HNC population and establish the optimal cutoff points for predictive accuracy. Methods: A multicenter observational study was performed across 12 tertiary hospitals in Andalusia (a region from the south of Spain). A total of 494 patients diagnosed with HNC between 2020 and 2022 at different stages were included in this study, with a minimum follow-up period of 12 months. The BIA assessment was carried out during the first 2 weeks of radical radiotherapy treatment with chemotherapy or other systemic treatments. A multivariate logistic regression analysis of overall survival, complications, hospital admission, and palliative care and its relationship with BIA nutritional assessment was performed. Results: Significant prognostic factors identified in the multivariable analysis encompassed phase angle (PA), standardized phase angle (SPA), body cell mass (BCM), and BCM index (BCMI). Lower PA and BCM values were significantly associated with adverse clinical outcomes. A BCM threshold above 17 kg/m2 was the most significant predictor for predicting survival within the overall HNC population. The PA values of <5.1° in male and <4.8° in female patients showed the best predictive potential for mortality. Increased PA (as a continuous variable) demonstrated a significantly reduced risk for mortality (OR, 0.64; 95% CI, 0.43-0.94; p < 0.05) and a decreased likelihood of hospital admission (OR, 0.75; 95% CI, 0.52-1.07; p < 0.05). Higher BCM correlated with a lower risk of mortality (OR, 0.88; 95% CI, 0.80-0.96; p < 0.01) and a diminished probability of hospital admission (OR, 0.91; 95% CI, 0.83-0.99; p < 0.05). Conclusion: BIA is a crucial tool in the nutritional assessment of HNC patients. BCM and PA are the main bioelectrical parameters used to predict clinical outcomes in this population. Future studies are needed to validate BIA variables in a large cohort to ensure whether early intensification of nutritional treatment would improve survival.

Ultrasound Cut-Off Values for Rectus Femoris for Detecting Sarcopenia in Patients with Nutritional Risk.

BACKGROUND: A nationwide, prospective, multicenter, cohort study (the Disease-Related caloric-protein malnutrition EChOgraphy (DRECO) study) was designed to assess the usefulness of ultrasound of the rectus femoris for detecting sarcopenia in hospitalized patients at risk of malnutrition and to define cut-off values of ultrasound measures. METHODS: Patients at risk of malnutrition according to the Malnutrition Universal Screening Tool (MUST) underwent handgrip dynamometry, bioelectrical impedance analysis (BIA), a Timed Up and Go (TUG) test, and rectus femoris ultrasound studies. European Working Group on Sarcopenia in Older People (EWGSOP2) criteria were used to define categories of sarcopenia (at risk, probable, confirmed, severe). Receiver operating characteristic (ROC) and area under the curve (AUC) analyses were used to determine the optimal diagnostic sensitivity, specificity, and predictive values of cut-off points of the ultrasound measures for the detection of risk of sarcopenia and probable, confirmed, and severe sarcopenia. RESULTS: A total of 1000 subjects were included and 991 of them (58.9% men, mean age 58.5 years) were evaluated. Risk of sarcopenia was detected in 9.6% patients, probable sarcopenia in 14%, confirmed sarcopenia in 9.7%, and severe sarcopenia in 3.9%, with significant differences in the distribution of groups between men and women (p < 0.0001). The cross-sectional area (CSA) of the rectus femoris showed a significantly positive correlation with body cell mass of BIA and handgrip strength, and a significant negative correlation with TUG. Cut-off values were similar within each category of sarcopenia, ranging between 2.40 cm2 and 3.66 cm2 for CSA, 32.57 mm and 40.21 mm for the X-axis, and 7.85 mm and 10.4 mm for the Y-axis. In general, these cut-off values showed high sensitivities, particularly for the categories of confirmed and severe sarcopenia, with male patients also showing better sensitivities than women. CONCLUSIONS: Sarcopenia in hospitalized patients at risk of malnutrition was high. Cut-off values for the better sensitivities and specificities of ultrasound measures of the rectus femoris are established. The use of ultrasound of the rectus femoris could be used for the prediction of sarcopenia and be useful to integrate nutritional study into real clinical practice.

