Guías de práctica clínica para la evaluación y tratamiento de la osteoporosis asociada a enfermedades endocrinas y nutricionales

ObjectiveTo provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions.ParticipantsMembers of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist.MethodsRecommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND “osteoporosis”, “fractures”, “bone mineral density”, and “treatment”. Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group.ConclusionsThe document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.     

Guía de práctica clínica para el diagnóstico y tratamiento de la apoplejía hipofisaria

Classic pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by acute hemorrhage and/or infarction of the pituitary gland. PA is considered a neuroendocrinological emergency. However, there is no consensus about the best options for PA diagnosis and management.ObjectiveTo develop a clinical practice guideline with a number of recommendations for diagnosis and treatment of patients with PA based on the medical evidence available, in order to help clinicians involved in their care.MethodsThe clinical guideline for diagnosis and treatment of pituitary apoplexy issued in 2006 by the Neuroendocrinology Working Group of the Spanish Society of Endocrinology and Nutrition (SEEN) and the British Clinical Practice Guideline published in 2011 were taken as the basis. The text has been adapted to the format used in most international medical journals. For this, after updated medical literature, the quality of evidence and the strength of the recommendations were evaluated using the system proposed by the Agency for Health Care Policy and Research (AHCPR).ConclusionsDiagnosis of pituitary apoplexy should be considered in all patients with acute severe headache with or without neuro-ophthalmic signs. Patients with PA must undergo a complete history and physical examination. All patients with suspected pituitary apoplexy should have urgent blood samples drawn to test electrolytes, renal function, liver function, coagulation screen, complete blood count, and basal levels of pituitary and peripheral hormones, and to rule out adrenocorticotropic hormone (ACTH) deficiency. Formal visual field assessment should be performed when the patient is clinically stable. Magnetic resonance imaging (MRI) is the imaging test of choice to confirm diagnosis. Indications for empirical urgent corticosteroid therapy in patients with PA include hemodynamic instability, impaired consciousness, reduced visual acuity, and severe visual field defects. In patients with these severe neuro-ophthalmic signs, surgery should be considered. Surgery should preferably be performed within seven days of the onset of symptoms. Patients with mild and stable signs may be managed conservatively with careful monitoring. Treatment and long-term follow-up of patients with PA should be conducted by a multidisciplinary team consisting, amongst others, of an experienced pituitary neurosurgeon, an ophthalmologist, and an endocrinologist.     

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.     

Guía clínica para el manejo del nódulo tiroideo y cáncer de tiroides durante el embarazo

Special considerations are warranted in management of thyroid nodule and thyroid cancer during pregnancy. The diagnostic and therapeutic approach of thyroid nodules follows the standard practice in non-pregnant women. On the other hand, differentiated thyroid cancer management during pregnancy poses a number of challenges for the mother and fetus. The available data show that pregnancy is not a risk factor for thyroid cancer development or recurrence, although flare-ups cannot be completely ruled out in women with active disease. If surgery is needed, it should be performed during the second term or, preferably, after delivery. A majority of pregnant patients with low-risk disease only need adjustment in levothyroxine therapy. However, women with increased serum thyroglobulin levels before pregnancy or structural disease require regular thyroglobulin measurements and neck ultrasound throughout pregnancy. Pregnancy is an absolute contraindication for radioactive iodine administration.     

Evaluación del riesgo de caídas. Protocolos de valoración clínica

Falls are one of the main causes of lesions, disability and even death in elderly patients. In all patients who fall, the repercussions and risk factors for falls and their recurrence should be evaluated. Evaluation of risk factors for falls should include the following: thorough medical history, exhaustive geriatric evaluation, general physical examination, examination of sense organs, balance and gait, evaluation of the environment, and complementary examinations (posturography). Evaluation protocols allow a greater number of risk factors to be identified. Numerous clinical tests (Tinetti, timed and go) allow the risk of new falls and of severe consequences to be assessed.The creation of falls units with multidisciplinary teams specifically designated to evaluate the elderly with recurrent falls and the prevention of falls is highly important.