Nuevas perspectivas en el tratamiento farmacológico de la enfermedad de Cushing

Hypercortisolism induced by Cushing disease causes high morbidity and mortality.The treatment of choice is pituitary surgery, but it often fails to achieve cure, and other treatment modalities (radiotherapy, bilateral adrenalectomy) may therefore be required. If these treatments are not effective or while waiting for their results, hypercortisolism should be controlled with drugs.The classical drug treatments are those that act by inhibiting cortisol secretion by the adrenal gland (ketoconazole, metyrapone, mitotane, etomidate).The preliminary results of a new drug (LCI699) which is a potent enzyme inhibitor of cortisol secretion have been reported.A clinical trial of the safety and efficacy of mifepristone, a glucocorticoid receptor antagonist, has just been published.The drugs deserving more attention today are those with a direct action on the tumor by inhibiting ACTH secretion: somatostatin analogues (pasireotide), dopamine agonists (cabergoline), PPAR-γ, and retinoic acid.A special review is made of the available clinical trials with pasireotide and cabergoline.     

Utilidad de la estación unipodal en la valoración del riesgo de caídas

Aimsto compare posturographic test with One-Leg Balance test in the elderly.Methodswe studied 59 healthy men and women living in the community who were at least 65 years of age. All of them were evaluated with One–Leg Balance (defined as the ability to stand on one leg unsupported for 5 seconds) and Modifies Clinical Test for the Sensory Interaction on Balance by the Balance Master (Neurocom®). We distributed the patients in two groups. Group A included those who couldn’t perform one-leg balance and group B those who could perform it.Results62.6% of subjects could perform one-leg balance and 37.2% could not perform it. On a firm surface with opened eyes, the A group made a variation of 0.4 deg/s (0.28-0.6) in the gravity center position and the B group 0,2 deg/s (0.1-0.3) (p = 0.010). On a firm surface with closed eyes, the A group made a variation of 0.5 deg/s (0.3-0.8) and the B group 0.3 deg/s (0.1- 0.4) (p = 0.002). On a foam surface with open eyes, the A group made a variation of their gravity center position of 1.10 deg/s (0.90-1.60) and the B group 0.9 deg/s (0.73-1.30) (p = 0.045). On a foam surface with closed eyes the A group made a variation of their gravity center position of 6 deg/s (4-6) and the B group 2.3 deg/s (1.63-3.08) (p < 0.001).Conclusionselderly patients who can perform one-leg balance, make less variations of their gravity centre. The results are the same when visual and propioceptive afferences are suppressed.     

Nutrición basada en la evidencia en la pancreatitis aguda y la enfermedad hepática crónica estable

Acute pancreatitis is a disease that, by definition, generates an increase in metabolism. This metabolic reaction, together with the anorexia produced by the disease, clearly increases morbidity and mortality secondary to malnutrition.Malnutrition affects almost 70% of patients with cirrhosis, with a consequent increase in complications. The present review aims to evaluate the utility of the use of total parenteral nutrition (TPN) and/or enteral nutrition (EN) in patients with acute pancreatitis and in those with stable chronic liver disease.In patients with acute pancreatitis, the administration of enteral nutrition seems to confer advantages over parenteral nutrition in clinical variables (infections, surgical interventions, and mean length of hospital stay) (A-B); nevertheless, further studies stratifying patients according to the severity of pancreatitis and probably its etiology should be designed. Glutamine supplementation can be effective in reducing length of hospital stay and duration of nutritional support (B).In patients with stable chronic liver disease, there are no studies that demonstrate the superiority of EN over PN, or vice versa, in relevant clinical variables (mortality, length of hospital stay, etc.). There is only one study that has demonstrated that EN is superior to oral intake in reducing mortality (B).Improved study designs and the need to perform studies according to the type and severity of liver disease should be a research priority.     

Evaluación de la utilidad diagnóstica de la biopsia ungueal en las onicomicosis

BackgroundOnychomycosis affects between 2% to 30% of the world population. Nail biopsy may help in making a diagnosis and can distinguish between invasion and colonisation.AimsTo evaluate the diagnostic usefulness of nail biopsy with Periodic acid–Schiff (PAS) staining for onychomycosis, compared to direct KOH examination, culture and its combination in a reference laboratory in Colombia.MethodsThe study included 66 patients in whom a blind and independent reading of the three tests was performed. The usefulness was defined based on the validity (sensitivity, specificity, Youden's index, likelihood ratios), performance (predictive values) efficiency (proportion of correctly diagnosed patients), and reproducibility (kappa coefficient).ResultsThe mean age of the patients was 55 ± 16 years, and included 76% women. The direct tests with KOH were positive in 66.7% (n = 44), 62.1% (n = 41) were positive with culture, and 56.1% (n = 37) with the biopsy. The main causal agents were non-dermatophytes moulds in 36.4% (n = 24). The most frequent species were Neoscytalidium dimidiatum (n = 11), Trichophyton rubrum (n = 11), and Candida parapsilosis (n = 13). The sensitivity of nail biopsy, when compared to the standard (KOH and/or culture), was 71%, specificity 83%, Youden's index 0.54, positive likelihood ratio 4.25, negative likelihood ratio 0.35, positive predictive value 92%, negative predictive value 52%, efficiency 74% and kappa coefficient 0.45. When biopsy was evaluated only in patients with onycholysis of the nail plate greater than 50%, all the parameters of diagnostic usefulness increased.ConclusionsThe overall usefulness of the biopsy was moderate for patients with more severe symptomatology, which makes its use advisable in cases of extensive onycholysis, and when discriminating colonisation from invasion is required.     

