Emilia Gómez Hoyos

Impacto económico y satisfacción de la implantación de una consulta de alta resolución de patología nodular tiroidea en Endocrinología

BACKGROUND AND OBJECTIVE No conclusive data exist on the value of a high resolution thyroid nodule clinic for management of nodular thyroid disease. The aim of this study was to evaluate the economic impact of and user satisfaction with a high resolution thyroid nodule clinic (HRTNC) in coordination with primary care. PATIENTS AND METHOD A prospective, observational, descriptive study was conducted to analyze data from 3,726 patients (mean age 61±12 years; 85% women) evaluated at an HRTNC during 2014 and 2015. Demographic data (sex and age), number of ultrasound examinations and fine needle aspiration cytologies (FNAC), referral center and consultation type were assessed. RESULTS In 2014 and 2015, 3,726 neck ultrasound examinations and 926 FNACs (3.8% rated as non-diagnostic) were performed. Among the 1,227 patients evaluated for the first time, 21.5% did not require a second endocrine appointment, which resulted in mean estimated savings of 14,354.55 euros. Of all patients, 41.1% were referred from primary care, 33.4% from endocrinology, and 26.5% from other specialties. As compared to 2013, the number of thyroid ultrasound examinations requested decreased by 65.3% and 59.7% in 2014 and 2015 respectively, with mean estimated savings of 137,563.92 euros. Mean user satisfaction assessed was 4.0 points (95% confidence interval, 3.7-4.3) on a 5-point scale. CONCLUSIONS HRTNCs at endocrinology departments, coordinated with primary care, are a viable, cost-effective alternative with a positive user perception.

The 10-item eating assessment tool is associated with nutritional status, mortality and hospital stay in elderly individuals requiring hospitalization with acute diseases

OBJECTIVE the purpose of this investigation was to investigate the associations between nutritional status by Mini Nutritional Assessment (MNA) test and dysphagia by EAT-10 in elderly individuals requiring nutritional oral care in an acute hospital. PATIENTS this was a cross-sectional survey covering a sample of 560 elderly individuals. As anthropometric parameters, weight and body mass index (BMI) have been included. Glucose, creatinine, sodium, potassium, albumin, prealbumin and transferrin serum levels were measured. The EAT-10 and MNA tests were carried out. The days of hospital stay and mortality were recorded. RESULTS the mean EAT-10 was 11.2 ± 0.89, the median was 10 and the interquartile range, 6-15. A total of 465 (83.1%) elderly patients had EAT-10 scores between 3 and 40, indicating the presence of dysphagia. The mean MNA test was 15.2 ± 1.1, median was 15 and interquartile rage, 11-18.5. According to their MNA score, a total of 340 (60.7%) elderly patients had MNA scores under 17 (malnutrition) and 177 subjects (31.6%) had a MNA score of 17-23.5 (risk of malnutrition). The MNA score and EAT-10 score were independently associated with hospital stance Beta -0.111 (CI 95%: -0.031- -0.78) and Beta 0.122 (CI 95%: 0.038-0.43), respectively. MNA score was associated with EAT-10 score Beta -0.236 (CI 95%: -0.213-0.09). The MNA score and EAT-10 score were independently associated with mortality odds ratio 0.91 (CI 95%: 0.84-0.96) and 1.040 (CI 95%: 1.008-1.074), respectively. CONCLUSION dysphagia assessed by the EAT-10 is associated with nutritional status in elderly subjects requiring acute hospitalization. Subsequently, malnutrition and dysphagia were associated with poor outcome such as hospital stay and mortality.

