Manejo quirúrgico del incidentaloma suprarrenal / Surgical management of adrenal incidentaloma

Background: The adrenal incidentaloma is a lesion found on imaging studies for diagnosis of non-adrenal disorders. Most of these patients are not of surgical treatment. Our objective was to describe the clinical features and results of surgical management of adrenal incidentalomas in the Hospital de la Universidad de Chile. Material and Methods: Retrospective descriptive study. Period 2000 to 2009. Information was gathered from medical records and biopsies registers of patients with operated adrenal incidentaloma. Results: We evaluated 24 patients undergoing surgery, 66.7 percent female, 58.3 percent between 41 and 70 years. 58.3 percent were found in the study of abdominal pain. Surgical indications were: size ≥ 4 cm, enlarged in controls, atypical features in the abdominal and pelvic CT and/or functionality. 54.2 percent were ≥ 4 cm, 16.7 percent increase in size in controls, 45.8 percent had atypical features in the abdominal and pelvic CT and 33.3 percent were functioning, being the most frequent hypercortisolism. In 87.5 percent of patients the approach was laparoscopically. The morbidity was 12.6 percent (pneumonia, wound infection and stroke) and perioperative mortality was 0 percent. Discussion: The adrenal incidentaloma is a rare indication for surgery of adrenal tumors. Before the intervention should be studies in order to evaluate functionality and suspicion of malignancy. Functionating tumors and suspicious of malignancy should be resected, being the laparoscopic approach the election, likely in most cases.

Introducción: El incidentaloma suprarrenal es aquella lesión encontrada como hallazgo en estudios imagenológicos para el diagnóstico de desórdenes no suprarrenales. La gran mayoría de esos pacientes no son de resorte quirúrgico. Nuestro objetivo es describir las características clínicas y resultados del manejo quirúrgico de los incidentalomas suprarrenales operados en el Hospital Clínico de la Universidad de Chile. Material y Método: Estudio descriptivo-retrospectivo. Período 2000-2009. Se obtuvo información de fichas clínicas y registro de biopsias de los pacientes operados por incidentaloma suprarrenal. Resultados: Se evaluaron 24 pacientes intervenidos quirúrgicamente, el 66,7 por ciento sexo femenino, el 58,3 por ciento entre los 41 y los 70 años. El 58,3 por ciento se pesquisaron durante el estudio de dolor abdominal. Las indicaciones quirúrgicas fueron: tamaño ≥ 4 cm, aumento de tamaño en controles, características atípicas en la TC abdomino-pelviana y/o la funcionalidad. El 54,2 por ciento fueron ≥ de 4 cm, 16,7 por ciento aumento de tamaño en controles, 45,8 por ciento tenía características atípicas en la TC abdomino-pelviana y 33,3 por ciento fueron funcionantes, siendo lo más frecuente el hipercortisolismo. El 87,5 por ciento de los pacientes se abordaron por vía laparoscópica. La morbilidad fue de 12,6 por ciento (neumonía, infección de herida operatoria y AVE) y la mortalidad peri operatoria fue de 0 por ciento. Discusión: El incidentaloma suprarrenal es una indicación infrecuente de cirugía de tumores suprarrenales. Antes de la intervención deben estudiarse con el propósito de evaluar funcionalidad y sospecha de malignidad. Los tumores funcionantes y sospechosos de malignidad deben ser resecados, siendo la vía laparoscópica la de elección, factible en la gran mayoría de los casos.

Mecanismos fisiopatológicos de la diabetes mellitus 2 / Physiopathological mechanisms of type 2 diabetes mellitus

Classically, it has been attributed to muscle and liver insulin resistance (IR) the main responsibility in the pathogenesis of type 2 diabetes mellitus (DM2). To date, several authors have shown the involvement of other components in its progression. The adipose tissue plays an importantrole for the increase in circulating free fatty acids due to enhanced lipolysis, which results in increased liver and muscle IR. Incretins, secreted in small bowel, potentiate insulin secretionin response to the ingestion of fat and carbohydrate. In type 2 diabetic subjects, it has been demonstrated alterations in its levels. In the diabetic kidney, increases in SGLT2 transporterexpression, enhances glucose reabsorption. Also in the brain, IR could be manifested, determining changes in appetite and satiety regulation. Finally, increased levels of glucagon and the progression of beta cell failure, determine the onset of hyperglycemia. The mechanism through each of them determines IR and progression to DM2 are reviewed.

