Victoria Mendoza-Zubieta

Utility of the waist-to-height ratio, waist circumference and body mass index in the screening of metabolic syndrome in adult patients with type 1 diabetes mellitus

BackgroundThe incidence of macrovascular complications and morbidities associated to metabolic syndrome are increasing in patients with type 1 diabetes mellitus (T1DM). The combination of T1DM with features of insulin resistance similar to that of type 2 diabetes (T2DM), sometimes called “double diabetes”, has been associated with central obesity. Since the most methods to accurately detect body fat and insulin resistance are not readily available, we propose that certain indirect indexes for detecting obesity as waist-to-height ratio, waist circumference and body mass index, may be useful when screening for metabolic syndrome in patients with T1DM.MethodsWe performed a transversal evaluation (clinical and biochemical) in all the patients of the T1DM Clinic (n = 120). We determined the presence of metabolic syndrome according to the Joint Statement Criteria by the American Heart Association/ National Heart Lung and Blood Institute and the International Diabetes Federation and the utility of certain anthropometric indexes for predicting double diabetes was evaluated.ResultsThirty seven percent of the patients were considered to have metabolic syndrome using these criteria (n = 30). These patients were significantly older (p = 0.002), have a higher glycated hemoglobin (p = 0.036), cholesterol (p < 0.012) and triglyceride concentration (p < 0.01) as well as body mass index (p = 0.004), waist circumference (p = 0.01) and waist-to-height ratio (p < 0.01) than the group without metabolic syndrome. Also their c-HDL is lower (p < 0.01). A value of 0.52 for waist-to-height ratio correctly classified the largest number of patients (68% of correctly classified) well as the waist circumference (66% of correctly classified) with an adequate specificity and sensibility. Meanwhile the most precise body mass index value only classified correctly to 61% of patients.ConclusionOur data show that waist circumference and waist-to-height ratio indexes are useful to predict the presence of metabolic syndrome in adult patients with type 1 diabetes mellitus.

High Thyroid-stimulating Hormone Levels Increase Proinflammatory and Cardiovascular Markers in Patients with Extreme Obesity

BACKGROUND AND AIMS Obesity is an important health problem worldwide and many studies have suggested a relationship between obesity and thyroid function, with controversial results. Interestingly, high TSH levels have been involved with the presence of inflammatory state and risk for developing cardiovascular diseases in hypothyroid and obese patients. The aim in this work was to determine the prevalence of hypothyroidism in patients with extreme obesity and to determine whether their TSH levels were related to increased serum levels of inflammatory and cardiovascular markers. METHODS A cross-sectional study in 101 patients with extreme obesity (BMI ≥40) was performed. Anthropometric (weight, height and waist circumference) and biochemical (fasting glucose, glycosylated hemoglobin, triglycerides, total cholesterol, LDL-C, HDL-C and insulin) parameters were measured. TSH and FT4 levels as well as clinical exploration for diagnosis of hypothyroidism were carried out. Serum concentration of IL-10, IL-6, adiponectin, resistin, leptin, ICAM-1, VCAM-1 and E-selectin were determined. RESULTS A high prevalence for diabetes (37.6%), prediabetes (50.5%), dyslipidemia (74.3%), hypertension (61.4%) and hypothyroidism (48.5%) was observed in patients with extreme obesity. The presence of hypothyroidism increased serum concentration of proinflammatory cytokines IL-6 and leptin and decreased the antiinflammatory cytokine adiponectin. In addition, serum TSH levels showed a correlation for waist circumference, weight, BMI, A1c, insulin, IL-6, leptin, ICAM-1 and E-selectin. CONCLUSION There is a high prevalence for hypothyroidism in patients with extreme obesity. High levels of TSH contribute to elevate proinflammatory and cardiovascular risk markers, increasing the risk for development of cardiovascular diseases.

HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH NONFUNCTIONING PITUITARY ADENOMAS UNDERGOING POSTOPERATIVE RADIATION THERAPY: A CASE-CONTROL STUDY

OBJECTIVE Nonfunctioning pituitary adenomas (NFPAs) can be associated with significant morbidity including a compromised quality of life (QoL). Radiotherapy (RT) is listed as one of the contributing factors to QoL impairment in these patients, however the evidence supporting this association is scarce and conflicting. Here we evaluate health-related QoL (HRQoL) impairment in patients with NFPA and to what extent this is due to RT. METHODS HRQoL was evaluated with the short form-36 questionnaire (SF-36), which explores 8 domains pertaining physical, emotional, and mental well being. We assessed 50 patients with NFPA subjected to RT after pituitary surgery, and their results were compared to those from 127 subjects who had undergone surgery but not RT. Both groups were matched for age, sex, and metabolic and cardiovascular comorbidities. The SF-36 was applied a median of 72 months after RT in the group of cases and 78 months after the last surgical procedure in the control group. RESULTS Both groups scored equally low in the 8 areas explored by the survey. In a multiple linear regression model, age was significantly associated with worse physical health scores, whereas female sex was associated with worse general health perception and lower emotional role and physical role scores. The presence of a visual field defect was significantly associated with a worse social role functioning score. CONCLUSION QoL in patients with NFPAs is significantly compromised in most scales evaluated by the SF-36 survey. However, RT itself does not affect QoL.

