Guía para el diagnóstico y tratamiento de la insuficiencia suprarrenal en el adulto

Adrenal insufficiency (AI) is a disease characterized by a deficient production or action of glucocorticoids, with or without deficiency in mineralcorticoids and/or adrenal androgens. It can result from disease intrinsic to the adrenal cortex (primary AI), from pituitary diseases that hamper the release of corticotropin (secondary AI) or from hypothalamic disorders that impair the secretion of the corticotropin-releasing hormone (tertiary AI).It is a disease with a low prevalence but its impact on the affected individual is very high as it can be life-threathening if not treated or lead to health problems if inadequately treated. However, currently there are no specific guidelines for the management of this disease. Therefore, at the proposal of the Spanish Society of Endocrinology and Nutrition (SEEN) board, a task-force under the Neuroendocrinology Knowledge Area of the SEEN was established, with the mandate of updating the diagnosis and treatment of AI. In fulfilment of this mandate the task-force has elaborated the present guide that, based on a comprehensive review of literature, is intended to provide an answer to questions related to the management of this disease. It is, therefore, an essentially practical document, mainly aimed at guiding the health professionals involved in the care of IA patients.     

Alteraciones del metabolismo glucídico en el estudio de control de factores de riesgo de Extremadura (estudio COFRE)

AimsTo assess the prevalence and control of glucose metabolism disorders in a population of Extremadura (Spain) with at least one cardiovascular risk factor and to compare the characteristics of these patients with those who were normoglycemic in the risk factor control in Extremadura (COFRE study).Patients and methodsThe prevalence and control of cardiovascular risk factors were recorded in a sample of 1,022 patients with at least one cardiovascular risk factor consecutively visiting a primary care office. Of these, 951 patients were included in the analysis. In all patients, fasting glycemia was recorded. Glycated hemoglobin was recorded in diabetic patients.ResultsA total of 320 patients (33.6%) were previously known to be diabetic (DM) and 84 (8.8%) had glycemia ≥126 mg/dl without a previous diagnosis of diabetes (12 with glycemia above 200 mg/dl). Impaired fasting glycemia (IFG) was found in 211 (22.2%) and normoglycemia (NG) in 336 (35.3%). Within the DM group, glycemia <126 mg/dl was found in only 31.4% but glycated hemoglobin lower than 7% was found in 46.8%. Triglyceride concentrations were higher in the IFG group than in the NG group (137±65 mg/dL vs 124±65 mg/dL, p=0,041). Pulse pressure was also higher, but no differences were found in diastolic blood pressure (DBP) or heart rate. Differences in systolic blood pressure (SBP) were at the limit of significance (DM 139.5±17 vs NG 136.5±16 mmHg; p=0.056). No significant differences were found in any of these parameters between the DM and IFG groups.ConclusionsThe prevalence of glucose metabolism disorders was very high in the recruited sample. Patients with IFG showed higher pulse pressure and triglyceride concentrations than those with NG but there were no differences in comparison with DM patients. Diabetic control was poor when assessed by fasting glycemia but glycated hemoglobin showed better control.     

Guía clínica de diagnóstico y tratamiento del prolactinoma y la hiperprolactinemia

ObjectiveTo provide practical and up to date recommendations for evaluation, differential diagnosis, and treatment of prolactinoma and hyperprolactinemia in various clinical settings.ParticipantsMembers of the Neuroendocrinology Working Group of the Spanish Society of Endocrinology.MethodsRecommendations were formulated according to the Grading of Recommendations, Assessment, Development, and Evaluation system (GRADE) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in Medline (Pubmed) for each subject, and authors’ considerations were added in areas where the literature provided scarce evidence. Finally, recommendations were jointly discussed by the Working Group.ConclusionsThe document provides evidence-based practical and updated recommendations for diagnosis and management of hyperprolactinemia and prolactinoma, including drug-induced hyperprolactinemia, treatment options for prolactinoma (drugs, surgery, and radiotherapy), prolactinoma in pregnancy, adverse effects of dopaminergic agents, and drug-resistant and malignant prolactinomas.     

