Luis Felipe Pallardo

Obstetric and perinatal complications in HIV-infected women. Analysis of a cohort of 167 pregnancies between 1997 and 2003

Background. The unquestionable benefit of antiretroviral therapy in reducing the rate of mother‐to‐child transmission can be lessened by potential maternal or neonatal toxicity. Objective. To analyze obstetric and perinatal complications in a cohort of HIV‐infected pregnant women and their relationship with maternal antiretroviral therapy. Population. One hundred and sixty‐seven HIV‐infected pregnant women who delivered at Hospital Universitario La Paz, Madrid, Spain between January 1997 and December 2003. Methods. Data on the clinical and epidemiological characteristics of HIV‐infected patients, previous and current antiretroviral therapy, gestational diabetes mellitus, length of pregnancy, mode of delivery, and weight of the newborn were collected. Pregnancy outcomes were compared with those of all the pregnant women attended at our hospital. Main outcome measures. Gestational diabetes mellitus, premature delivery, and low birth weight. Results. Gestational diabetes mellitus was diagnosed in 8.9% of patients. All the cases of gestational diabetes were in the combined antiretroviral therapy group, and the majority were receiving triple antiretroviral therapy with a protease inhibitor. The risk of developing this pathology was greater among women receiving antiretroviral therapy prior to pregnancy. The premature delivery rate was 29% and the low birth weight rate was 28%. Conclusion. Gestational diabetes mellitus is more common in HIV‐infected women than in the general population and is related to combined antiretroviral therapy, especially the use of protease inhibitors, which suggests the need for close follow‐up during pregnancy in HIV‐infected patients. Nevertheless, the adverse perinatal consequences observed were more related to maternal factors than to antiretroviral therapy.

Molecular scanning for mutations in the insulin receptor substrate-1 (IRS-1) gene in Mexican Americans with Type 2 diabetes mellitus

Insulin receptor substrate‐1 (IRS‐1) is an endogenous substrate for the insulin receptor tyrosine kinase, which plays an important role in insulin signaling. Mutations in the IRS‐1 gene are associated in some populations with obesity and Type 2 diabetes.

Is Pregnancy Outcome Worse in Type 2 Than in Type 1 Diabetic Women

Most research on pregestational diabetes has focused on type 1 diabetes, and surprisingly little knowledge exists concerning outcomes of pregnancies of women with type 2 diabetes. A dearth of published data suggest outcomes similar to those of type 1 diabetic women (1,2), although recent studies report poorer outcomes in women with type 2 diabetes (3–7). We retrospectively compared maternal and perinatal outcomes of 93 consecutive singleton pregnancies in women with type 2 diabetes and 532 consecutive singleton pregnancies in women with type 1 diabetes referred to the Diabetes and Pregnancy Unit at University Hospital La Paz from 1984 to 2004. Women with type 2 diabetes were significantly older ([means ± SD] 31.8 ± 5.5 …

Use of insulin lispro during pregnancy in women with pregestational diabetes mellitus.

BACKGROUND AND OBJECTIVE To assess the safety and efficacy of insulin analogues versus human insulin in pregnant women with pregestational diabetes. PATIENTS AND METHODS We collected data on pregnant women with type 1 or type 2 diabetes who were attended at the Diabetes and Pregnancy Unit between January 1998 and April 2008 (N=351). Two hundred and forty one patients were treated with regular insulin and NPH and 110 were treated with different combinations of insulins including an insulin analogue (most of them with NPH and lispro). RESULTS There was no significant difference in terms of congenital malformation rate between groups (3.3% and 3.6%). The group on insulin analogue had slightly higher mean HbA1c during the first trimester than the group on human insulin (6.6 [1.0]% vs 6.9 [1.1]%; P=0,022) and needed smaller insulin doses during whole pregnancy. Severe hypoglycaemia was significantly less frequent among women treated with a rapid insulin analogue (2.3 vs 10.0%; P=0,025). Neonatal hypoglycaemia was significantly more frequent in the group treated with a rapid insulin analogue (34.9 vs 23.6%; P=0.043) due to the concomitant use of an insulin pump. Other obstetric and neonatal variables were not different between the two groups. CONCLUSION Our study shows that insulin analogues are safe during pregnancy in women with pregestational diabetes mellitus. Overall, glycaemic control, maternal and foetal outcome were similar to those with human insulin. The main advantage with respect to human insulin was to importantly reduce maternal severe hypoglycaemia.

