Spyridoula Maraka

Bisphosphonates for the prevention and treatment of osteoporosis

Osteoporosis is a systemic skeletal disorder characterized by bone loss, which leads to impaired bone strength and an increased risk of fractures. Two million fractures are attributed to osteoporosis annually in the United States and they are associated with serious morbidity and mortality. Bisphosphonates reduce the risk of fracture by suppressing bone resorption and increasing bone strength, and they have been widely used for the prevention and treatment of osteoporosis. However, the use of these drugs for the management of osteoporosis remains a clinical challenge. There are several important considerations including appropriate patient selection, pretreatment evaluation, potential adverse effects, patient preferences, and adherence. This review will discuss the evidence informing the clinical strategy for using bisphosphonates in patients with osteoporosis and those at high risk of fracture, focusing on the benefits and risks of treatment. We will also consider issues related to the monitoring and duration of treatment.

Thyroid hormone treatment among pregnant women with subclinical hypothyroidism: US national assessment

Objective To estimate the effectiveness and safety of thyroid hormone treatment among pregnant women with subclinical hypothyroidism. Design Retrospective cohort study. Setting Large US administrative database between 1 January 2010 and 31 December 2014. Participants 5405 pregnant women with subclinical hypothyroidism, defined as untreated thyroid stimulating hormone (TSH) concentration 2.5-10 mIU/L. Exposure Thyroid hormone therapy. Main outcome measure Pregnancy loss and other pre-specified maternal and fetal pregnancy related adverse outcomes. Results Among 5405 pregnant women with subclinical hypothyroidism, 843 with a mean pre-treatment TSH concentration of 4.8 (SD 1.7) mIU/L were treated with thyroid hormone and 4562 with a mean baseline TSH concentration of 3.3 (SD 0.9) mIU/L were not treated (P<0.01). Pregnancy loss was significantly less common among treated women (n=89; 10.6%) than among untreated women (n=614; 13.5%) (P<0.01). Compared with the untreated group, treated women had lower adjusted odds of pregnancy loss (odds ratio 0.62, 95% confidence interval 0.48 to 0.82) but higher odds of preterm delivery (1.60, 1.14 to 2.24), gestational diabetes (1.37, 1.05 to 1.79), and pre-eclampsia (1.61, 1.10 to 2.37); other pregnancy related adverse outcomes were similar between the two groups. The adjusted odds of pregnancy loss were lower in treated women than in untreated women if their pre-treatment TSH concentration was 4.1-10 mIU/L (odds ratio 0.45, 0.30 to 0.65) but not if it was 2.5-4.0 mIU/L (0.91, 0.65 to 1.23) (P<0.01). Conclusion Thyroid hormone treatment was associated with decreased risk of pregnancy loss among women with subclinical hypothyroidism, especially those with pre-treatment TSH concentrations of 4.1-10 mIU/L. However, the increased risk of other pregnancy related adverse outcomes calls for additional studies evaluating the safety of thyroid hormone treatment in this patient population.

Bariatric surgery and diabetes: Implications of type 1 versus insulin-requiring type 2

To report the impact of bariatric surgery on metabolic outcomes in patients with type 1 diabetes (DM1) versus insulin‐requiring type 2 diabetes mellitus (IRDM2).

Is It Possible to Manage Hypertension and Evaluate Therapy Without Ambulatory Blood Pressure Monitoring

In the management of patients with hypertension, blood pressure (BP) has been traditionally measured in the physician’s office. The contribution of ambulatory BP monitoring (ABPM) to the management of hypertensive patients has been increasingly recognized through clinical and epidemiological research. Ambulatory BP monitoring can enhance the ability to detect white-coat or masked hypertension, determine the absence of nocturnal dipping status, and evaluate BP control in patients on antihypertensive therapy. Recently, the United Kingdom National Clinical Guideline Centre published guidelines for the clinical management of primary hypertension in adults, recommending the routine use of ABPM to make the initial diagnosis of hypertension. While the advantages of ABPM are apparent from a clinical perspective, its use should be considered in relation to the cost of the equipment, data evaluation, and staff training as well as the possible inconvenience to the patient. In this review, we summarize the clinical importance of ABPM and discuss the current guidelines for establishing the diagnosis of hypertension.

Cybersecurity in Artificial Pancreas Experiments

Medical devices have transformed modern health care, and ongoing experimental medical technology trials (such as the artificial pancreas) have the potential to significantly improve the treatment of several chronic conditions, including diabetes mellitus. However, we suggest that, to date, the essential concept of cybersecurity has not been adequately addressed in this field. This article discusses several key issues of cybersecurity in medical devices and proposes some solutions. In addition, it outlines the current requirements and efforts of regulatory agencies to increase awareness of this topic and to improve cybersecurity.

Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis

Background: Transgender individuals receive cross‐sex hormonal therapy to induce desired secondary sexual characteristics despite limited data regarding its effects on cardiovascular health. Methods: A comprehensive search of several databases up to 7 April 2015 was conducted for studies evaluating the effect of sex steroid use on lipids, myocardial infarction, stroke, venous thromboembolism (VTE), and mortality in transgender individuals. Pairs of reviewers selected and appraised the studies. A random‐effects model was used to pool weighted mean differences and 95% confidence intervals (CIs). Results: We found 29 eligible studies with moderate risk of bias. In female‐to‐male (FTM) individuals, sex steroid therapy was associated with statistically significant increases in serum triglyceride (TG) levels at 3 to 6 months and at ≥24 months (21.4 mg/dL; 95% CI: 0.14 to 42.6) and in low‐density lipoprotein cholesterol (LDL‐C) levels at 12 months and ≥24 months (17.8 mg/dL; 95% CI: 3.5 to 32.1). High‐density lipoprotein cholesterol (HDL‐C) levels decreased significantly across all follow‐up periods (highest at ≥24 months, −8.5 mg/dL; 95% CI: −13.0 to −3.9). In male‐to‐female (MTF) individuals, serum TG levels were significantly higher at ≥24 months (31.9 mg/dL; 95% CI: 3.9 to 59.9) without any changes in other parameters. Few myocardial infarction, stroke, VTE, and death events were reported (more frequently in MTF individuals). Conclusions: Low‐quality evidence suggests that sex steroid therapy may increase LDL‐C and TG levels and decrease HDL‐C level in FTM individuals, whereas oral estrogens may increase TG levels in MTF individuals. Data about important patient outcomes remain sparse.

HbA1c in the Evaluation of Diabetes Mellitus.

A 76-year-old man presented to his physician’s office, requesting assistance managing his type 2 diabetes. He was diagnosed 18 months previously, based on a fasting blood glucose level of 200 mg/dL (11 mmol/L), and was prescribed metformin. The metformin was discontinued 12 months later, when his hemoglobin A1c (HbA1c) was 6.4% (46 mmol/mol). He had a history of hypertension, hereditary spherocytosis, and cholecystectomy. Medications included aspirin, atorvastatin, and lisinopril-hydrochlorothiazide. His body mass index was 38 (calculated as weight in kilograms divided by height in meters squared), blood pressure was 126/64 mm Hg, and clinical examination results were normal. He reported polyuria and polydipsia. His fingerstick blood glucose diary showed consistent recordings of greater than 350 mg/dL. His laboratory data are shown in Table 1.

Diagnostic accuracy of thyroid nodule growth to predict malignancy in thyroid nodules with benign cytology: Systematic review and meta-analysis

Thyroid ultrasound to assess for nodular growth is commonly performed during the follow‐up of patients with benign thyroid nodules, with the goal of identifying patients with a missed diagnosis of thyroid cancer. The objective of this study was to summarize the evidence regarding the diagnostic accuracy of growth during follow‐up of benign thyroid nodules for thyroid cancer.

Procedural and clinical outcomes of percutaneous adrenal biopsy in a high-risk population for adrenal malignancy.

The role of percutaneous adrenal biopsy in a high‐risk population for adrenal malignancy has not been fully investigated. Our aim was to describe the clinical presentation leading to the adrenal biopsy and evaluate the diagnostic performance, complications and non diagnostic rate of adrenal biopsy.

When and how should patients with multiple endocrine neoplasia type 1 be screened for thymic and bronchial carcinoid tumours

Patients with multiple endocrine neoplasia type 1 (MEN1) are commonly evaluated for clinical manifestations of this syndrome with the rationale that early diagnosis and adequate treatment will result in improved survival and quality of life. Thymic and bronchial carcinoid tumours are uncommon but important manifestations of MEN1. Current practice guidelines recommend evaluation with computed tomography or magnetic resonance imaging scan of the chest every 1–2 years to detect these neoplasms. However, the certainty that patients will be better off (increased survival or quality of life) as a result of this case detection strategy is based on evidence at moderate–high risk of bias that yields only imprecise results of indirect relevance to these patients. In order to improve the care that patients with MEN1 receive, co‐ordinated efforts from different stakeholders are required so that large, prospective, multicentre studies evaluating patient important outcomes are carried out.