Hacia el diagnóstico temprano de la candidiasis invasora en el paciente crítico

The management of invasive fungal infections in critically ill patients, from diagnosis to selection of the ther- apeutic protocol, is often a challenge. Early diagnosis and treatment are associated with a better prognosis, but apart from cases with positive cultures from blood or fluid/tissue biopsy, diagnosis is neither sensitive nor specific, and there is a need for specific markers in these diseases. Serodiagnostic assays such as mannan an-tigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, and mo-lecular techniques for the detection of fungal-specific DNA have been developed with promising results in critical care settings. One of the main features in diagnosis is the evaluation of risk factors for infection, which will identify patients in need of preemptive or empirical treatment. Clinical scores were built from those risk factors. The combination of prediction rules and non-culture microbiological tools could be currently be the key to improving the diagnosis and prognosis of invasive fungal infections in critically ill patients.     

Valoración de la utilidad del test de estimulación intraarterial con calcio en el diagnóstico de localización del hiperinsulinismo endógeno

Background and objectiveThe aim of this study was to assess the utility of arterial calcium stimulation with hepatic venous sampling (ASVS) in the localization of tumors in patients with endogenous hyperinsulinism not detected with other methods.Patients and methodsWe performed a retrospective study of 26 patients admitted to our hospital for hypoglycemia who underwent ASVS because the source of hyperinsulinism was not clearly identified by other imaging techniques. The histopathological result in patients who underwent a surgical procedure was considered the reference for statistical study of the accuracy of this technique. Statistical analysis was performed by comparing proportions with the chi-squared test with Yates’ correction for contingency tables, and Cohen′s kappa coefficient as a measure of interrater agreement between two observations.ResultsSurgery was performed in 17 patients, 13 with positive ASVS and the remaining four with negative results. An insulinoma was removed in 12 patients, and 10 of these were detected in the ASVS. A total of 76.9 % of positive ASVS tests corresponded to a histological diagnosis of insulinoma, and 83% of these insulinomas were positive in ASVS. This association was statistically significant (chi cuadrado = 7.340; p = 0.012). Two of three patients with nesidioblastosis had a positive response in the ASVS. A good and statistically significant agreement was obtained between histopathologic diagnosis and ASVS results (κ=0.556, p = 0.007).ConclusionsASVS is a useful procedure in the localization diagnosis of endogenous hyperinsulinism not detected by other imaging tests. This technique allows tumors in the pancreatic gland to be identified and may be useful in the choice of the surgical technique to be used.     

Prevalencia de alteraciones del metabolismo hidrocarbonado en una población infanto-juvenil con obesidad grave

IntroductionThere is currently a disproportionate increase in childhood and adolescent obesity worldwide, together with other disorders involving substantial cardiometabolic risk in adulthood, such as alterations in carbohydrate metabolism.ObjectiveTo establish the prevalence of prediabetes, defined as impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) after an oral glucose tolerance test, and the prevalence of type 2 diabetes mellitus (DM-2) in a pediatric population with severe obesity. Additionally, we aimed to assess clinical metabolic differences between prediabetic obese patients and obese subjects without prediabetes.Material and methodsA cross-sectional study was carried out in children and adolescents with severe obesity (>97th percentile). The variables studied were age, sex, height, weight, body mass index, waist circumference, fasting plasma glucose and oral glucose tolerance test, insulinemia, insulin resistance assessed by the homeostasis model assessment (HOMA) index, glycated hemoglobin (HbA_1c), triglycerides, high-density lipoprotein cholesterol (HDL), and systolic and diastolic blood pressure.ResultsA total of 133 patients were included: 67 boys (50.4%) and 66 girls (49.6%), with a mean age of 12.17±3.27 years. Fourteen patients (10.52%) had prediabetes (10 IFG, 3 IGT, 1 IFG+IGT): 7 girls and 8 boys, with a mean age of 13.2±3.3 years. One patient had DM2 (0.75%). Patients with prediabetes had significantly higher concentrations of fasting glucose (98±10.76 vs 88.53±6.3 mg/d; p=0.001), insulinemia (35.38±14.22 vs 22.95±14.30 μU/ml; p=0.009) and HOMA index (8.10±3.24 vs 4.89±3.27; p=0.004) than patients without impaired carbohydrate metabolism. These patients also had higher values of HbA_1c, triglycerides, blood pressure and HDL concentrations, although differences were not statistically significant.ConclusionsThe prevalence of prediabetes (IFG/IGT) in children with severe obesity was high (10.52%). These patients should therefore be investigated to establish early diagnosis and appropriate treatment. Obese patients with prediabetes have significantly higher levels of insulin and insulin resistance than individuals without impaired carbohydrate metabolism.     