High-dose corticosteroid pulse therapy increases the survival rate in COVID-19 patients at risk of hyper-inflammatory response.

OBJECTIVE: Test whether high dose corticosteroid pulse therapy (HDCPT) with either methylprednisolone or dexamethasone is associated with increased survival in COVID-19 patients at risk of hyper-inflammatory response. Provide some initial diagnostic criteria using laboratory markers to stratify these patients. METHODS: This is a prospective observational study, 318 met the inclusion criteria. 64 patients (20.1%) were treated with HDCPT by using at least 1.5mg/kg/24h of methylprednisolone or dexamethasone equivalent. A multivariate Cox regression (controlling for co-morbidities and other therapies) was carried out to determine whether HDCPT (among other interventions) was associated with decreased mortality. We also carried out a 30-day time course analysis of laboratory markers between survivors and non-survivors, to identify potential markers for patient stratification. RESULTS: HDCPT showed a statistically significant decrease in mortality (HR = 0.087 [95% CI 0.021-0.36]; P < 0.001). 30-day time course analysis of laboratory marker tests showed marked differences in pro-inflammatory markers between survivors and non-survivors. As diagnostic criteria to define the patients at risk of developing a COVID-19 hyper-inflammatory response, we propose the following parameters (IL-6 > = 40 pg/ml, and/or two of the following: C-reactive protein > = 100 mg/L, D-dimer > = 1000 ng/ml, ferritin > = 500 ng/ml and lactate dehydrogenase > = 300 U/L). CONCLUSIONS: HDCPT can be an effective intervention to increase COVID-19 survival rates in patients at risk of developing a COVID-19 hyper-inflammatory response, laboratory marker tests can be used to stratify these patients who should be given HDCPT. This study is not a randomized clinical trial (RCT). Future RCTs should be carried out to confirm the efficacy of HDCPT to increase the survival rates of COVID-19.

[Screening for Cushing's syndrome in obese patients; is it really necessary?]. / Despistaje rutinario de síndrome de Cushing en pacientes con obesidad mórbida: ¿es realmente necesario?

to be more frequent among patients with metabolic syndrome. Previous studies have suggested to perform a routine screening for CS in obese patients; however, more recent reports only recommend a case-finding approach in patients with uncontrolled diabetes and hypertension, despite appropriate treatment. Objective: The aim of this study was to evaluate the prevalence of unsuspected CS in morbidly obese patients in an outpatient's clinic. Patients and methods: Retrospective case-note study. We reviewed the medical records of morbidly obese patients referred to our clinic prior to bariatric surgery between january 2001 and december 2011. All patients had a complete medical history including physical examination, and 399 underwent screening for CS as part of our pre-surgical protocol. As screening for autonomous cortisol secretion, we performed an overnight 1 mg Dexamethasone Suppression Test (DST). Serum cortisol < 1.8 µg/dl was the cut-off point for normal suppression. Results: 399 patients (308 female; mean age 41.9 ± 10.5 years; mean BMI 51.5 ± 8.4 kg/m2). In the retrospective analysis, prediabetes and diabetes mellitus were observed in 10.3% and 27.8% respectively. In 21 of 399 patients, screening was considered to be abnormal. Eight of these 21 patients had subsequent normal 24h Urinary Free Cortisol (UFC) levels (150 µg/24h). In 13 of 20 patients, we repeated an overnight 1mg DST, on suspicion of failing to take the dexamethasone correctly. Three patients failed to suppress their cortisol levels, two of them were on carbamazepine, which was considered to be a false positive result. The other patient with abnormal UFC levels was diagnosed with CS (0.26%), whose cause was a pituitary microadenoma. Conclusion: A low proportion of patients with morbid obesity were found to have CS. Our findings suggest that morbidly obese patients should not be routinely screened for CS.

