[Prevalence of hypokalemia in patients with methylprednisolone pulse therapy]. / Prevalencia de hipokalemia en pacientes tratados con pulsos de metilprednisolona.

OBJECTIVE: To determine the prevalence of hypokalemia in patients with methylprednisolone pulse therapy. DESIGN: We carried out a descriptive, cross-sectional study. MATERIAL AND METHODS: We enrolled 110 outpatients who received pulse doses of 1 g of intravenous methylprednisolone for three consecutive days. Demographic variables, serum electrolytes and an electrocardiogram were documented. RESULTS: The study group consisted of 31 men (28.2%) and 79 women (71.8%). Average age was 40 +/- 13.6 years. Mild hypokalemia was present in 19 patients (17.27% [95% CI 9.75-24.79]); moderate potassium levels were found in just one patient 0.9% [IC 95 0.023-4.96]); no cases of severe hypokalemia occurred. Total prevalence was 18.18% (95% CI 10.5-25.8). There were no significant electrocardiographic changes. DISCUSSION AND CONCLUSION: Mild and moderate hypokalemia was 18.18% without clinical or electrocardiographic consequences. Since there were no cases of severe hypokalemia, close monitoring of potassium levels should be restricted to those patients with other risk factors.

[Treatment of macroprolactinoma with cabergoline during pregnancy]. / Tratamiento del macroprolactinoma con cabergolina durante el embarazo.

OBJECTIVE: Management of macroprolactinomas in women who plan to get pregnant is controversial and when this happen there is a risk of pituitary enlargement, if this happens bromocriptine has a safe profile to be used during pregnancy, but if it is not tolerated cabergoline is a good alternative. CLINICAL CASES: We describe two patients with macroprolactinomas who intended to get pregnant. One of them had been previously treated surgically and the second one was treated with bromocriptine and got pregnant before the tomographic studies were checked. Both patients developed during pregnancy symptoms of macroprolactinoma enlargement and were initially treated with bromocriptine but this was not tolerated and were switched to cabergoline. Both pregnancies ended with a normal full term newborn. CONCLUSION: Pregnant women with symptoms of pituitary enlargement must be treated with bromocriptine, but if it is not tolerated cabergoline is a good choice.

[Neonatal morbidity associated to gestational diabetes. A descriptive study on 74 patients]. / Morbilidad neonatal asociada a diabetes gestacional. Estudio descriptivo de 74 pacientes.

INTRODUCTION: women with gestational diabetes have an increase risk for maternal and neonatal metabolic complications. OBJECTIVE: to evaluate detection, treatment and close surveillance. METHODS: we recruited all women with gestational diabetes whose pregnancies ended in this hospital between September to November of 2005. All newborns were examined by a neonatologist and initiated early feeding with infant formula or glucose solution. RESULTS: a total of 74 patients with gestational diabetes were included. The age was 31.03 +/- 4.79 years, and the body mass index before pregnancy was 32.31 +/- 6.41. Eighteen patients developed third-trimester complications, in fourteen of them it was hypertensive disease of pregnancy. All were single pregnancies that ended in 71 term and 3 preterm newborns. There were not fetal or perinatal deaths. There were four small newborns for gestational age, 18 large for gestational age and 52 normal weight newborns. Eleven neonates had metabolic complications, eight of them had idiopathic respiratory distress syndrome, four had hypoglycaemia and one large for gestational age had obstetric trauma. Also two neonates with cardiovascular malformations were diagnosed. Thirty-six mothers returned for revaluation, eight had type 2 diabetes, six glucose intolerance. CONCLUSIONS: this group of patients shows the maternal and neonatal morbidity associated to gestational diabetes in patients under close surveillance. Systematic early screening in women at risk and close surveillance are required to obtain healthy newborns.

Nondiagnostic thyroid fine needle aspiration cytology: outcome in surgical treatment.

