Variación estacional de los niveles de vitamina D y su relación con la obesidad en una población de embarazadas de alto riesgo en Buenos Aires

RESUMEN Introducción: La prevalencia de obesidad es alta en el embarazo y puede modificar los valores de 25OHD. La obesidad y la deficiencia de 25OHD tienen consecuencias materno-fetales. En Argentina existe una gran variación estacional de 25OHD. Objetivo: Comparar niveles de vitamina D en embarazadas de alto riesgo en tercer trimestre teniendo en cuenta variación estacional (invierno-verano) y el IMC. Materiales y Métodos: Estudio de corte transversal donde se evaluaron pacientes con embarazo de alto riesgo en tercer trimestre. Se consideró alto riesgo la presencia de: disfunción tiroidea, diabetes pregestacional, hipertensión inducida por el embarazo o diabetes gestacional. Variables analizadas: edad, semana de embarazo, IMC, estación del año (invierno/verano) y 25OHD (D2 +D 3) Se consideró obesidad con IMC: > 30 kg/m2. Según niveles de 25OHD, se clasificó en: deficiencia severa: <10 ng/ml, deficiencia: 10.1-19.9 ng/ml, insuficiencia: 20-29.9 ng/ml y suficiencia >30 ng/ml. Resultados: 60 mujeres embarazadas 30±6.3 años. Los valores de 25OHD fueron más bajos en invierno (n=19) vs verano (n=41) 10.7±3.5 vs 26.3±8.2 ng/ml (p<0.0001), con mayor deficiencia severa en invierno vs verano: 47.4% vs 2.5% (p<0.0001). Las mujeres obesas (n=22) tuvieron menor 25OHD vs no obesas (n=38): 18±0.91 vs 23.4±10.3 ng/ml (p=0.004) y esto fue independiente de la estación del año: obesas/invierno vs no obesas/invierno: 8.9±1.4 vs 11.8±3.9 ng/ml (p=0.003) y obesas/verano vs no obesas/verano: 22.2±7.9 vs 28.7±7.6 ng/ml (p=0.01). Conclusiones: Las embarazadas de alto riesgo obesas, en tercer trimestre y durante el invierno deben ser considerados de muy alto riesgo para el déficit de vitamina D.

ABSTRACT Obesity is a risk factor for vitamin D deficiency and both determine to maternal-fetal pathologies. In our country there is a wide seasonal variation ofvitamin D levels. Aim: To evaluate the relationship between vitamin D levels, season and body mass index (BMI) in high-risk pregnant. Method: Cross-sectional study, patients were evaluated in the third trimester of pregnancy. It was considered: age, week of pregnancy, BMI, season and 25OHD measurement Obesity was defined: BMI >30 kg/m2. Vitamin d status was classified as: severe deficiency: <10 ng/ml, deficiency: 10.1-19.9 ng/ml, insufficiency: 20-29.9 ng/ml and sufficiency >30 ng/ml. Results: 60 pregnant of 30.1±6.3 years, in third trimester (31.2±4.3 weeks) were included. 25OHD values were lower in winter (n=19) vs summer (n=41): 10.7±3.5 vs 26.3±8.2 ng/ml (p<0.0001). According 25OHD in winter vs summer, patients with severe deficiency: 47.4% vs 2.5% (p<0.0001), deficiency: 94.7% vs 17.1% (p<0.0001), insufficiency: 100% vs 61% (p=0.001). No patients had levels of sufficiency in winter vs 39% in summer. Obese patients (n=22) had lower levels of 25OHD vs non-obese (n=38): 18.0±9.1 vs 23.4±10.3 ng/ml (p=0.04). According to BMI and season, obese had lower 25OHD compared with non-obese in winter: 8.9±1.4 vs 11.8±3.9 ng/ml (p=0.03), and summer: 22.2±7.9 vs 28.7±7.6 ng/ml (p=0.01) Conclusions: High-risk pregnant in the third trimester have significantly lower vitamin D in winter than in summer and in obese than in non-obese. Patients with obesity in winter should be considered high risk ofvitamin D deficiency.

Ginecomastia: aspectos clínicos y etiológicos. Estudio retrospectivo y multicéntrico / Gynecomastia: Clinical and Ethiological Aspects. Retrospective, Multicenter Study