Introducción: El síndrome de Cushing (SC) es más frecuente en pacientes con síndrome metabólico. Estudios previos han sugerido que es necesario realizar un despistaje de SC en pacientes obesos; sin embargo, estudios más recientes sólo recomiendan el despistaje en pacientes con hipertensión o diabetes mal controlados, a pesar de tratamiento. Objetivo: Evaluar la prevalencia de SC oculto en pacientes con obesidad mórbida. Pacientes y métodos: Estudio observacional retrospectivo en el que se incluyeron 399 pacientes que iban a someterse a cirugía bariátrica. A todos los pacientes se les realizó una historia clínica completa, incluyendo exploración física y test de Nugent, como parte del protocolo precirugía. Resultados: 399 pacientes (308 mujeres, edad media 41,9 ± 10,5 años; IMC medio 51,5 ± 8,4 kg/m2). El 10,3% de los pacientes presentaban prediabetes y el 27,8% diabetes. En 21 de los 399 pacientes, el despistaje fue anormal. En 8 pacientes, medimos cortisol libre en orina de 24 horas (CLU), siendo en todos normal al menos en dos ocasiones (CLU < 150 mcg/24 h), lo que descartaba SC. En 13 pacientes, repetimos el test de Nugent; sólo en 3, el test resultó patológico. Dos de los pacientes estaban en tratamiento con carbamacepina, lo que se consideró un falso positivo. El otro paciente se diagnosticó de Enfermedad de Cushing. Conclusión: La prevalencia de SC fue muy baja en pacientes con obesidad mórbida. Nuestros datos sugieren que no se debería realizarse un despistaje de SC de forma rutinaria.

[Percutaneous endoscopic gastrostomy in a myotrophic lateral sclerosis. Experience in a district general hospital]. / Gastrostomía endóscopica percutánea en esclerosis lateral amiotrófica; experiencia en un hospital de tercer nivel.

BACKGROUND: Amyotrophic Lateral Sclerosis (ALS) is a degenerative disorder that affects the pyramidal tract, producing progressive motor dysfunctions leading to paralysis. These patients can present with dysphagia, requiring nutritional support with a nasogastric tube or Percutaneous Endoscopic Gastrostomy (PEG). PEG is associated with increased survival rates. However, the timing of PEG placement remains a significant issue for clinicians. OBJECTIVE: To analyse the characteristics of ALS patients at the moment of PEG placement and their progression. METHODS AND MATERIALS: Descriptive retrospective study including patients diagnosed with ALS and PEG who were assessed during the 2005-2014 period in our hospital. Nutritional parameters and respiratory function were assessed for all patients, as well as their progression. The data was analysed using SPSS15. RESULTS: 37 patients were included (56.8% men, 43.2% women) with an average age of 60 at diagnosis, and an average age of 63.1 at PEG placement. 48.6% started with spinal affection and 51.4%, with bulbar affection. 43.2% of the patients received oral nutritional supplements prior to PEG placement for a mean period of 11.3 months. The mean forced vital capacity at diagnosis was 65.45±13.67%, with a negative progression up to 39.47±14.69% at the moment of PEG placement. 86.5% of patients required non-invasive positive-pressure ventilation. 86.5% presented with dysphagia, 64.9% with weight loss > 5-10% from their usual weight, 8.1% with low Body Mass Index, 27% with malnutrition and 73% with aworsened breathing function; therefore, 100% met the criteria for PEG placement according to our protocol. The period on enteral feeding was extended for 10.1 months with a mortality of 50% during the first 6 months from PEG placement. CONCLUSIONS: There is evidence of a 3-year delay between diagnosis and PEG placement, with a survival rate of 50% at 6 months from PEG insertion. Further studies are required to establish whether an earlier placement might increase survival rates.