Diagnóstico actual y alternativas de tratamiento médico en diabetes mellitus tipo 2 / Actual diagnosis and medical treatment alternatives of type 2 diabetes mellitus

The goal of the therapy in type 2 diabetes is defined according to hemoglobin A1c (HbA1c) level, which reflects chronic hyper glycemia. In 2009, an acceptable metabolic control was defined as HbA1c <7 percent. But recently, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) released a consensus position onpersonalized HbA1c goals, centered in the patient. Available therapies to treat and control type 2 diabetes are reviewed; traditional therapies as metformin, sulfonylureas, and insulin and new therapies as GLP-1 analogues and DPP-4 inhibitors.

Coexistencia de hiperparatiroidismo primario y carcinoma diferenciado del tiroides en tres casos clínicos / Coexistence of a primary hyperparathyroidism and a differentiated thyroid carcinoma: report of three cases

In 15 percent of patients with primary hyperparathyroidism subjected to parathyroid surgery, a coexistent differentiated thyroid carcinoma is found. We report three female patients aged 57, 53 and 57 years with a primary hyperparathyroidism and ultrasonographic thyroid nodules. During parathyroid surgery, a thyroidectomy was performed, confirming the presence of a differentiated thyroid carcinoma. Two patients had a microcarcinoma measuring 1 and 2 mm diameter and other had a follicular thyroid carcinoma, and parathyroid carcinom whose association with primary hyperparathyoidism is even more uncommon.

Cirugía metabólica: ¿una nueva alternativa para el tratamiento de la diabetes mellitus tipo 2? / Metabolic surgery: new alternative for diabetes mellitus type 2?

Type 2 Diabetes Mellitus is a global epidemic. Classical studies have demonstrated the benefits of tight glycemic control, showing a decrease in complications and mortality. Current therapy based on changes in lifestyle and medication accomplishes these goals in an insufficient number of patients. Follow up of obese patients undergoing bariatric surgery has shown us a significant reduction in overweight and control comorbidities. In diabetic patients, there is adequate glycemic control, decreased insulin resistance, and decrease in glycosylated hemoglobin.The pathophysiological mechanisms that explain these effects are being studied, and includes benefits associated with significant and sustained weight loss, and mechanisms independent of weight loss that appear early after surgery. The latter would be due to changes in GI anatomy induced by surgery, including activation of the entero insular axis, exclusion of the foregut, and stimulation of the distal ileum with enhanced incretin production. Since the surgery seems to have an effect on diabetes that is primary, specific and independent of weight loss, authors have suggested de idea of extending surgical indication to diabetic patients with BMI <35. Initial surgical experience in this group of patients show encouraging results, however, at this point there is insufficient data to generalize its indication. The results of on going surgical protocols will help to clarify the role of surgery in the treatment of Type 2 Diabetes in patients with BMI <35.

Métodos de medición de la sensibilidad a la insulina y otros parámetros relacionados: correlación con la clínica / Methods to measure insulin sensitivity in the clinical setting: an update

Insulin resistance appears in several pathological conditions but unfortunately a simple, low cost, reproducible and easy to perform method to measure it isstill lacking. This method should resemble as closely as possible the physiological response to insulin and should be able to evaluate the sensitivity to the hormone of different tissues and systems. We herein analyze the factors that modify basal insulin determinations and the different methods available to measure insulin resistance.

Valores normales de captación de 131Yodo de 2 y 24 horas / Normal 131Iodine uptake values at 2 ano 24 hours

Background: Radiolabeled iodine uptake is a useful tool in the study of thyroid diseases. Aim: To obtain normal values for 131 Iodine thyroid uptake in healthy volunteers. Material and methods: A total of 105 subjects were included (52 males and 53 females), with a mean age of 45 years (range: 20 to 68, evenly distributed in decades). A questionnaire was applied and a clinical examination was performed to rule out endocrine diseases. Serum TSH and anti-thyroperoxidase antibodies were also measured. The oral 131I dose was 5-10 fiCi, and a Thyrad equipment was used for measurements at 2 and 24 h. Results: Mean global iodine uptake was 5.5 percent±1.8 percent (range: 2.3-12.0) at 2 h and 16.2±4.8 percent (range: 6.5-30.1) at 24 h. The values at 2 h among women and men were 6.0±1.8 and 4.9±1.6 percent, respectively, (p <0.02). At 24 h, the figures were 17.3±4.5 and 15.0±4.9 percent, respectively (p =0.01). Compared to their younger counterparts, radioactive iodine uptake was lower among volunteers older than 40 years, at 2 h (5.0±1.7 and 6.0±1.8, respectively, p <0.02) and at 24 h (14.9±4.4 and 17.6±4.9 percent, respectively, p <0.01). Conclusions: Normal thyroid uptake values in adults are influenced bygender and age. Normal thyroid iodine uptake values are slightly higher in females. Iodine thyroid uptake values decrease slightly in subjects aged more than 40years.