Body weight, weight gain and hyperglycaemia are associated with hypertensive disorders of pregnancy in women with gestational diabetes

AIM The aim of this study was to measure the capacity of glucose- and weight-related parameters to predict pregnancy-induced hypertensive disorders in women with gestational diabetes. METHODS An observational study was conducted involving 2037 women with gestational diabetes. The associations of glycaemic and weight-related parameters with pregnancy-induced hypertensive disorders were obtained by univariate and adjusted multivariate analyses. Also, model predictability and attributable predictor risk percentages were calculated, and collinearity and factor interactions examined. RESULTS Multivariate analyses revealed that hypertensive disorders were mainly predicted by average third-trimester glycated haemoglobin (HbA(1c)) levels ≥ 5.9%, by being overweight or obese before pregnancy and by excess gestational weight gain after adjusting for age, tobacco use, chronic hypertension, parity, urinary tract infections and gestational age at delivery. Prepregnancy body weight (overweight and obesity) had the strongest impact on pregnancy-related hypertensive disorders (attributable risk percentages were 51.5% and 88.8%, respectively). The effect of being overweight or obese on hypertensive disorders was enhanced by HbA(1c) levels and gestational weight gain, with elevated HbA(1c) levels multiplying the effect of being overweight before pregnancy. CONCLUSION The average third-trimester HbA1c level is a novel risk factor for pregnancy-induced hypertensive disorders in women with gestational diabetes. HbA(1c) levels ≥ 5.9%, prepregnancy overweight or obesity and excess gestational weight gain are all independent risk factors of pregnancy-related hypertensive disorders in such women. In treated gestational diabetes patients, the strongest influence on hypertensive disorders is prepregnancy obesity.

Solitary Hemorrhagic Cerebellar Metastasis from Occult Papillary Thyroid Microcarcinoma

BACKGROUND Cerebellar metastasis (CM) from papillary thyroid carcinoma (PTC) is exceptional with only 12 reported cases and usually carries a very poor prognosis. In the two previously reported patients in whom CM was detected before PTC, other distant or local metastases were already present by the time of PTC diagnosis. We report a patient found to have papillary thyroid microcarcinoma after surgical resection and histopathological study of a large solitary hemorrhagic CM, who showed no evidence of other metastatic sites and survived 7 years after initial diagnosis. SUMMARY A 65-year-old female patient with a history of surgical resection of a 7-cm cerebellar mass diagnosed with PTC metastasis, and adjuvant treatment with cranial external radiotherapy, was referred to us. The neck ultrasonography showed a solitary 4-mm right thyroid nodule. Histopathology after total thyroidectomy revealed a 2-mm papillary thyroid microcarcinoma, sclerosing variant, with capsule infiltration but no regional lymph node invasion. Although she received a total dose of 500 mCi of 131-I after surgery and the last two whole-body scans were normal, serum thyroglobulin levels progressively increased. The patient refused any further test or treatment other than basal blood sampling and suppressive therapy with levothyroxine and remained stable for 4 years until she started to complain about deviation of her walk. A computed tomography scan showed a regrowth of the metastasis. She suffered a sudden worsening of her neurological status because of a big intratumoral hemorrhage that required decompressive craniectomy and hematoma evacuation surviving 3 years more after this episode. CONCLUSIONS To our knowledge, this is the first reported case of a solitary CM from an occult PTC, and also the first that developed an acute cerebellar hemorrhage years after cranial surgery, however, exhibiting the longest reported survival. This case highlights the importance of not only an appropriate initial treatment of the CM and primary PTC in these patients, but also a close follow-up, to avoid further complications and improve their prognosis.

Low Toe-Brachial Pressure Index Predicts Increased Risk of Recurrent Cardiovascular Disease in Type 2 Diabetes

Ankle-brachial pressure index (ABI) and toe-brachial pressure index (TBI) are used for the detection of peripheral arterial disease. Low ABI is associated with increased risk of myocardial infarction and cardiovascular death (1,2). The validity of TBI in the prediction of cardiovascular events in patients with diabetes has been hardly evaluated. After an acute coronary syndrome, 81 patients with type 2 diabetes were recruited (2003–2011). Baseline parameters (men 74.1%, age 65.3 ± 9.1 years, diabetes duration 13.4 ± 9.2 years) were collected and ABI and TBI were measured using standard procedures. TBI data were missing for eight patients, and three patients with an ABI ≥1.3 were excluded from the ABI analysis. During follow-up, all major cardiovascular events (new episode of myocardial infarction, ischemic cerebrovascular disease, or peripheral arterial disease) were registered. Adjusted Cox proportional hazards regression models were …

Identification of eight new mutations in the GCK gene by DHPLC screening in a Spanish population.