Introducción: La Esclerosis Lateral Amiotrófica (ELA) es una enfermedad degenerativa neurológica con afectación de la vía piramidal, produciendo trastornos motores progresivos que evolucionan hasta la parálisis. Estos pacientes pueden asociar disfagia, precisando soporte nutricional a través de de sonda nasogástrica o Gastrostomía Endoscópica Percutánea (PEG). La PEG está asociada con aumento de la supervivencia, sin embargo la evidencia acerca del momento óptimo para su colocación es escasa. Objetivo: Analizar las características de los pacientes con ELA en el momento de colocación de la PEG y su evolución. Material y métodos: Estudio descriptivo retrospectivo. Se incluyeron pacientes con diagnóstico de ELA y PEG valorados durante los años 2005-2014 en nuestro hospital. Se analizaron parámetros nutricionales y respiratorios, y evolución de los pacientes. Los resultados se analizaron en el programa SPSS15. Resultados: 37 pacientes fueron incluidos (56,8% hombres, 43,2% mujeres) con una edad media al diagnóstico 60 años, y edad media de colocación de PEG de 63,1 años, el 48,6% debutó con afectación espinal y el 51,4%, con bulbar. El 43,2% de los pacientes recibieron suplementos previa colocación de PEG durante un promedio de 11,3 meses. La capacidad vital forzada (CVF) media al diagnóstico fue del 65,45±13,67%, evolucionando desfavorablemente hasta un 39,47±14,69% en el momento de colocación de la PEG. El 86,5% de los pacientes precisaron soporte respiratorio con ventilación mecánica no invasiva (VMNI). El 86,5% presentaron disfagia, el 64,9% pérdida de peso > 5-10% de su peso habitual, el 8,1% IMC bajo, el 27% parámetros bioquímicos de desnutrición y el 73% empeoramiento de función respiratoria, por tanto, el 100% cumplían criterios de colocación de PEG según nuestro protocolo. La duración de la nutrición enteral fue de 10,1 meses con una mortalidad del 50% en los primeros 6 meses de la colocación de la PEG. Conclusiones: Evidenciamos una demora de 3 años entre el diagnóstico y la colocación de la PEG, con una supervivencia del 50% a los 6 meses de la realización de la misma. Más estudios son necesarios para determinar si una colocación más precoz podría aumentar la supervivencia.

Clinical efficacy of intravenous glucocorticoid treatment in Graves' ophtalmopathy.

OBJECTIVE: To assess the efficacy of intermittent, high-dose treatment with intravenous glucocorticoids (IV GCs) in moderate to severe Graves' ophthalmopathy (GO). MATERIALS AND METHODS: Patients with GO treated with IV GCs from August 2007 to August 2011 at the Endocrinology Department of Reina Sofía Hospital were enrolled into the study. IV pulse prednisolone (7.5 mg/kg/day) was administered twice weekly every two weeks for 6 weeks, and at half the dose for 6 additional weeks. RESULTS: Eighteen patients (mean age, 43 ± 11 years) with moderate to severe GO were analyzed (83.3% females). Four were active smokers, five former smokers, and the rest had never smoked. Hyperthyroidism due to Graves' disease was found in 66.7% of patients, 41.6% of whom had received radioiodine therapy. Response to treatment was satisfactory in 72.2%, partial in 11.1%, and poor in 16.7%. Mild side effects were reported by 5 patients. Before treatment, 83.3% had diplopia, 33.3% eyelid retraction, 72.2% eye pain, and 44.4% exophthalmos. After treatment, only 33.3% had diplopia (P=.004), 5.6% eyelid retraction (P=.063), 16.7% eye pain (P=.002), and 11.1% exophthalmos (P=.031). Response to treatment was not related to the underlying disease (P=.866), prior radioiodine treatment (P=.447), or smoking status (P=.368). CONCLUSIONS: Intravenous glucocorticoid therapy decreased activity in patients with moderate to severe active GO, with major improvement occurring in diplopia, eye pain, and exophthalmos. Side effects were mild and uncommon. Treatment response was independent from the underlying disease, prior radioiodine treatment, or smoking status.