BACKGROUND: Fine-Needle Aspiration (FNA) is the main screening process for distinguishing benign from malignant thyroid nodules. Despite this, by 5-29% of patients, their FNA results are not enough to confirm malign neoplasia, particularly in cases with follicular lesions. The objective of this report is to present the definitive histological results of a group of 41 patients with FNA of Thyroid nodule catalogued as "indeterminate/non diagnostic" sent for surgical treatment. MATERIAL AND METHODS: A retrospective analysis was done on all of the patients who had underwent surgery for thyroid nodule, with a previous diagnosis of "indeterminate/non diagnostic" by FNA. Forty-one patients, three male (7.31%), and 38 female (92.68%), were included in the present study. RESULTS: Fifteen women and one man were positive for malignancies (39.02%). The nodule was bigger than 4 cm in 23 patients in total (56.09%), and of this percentage, 6 were malignant (26.09%). According to age, 24 patients were older than 45 years (58.5%), 8 of whom showed malignant pathology (33.3%). All these variables were non significant. Fifteen of 16 patients had a definitive diagnosis of papillary carcinoma and one follicular carcinoma. CONCLUSIONS: The majority of patients with a diagnosis of "indeterminated/non diagnostic" had benign lesions (60.9%). The usual predictive factors for malignity such as age, sex, size of nodule, did not present a significant support in the differential diagnosis.

[Usefulness of Doppler ultrasonography to detect fetal anemia in rh alloimmunized pregnancies]. / Ultrasonido Doppler para la detección de anemia fetal por isoimmunización a Rh.

BACKGROUND: pregnant women with Rh alloimmunization (RhA) are submitted to invasive procedures to assess fetal anemia (FA). Recently a non-invasive approach to FA diagnosis has been proposed using Doppler ultrasound (DU) to identify increased peak velocity of systolic blood flow (Vm) in the middle cerebral artery (MCA). METHODOLOGY: eleven Rh alloimmunized pregnant women with serum red-cell antibody titers > 1:16 were included. Twenty-four procedures were done measuring the VmMCA followed by cordocentesis and fetal hemoglobin (FH) analysis. Pearson's linear correlation was calculated between the multiples of the median (MoM) of the VmMCA and the MoM of the FH, as well as the sensitivity, specificity and positive predictive value (PPV) for FA prediction. RESULTS: we found FA (FH mean = 6 g/dL) in 12 of 24 evaluations with a VmMCA mean of 1.5 MoM and a range from 1.22 to 1.68 MoM; in the remaining 12 cases the FH was normal (FH mean = 13.1 g/dL) with a VmMCA mean of 0.97 MoM and a range from 0.35-1.17 MoM (p < 0.001). Eleven fetuses with anemia had a MoM of the VmMCA above 1.29, except one with 1.22 MoM. The linear correlation between the MoM of the VmMCA and the MoM of FH was 0.83. The sensitivity of the MoM of the VmMCA to detect FA was 91%, specificity of 100% and PPV of 100%. CONCLUSIONS: DU measurement of the VmMCA was a useful non-invasive technique to evaluate FA. The sensitivity and PPV for FA diagnosis in RhA was above 90%.

[Hypoglycemia in the newborns of women with diabetes mellitus]. / Hipoglucemia neonatal en hijos de madres con diabetes mellitus.

