Sobre la profesionalidad en el manejo de los tumores de la tiroides y los grupos de trabajo multidisciplinarios / On professionalism in the management of thyroid tumors and multidisciplinary working groups

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Long-term remission following antithyroid drug withdrawal in patients with Graves' hyperthyroidism: parameters with prognostic value.

OBJECTIVE: To assess the predictive value of some clinical and biochemical parameters, and of the +49 A/G polymorphism of the CTLA-4 gene, for long-term remission following the withdrawal of antithyroid drugs before starting antithyroid drug therapy. STUDY DESIGN: Observational, prospective and longitudinal study. METHODS: Seventy-two patients (11 of whom were men) with newly diagnosed Graves' hyperthyroidism who had been attended consecutively at a University Clinic in a population with sufficient iodine intake were included in the study. EXCLUSION CRITERIA: patients under the age of 18, pregnant women and non-Caucasian patients. All subjects were treated following a well-defined protocol. Long-term remission was calculated at 12 and 36 months following withdrawal of the antithyroid drug. RESULTS: Thirty-six of the 72 study subjects experienced a remission of at least 12 months following withdrawal of methimazole, with no differences according to their age or sex. A comparison made between the remission rates seen in both groups yielded significant differences regarding the presence of Graves' orbitopathy, the duration of the treatment with methimazole and the absence of the CTLA-4 G/G genotype. In the univariate and multivariate analyses performed, only lower frequencies of Graves' orbitopathy and an absence of the CTLA-4 G/G genotype were considered independent predictors of long-term remission. CONCLUSIONS: The absence of Graves' orbitopathy and of the CTLA-4 G/G genotype are independent predictors of long-term remission following a first course of antithyroid drugs.

Limitations of current thyroid function tests / Limitaciones de las pruebas actuales de la función tiroidea

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Eating disoders in type 2 diabetic people: Brief review.

BACKGROUND: Relationship between type 1 diabetes and Eating disorders is well-known, less information exists on the relationship between type 2 diabetes (T2DM) people and eating disorders. AIM: Review information on the prevalence and impact of type 2 diabetes and eating disorders comorbidity. METHODS: Search in Medline and PubMed relevant articles on the aforementioned co-morbidity. Review includes articles on epidemiological, clinical and therapeutics aspects. CONCLUSIONS: Disordered eating behaviours may affect around 40% of T2DM people, being the predominant clinical forms: Eating Disorders Non otherwise specified (EDNOS), Night Eating Syndrome (NES) and Binge Eating Disorder (BED), however, population-based estimates of T2DM and ED comorbidity are mandatory to determine the prevalence of ED in T2DM people. The association between both entities has a consequence which is an impairment of metabolic control, associated to increase risk of vascular complications and difficult body weight loss, basis of T2DM treatment.

Adherencia a la dieta Mediterránea en una muestra de la población adulta del sur de Galicia / Mediterranean diet adherence in a sample of population in South Galicia

Objetivo: Conocer el grado de adherencia a la dieta mediterránea en Galicia. Métodos: En el estudio fueron incluidos 201 personas, 103 mujeres, con una edad media de 56,6 ± 19 años, (rango 18- 88 años). El IMC medio fue de 25 ± 4. Fueron sometidos a un cuestionario sencillo y muy útil en la práctica clínica, sobre la adherencia a la dieta mediterránea, que consiste en 9 preguntas, utilizado en los estudios del grupo PREMID. Resultados: El porcentaje de personas con baja, intermedia y alta adherencia fue de 62,2%, 23,8% y 13,9% respectivamente. El 89,3% de los sujetos con normopeso tenían una puntuación de alta adherencia, mientras que en el grupo con IMC ≥ 30 fue de 10,7%, p < 0,05. Conclusiones: Observamos una baja adherencia en la muestra de población estudiada y las personas con baja adherencia tenían mayor tendencia a ser obesos (AU)