[Bariatric surgery in inflammatory bowel disease; case report and review of the literature]. / Cirugía bariátrica en enfermedad inflamatoria intestinal; presentación de un caso clínico y revisión de la literatura.

Inflammatory bowel disease (IBD) is rarely associated with obesity, as malabsorption is a common feature of these diseases (1). However, some patients may experience morbid obesity and associated complications refractory to dietary treatment and benefit from bariatric surgery. It has even been postulated that surgery may result in improvement of IBD by reducing inflammatory markers (2). However, patients may experience a higher incidence of complications following surgery in the context of immunosuppressive therapy and prior malabsorption. Therefore, if surgery is performed, careful patient selection and individualization of technique are essential. We present a patient diagnosed with ulcerative colitis who presented severe protein malnutrition after bariatric surgery type bilio-pancreatic diversion and review the available literature.

La Enfermedad Inflamatoria Intestinal (EII) raramente se asocia a obesidad, ya que la malabsorción es una característica frecuente de este grupo de patologías (1). Sin embargo, algunos pacientes pueden padecer obesidad mórbida asociada a complicaciones y refractaria a tratamiento dietético y beneficiarse de la cirugía bariátrica. Incluso se ha postulado que podría producirse una mejoría de la EII al disminuir los marcadores inflamatorios tras la cirugía (2). No obstante, los pacientes pueden experimentar mayor incidencia de complicaciones tras la cirugía en el contexto de terapias inmunosupresoras y agravamiento de la malabsorción previa. Por ello, si se realiza la cirugía, la cuidadosa selección de los pacientes y la individualización de la técnica a realizar son imprescindibles. Presentamos una paciente diagnosticada de Colitis Ulcerosa que presenta desnutrición proteica severa tras cirugía bariátrica tipo derivación bilio-pancreática y realizamos una revisión de la literatura disponible.

Gastrostomía endóscopica percutánea en esclerosis lateral amiotrófica; experiencia en un hospital de tercer nivel / Percutaneous endoscopic gastrostomy in amyotrophic lateral sclerosis, experience in a district general hospital

Introducción: La Esclerosis Lateral Amiotrófica (ELA) es una enfermedad degenerativa neurológica con afectación de la vía piramidal, produciendo trastornos motores progresivos que evolucionan hasta la parálisis. Estos pacientes pueden asociar disfagia, precisando soporte nutricional a través de de sonda nasogástrica o Gastrostomía Endoscópica Percutánea (PEG). La PEG está asociada con aumento de la supervivencia, sin embargo la evidencia acerca del momento óptimo para su colocación es escasa. Objetivo: Analizar las características de los pacientes con ELA en el momento de colocación de la PEG y su evolución. Material y métodos: Estudio descriptivo retrospectivo. Se incluyeron pacientes con diagnóstico de ELA y PEG valorados durante los años 2005-2014 en nuestro hospital. Se analizaron parámetros nutricionales y respiratorios, y evolución de los pacientes. Los resultados se analizaron en el programa SPSS15. Resultados: 37 pacientes fueron incluidos (56,8% hombres, 43,2% mujeres) con una edad media al diagnóstico 60 años, y edad media de colocación de PEG de 63,1 años, el 48,6% debutó con afectación espinal y el 51,4%, con bulbar. El 43,2% de los pacientes recibieron suplementos previa colocación de PEG durante un promedio de 11,3 meses. La capacidad vital forzada (CVF) media al diagnóstico fue del 65,45±13,67%, evolucionando desfavorablemente hasta un 39,47±14,69% en el momento de colocación de la PEG. El 86,5% de los pacientes precisaron soporte respiratorio con ventilación mecánica no invasiva (VMNI). El 86,5% presentaron disfagia, el 64,9% pérdida de peso > 5-10% de su peso habitual, el 8,1% IMC bajo, el 27% parámetros bioquímicos de desnutrición y el 73% empeoramiento de función respiratoria, por tanto, el 100% cumplían criterios de colocación de PEG según nuestro protocolo. La duración de la nutrición enteral fue de 10,1 meses con una mortalidad del 50% en los primeros 6 meses de la colocación de la PEG. Conclusiones: Evidenciamos una demora de 3 años entre el diagnóstico y la colocación de la PEG, con una supervivencia del 50% a los 6 meses de la realización de la misma. Más estudios son necesarios para determinar si una colocación más precoz podría aumentar la supervivencia (AU)