Neonatal hypoglycemia is a frequent event in the first hours of life of newborns from mothers with diabetes mellitus. We studied a group of diabetic mothers newborns during the first day of life, taking venous blood samples at < 6 h, 6-12 h and 12-24 h of life for glucose analysis (n = 85), defining hypoglycaemia as a glucose level < 35 mg/dL. Calcium serum levels were also determined in the first venous sample in 19 neonates and 7 mEq/L was the criteria for hypocalcemia. The mothers age (mean +/- standard deviation) was 30.5 +/- 5.5 years (range 16-41 years), 43 (50.6%) of them with gestational diabetes, 40 (47.1%) with type 2 diabetes and 2 (2.4%) with type 1 diabetes. Pregnancies ended by caesarean section in 78 (91.8%) and by partum in seven (8.2%) women. There were 20 (23.5%) preterm newborns. In relation to neonates weight, 27 (31.7%) were macrosomic and 7 (8.2%) were premature, two of them with very low weight. A total of 55 (64.77%) newborns had hypoglycaemia, but only one of them had a convulsive episode, the rest were asymptomatic. In relation to the newborns weight, 18 (66.6%) of the macrosomic, 33 (64.7%) of the normal weight and four (57.1%) of the premature groups had hypoglycaemia. The comparisons between the newborns weight groups showed non significant differences, but the prevalence of neonatal hypoglycaemia was significantly higher in the group of gestational diabetes than in the type 2 diabetes group (p < 0.05). Calcium analysis also disclosed asymptomatic hypocalcemia in five (7.25%) newborns. These results show an elevated prevalence of asymptomatic neonatal hypoglycaemia in the offspring of women with diabetes mellitus in their early hours of life, and stress the importance of systematic glucose monitoring and early treatment in the first hours of life of these neonates.

Hipoglucemia neonatal en hijos de madres con diabetes mellitus / Hypoglycemia in the newborns of women with diabetes mellitus

Neonatal hypoglycemia is a frequent event in the first hours of life of newborns from mothers with diabetes mellitus. We studied a group of diabetic mothers newborns during the first day of life, taking venous blood samples at < 6 h, 6-12 h and 12-24 h of life for glucose analysis (n = 85), defining hypoglycaemia as a glucose level < 35 mg/dL. Calcium serum levels were also determined in the first venous sample in 19 neonates and 7 mEq/L was the criteria for hypocalcemia. The mothers age (mean ± standard deviation) was 30.5 ± 5.5 years (range 16-41 years), 43 (50.6%) of them with gestational diabetes, 40 (47.1%) with type 2 diabetes and 2 (2.4%) with type 1 diabetes. Pregnancies ended by caesarean section in 78 (91.8%) and by partum in seven (8.2%) women. There were 20 (23.5%) preterm newborns. In relation to neonates weight, 27 (31.7%) were macrosomic and 7 (8.2%) were premature, two of them with very low weight. A total of 55 (64.7%) newborns had hypoglycaemia, but only one of them had a convulsive episode, the rest were asymptomatic. In relation to the newborns weight, 18 (66.6%) of the macrosomic, 33 (64.7%) of the normal weight and four (57.1%) of the premature groups had hypoglycaemia. The comparisons between the newborns weight groups showed non significant differences, but the prevalence of neonatal hypoglycaemia was significantly higher in the group of gestational diabetes than in the type 2 diabetes group (p < 0.05). Calcium analysis also disclosed asymptomatic hypocalcemia in five (7.25%) newborns. These results show an elevated prevalence of asymptomatic neonatal hypoglycaemia in the offspring of women with diabetes mellitus in their early hours of life, and stress the importance of systematic glucose monitoring and early treatment in the first hours of life of these neonates.