Cardiovascular Risk and Metabolic Syndrome Characteristics in Patients with Nonfunctional Pituitary Macroadenoma

Context An elevated incidence of type 2 diabetes and cardiovascular disease (CVD) has been reported in patients with nonfunctional pituitary macroadenoma (NFPMA). There is no information about metabolic syndrome and cardiovascular risk in patients with NFPMA in our population. Objective Analyze the metabolic syndrome (MetS) components and estimate cardiovascular risk in patients with NFPMA. Design and Setting Retrospective study, at the tertiary care center. Patients and Methods 71 patients with NFPMA treated according to a preestablished multimodal protocol. Main Outcome Measures Prevalence of diabetes, hypertension, high cholesterol, obesity, and cardiovascular risk and its relationship with the clinical and biochemical characteristics. Results The prevalence of diabetes, hypertension, high cholesterol, and obesity at diagnosis was 30%, 27%, 48%, and 85% and did not change upon the last visit. The prevalence of MetS changes from 54 to 48% (p = 0.001). NFPMA patients showed a significant increase risk for high total cholesterol (SMR 1.68, 95% CI 1.28–2.17, p = 0.001) and diabetes (SMR 3.19, 95% CI 2.19–4.49, p = 0.01). According to Globorisk, the male gender was an evidence of high CVD before (81% versus 18%, p = 0.01) and after (72% versus 28%, p = 0.01) multimodal treatment. Conclusion A high prevalence of cardiovascular and metabolic disease and a high cardiovascular risk were evidenced in patients with NFPMA, especially in men. Risk factors such as the personal history of hypertension and dyslipidemia could explain the foregoing, so the control and treatment of metabolic parameters and cardiovascular risk should be an integral part of the follow-up of these patients.

Anorexia–cachexia syndrome-like hypothalamic neuroendocrine dysfunction in a patient with a papillary craniopharyngioma

The craniopharyngiomas are solid cystic suprasellar tumors that can present extension to adjacent structures, conditioning pituitary and hypothalamic dysfunction. Within hypothalamic neuroendocrine dysfunction, we can find obesity, behavioral changes, disturbed circadian rhythm and sleep irregularities, imbalances in the regulation of body temperature, thirst, heart rate and/or blood pressure and alterations in dietary intake (like anorexia). We present a rare case of anorexia–cachexia syndrome like a manifestation of neuroendocrine dysfunction in a patient with a papillary craniopharyngioma. Anorexia–cachexia syndrome is a complex metabolic process associated with underlying illness and characterized by loss of muscle with or without loss of fat mass and can occur in a number of diseases like cancer neoplasm, non-cancer neoplasm, chronic disease or immunodeficiency states like HIV/AIDS. The role of cytokines and anorexigenic and orexigenic peptides are important in the etiology. The anorexia–cachexia syndrome is a clinical entity rarely described in the literature and it leads to important function limitation, comorbidities and worsening prognosis. Learning points: Suprasellar lesions can result in pituitary and hypothalamic dysfunction. The hypothalamic neuroendocrine dysfunction is commonly related with obesity, behavioral changes, disturbed circadian rhythm and sleep irregularities, but rarely with anorexia–cachexia. Anorexia–cachexia syndrome is a metabolic process associated with loss of muscle, with or without loss of fat mass, in a patient with neoplasm, chronic disease or immunodeficiency states. Anorexia–cachexia syndrome results in important function limitation, comorbidities that influence negatively on treatment, progressive clinical deterioration and bad prognosis that can lead the patient to death. Anorexia–cachexia syndrome should be suspected in patients with emaciation and hypothalamic lesions.

Gastroesophageal reflux disease in patients with long standing type 1 diabetes mellitus: utility of two self-report questionnaires in a multifactorial disease

Abstract Background: Gastroesophageal pathologies are common and multifactorial in patients with type 1 diabetes (T1DM). The evaluation with endoscopy and 24 h pH esophageal monitoring is expensive and not always available in all medical centers, especially in developing countries so more cost-effective algorithms for diagnosis are required. Clinical questionnaires are easy to apply but its utility for gastroesophageal reflux disease screening in patients with long standing T1DM must be analyzed. Objective: To evaluate the utility of the FSSG and Carlsson-Dent (CDQ) questionnaires to detect the frequency of gastroesophageal reflux disease in patients with T1DM. Methods: Analytic cross-sectional study, included 54 randomly selected patients from the T1DM clinic in our hospital. Before their routine evaluation, were asked to answer FSSG and CDQ questionnaires, classifying them as positive with a score >8 or >4, respectively. we associated and compared the clinical and biochemical characteristics between patients with or without gastroesophageal reflux detected through questionnaires. Results: Median age was 29 years (22-35), 67% were female (median of 16 years from diagnosis). In 39% of the patients FSSG was positive, CDQ was positive in 28%. A total of 71% of patients were taking medications to treat non-specific gastric symptoms. The concordance between questionnaires was 65% (p: <0.001). Those patients with tobacco consumption as well as those with poor glycemic control were more likely to score positive in either questionnaire. Conclusions: Patients T1DM had a high prevalence of gastroesophageal reflux disease. In those patients FSSG questionnaire detected a higher number of patients in comparison with CDQ.