Maturity onset diabetes of the young (MODY) is a genetically heterogeneous disorder characterized by autosomal dominant inheritance, altered function of pancreatic beta cells and early onset diabetes mellitus, usually before 25 years old. The prevalence of specific mutations of MODY genes differs considerably among different countries. In this study we analyzed 53 index cases from unrelated MODY families who are potential carriers of mutations in GCK gene. In addition, 122 relatives were also studied. We have identified eight new mutations in the GCK gene. One of them is a non-frameshift deletion involving Lysine 143. This amino acid is part of the conserved stretch of basic residues (KHKKL) which spans from residue 140 to 144. The non-frameshift deletion might implicate the affinity of GCK for GCKRP, and potentially the abnormal nuclear localization of GCK. Additional studies should be performed to confirm this possibility.

Riesgo asociado a obesidad según estadiaje de Edmonton en cirugía bariátrica

UNLABELLED With a prevalence of Morbid Obesity of 1,2% of the Spanish population, the current criteria for Bariatric Surgery do not classify patients taking into consideration co-morbidities or functional status. We need new staging systems useful in predicting mortality and able to support prioritizing treatments. AIM Applying Edmonton staging system to patients awaiting Bariatric Surgery. METHOD Data collected from 81 patients from 2011- 2013 after pre-surgery protocol. Weight, height, waist, BMI, biochemical parameters and blood pressure are registered. Also taken down are hepatic, renal, osteoarticular diseases, sleep-apnea syndrome and/or gastro-oesophageal reflux, if present. Edmonton staging of ten variables is applied to each patient. RESULTS 81 patients: 67% women, average age 47y, 18% below 30y. Average BMI of 47, 90% of patients have a BMI >40. 34% of patients show sleep-apnea syndrome and 25% gastro-oesophageal reflux. 9% of the patients have a BMI >45, diabetes mellitus and sleep-apnea syndrome. Applying the Edmonton Staging, nine patients (11%) are in the highest risk range (stage 3), 70% are in the high-risk range (stage 2) and 15 patients (18%) are included in the low-risk range. No patient was found to be in stage 0 without obesity risk factors. CONCLUSIONS The Edmonton staging system provides us with information on presence or extent of co-morbidities that guide decision making in individuals. The mortality- predictive ability of Edmonton proposal could help to assist in determining the urgency of Bariatric Surgery and establish better criteria to prioritize these group of patients.

Influencia del control metabólico preconcepcional en la evolución de la gestación de la paciente diabética

Fundamento En la paciente diabetica es preciso un control metabolico estricto en los momentos previos a la concepcion y en las primeras semanas del embarazo para disminuir la morbilidad maternofetal. En nuestro estudio tratamos de comprobar si dicho control se relaciona o no con la aparicion de abortos y de complicaciones neonatales Pacientes y metodo Se examina a 69 pacientes diabeticas, 62 diabeticas tipo 1 y 7 diabeticas tipo 2, sometidas a control preconcepcional en la unidad de diabetes y embarazo en el periodo 1992-1998. Se llevo a cabo control metabolico en el periodo preconcepcional y a lo largo de la gestacion. Se analiza la relacion entre los parametros de control metabolico en el periodo preconcepcional inmediato y la evolucion de la gestacion Resultados Un total de 50 mujeres (72,6%; intervalo de confianza [IC] del 95%: 62-83%) finalizaron el control preconcepcional con embarazo. De estas pacientes, 8 (16%; IC del 95%: 5,5–27%) abortaron. No hubo diferencias entre las pacientes que abortaron y las que no, en relacion con la hemoglobina glucosilada (HbA 1c) con que terminaron el control preconcepcional, edad, tiempo de evolucion de la diabetes y edad al diagnostico, presencia de anticuerpos antitiroideos o de vasculopatia. En los 41 embarazos con feto unico, hubo macrosomia en un 36,6% (IC del 95%: 21,2-52%), hipoglucemia neonatal en un 19,5% (IC del 95%: 6,9-32%) y malformaciones graves en un caso (2,4%; IC del 95% 2-7,4%). La HbA 1c media (desviacion estandar) de las 41 pacientes embarazadas con feto unico al inicio del periodo preconcepcional fue del 7,6 (1,3) (IC del 95%: 7,1-7,9%) y al final de dicho periodo del 6,5% (0,7) (IC del 95%: 6,3-6,7%) (p Conclusion Un mejor control metabolico en el periodo preconcepcional puede contribuir a disminuir la incidencia de macrosomia y de morbilidad neonatal