La hipoglucemia neonatal es un evento frecuente en las primeras horas de vida del recién nacido (RN) de madres que padecen diabetes mellitus (DM). Para conocer su prevalencia estudiamos los hijos de mujeres con DM y embarazo (n = 85) y cuyos nacimientos ocurrieron en el periodo de reclutamiento de cuatro meses. A estos neonatos se les determinaron las concentraciones de glucosa en sangre venosa realizando una toma en las primeras seis horas, la segunda toma entre las seis y las doce horas y una tercera toma entre las 12-24 horas de vida, usando como criterio de hipoglucemia el propuesto por Cornblath para RN con factores de riesgo para hipoglucemia neonatal (glucosa < 35 mg/dL). Además, en 19 de estos niños se determinó la concentración de calcio en suero en la primera muestra de sangre venosa, tomando como criterio de hipocalcemia < 7 mEq/L. La edad de las madres fue de 30.5 + 5.5 años (media ± DE) de 30.5 ± 5.5 años, con una banda de variación de 16-41 años, 43 (50.6%) padecían DM gestacional, 40 (47.1%) DM tipo 2 y dos DM tipo 1 (2.4%). Setenta y ocho embarazos (91.8%) terminaron por cesárea y siete (8.2%) por parto, obteniéndose 85 RN vivos, de los cuales 20 (23.5%) fueron pretérmino y 65 (76.5%) de término. De acuerdo con el peso al nacer, hubo 27 (31.7%) RN macrosómicos y siete (8.2%) prematuros. Un total de 55 (64.7%) neonatos presentaron hipoglucemia, uno de los cuales desarrolló un episodio convulsivo, el resto no tuvo signos clínicos. La hipoglucemia ocurrió en 18 (66.6%) de los macrosómicos, 33 (64.7%) de los neonatos de peso normal y en cuatro (57.1%) de los prematuros. La comparación de la prevalencia de hipoglucemia por grupos de peso neonatal no mostró diferencias significativas entre los tres grupos, pero la comparación de la prevalencia de hipoglucemia con relación a la variante del tipo de diabetes materna mostró una mayor prevalencia en los hijos de mujeres con diabetes gestacional (p < 0.05). Hubo además cinco niños (7.25%) que presentaron hipocalcemia asintomática. Estos resultados muestran la alta prevalencia de hipoglucemia neonatal asintomática y la necesidad de establecer una vigilancia activa de la glucemia durante las primeras horas de vida en los RN de madres que padecen DM.

[Insulin therapy in patients with severe hypertriglyceridemia]. / Terapia con insulina en pacientes con hipertrigliceridemia severa.

A series of seven patients with severe hypertriglyceridemia (triglyceride levels > 1000 mg/dL) is presented. Four of the patients were diabetics, two of them were in treatment with anti-retroviral drugs, and three of them presented acute pancreatitis. In all patients intravenous infusion of insulin was initiated at a rate of 0.05-2 U/kg/day. Two and a half days after this treatment, the serum triglyceride level remained lower than 400 mg/dL. There were no complications during the treatment. The long treatment included basal insulin, fibrates and avoidance of pharmacotherapy. Insulin therapy for diabetic and non-diabetic patients with severe hypertriglyceridemia is an effective and safe treatment.

Diabetes and pregnancy.

Diabetes in pregnant women is associated with an increased risk for maternal and neonatal morbidities and remains a significant medical challenge. Fortunately, the prognosis has changed dramatically, related to an increased clinical awareness of the potential risks for the mother and the infant, better health care and intensive treatment strategies to maintain the closest to normal metabolic milieu. Diabetes and pregnancy may be divided into pregestational diabetes (women previously diagnosed with type 1 or type 2 diabetes) and gestational diabetes defined as any glucose intolerance detected during pregnancy that has evolved from a diagnosis associated with the metabolic risk of type 2 diabetes to a clinical condition associated with higher risks for maternal and perinatal morbidity. Early diagnosis of gestational diabetes is an important step to improve outcomes and systematic or selective screening with the OGTT should be established. Associated with the global epidemic in diabetes, pregnancy associated with diabetes is saturating high-risk obstetric clinics and neonatal intensive care units, becoming a heavy burden to the health care systems around the world.

[Thyroid cancer in children and adolescents]. / Cáncer de tiroides en niños y adolescentes.

BACKGROUND: Thyroid nodules in children and adolescents may be associated to malignant neoplasms. Although thyroid cancer is a rare event in this age group, delayed diagnosis is associated to metastatic, regional or lung disease, but even in these circumstances appropriate treatment may be followed by good prognosis. We decided to review the clinical course of these patients in our hospital from 1980 to 2001. METHODS: We found fifteen patients younger than 18 years diagnosed with thyroid carcinoma, which had been followed by at least 12 months, with a mean of 95 months and a maximal of 10 years. All patients were treated by surgery and 131 iodine, and followed by scans, ultrasound and thyroglobulin analysis. RESULTS: The patients group were thirteen females and two males. At diagnosis, seven patients (46.7o%) had metastatic regional disease and eight had a thyroid nodule. Total thyroidectomy with a modified neck dissection and 131 iodine was the initial treatment for patients with regional disease and subtotal thyroidectomy and 131 iodine in the follow-up to treat the thyroid bed or metastases was the treatment for patients with localized disease. All patients had a histologic pattern of papillary carcinoma. Nine patients (60%) had local recurrence in a mean follow-up of 37 months, one patient that had been previously treated by total thyroidectomy and all patients that were treated by subtotal thyroidectomy, however, all responded to the complementary treatment. At this moment the mean follow up is 95 months and all the patients have survived. CONCLUSIONS: In our experience thyroid cancer in children and adolescents is a rare event whose delayed diagnosis is associated to regional lymph node or lung metastases. Subtotal thyroidectomy was associated to disease progression to metastases, but complementary treatment was successful and all patients have survived.