Letter to the EditorResponse: High Thyroid-stimulating Hormone Levels Increase Proinflammatory and Cardiovascular Markers in Patients with Extreme Obesity

We agree that it is not possible to assume an association between TSH levels and inflammatory and cardiovascular markers in serum only by performing a correlation test. We did not infer that association in our paper (1), further studies are necessary to probe it. We suggest a contribution of TSH levels on the inflammatory and cardiovascular markers: IL-6, leptin, ICAM-1 and Eselectin using a correlation test, as was previously published by some other authors (2,3). However, we did not evaluate how much serum levels of inflammatory and cardiovascular markers are likely to change for a unit of TSH. To accomplish that, we have performed a linear regression analysis as you suggested. TSH levels showed a statistical significant correlation with inflammatory and cardiovascular markers (IL-6, leptin, ICAM-1 and E-selectin) in our study (1). The results obtained showed that TSH correlate with increasing levels of IL-6 (B 1.06; 95% CI: 2.11 to 4.22; p 5 0.507), Leptin (B 4.22; 95% CI: 0.027e7.872; p ! 0.05), ICAM-1 (B 3.71, 95% CI: 2.48e4.94; p !0.001) and E-selectin (B 0.93; 95% CI: 0.52e1.37; p !0.001). These values were maintained without changes after adjusting by age, gender or BMI. Except for leptin, which decrease the regression coefficient and lost its statistical significance when adjusted by BMI (B 2.96; 95% CI: 8.74 to 6.793; p 5 0.13). This relationship between BMI and leptin has been wide reported in the literature, suggesting that the increase of leptin in extreme obese patients are mainly related to BMI; probably, TSH could act directly on adipocytes regulating leptin secretion (4), because TSH levels in hypothyroid patients with normal weight have been related to high leptin values (2). Is important to note that in all statistical models used for linear regression analysis, ICAM-1 and E-Selectin increase significantly their serum levels by unit of TSH. This results are in agreement with previously published data, where patients with subclinical hypothyroidism had high levels of ICAM-1 in comparison with control subjects (5). Both ICAM-1 and E-selectin are adhesion molecules augmented in the inflammatory process, endothelial dysfunction and

MANDIBULAR BROWN TUMOUR AS ATYPICAL PRESENTATION OF PRIMARY HYPERPARATHYROIDISM, CLINICAL CONSIDERATIONS AND DIFFERENTIAL DIAGNOSIS. TWO CASES REPORT AND REVIEW OF THE LITERATURE.

Objective. We report two cases of patients who developed solitary expansive mandibular tumor of aggressive behavior who were surgically removed in suspicion of malignancy with histopathological diagnosis of Central Giant Cell Granuloma and Giant Cell Bone Tumor in patients undiagnosed of primary hyperparathyroidism (PHTP). Methods: Two cases report and review of the literature. Results: We present two cases of single mandibular tumor with aggressive, expansive, rapidly evolving behavior. In both cases, a malignant tumor process was suspected and the lesion was surgically resected. The histopathological diagnosis was Giant Cell Bone Tumor (GCTB) in one and Central Giant Cell Granuloma (CGCG) in the other. We are unaware of their biochemical studies of both patients at the time of the intervention. Several months later, they were sent to the Endocrinology Service for hypercalcemia. One of them presented hypercalcemic crisis and pancreatitis and the other a pathological fracture of humerus. The diagnosis of ...

Persistent Primary Hyperparathyroidism, Severe Vitamin D Deficiency, and Multiple Pathological Fractures.

Persistent primary hyperparathyroidism (PHPT) refers to the sustained hypercalcemia state detected within the first six months following parathyroidectomy. When it coexists with severe vitamin D deficiency, the effects on bone can be devastating. We report the case of a 56-year-old woman who was sent to this center because of persistent hyperparathyroidism. Her disease had over 3 years of evolution with nephrolithiasis and hip fracture. Parathyroidectomy was performed in her local unit; however, she continued with hypercalcemia, bone pain, and pathological fractures. On admission, the patient was bedridden with multiple deformations by fractures in thoracic and pelvic members. Blood pressure was 100/80, heart rate was 86 per minute, and body mass index was 19 kg/m2. Calcium was 14 mg/dL, parathormone 1648 pg/mL, phosphorus 2.3 mg/dL, creatinine 2.4 mg/dL, urea 59 mg/dL, alkaline phosphatase 1580 U/L, and vitamin D 4 ng/mL. She received parenteral treatment of hypercalcemia and replenishment of vitamin D. The second surgical exploration was radioguided by gamma probe. A retroesophageal adenoma of 4 cm was resected. Conclusion. Persistent hyperparathyroidism with severe vitamin D deficiency can cause catastrophic skeletal bone softening and fractures.