Consenso elaborado por la Sociedad Chilena de Endocrinología y Diabetes sobre resistencia a la insulina(RI) y síndrome metabólico (SM): aspectos clínicos y terapéuticos / Chilean society of endocrinology and diabetes consensus on clinical and therapeutic aspects of insulin resistance and metabolic syndrome

Background: The concept insulin resistance as the basis for a series of metabolic alterations and diseases was introduced by Gerald Reaven in 1988, when he described a cluster of alterations that named syndrome X. Aim: To review and discuss the present information about insulin resistance (IR) and metabolic syndrome (MS). Material and methods: The IR concept is defined,the affected metabolic ways, its consequences and relationship with different diseases are presented. The importance of central obesity with its metabolic, inflammatory and prothrombotic consequences playing a key role in cardiovascular risk, is discussed. The cluster of factors focused on cardiovascular disease and eventually diabetes is named MS. Several definitions of MS are analyzed and compared. A proposition is made about the definition to be used in the Chilean population. Differences between IR syndrome and MS are discussed. Diagnostic methods of IR and MS are presented, recommendations are made about their usefulness and reliability. Non pharmacological and pharmacological treatments of IR and MS are analyzed. Other related diseases, such as polycystic ovary syndrome, non alcoholic steatohepatitis and sleep apnea are discussed. Conclusions. Until further studies are made to define a local waist circumference cut-off associated with high risk, the ATPIII MS definition is preferred. A clinical approach is recommended for diagnosis. A search for all components of the MS is important. There is no evidence about the benefits of MS treatment on the prevention of cardiovascular diseases or diabetes. Evidence supports the use of lifestyle changes and some drugs, such as metformin on the prevention of diabetes in prediabetic states.

Caso clínico: síndrome poliglandular autoinmune tipo II, forma de presentación en un paciente adulto / Clinical case: autoimmune polyglandular syndrome type II, presentation in adult patient

Autoimmune Polyglandular Syndrome (APS) type II or Schmidt`s Syndrome is diagnosed when a patient has adrenocortical deficiency with type 1 diabetes mellitus, chronic lymphocyticthyroiditis, or Graves’ disease. The disease commonly manifests in the third or fourth decade. We present the case of a 45 yo male patient who manifested simultaneously at the moment of diagnosis, clinical and laboratory features of hypothyroidism, pernicious anemia and Addison disease. We discuss etiologic, clinical and biochemical aspects in type II APS.

Tiroides y depresión: enfoque terapéutico actual y bases moleculares / Thyroid and depression: actually and therapeutic approach and molecular basis

Depression is a serious and high-priority public health problem. In Chilean population, prevalence ranges from 5 to 27,3 percent. Therapy is based mainly in the use of selective serotonin reuptake inhibitors (SSRIs). Combination of thyroid hormone, sodium liothyronine, associated to traditional antidepressants to improve or accelerate therapeutic response is currently accepted. The use of this combination is based on hypothalamus-hypophysis-thyroid axis (HHT) alterations and on the peripheral conversion to active hormone, the triiodothyronine (T3), by type 2 and 3deiodinases (D2 and D3). Subtle changes in enzyme activity could have a strong impact in T3 brain availability. In major depression as high as a 25 percent of altered responses of HHT axis to the TRH stimulus may be observed. Certain polymorphisms of the D2 gene could be associated to enzyme activity changes. Isotopic studies are able to assess brain flow in diverse conditions, like global or specific regional perfusion variations in patients with mild hypothyroidism, pre and post T4 or SSRIs therapy in depressive patients.