Background: Amyotrophic Lateral Sclerosis (ALS) is a degenerative disorder that affects the pyramidal tract, producing progressive motor dysfunctions leading to paralysis. These patients can present with dysphagia, requiring nutritional support with a nasogastric tube or Percutaneous Endoscopic Gastrostomy (PEG). PEG is associated with increased survival rates. However, the timing of PEG placement remains a significant issue for clinicians. Objective: To analyse the characteristics of ALS patients at the moment of PEG placement and their progression. Methods and materials: Descriptive retrospective study including patients diagnosed with ALS and PEG who were assessed during the 2005-2014 period in our hospital. Nutritional parameters and respiratory function were assessed for all patients, as well as their progression. The data was analysed using SPSS15. Results: 37 patients were included (56.8% men, 43.2% women) with an average age of 60 at diagnosis, and an average age of 63.1 at PEG placement. 48.6% started with spinal affection and 51.4%, with bulbar affection. 43.2% of the patients received oral nutritional supplements prior to PEG placement for a mean period of 11.3 months. The mean forced vital capacity at diagnosis was 65.45±13.67%, with a negative progression up to 39.47±14.69% at the moment of PEG placement. 86.5% of patients required non-invasive positive-pressure ventilation. 86.5% presented with dysphagia, 64.9% with weight loss > 5-10% from their usual weight, 8.1% with low Body Mass Index, 27% with malnutrition and 73% with aworsened breathing function; therefore, 100% met the criteria for PEG placement according to our protocol. The period on enteral feeding was extended for 10.1 months with a mortality of 50% during the first 6 months from PEG placement. Conclusions: There is evidence of a 3-year delay between diagnosis and PEG placement, with a survival rate of 50% at 6 months from PEG insertion. Further studies are required to establish whether an earlier placement might increase survival rates (AU)

Despistaje rutinario de Síndrome de Cushing en pacientes con obesidad mórbida; ¿es realmente necesario? / Screeening for cushing’s syndrome in obese patients: is it really necessary?

Introducción: El síndrome de Cushing (SC) es más frecuente en pacientes con síndrome metabólico. Estudios previos han sugerido que es necesario realizar un despistaje de SC en pacientes obesos; sin embargo, estudios más recientes sólo recomiendan el despistaje en pacientes con hipertensión o diabetes mal controlados, a pesar de tratamiento. Objetivo: Evaluar la prevalencia de SC oculto en pacientes con obesidad mórbida. Pacientes y métodos: Estudio observacional retrospectivo en el que se incluyeron 399 pacientes que iban a someterse a cirugía bariátrica. A todos los pacientes se les realizó una historia clínica completa, incluyendo exploración física y test de Nugent, como parte del protocolo precirugía. Resultados: 399 pacientes (308 mujeres, edad media 41,9 ± 10,5 años; IMC medio 51,5 ± 8,4 kg/m2 ). El 10,3% de los pacientes presentaban prediabetes y el 27,8% diabetes. En 21 de los 399 pacientes, el despistaje fue anormal. En 8 pacientes, medimos cortisol libre en orina de 24 horas (CLU), siendo en todos normal al menos en dos ocasiones (CLU < 150 mcg/24 h), lo que descartaba SC. En 13 pacientes, repetimos el test de Nugent; sólo en 3, el test resultó patológico. Dos de los pacientes estaban en tratamiento con carbamacepina, lo que se consideró un falso positivo. El otro paciente se diagnosticó de Enfermedad de Cushing. Conclusión: La prevalencia de SC fue muy baja en pacientes con obesidad mórbida. Nuestros datos sugieren que no se debería realizarse un despistaje de SC de forma rutinaria (AU)