Repercusiones clínicas y económicas de la desnutrición relacionada con la enfermedad en un servicio quirúrgico

INTRODUCTION disease-related malnutrition (DRM) is currently a major challenge in our hospitals, both because of its high prevalence and because of the clinical and economic impact. Our study aims to assess the feasibility and importance of establishing a nutritional screening strategy in our Health Care System. PATIENTS AND METHODS this is a prospective study carried out in a Surgery Ward. The nutritional risk was assessed by applying to patients MUST at admission and weekly until discharge. Nutritional evaluation and nutritional intervention were performed if required, as well as coding of diagnoses and nutritional procedures at discharge. Clinical data, length of stay (LOS) and hospital costs were analyzed. RESULTS MUST detected 15.6% of patients at risk of malnutrition at admission. Patients with malnutrition at admission (MA) had four days longer LOS, higher annual mortality rate and urgent hospital readmissions in 2.4 and 2.0 times, respectively, one year after discharge. Age and urgent hospital admission were the factors associated with a higher annual mortality rate. Nine per cent of patients with an initial MUST < 2 suffered deterioration in their nutritional status during admission (DNS). These patients had longer LOS in seven days with equal comorbidity. Considering only the costs related to LOS in patients who presented MA or DNS, an overcost of 57% and 145%, respectively, was observed. CONCLUSION patients with malnutrition on admission had longer LOS, higher mortality rate and urgent hospital readmissions one year after discharge. Patients who present MA or DNE cause an economic cost overrun. A nutritional screening tool is essential for the management and early detection of DRM.

Estudio de tolerancia y aceptación de una fórmula enteral con alta densidad energética en pacientes de una unidad de coronarias

Objective: The aim of our study was to evaluate the tolerance of enteral formula with high energetic density in patients hospitalized in a coronary care unit requering enteral support for at least five days. Methods: Opened, non-comparative, nonrandomized, descriptive study, evaluating the tolerance of enteral formula with high energy density in patients admitted to a coronary care unit. Results: 31 patients were included with a mean age of 67.32 ± 13.8 years, 66.7% were male. The average prescribed final volume Nutrison Energy® was 928.5 ± 278.5 mL/day (range: 800-1,500 mL/day). The average duration of enteral nutrition was 11.2 ± 3.2 days. The average calorie intake was 1,392 ± 417 cal/day, with 169.9 ± 50.9 g/day of carbohydrates, 53.8 ± 16.1 g/day of fat and 55.7 ± 16.9 g/day of protein. After administration there was a significant increased levels of transferrin. A total of 3 patients had an episode of diarrhea (9.7%). The number of patients experiencing at least one episode of gastric residue was 5 (16.1%) not forced in any way to withdra wing enteral nutrition, forcing in 2 patients to diminish the nutritional intake volume for 24 hours. During nutritional support, in only 3 patients it was required to decrease the volume made the previous day energy formula. With regard to vomiting, in 1 patient this situation (3.2%) was verified. No patient in the study presented any digestive complications associated with the administration of the enteral nutrition formula. Finally, no adverse events related to the administered formulation were recorded. Conclusions: The results show that enteral formula with high energy density is a well-tolerated formula with a very low frequency of gastrointestinal symptoms, which favors compliance.

Insulinoma maligno avanzado. Respuesta y toxicidad con everolimus

A 56-year-old female patient with an unremarkable history was admitted to hospital in August 2009 for constitutional symptoms with a weight loss of 8 kg over the previous year, early satiety, and epigastric pain treated with omeprazole and domperidone on an outpatient basis. Physical examination revealed hepatomegaly extending 3 cm below the right costal margin and palpation of the spleen apex in the left hypochondriac region. Laboratory test results included: Hb, 11.3 g/dL (<12 g/dL); ESR, 73 mm/h (>20 mm/h); HbA1c, 6.7% (>5.7%); basal blood glucose, 117 mg/dL (60--100 mg/dL); LDH, 708 (>380 U/L). Fiberoptic gastroscopy showed a 3 cm × 4 cm lesion extrinsically compressing the antrum. An abdominal CT scan revealed multiple focal hepatic lesions with characteristics of hypervascular metastasis affecting 70% of the liver, and a focal lesion in the tail of the pancreas that caused splenic vein thrombosis. Ultrasound-guided FNA of the liver disclosed hepatic metastases from a well differentiated, synaptophysin-positive neuroendocrine carcinoma. Ki67 and chromogranin A could not be tested in the sample. Octreoscan showed a positive activity of somatostatin receptors in the liver. Tissue from primary tumor could not be obtained, and a histological characterization was therefore not possible. Based on a diagnosis of metastatic, well differentiated neuroendocrine tumor (NET), chemotherapy was started with streptozocin and adriamycin. Two days later, the patient was admitted to hospital for urinary tract infection and pain in the liver, and required dexamethasone. She had hyperglycemic decompensation, which was treated with subcutaneous insulin as a basal-bolus regimen, which was continued after discharge. A CT scan performed in April 2010 showed a significant decrease in the size and number of liver metastases, and a slight decrease in size of the pancreatic