La ginecomastia es el agrandamiento benigno del tejido mamario en el varón. Es una causa frecuente de consulta que produce ansiedad e incomodidad y puede ser la expresión clínica de una enfermedad relevante. Objetivos: 1) Evaluar las características de presentación de la ginecomastia y el perfil bioquímico; 2) Evaluar la etiología de la ginecomastia en la población estudiada. Material y Métodos: Estudio retrospectivo, multicéntrico. Se evaluaron las historias clínicas de 220 varones (18-85 años) con diagnóstico clínico y por imágenes de ginecomastia, con evaluación bioquímica completa. Resultados: Se observó mayor prevalencia entre 21-30 años de edad (n = 66; 30 %). La mayoría consultó en forma espontánea (77,7 %); el resto fue derivado por otras especialidades. Principales motivos de consulta: razones estéticas (70,4 %) y dolor (27,3 %). El 23,2 % tenía antecedente de ginecomastia puberal. El tiempo de evolución previo a la consulta fue muy variable: 1 mes a 40 años. Examen físico: 122 pacientes (55,4 %) presentaron ginecomastia bilateral y 98 (44,6 %) unilateral (54,1 % izquierda y 45,9 % derecha). El 44,8 % presentó sobrepeso y 22,4 % obesidad. En 29,1 % se constató dolor mamario al examen. Un paciente (con macroprolactinoma) presentó secreción mamaria espontánea y 3 pacientes secreción mamaria provocada. Etiología: la ginecomastia idiopática fue la más frecuente (49,1 %) y de las causas secundarias, el consumo de anabólicos. Se constató un 10 % de pacientes con hipoandrogenismo, 16,4 % con hiperprolactinemia y 10,5 % con hiperestrogenemia. En 6 casos coexistieron 2 causas (total 226 causas). No se hallaron marcadores oncológicos elevados. En los < 40 años las causas más frecuentes fueron uso de anabólicos y ginecomastia puberal persistente; y en los > 40 años fueron hipogonadismo y consumo de fármacos. Los pacientes con ginecomastia bilateral tuvieron mayor tiempo de evolución, mayor IMC y menores niveles de TT versus ginecomastia ...

Gynecomastia is a benign enlargement of breast tissue in men. It occurs physiologically in three stages of life: newborns, pubescent boys and older adults. It is a frequent reason for consulting and -though generally benign- it produces anxiety and discomfort. It is important to differentiate between the asymptomatic presence of palpable breast tissue, which is of little clinical relevance, and a recent onset breast enlargement usually associated with pain and swelling, which can be a sign of illness or pharmacological impact. Aims: To evaluate the presenting features (symptoms, duration, laterality, etc.) and biochemical profile of gynecomastia; to assess the etiology of gynecomastia in the study population. Methods: Retrospective, multicenter study. We evaluated the medical records of 220 men aged 18-85 years (average age 33 years: median 39.5 ± 19.6 years) with imaging and clinical diagnosis of gynecomastia who had undergone biochemical assessment. The consultation period was from May 2002 to June 2013. The following data was assessed: breast pain, duration of gynecomastia, sexual function, galactorrhea, weight change, habits (alcohol, drug addiction, anabolic steroids), history of pubertal gynecomastia, use of medication and family history of gynecomastia. Physical examination: weight, height, body mass index (BMI), breast and gonadal examination. Laboratory: total testosterone (TT), bioavailable testosterone (Bio-T), estradiol (E2), luteinizing hormone, follicle stimulating hormone, prolactin, thyrotropin, alpha fetoprotein, β subunit of human chorionic gonadotropin and carcinoembryonic antigen. For hormonal abnormalities, each site’s reference values were considered. In all patients, gynecomastia was confirmed by ultrasound and / or mammography. Results: A higher prevalence of gynecomastia is observed in the age range between 21 and 30 years (n = 66; 30 %). Most patients presented spontaneously (77.7 %); the rest were referred from other specialties. The most frequent reasons for consultation were aesthetic reasons (70.4 %) and breast pain (27.3 %). Twenty-three point two percent of subjects had a history of pubertal gynecomastia. Evolution time prior to consultation was highly variable (1 month to 40 years). On physical examination, 122 patients (55.4 %) had bilateral and 98 patients (44.6 %) had unilateral gynecomastia (54.1 % left and 45.9 % right); 44.8 % were overweight and 22.4 % were obese. BMI: 27.2 ± 4.3 kg/m2. In 29.1 % of patients breast pain was identified on medical examination. One patient (with macroprolactinoma) had spontaneous galactorrhea and in 3 patients mammary secretion was found on physical examination. Gonadal examination was performed in 147 patients, 126 had normal testicular volume, 10 had bilateral hypotrophy, 7 had unilateral hypotrophy and 4 unilateral absence of the testis. Idiopathic gynecomastia was the most common etiology (47.8 %). The most relevant secondary cause of gynecomastia was anabolic steroids consumption (14.1 %). In 6 cases two causes coexisted (total: 226 causes). Elevated cancer markers were not found in any of the cases. If we divide the population into patients younger and older than 40, in the former the most common second­ary causes were the use of anabolic steroids and persistent pubertal gynecomastia, while in patients older than 40, they were hypogonadism and medical drug use. Patients with bilateral gynecomastia had a longer history of gynecomastia: 3.4 ± 5.7 versus 1.4 ± 1.9 years (p = 0.0004); higher BMI: 28.4 ± 4.4 versus 25.5 ± 3.5 kg/m2 (p < 0.0001) and lower TT levels: 4.7 ± 2.0 versus 5.4 ± 1.9 ng/ml (p=0.019) than patients with unilateral gynecomastia, respectively. A negative correlation between BMI and TT was found (r= -0.38, p< 0.0001). No correlation between BMI and E2 and between BMI and bio-T was found. Ultrasound was used in 83.2 % of patients and mammography in 43.6 % (both 28.2 %). Conclusions: Patients with gynecomastia consulted more often for aesthetic reasons and secondarily for breast pain. Detection of galactorrhea was rare. Gonadal examination was normal in most patients and 66.7 % were overweight or obese. Just over half of the patients presented with bilateral gynecomastia and compared with cases of unilateral gynecomastia, they had a longer history of disease, higher BMI and lower TT levels. The most common cause of gynecomastia was idiopathic in all age groups. Persistent pubertal gynecomastia and anabolic steroids consumption were frequent in patients younger than 40 years, and medical drug use and hypogonadism in patients over 40. The presence of gynecomastia may be the expression of an underlying and clinically relevant disease. This highlights the need for an adequate and complete clinical, biochemical and imaging assessment in these patients. Rev Argent Endocrinol Metab 52:22-28, 2015 No financial conflicts of interest exist.