[Impact of the new criteria for the diagnosis of gestational diabetes on the estimate of its prevalence]. / Impacto del nuevo criterio para el diagnóstico de diabetes gestacional en la estimación de su prevalencia.

OBJECTIVE: This study was aimed to identify the prevalence of gestational diabetes (GD) defined as any glucose intolerance detected in a pregnant women using the oral glucose tolerance test (OGTT) protocol, proposed by the World Health Organization (WHO) and to explore the effect of late pregnancy on the glucose tolerance test. Two groups of pregnant women > 20 years of age were evaluated with an OGTT, one group at the beginning, and the other one at the end of the third trimester, newborns weight and gestational age were recorded at the end of pregnancy. PATIENTS AND METHODS: Group A (n = 152), was studied at 24-28 weeks and group B (n = 214) was studied at 32-36 weeks, after an overnight fasting a 75 g glucose load was provided and a blood sample was taken after 2 h. Glucose levels > 140 mg/dL were diagnostic of GD, women with glucose levels in the range of 140-199 mg/dL were prescribed dietary recommendations, but women with glucose levels > 200 mg/dL were treated with insulin. Newborns were considered macrosomic if weighted > 4,000 g and large for gestational age if exceeded the 97th percentile or the Lubchenko scale, both conditions are described as macrosomia in the text. Comparisons were done using the Chi-square and Fisher exact tests. RESULTS: In group A GD was diagnosed in 27 women (17.76%), but only three of them (1.97%) had glucose levels > 200 mg/dL and in group B-GD was diagnosed in 62 women (28.97%), but only eight of them (3.73%) had glucose levels > 200 mg/dL. The difference in rates between groups A and B was significant (p < 0.01). In group A, normal women had 19 (15.2%) macrosomic newborns and women with GD had nine (33.33%) macrosomic newborns, this difference was significant (p < 0.05); however, in group B women with GD vs. normal, had 10 (16.12%) and 19 (12.5%) macrosomic newborns, respectively (p = ns). CONCLUSIONS: The new criteria for GD diagnosis increases notoriously its prevalence in our population to 17.76% at the beginning of the third trimester, comparing with 1.97% of women with glucose levels > 200 mg/dL applying the WHO criteria for diabetes in nonpregnant adults, however, comparing the newborns weight of normal women vs. GD women the prevalence of macrosomia was almost the double, reflecting the importance of this diagnosis in perinatal health. Women screened at the end of pregnancy had a significant increase in GD prevalence, but macrosomia was not different of the normal women of this group suggesting that GD at this stage of pregnancy may help to detect women with a higher risk to develop diabetes, but have no impact on perinatal health.