Objective: To know the Mediterranean diet (MD) adherence in a sample of the population in South Galicia. Methods: Two-hundred-one (103 females) were included in the present study, mean age 56.6 ± 19 years, range 18-88, with a mean BMI of 25 ± 4. They were submitted to a simple questionnaire, useful for clinical practice, used for the PREMID group, consists of 9 questions. Results: 13.9%, 23.8% and 62.2%, from the total sample had high, intermediate and low adherence to the Mediterranean diet. When the sample of subjects was split for BMI, in the normal-weight group, 89.3% of subjects have higher adherence to the MD, while those with BMI ≥ 30 only 10.7% have high adherence, p <0.05. Conclusions: Low adherence to MD was observed in the sample of the population studied. Low, MD adherence is associated with high risk to develop obesity (AU)

Estudio comparativo de psicoterapia cognitivo-conductual y terapia nutricional en pacientes con diferentes tipos de trastornos de la conducta alimentaria / Comparative study of cognitive-behavioral psychotherapy and nutritional support in patients with different types of eating disorders

Fundamento y objetivo: Existen varios enfoques psicológicos para el tratamiento de la disfunción eréctil con eficacia siendo revelado por la investigación empírica; sin embargo ninguno de ellos es universalmente aceptada. El objetivo fue comparar la respuesta a la terapia cognitivo-conductual en pacientes con diferentes formas clínicas de trastornos de la alimentación. Material y método: Setenta y cuatro pacientes con diagnóstico de trastornos de la alimentación, 32 con anorexia nerviosa (AN), 19 con bulimia nerviosa (BN) y 23 con trastornos no especificados (TCANE) Comer fueron incluidos. Se trata de un estudio prospectivo y comparativo. Los pacientes fueron tratados con psicoterapia, el tratamiento nutricional y farmacológico. Resultados:Las tasas de recuperación en los grupos de pacientes con AN, BN y TCANE fueron 14 (43,7%), 8 (42,1%), 10 (43,4%), respectivamente, p> 0,05. Las tasas de mejoría fueron 14 (43,7%), 10 (52,6%), 12 (52,1%) para la AN, BN y TCANE, respectivamente, p> 0,05. Por último, la tasa de pacientes que tuvieron un mal resultado fueron 3 (9,3%), 1 (5,2%), y 1 (4,3%), p> 0,05, para AN, BN y TCANE, respectivamente. El análisis de regresión de Cox mostró que la edad de inicio de la enfermedad y no uso de drogas psicotrópicas predijeron una buena respuesta en los pacientes con disfunción eréctil. Conclusiones: La respuesta al tratamiento con terapia cognitivo-conductual, el apoyo nutricional y las drogas psicotrópicas en la mayoría de los pacientes fue favorable y similar en la mayoría de los pacientes con diferentes tipos de trastornos de la alimentación. Por otra parte, una edad temprana y no uso de drogas psicotrópicas predicen un resultado favorable en los pacientes con disfunción eréctil (AU)

Background and objective: There are several psychological approaches to treat ED with efficacy being revealed by empirical research; however none of them are universally accepted. The objective was to compare response to Cognitive Behavioral Therapy in patients with different clinical forms of Eating Disorders. Material and method: Seventy-four patients diagnosed with eating disorders, 32 with Anorexia nervosa (AN), 19 with Bulimia nervosa (BN) and 23 with Eating disorders not otherwise specified (EDNOS) were included. This is a prospective and comparative study. Patients were treated by psychotherapy, nutritional treatment and pharmacotherapy. Results: The recovery rates in the groups of patients with AN, BN and EDNOS were 14 (43.7%), 8 (42.1%), 10 (43.4%), respectively, p > 0.05. The rates of improvement were 14 (43.7%), 10 (52.6%), 12 (52.1%) for AN, BN and EDNOS, respectively, p > 0.05. Finally, the rate of patients who had poor outcome were 3 (9.3%), 1 (5.2%), and 1 (4.3%), p > 0.05, for AN, BN, and EDNOS, respectively. Cox regression analysis showed that the age of disease onset and no use of psychotropic drugs predicted a good response in patients with ED. Conclusions: The treatment response to Cognitive Behavioral Therapy, nutritional support and psychotropic drugs in the majority of patients was favorable and similar in most patients with different types of Eating Disorders. Furthermore, a young age and no use of psychotropic drugs predict a favorable outcome in patients with ED (AU)

Comparative study of cognitive-behavioral psychotherapy and nutritional support in patients with different types of eating disorders.