Asociación de los diferentes niveles de hipoxemia en la altura con el perfil lipídico y la glucemia en varones y mujeres a 4.100 m de altitud en los Andes Centrales del Perú

Background and objectivesAt a same altitude, people with greater hypoxemia would have higher hemoglobin (Hb) levels than less hypoxemic patients. It is not known whether higher hypoxemia levels (as measured by higher Hb values) affect basal glucose and lipid profile at an altitude of 4,100 mg (Carhuamayo and Junln).Materials and methodsGlucose, lipid, and hemoglobin levels and body mass index (BMI) were assessed in 158 males and 348 females aged 35 to 75 years. Association of lipid and glucose levels with systolic and diastolic blood pressure (SBP and DBP) was also assessed. Results were analyzed using Student's t test, Chi-square test, analysis of variance, correlations, and linear multivariate analyses adjusted for age, sex, BMI, smoking, and education.ResultsHigher hemoglobin levels were directly associated to higher levels of total cholesterol (P < 0.001), low density lipoprotein cholesterol (P < 0.002), non-high density lipoprotein cholesterol (non-HDL) (P < 0.01), and triglycerides (P < 0.01). No association was found between hemoglobin and glucose (P > 0.05). Levels of total cholesterol, high density lipoprotein cholesterol, triglycerides, low density lipoprotein cholesterol, and blood glucose were directly associated to DBP.ConclusionsIn people living at high altitude (4100 m), the non-HDL cholesterol fraction and triglycerides are directly associated to hemoglobin value, and increases in them are in turn associated to higher DBP.     

Efectos del uso del 17 β-estradiol y la genisteína en la enfermedad de Alzheimer en mujeres con menopausia

The use of 17 β-estradiol and genistein in women with menopause helps in the reduction of vasomotor symptoms and cognitive improvement. There is evidence on the use of certain flavonoids such as genistein, which has a potentially neuroprotective role in neurodegenerative diseases such as Alzheimer's. Scientific evidence on the effects of phytoestrogens and genistein during menopause and their effect on cognition are scarce, however, in the present review it was found that the intervention with 17 β-estradiol has positive effects on cognition in women with Alzheimer's disease. In addition, the use of genistein, daidzein or any supplement based on isoflavones may influence vasomotor symptoms. 17 β-estradiol supplements in women in early menopause and with some degree of cognitive impairment may have beneficial effects.     

Papel de los biomarcadores en el diagnóstico precoz de la enfermedad de Alzheimer

Alheimer's disease is the most frequent cause of cognitive decline and behavioral abnormalities in adults. Diagnosis is currently made in the advanced phases. An an early diagnosis in the prodromal phase (or earlier if possible) is required for the prevention of this disease, its early management and the development of potential therapies that could alter its natural course. The syndromic concept of mild cognitive impairment (the presence of detectable and quantifiable deterioration in one of the cognitive domains but without affecting -or without substantially affecting- autonomic performance of instrumental function) and its variants has aided understanding of the predementia stages of Alheimer's disease, even though its etiology may involve multiple factors. The use of biomarkers such as determination of the proteins involved in the disease in cerebrospinal fluid (Aβ42-amyloid, total and phosphorylated tau) and measurement of the hippocampus and entorhinal cortex with magnetic resonance imaging and positron emission tomography (both glucose and amyloid measurements), alone or combined, could allow early and etiologic diagnosis. Patients with Alzheimer's disease show reduced Aβ42-amyloid levels and increased total and phosphorylated tau levels in cerebrospinal fluid.