Frecuencia de amputaciones y sobrevida en pacientes hospitalizados con pie diabético entre 1985-2000 en el Hospital Clínico de la Universidad de Chile / Frequency of amputations and survival in patients hospitalized with diabetic foot between 1985-2000 in the Hospital Clínico de la Universidad de Chile

El pie diabético es la principal causa de amputación y mortalidad en pacientes diabéticos. Objetivo: establecer la frecuencia de amputaciones y característica clínicas en pacientes con el diagnóstico de pie diabético hospitalizados en el Hospital Clínico de la Universidad de Chile entre 1985-2000. Evaluar posibles factores de riesgo y la mortalidad posterior al egreso. Pacientes y método: análisis de ficha clínica, obtención de la fecha y causa de muerte del Servicio de Registro Civil e Identificación. Resultados: De 278 pacientes a 193 (69.4 por ciento) se les realizó una amputación. El nivel anatómico se distribuyó de la siguiente manera: 46 por ciento ortejo, 20 por ciento transmetatarsiana, 17 por ciento infracondílea y 17 por ciento supracondílea. Resultaron factores de riesgo para amputación: antecedente de amputación anterior (odds ratio [OR] 1.95, 95 por ciento IC 1.1-3.4); linfopenia ([OR] 0.96, 0.93-0.98); VHS aumentada ([OR] 1.012, 1.0044-1.02) y la presencia de retinopatía ([OR] 4.4, 2.2-9.1). La hospitalización fue más prolongada en los amputados (25 +/-22 vs 15 +/-13 días). El porcentaje de amputaciones en los períodos 1985 - 1994 y 1995 - 2000 fue similar (67 por ciento vs 70 por ciento). Un 35 por ciento de los pacientes amputados y un 52 por ciento de los no amputados fallecieron en un promedio de 3.38 años (rango 0-15.5 y 0-11.8 respectivamente). La primera causa de muerte en el grupo no amputado fue la cardiovascular y en el grupo amputado, fue la causa séptica. Conclusiones: aún existe una elevada frecuencia de amputaciones por pie diabético en nuestro medio lo que se asocia a hospitalizaciones prolongadas. El pie diabético complicado determina una elevada mortalidad antes de los 5 años del egreso.

The diabetic foot is the main cause of amputation and mortality in diabetic patients. Aim: To determine the frequency of lower extremity amputations and clinical features in patients with the diagnosis of diabetic foot assisted at the University of Chile Clinical Hospital between 1985-2000 to determine risks factors and mortality after the discharge. Patients and Method: Analysis of patient records and obtainment of the date and cause of death from the National Register of Citizens. Results: Of 278 patients 193 patients (69.4 percent) underwent an amputation. The anatomic level was: 46 percent toe; 20 percent transmetatharsal; 17 percent under the knee and 17 percent over the knee. Risk factors for amputation were: history of amputation (odds ratio [OR] 1.95, 95 percent IC 1.1-3.4); low lymphocytes count ([OR] 0.96, 0.93-0.98); high eritro sedimentation rate ([OR] 1.012, 1.0044-1.02) and retinopathy ([OR] 4.4, 2.2-9.1). Longer hospitalizations were observed in amputee patients (25 +/- 22 vs 15 +/- 13 days). A similar frequency of amputations was observed between 1985-1994 and 1995-2000 periods. A 35 percent of amputee patients and 52 percent of non amputee patients died in a mean of 3.34 years after the event (range 0-15.5 y 0-11.8 respectively). Among non amputee patients the main cause of death was cardiovascular disease and infectious processes were the main cause in amputee patients. Conclusions: A high frequency of amputations because diabetic foot is still observed in our diabetic patients that is associated to longer hospitalizations. The complicated diabetic foot determines a high mortality before 5 years of the event.

Estado de salud periodontal en diabéticos tipo 1, de 18 a 30 años de edad, de Santiago de Chile / Periodontal disease in Chilean type I diabetic patients between 18 and 30 years old

Background: The prevalence of periodontal diseases, gingivitis and periodontitis, is higher in diabetic patients and can have severe functional and esthetic consequences early in their lives. Aim: To evaluate the prevalence of periodontal disease in type 1 diabetics, aged between 18 and 30 years old, living in Santiago de Chile. Subjects and methods: One hundred male and female type 1 diabetics were examined. Glycated hemoglobin A1c, microalbuminuria, and fundoscopy were assessed in a sample of 52 subjects, separated in two groups according to the presence of periodontal disease. Results: The prevalence of gingivitis was 22 percent, periodontitis 41 percent. Only 37 percent of subjects were free of periodontal disease. When compared with patients without periodontal disease, in the group of patients with the disease there was a higher proportion of subjects with diabetes lasting more than 10 years (28 and 55 percent respectively) and a higher proportion of patients with chronic complications of diabetes (42 and 58 percent respectively). Conclusions: A high prevalence of periodontal diseases was observed in this sample of diabetic patients. A long history of diabetes and the presence of chronic complications were risk factors for these diseases in the analyzed sample