BACKGROUND AND OBJECTIVE: There are several psychological approaches to treat ED with efficacy being revealed by empirical research; however none of them are universally accepted. The objective was to compare response to Cognitive Behavioral Therapy in patients with different clinical forms of Eating Disorders. MATERIAL AND METHOD: Seventy-four patients diagnosed with eating disorders, 32 with Anorexia nervosa (AN), 19 with Bulimia nervosa (BN) and 23 with Eating disorders not otherwise specified (EDNOS) were included. This is a prospective and comparative study. Patients were treated by psychotherapy, nutritional treatment and pharmacotherapy. RESULTS: The recovery rates in the groups of patients with AN, BN and EDNOS were 14 (43.7%), 8 (42.1%), 10 (43.4%), respectively, p>0.05. The rates of improvement were 14 (43.7%), 10 (52.6%), 12 (52.1%) for AN, BN and EDNOS, respectively, p>0.05. Finally, the rate of patients who had poor outcome were 3 (9.3%), 1 (5.2%), and 1 (4.3%), p>0.05, for AN, BN, and EDNOS, respectively. Cox regression analysis showed that the age of disease onset and no use of psychotropic drugs predicted a good response in patients with ED. CONCLUSIONS: The treatment response to Cognitive Behavioral Therapy, nutritional support and psychotropic drugs in the majority of patients was favorable and similar in most patients with different types of Eating Disorders. Furthermore, a young age and no use of psychotropic drugs predict a favorable outcome in patients with ED.

Factors influencing the outcome of patients with incidental papillary thyroid microcarcinoma.

Objective. To analyze some factors that could influence the outcome of patients with PTMC. Material and Methods. This is a longitudinal observational study. All patients diagnosed and treated for papillary thyroid microcarcinoma at the University Hospital of Vigo, between January 1994 and December 2003, were included in the present study. Demographic characteristics, tumour characteristics, TNM stage, rate of recurrence, and treatment with (131)I were the study variables. Results. Ninety-one patients (75 females) with an average age of 47.7 ± 13.4 years, range 19-81, were studied. Initial tumour staging was T1 in 90 patients and T4a in 1 case. Initial lymph node involvement was present in 4 cases (4.4%). We only found one case with distant metastases at diagnosis. Postsurgical evaluation of thyroid specimens revealed that 28 (30.7%) tumours were multifocal. The average size of the tumour was 0.44 ± 0.25 cm, range 0.1-1. Univariate analysis reveals a statistically significant association between tumour multifocality and postsurgical (131)I therapy with the recurrence rate. In the multivariate analysis only multifocality (P = 0.037, HR 5.7) was a significant risk factor for the recurrence rate. Conclusions. Our results indicate that tumour multifocality is an independent predictor of relapse but neither the tumour size nor postsurgical (131)I therapy.

Disruptores endocrinos y obesidad: obesógenos / Endocrine disruptors and obesity: obesogens

La incidencia y prevalencia de sobrepeso y obesidad ha experimentado un gran incremento en las últimas tres décadas y afecta a casi todos los países del orbe. Este fenómeno no se explica fácilmente por los cambios del estilo de vida en las distintas poblaciones con hábitos de partida muy distintos. Por lo que además del cambio del estilo de vida, otros factores empiezan a tenerse en cuenta, los llamados disruptores endocrinos y más concretamente los obesógenos. Revisamos la evidencia que existe sobre sustancias químicas que polucionan el ambiente que potencialmente puedan ser obesógenos en humanos: el dietilestilbestrol (DES), la ginesteína, el bisfenol-A, los derivados orgánicos de estaño y los ftalatos. Los tres primeros actúan principalmente sobre los receptores estrogénicos y los derivados orgánicos del estaño y los ftalatos activando los PPARγ. En conclusión, existen evidencias del efecto obesógeno de estas sustancias en estudios en animales de experimentación, tanto in vitro como in vivo, pero muy pocas en humanos. (AU)