Estudio de causas secundarias de osteoporosis masculina / Study of secondary causes of male osteoporosis

La osteoporosis (OP) es una enfermedad subdiagnosticada y subtratada en la mayoría de los hombres. Un tercio de las fracturas de cadera ocurren en la población masculina, con más complicaciones secundarias que en la población femenina y una tasa de mortalidad de 37,5 % dentro del año posterior a la fractura. Un gran número de fracturas ocurren en hombres cuya densidad mineral ósea (DMO) no está en rango osteoporótico, esto resalta la importancia de evaluar factores distintos a la DMO en la determinación del riesgo de fractura. Objetivos: establecer la prevalencia de causas secundarias de OP en hombres mayores de 50 años y analizar las posibles asociaciones entre los valores de DMO y distintos parámetros bioquímicos. Se evaluaron retrospectivamente 918 historias clínicas de varones mayores de 50 años, cuyo motivo de admisión fuese OP, osteopenia o fracturas óseas en cualquier localización. Criterios de inclusión: medición de parámetros plasmáticos y urinarios de metabolismo fosfocálcico, testosterona total y DMO de raquis lumbar, cuello femoral y trocánter. Resultados: 113 pacientes, de 70,6 ± 9,8 años, cumplieron los criterios de inclusión, el 75,2 % tenían diagnóstico de OP en al menos una localización y el 24,8 % osteopenia. En el 85,8 % de los pacientes se encontraron causas secundarias de OP, siendo las más frecuentes: hipovitaminosis D, hipogonadismo, corticoterapia crónica e hipercalciuria. El 22 % de los pacientes padeció alguna fractura sin sospecha previa de baja masa ósea. Conclusiones: en un alto porcentaje de hombres con OP se observaron causas secundarias. El diagnóstico de OP en el varón es tardío ya que el 22 % había padecido alguna fractura sin sospecha previa de baja masa ósea. Esto resalta la importancia de este problema y la necesidad de realizar un diagnóstico y tratamiento temprano en la población masculina.

Male osteoporosis (OP) is an underdiagnosed and undertreated disease in the majority of men. One third of hip fractures occur in men, who present more secondary complications than women, with a mortality rate of 37.5 % within one year of facture. The observation that most fractures occur in men, whose bone mineral density is not in the osteoporotic range, highlights the importance of different factors others than bone densitometry to evaluate the risk of fracture. Aims: to establish the prevalence of secondary factors OP in men older than 50 years and to analyze the possible associations between bone mineral density and biochemical parameters. Retrospective analysis of 918 medical records of men over 50 years old, admitted because of OP, osteopenia or bone fractures in any location. Inclusion criteria: measurements of plasma and urinary bone metabolism parameters, total testosterone, lumbar spine, femoral neck and trochanter bone mineral density. Results: 113 patients met the inclusion criteria, the mean age was 70.6 ± 9.8 years, of which 85 (75.2 %) had OP diagnosis in one location and 28 (24.8 %) osteopenia. Of 113 patients assessed, 97 (85.8 %) had secondary OP causes, such as hypovitaminosis D, hypogonadism, chronic corticotherapy and hypercalciuria. Twenty two per cent of the patients had suffered a fracture without previous suspicion of low bone mass. Conclusions: A high proportion of men with OP present secondary factors. Most of these factors are diagnosed by history taking and biochemical study. The diagnosis of male OP is delayed as 22 % had suffered a fracture without previous suspicion of low bone mass. This indicates the importance of this issue and its early diagnosis and treatment in the male population.