Tratamiento del hipertiroidismo con radioyodo: efecto de la dosis administrada sobre la función tiroidea y complicaciones asociadas / Treatment of hyperthyroidism with radioiodine: effects of administered dose on complications and thyroid function

Background: Radio-iodine is a definite therapy for Graves disease hyperthyroidism. However, the optimal dosage is still debatable. Aim: To assess the effects of different radioiodine doses on thyroid function and complications in patients with hyperthyroidism. Material and methods: A retrospective analysis of 139 patients with hyperthyroidism, treated with ratioiodine between 1988 and 1998. Radio iodine dose used was classified as low (<10 mCi), intermediate (10-14.9 mCi) or high (ü 15 mCi). Results: Thirty five patients were treated with low doses, 33 with intermediate doses and 71 with high doses. There were no differences between these patients in age, disease severity, frequency of post treatment euthyroidism or complications. Patients treated with low doses had a higher frequency of persistent hyperthyroidism than patients treated with high doses (25.7 and 4.2 percent respectively, p<0,001). Likewise, the frequency of subsequent hypothyroidism was 60 percent in patients treated with low doses and 84.5 percent of those with high doses, in whom it also appeared earlier. Associated complications were clinically irrelevant. In seven patients, Graves ophtalmopathy progressed after treatment, but this progression was not associated with the dose used. Conclusions: Radio iodine in high doses is useful, safe and effective for the treatment of Graves hyperthyroidism

Síndrome de huesos hambrientos: experiencia clínica en su diagnóstico y tratamiento / Hungry bone syndrome: report of 4 cases

Hungry bone syndrome is a unusual complication of the postoperative period of primary hyperparathyroidism. This syndrome is characterized by hypocalcemia, hypophosphatemia and hypomagnesemia, due to an excessive bone remineralization. We report the clinical features, laboratory and therapy in four females (aged 39 to 73 years old) with a long standing hyperparathyroidism, elevated alkaline phosphatases and decreased bone mineralization in two. The mean size of the adenoma was 2.9 ñ 1.1 cm. Hypocalcemia appeared between days 1 and 6 of the postoperative period. All were treated with calcium, calcitriol and magnesium at different timing and dosages. The mean hospitalization period was 19.8 ñ 2.1 days. As reported previously, low bone mineralization and a large adenoma are risk factors for the syndrome. Serial monitoring of serum calcium and magnesium and an early supplementation of these minerals could prevent hypocalcemia and decrease the hospitalization time

Remisión parcial del hipercortisolismo en una enfermedad de Cushing posterior a una apoplejia hipofisiaria: caso clínico / Partial remission of Cushing disease after pituitary apoplexy: report of 1 case

ACTH secreting macroadenomas and pituitary apoplexy are unusual in Cushing disease. In the few cases reported in the literature, they have been found in long term hypercortisolism. We communicate a 43 yr old woman with a 4 year evolution Cushing syndrome, who developed sudden cephalea and oftalmoplejia. A Computed Tomography of the pituitary fossa disclosed a macroadenoma with intracapsular hemorrhage and suprasellar expansion. In the functional tests, serum cortisol was suppressed with dexamethasone in a dose of 1 and 8 mg and responded to the desmopressin stimulus. Nevertheless, cortisol levels were lower than those observed in Cushing syndrome of similar magnitude. The tumor was resected by transphenoidal surgery and immunohistochemistry to ACTH was positive. In this case, the laboratory results suggest a partial remission of the hypercortisolism after pituitary apoplexy

Efecto de un preparado en forma de gel de 17 ß estradiol sobre diferentes parámetros hormonales en mujeres menopáusicas / Effects of a 17 ß estradiol gel preparation on different hormonal parameters in menopausal women

Different delivery forms of supplemental estrogens may differ in their hormonal effects. The aim of this study was to assess the effects of a daily dose of 2.5 g of 17 ß estradiol transdermal gel, given during four weeks, on hormon levels of six postmenopausal women. At the fourth week we observed a significant increase in estradiol and a dicrease in FSH levels. estrone levels alsa increased but the estradiol-estrone ratio was maintained in values over 1. No changes in SHBG or IGF1 levels were observed. Two patients that used the gel in the abdominal skin achieved lower estradiol levels (below 60 pg/ml). We conclude that the gel increased serum estradiol levels over 60 pg/ml in four of six women, that there is a big individual variability and the application zone could influence the serum estradiol levels achieved