ncidence and prevalence of owerweight and obesity have greatly increased over the past three decades in almost all countries around the world. This phenomenon is not easily explained by lifestyle changes in populations with very different initial habits. This has led to consider the influence of other factors, the so-called endocrine disruptors, and more specifically obesogens. This study reviewed the available evidence about polluting chemical substances which may potentially be obesogens in humans: DES, genistein, bisphenol A, organotins (TBT, TPT), and phthalates. The first three groups of substances mainly act upon estrogen receptors, while organotins and phthalates activate PPARγ. It was concluded that evidence exists of the obesogenic effect of these chemical substances in tissues and experimental animals, but few data are available in humans (AU)

[Endocrine disruptors and obesity: obesogens]. / Disruptores endocrinos y obesidad: obesógenos.

Incidence and prevalence of owerweight and obesity have greatly increased over the past three decades in almost all countries around the world. This phenomenon is not easily explained by lifestyle changes in populations with very different initial habits. This has led to consider the influence of other factors, the so-called endocrine disruptors, and more specifically obesogens. This study reviewed the available evidence about polluting chemical substances which may potentially be obesogens in humans: DES, genistein, bisphenol A, organotins (TBT, TPT), and phthalates. The first three groups of substances mainly act upon estrogen receptors, while organotins and phthalates activate PPARγ. It was concluded that evidence exists of the obesogenic effect of these chemical substances in tissues and experimental animals, but few data are available in humans.

High prevalence of eating disorders not otherwise specified in northwestern Spain: population-based study.

PURPOSE: To determine the incidence and prevalence of eating disorder and its clinical forms. METHODS: All new ED cases of both genders, ≥15 years old, diagnosed from January 2005 to December 2009 were included. All patients who suffered from ED in December 2009 were included in the prevalence study. This is a prospective, population-based study. Cumulative incidence rates and 20-year prevalence were calculated. RESULTS: The ED incidence was 14.1 (95% CI 11.4-16.1) cases per 100,000 inhabitants per year, for AN, BN and EDNOS 3.1 (95% CI 2.00-4.1), 4.4 (95% CI 3.0-8.00) and 6.5 (95% CI 4.8-7.9), respectively. The incidence of ED at the four age-intervals, 15-24, 25-34, 35-45 and >45 years, revealed that the 25-34-year interval had the highest incidence; moreover, new cases were observed even in the >45-year interval. The prevalence of ED was 82.8 (95% CI 69.4-94.5) per 100,000 inhabitants, being for AN, BN and EDNOS 18.6 (95% CI 12.5-24.4), 25.7 (95% CI 18.5-32.5) and 38.3 (95% CI 29.4-46.5), respectively. CONCLUSIONS: The incidence and prevalence of EDNOS are the highest in the ED cases; furthermore, new cases of ED are observed above the age of 45, which are remarkable data.

Disordered eating behaviors in type 1 diabetic patients.

Patients with type 1 diabetes mellitus are at high risk for disordered eating behaviors (DEB). Due to the fact that type 1 diabetes mellitus is one of the most common chronic illnesses of childhood and adolescence, the coexistence of eating disorders (ED) and diabetes often affects adolescents and young adults. Since weight management during this state of development can be especially difficult for those with type 1 diabetes, some diabetics may restrict or omit insulin, a condition known as diabulimia, as a form of weight control. It has been clearly shown that ED in type 1 diabetics are associated with impaired metabolic control, more frequent episodes of ketoacidosis and an earlier than expected onset of diabetes-related microvascular complications, particularly retinopathy. The management of these conditions requires a multidisciplinary team formed by an endocrinologist/diabetologist, a nurse educator, a nutritionist, a psychologist and, frequently, a psychiatrist. The treatment of type 1 diabetes patients with DEB and ED should have the following components: diabetes treatment, nutritional management and psychological therapy. A high index of suspicion of the presence of an eating disturbance, particularly among those patients with persistent poor metabolic control, repeated episodes of ketoacidosis and/or weight and shape concerns are recommended in the initial stage of diabetes treatment, especially in young women. Given the extent of the problem and the severe medical risk associated with it, more clinical and technological research aimed to improve its treatment is critical to the future health of this at-risk population.