Carta científicaInsulinoma maligno avanzado. Respuesta y toxicidad con everolimusAdvanced malignant insulinoma. Everolimus response and toxicity

A 56-year-old female patient with an unremarkable history was admitted to hospital in August 2009 for constitutional symptoms with a weight loss of 8 kg over the previous year, early satiety, and epigastric pain treated with omeprazole and domperidone on an outpatient basis. Physical examination revealed hepatomegaly extending 3 cm below the right costal margin and palpation of the spleen apex in the left hypochondriac region. Laboratory test results included: Hb, 11.3 g/dL (<12 g/dL); ESR, 73 mm/h (>20 mm/h); HbA1c, 6.7% (>5.7%); basal blood glucose, 117 mg/dL (60--100 mg/dL); LDH, 708 (>380 U/L). Fiberoptic gastroscopy showed a 3 cm × 4 cm lesion extrinsically compressing the antrum. An abdominal CT scan revealed multiple focal hepatic lesions with characteristics of hypervascular metastasis affecting 70% of the liver, and a focal lesion in the tail of the pancreas that caused splenic vein thrombosis. Ultrasound-guided FNA of the liver disclosed hepatic metastases from a well differentiated, synaptophysin-positive neuroendocrine carcinoma. Ki67 and chromogranin A could not be tested in the sample. Octreoscan showed a positive activity of somatostatin receptors in the liver. Tissue from primary tumor could not be obtained, and a histological characterization was therefore not possible. Based on a diagnosis of metastatic, well differentiated neuroendocrine tumor (NET), chemotherapy was started with streptozocin and adriamycin. Two days later, the patient was admitted to hospital for urinary tract infection and pain in the liver, and required dexamethasone. She had hyperglycemic decompensation, which was treated with subcutaneous insulin as a basal-bolus regimen, which was continued after discharge. A CT scan performed in April 2010 showed a significant decrease in the size and number of liver metastases, and a slight decrease in size of the pancreatic

Tratamiento de carcinoides gástricos bien diferenciados con análogos de somatostatina

inactivating CaSR mutation who had episodes of psychosis and osteoporosis. After treatment with cinacalcet for 12 months, serum calcium levels gradually normalized. FestenSpanjer et al.7 reported a 37-year-old female patient with FHH and a 10-year history of recurrent pancreatitis who was treated with cinacalcet 30 mg/day for four weeks. Alon and Van DeVoorde4 reported a 6-year-old boy with FHH in whom hypercalcemia appeared to interfere with tissue healing after a tympanoplasty. He was treated with cinacalcet for one year, and initially showed partial response to treatment with doses of 30 mg/day. When this dose was doubled, adequate healing and normalization of serum levels of Ca and PTH were achieved. Cinacalcet is thought to interact with CaSR segments, enhancing transduction and activation signals from the receptor and inducing conformational changes in CaSR. However, the pharmacodynamic mechanisms by which cinacalcet increases sensitivity to Ca in the mutated CaSR are not known yet. We report our positive clinical and analytical experience with cinacalcet in a 25-year-old patient with severe hypercalcemia due to FHH and an altered CaSR gene. Cinacalcet represents a new alternative for treating patients with hypercalcemia secondary to mutation in the calciumsensing receptor.