Background: Cushing’s syndrome (CS) is considered to be more frequent among patients with metabolic syndrome. Previous studies have suggested to perform a routine screening for CS in obese patients; however, more recent reports only recommend a case-finding approach in patients with uncontrolled diabetes and hypertension, despite appropriate treatment. Objective: The aim of this study was to evaluate the prevalence of unsuspected CS in morbidly obese patients in an outpatient’s clinic. Patients and methods: Retrospective case-note study. We reviewed the medical records of morbidly obese patients referred to our clinic prior to bariatric surgery between january 2001 and december 2011. All patients had a complete medical history including physical examination, and 399 underwent screening for CS as part of our pre-surgical protocol. As screening for autonomous cortisol secretion, we performed an overnight 1 mg Dexamethasone Suppression Test (DST). Serum cortisol < 1.8 µg/dl was the cut-off point for normal suppression. Results: 399 patients (308 female; mean age 41.9 ± 10.5 years; mean BMI 51.5 ± 8.4 kg/m2). In the retrospective analysis, prediabetes and diabetes mellitus were observed in 10.3% and 27.8% respectively. In 21 of 399 patients, screening was considered to be abnormal. Eight of these 21 patients had subsequent normal 24h Urinary Free Cortisol (UFC) levels (150 µg/24h). In 13 of 20 patients, we repeated an overnight 1mg DST, on suspicion of failing to take the dexamethasone correctly. Three patients failed to suppress their cortisol levels, two of them were on carbamazepine, which was considered to be a false positive result. The other patient with abnormal UFC levels was diagnosed with CS (0.26%), whose cause was a pituitary microadenoma. Conclusion: A low proportion of patients with morbid obesity were found to have CS. Our findings suggest that morbidly obese patients should not be routinely screened for CS (AU)

Cirugía bariátrica en enfermedad inflamatoria intestinal; presentación de un caso clínico y revisión de la literatura / Bariatric surgery in inflammatory bowel disease; case report and review of the literature

La Enfermedad Inflamatoria Intestinal (EII) raramente se asocia a obesidad, ya que la malabsorción es una característica frecuente de este grupo de patologías (1). Sin embargo, algunos pacientes pueden padecer obesidad mórbida asociada a complicaciones y refractaria a tratamiento dietético y beneficiarse de la cirugía bariátrica. Incluso se ha postulado que podría producirse una mejoría de la EII al disminuir los marcadores inflamatorios tras la cirugía (2). No obstante, los pacientes pueden experimentar mayor incidencia de complicaciones tras la cirugía en el contexto de terapias inmunosupresoras y agravamiento de la malabsorción previa. Por ello, si se realiza la cirugía, la cuidadosa selección de los pacientes y la individualización de la técnica a realizar son imprescindibles. Presentamos una paciente diagnosticada de Colitis Ulcerosa que presenta desnutrición proteica severa tras cirugía bariátrica tipo derivación bilio-pancreática y realizamos una revisión de la literatura disponible (AU)

Inflammatory bowel disease (IBD) is rarely associated with obesity, as malabsorption is a common feature of these diseases (1). However, some patients may experience morbid obesity and associated complications refractory to dietary treatment and benefit from bariatric surgery. It has even been postulated that surgery may result in improvement of IBD by reducing inflammatory markers (2). However, patients may experience a higher incidence of complications following surgery in the context of immunosuppressive therapy and prior malabsorption. Therefore, if surgery is performed, careful patient selection and individualization of technique are essential. We present a patient diagnosed with ulcerative colitis who presented severe protein malnutrition after bariatric surgery type bilio-pancreatic diversion and review the available literature (AU)