Factores pronósticos de remisión a largo plazo tras cirugía transesfenoidal en la enfermedad de Cushing

There is no consensus on the remission criteria for Cushing's disease or on the definition of disease recurrence after transsphenoidal surgery, and comparison of the different published series is therefore difficult. A long-term recurrence rate of Cushing's disease ranging from 2%-25% has been reported. Predictors of long-term remission reported include: 1) adenoma–related factors (aggressiveness, size, preoperative identification in MRI), 2) surgery-related factors, mainly neurosurgeon experience, 3) clinical factors, of which dependence on and duration of glucocorticoid treatment are most important, and 4) biochemical factors. Among the latter, low postoperative cortisol levels, less than 2 mcg/dL predict for disease remission. However, even when undetectable plasma cortisol levels are present, long-term recurrence may still occur and lifetime follow-up is required. We report the preliminary results of the first 20 patients with Cushing's disease operated on at our hospital using nadir cortisol levels less than 2 mcg/dl as remission criterion.     

Expresión sexual y regulación de la sexualidad en residencias de personas mayores

Objectives

The study had three objectives: (a) To determine how staff perceives the frequency of different sexual expressions in long-term care facilities for older people; (2) to quantify policies aimed at guaranteeing residents’ sexual rights in such institutions, and (3) to determine factors influencing the presence of these kind of policies.

Incorporación de la ecografía y la punción de tiroides a la actividad de endocrinología en una consulta de alta resolución

IntroductionFine-needle aspiration biopsy (FNAB) is considered the reference diagnostic procedure for thyroid nodules.Materials and methodsRoutine performance of thyroid ultrasound and ultrasound-guided FNAB by endocrinologists allows a more efficient approach in the setting of a high-resolution practice, thus reducing costs and the time elapsed until diagnosis.ResultsWe present our initial results of this procedure 2 years after its introduction, with a total of 286 biopsies performed. After a progressive learning curve over time and according to the endocrinologists’ previous experience, 72.72% samples were considered satisfactory for diagnosis. Greater difficulty was observed in obtaining optimal cytological specimens in smaller nodules. In conclusion, we have successfully incorporated thyroid ultrasound and ultrasound-guided FNAB into routine endocrine practice.ConclusionRoutine performance of thyroid ultrasound in endocrine practice will considerably aid the management of nodular thyroid disease.     

Utilización del POMA en nuestro medio para la valoración del equilibrio y la marcha en una población de personas mayors residentes en la comunidad

Objectivesto study the balance and the gait by the Performance Oriented Mobility Assessment (POMA) in the population of people ≥ 65 years in function of age, gender; relation with the capacity to develop the activities of daily living, physical exercise, perception of health and previous falls.Material and methodsWe study a cohort of 443 people, 262 women and 181 men, representative of the population ≥ 65 years, resident in the community and able to walk from the city of Mataró. The evaluation was made with the 22 items POMA. Basic and instrumental activities of the daily life (Katz Index and Lawton), physical activity, health perception (Iowa test) were also assessed.Results29.3% of subjects did not present abnormalities in any of the items, 22.6% presented one abnormality, 12.4% two, and 35.7% three or more. 35.9% and 50.2 of subjects did not present abnormalities in the static and dynamic components respectively. Women had greater number of abnormalities than men (42.0% vs 20.6%) for the global and also for each of the two components (static and dynamic) (p < 0.0001). The number of abnormalities increased significantly with age, specially on those 75 years and older (p < 0.0001). A greater number of errors was correlated with less independence on the basic and instrumental activities of daily living, with less physical activity, health perception and with antecedents of previous falls.     

Valoración de la musculatura isquiosural en personas mayores

Objectiveto evaluate hamstring flexibility in older adults.Materials and methodsa total of 177 subjects (13 men and 164 women) aged between 43 and 80 years old (mean age = 63.4 ± 6.7 years) who attended fitness classes were evaluated. The mean height was 161 ± 10 cm and the mean weight was 74 ± 5.6 kg. Hamstring flexibility was evaluated using the straight leg raise test.Resultsthe mean flexion in the right hip was 72° ± 13.2° and the mean flexion of the left hip was 72.4° ± 13.8°. No significant differences were found in the values obtained from the straight leg raise test in the left and right legs. For the right leg, 48.02% of the subjects’ values were within the normal range, while 28.81% showed grade I shortness, and 23.61% showed grade II shortness. For the left leg, 49.94% showed normal values, 29.94% showed grade I shortness, and 22.03% showed grade II shortness.Conclusionshalf of the adults and elderly individuals that took part in the present study had hamstring shortness, which increased in frequency with age.