Falla gonadal prematura: experiência clínica / Premature gonodal iailure: clinical experience

Se estudiaron 26 pacientes con diagnóstico de falla gonadal precoz, mediante cuadro clínico, administración de progesterona, administración de estrógeno más progesterona, estudio radiológico de silla turca, determinación de triyodotironina, tetrayodotironina, índice de tiroxina normalizada, FSH, hormona luteinizante, y prolactina mediante radioinmunoanálisis, biopsia de endometrio y laparoscopia con toma de biopsia de ovario. Todas las pacientes mostraron hipoestrogenismo; 84.6% tuvieron respuesta negativa a progesterona. Todas las pacientes fueron positivas con la administración de estrógenos más progesterona; la silla turca fue normmal; las pruebas tiroideas fueron normales en todos los casos; 46.6% mostraron endometrio atrófico; en 33.3% el endometrio fue proliferativo. La media para FSH fue 110.4; y para LH, fue 72.6; prolactina, 8.0; estradiol menor de 75.0 pg/mL en todos los casos. En la biopsia, los ovarios mostraron ausencia de aparato folicular en todas las pacientes. El diagnóstico de menopausia premmatura lo hace el estudio histológico del ovario

Esterilidad de origen endocrino-gonadal relacionada con amenorrea-galactorrea: tratamiento con bromocriptina / Sterility of endocrine-gonadal origin related to amenorrhea-galactorrhea: treatment with bromocriptine

Se estudió a 80 pacientes con síndrome de amenorrea-galactorrea relacionado con esterilidad endocrino-gonadal primaria (77.5%) o secundaria (22.5%)). El diagnóstico de anovulación se realizó mediante biopsia de endometrio o cuando se demostró un valor de prolactina sérica superior a 25 ng/ml pero inferior a 100 ng/ml. Se descartó la presencia de tumor hipofisiario empleando estudios de tomografía computada. El tratamiento de las pacientes consistió en la administración de bromocriptina en dosis de 5 mg por día durante un periodo de tres meses mínimo. La respuesta a la terapéutica se manifestó por la aparición de menstruación cíclica en 82.5% de pacientes, ovulación en 70% y embarazo en 42.5%. El índice de embarazos en los casos de esterilidad primaria fue 88.2% contra 11.8% de los de esterilidad secundaria; la evolución de los embarazos fue normal, registrándose sólo dos abortos; todos los productos fueron normales. Se concluye que en el estudio de pacientes con esterilidad anovulatoria, con o sin amenorrea y galactorrea, debe cuantificarse la prolactina sérica para establecer el diagnóstico correcto

Inducción de espermatogénesis com HCG en un paciente con deficiencia aislada de gonadotropinas / Induction of spermatogenesis with HCG in a patient with isolated gonadotropin deficiency

Se informa de un paciente en quien se comprobó la existencia de hipogonadismo hipogonadotrópico y que se sometió a tratamiento con gonadotropina coriónica (HCG) y testosterona (T), con inducción de la espermatogénesis hasta llegar a nivels considerados compatibles con la fecundidad masculina. Se realizaron dos pruebas con gonadorrelina (LH-RH) antes y después del tratamiento, las cuales mostraron un cambio en el patrón de reacción de la adenohipófisis a la hormona luteinizante (LH), lo que sugiere que estos pacientes pueden ser variantes del síndrome de Kallman. La inducción de espermatogénesis con HCG sugiere que algunos pacientes con hipogonadismo hipogonadotrópico pueden generar espermatozoides si reciben este tratamiento

Coccidioidomicosis pulmonar crónica progresiva en una paciente con diabetes mellitus tipo II / Chronic progressive pulmonary coccidioisis in a patient with type II diabetes mellitus

Se informa una paciente con diabetes mellitus tipo II y coccidioidomicosis pulmonar crónica progresiva. Esta paciente recibió tratamiento para tuberculosis pulmonar durante 2 años, a pesar de la persistencia de la sintomatología y la evolución de las lesiones. La citología exfoliativa del esputo, teñida con Papanicolaou mostró la presencia de endosporas las cuales se confirmaron con las ticiones de PAS y Grocott, asimismo el cultivo en Sabouraud desarrolló C. immítis. Siendo Nuevo León una zona endémica de coccidioidomicosis, es necesario considerar esta posibilidad en todo paciente con lesiones radiográficas pulmonares. Asimismo, debido a la facilidad de su transformación aérea, debe considerarse esta posibilidad e investigarla en los pacientes con antecedente de estancia o visita a las zonas endémicas localizadas en la franja fronteriza México-Estados Unidos