Evaluación de la efectividad del tratamiento con glucocorticoides intravenosos en la oftalmopatía de Graves / Obesity: etiologic and pathophysiological analysis

Objetivo: Evaluar la efectividad del protocolo de tratamiento intermitente con glucocorticoides a altas dosis por vía intravenosa (i.v.) en la oftalmopatía de Graves (OG) moderada-grave del Hospital Reina Sofía. Material y métodos Se incluyeron los pacientes con OG tratados con glucocorticoides i.v. en nuestro servicio desde agosto de 2007 a agosto de 2011. Se administró prednisolona i.v. en dosis de 7,5mg/kg/d 2d alternos durante 6 semanas alternas y mitad de la dosis durante 6 semanas más. Resultados Analizamos 18 pacientes (83,3% mujeres) con una edad media de 43±11 años. Cuatro eran fumadores, 5 habían dejado el hábito y el resto nunca habían fumado. El 66,7% presentaban hipertiroidismo por enfermedad de Graves, de los cuales el 41,6% habían recibido radioyodo. La respuesta al tratamiento fue buena en el 72,2%, parcial en 11,1% y mala en 16,7%. En 5 aparecieron efectos secundarios leves. Antes del tratamiento el 83,3% presentaron diplopía, el 33,3% retracción palpebral, el 72,2% dolor ocular y el 44,4% exoftalmos. Después del tratamiento solo el 33,3% continuaron con diplopía (p=0,004), el 5,6% con retracción palpebral (p=0,063), el 16,7% con dolor ocular (p=0,002) y el 11,1% con exoftalmos (p=0,031). El 22,2% precisaron radioterapia. La respuesta al tratamiento no se asoció a la enfermedad de base (p=0,866) al haber recibido radioyodo previo como tratamiento del hipertiroidismo (p=0,447) o al ser fumador (p=0,368).Conclusiones El tratamiento con glucocorticoides i.v. en la oftalmopatía tiroidea reduce significativamente la diplopía, el dolor ocular y el exoftalmos. Los efectos secundarios son leves y poco frecuentes. La respuesta al tratamiento es independiente de la enfermedad de base, de haber recibido radioyodo y de ser fumador (AU)

Objective: To assess the efficacy of intermittent, high-dose treatment with intravenous glucocorticoids (IV GCs) in moderate to severe Graves’ ophthalmopathy (GO).Materials and methods: Patients with GO treated with IV GCs from August 2007 to August 2011at the Endocrinology Department of Reina Sofía Hospital were enrolled into the study. IV pulseprednisol one (7.5 mg/kg/day) was administered twice weekly every two weeks for 6 weeks, and at half the dose for 6 additional weeks. Results: Eighteen patients (mean age, 43+/-11 years) with moderate to severe GO were analyzed (83.3% females). Four were active smokers, five former smokers, and the rest had never smoked. Hyperthyroidism due to Graves’ disease was found in 66.7% of patients, 41.6% of whom had received radioiodine therapy. Response to treatment was satisfactory in 72.2%, partial in11.1%, and poor in 16.7%. Mild side effects were reported by 5 patients. Before treatment,83.3% had diplopia, 33.3% eyelid retraction, 72.2% eye pain, and 44.4% exophthalmos. After treatment, only 33.3% had diplopia (P = .004), 5.6% eyelid retraction (P = .063), 16.7% eye pain(P = .002), and 11.1% exophthalmos (P = .031). Response to treatment was not related to the underlying disease (P = .866), prior radioiodine treatment (P = .447), or smoking status (P = .368).Conclusions: Intravenous glucocorticoid therapy decreased activity in patients with moderate to severe active GO, with major improvement occurring in diplopia, eye pain, and exophthalmos. Side effects were mild and uncommon. Treatment response was independent from the underlying disease, prior radioiodine treatment, or smoking status (AU)