[Phenotype of the C634Y mutation in the RET proto-oncogene in MEN2A: report of a family]. / Fenotipo de la mutación C634Y del protooncogén RET en el MEN2A: a propósito de una familia.

BACKGROUND AND OBJECTIVES: Genetic testing of RET proto-oncogen allows an early diagnosis of Multiple Endocrine Neoplasia syndrome type 2 and establish a correlation between genotype and clinical manifestations. The purpose of this study was to demonstrate the benefits of an early diagnosis with genetic testing followed by prompt surgery on the cure of MTC versus a later diagnosis with serum calcitonin. PATIENTS AND METHOD: Retrospective descriptive study of 8 members of a MEN 2A family by C634Y mutation. We performed serum calcitonin screening until 1999 and subsequently RET genetic testing was obtained. Carriers underwent total thyroidectomy and periodic determination of calcitonin, urinary metanephrines, calcium, phosphorus and neck and abdominal imaging techniques. RESULTS: Five patients were diagnosed by calcitonin familial screening and all of them have high calcitonin by now. Three patients were diagnosed by genetic testing (an adult and two children) and they are free of disease. Calcitonin was closely monitored in children and they underwent surgery when it started to raise, at 6 and 10 years old respectively, finding nodular C-cell hyperplasia in both. Of 8 carriers 3 developed pheochromocytomas, bilateral and asynchronous, one-half had normal urinary metanephrines and two of them were simultaneous with MTC. No patient had biochemical data suggesting hyperparathyroidism although in one patient multiple parathyroid adenomas were found at thyroidectomy. CONCLUSIONS: RET genetic analysis has achieved an early diagnosis and treatment with no development of MTC in our patients, adjusting the time and type of surgery and allowing a genotype-phenotype correlation. It demonstrates how a genetic alteration is associated with a pathology that we can prevent and manage improving the prognosis of our patients.

Fenotipo de la mutación C634Y del protooncogén RET en el MEN2A: a propósito de una familia / Phenotype of the C634Y Mutation in the RET Proto-oncogene in MEN2A: Report of a Family

Antecedentes y objetivos: El estudio genético del protooncogén RET permite un diagnóstico precoz del síndrome de neoplasia endocrina múltiple tipo 2 y establece una correlación entre el genotipo y las manifestaciones clínicas. El objetivo del presente trabajo es demostrar los beneficios del diagnóstico precoz por estudio genético seguido de tratamiento temprano en la curación del carcinoma medular de tiroides (CMT) frente al diagnóstico más tardío con la calcitonina sérica. Pacientes y método: Estudio descriptivo retrospectivo de 8 miembros de una familia con MEN2A por mutación C634Y. Se realizó despistaje con calcitonina sérica hasta 1999 y estudio genético de RET posteriormente. A los portadores se les realizó tiroidectomía total y determinaciones periódicas de calcitonina, metanefrinas urinarias, calcio, fósforo y pruebas de imagen a nivelcervical y abdominal. Resultados: Los 5 pacientes diagnosticados por despistaje familiar con calcitonina presentan en la actualidad cifras de calcitonina elevadas. Los 3 diagnosticados por estudio genético (un adulto y dos niños) se encuentran libres de enfermedad. En los niños se monitorizó la calcitonina y se les intervino cuando esta comenzó a elevarse, a los 6 y 10 años respectivamente, hallándose hiperplasia nodular de células C en ambos. De los 8 afectos 3 presentaron feocromocitomas, bilaterales y asincrónicos, la mitad con metanefrinas urinarias (..) (AU)

Background and objectives: Genetic testing of RET proto-oncogen allows an early diagnosis of Multiple Endocrine Neoplasia syndrome type 2 and establish a correlation between genotype and clinical manifestations. The purpose of this study was to demonstrate the benefits of a nearly diagnosis with genetic testing followed by prompt surgery on the cure of MTC versus alater diagnosis with serum calcitonin. Patients and method: Retrospective descriptive study of 8 members of a MEN 2A family byC634Y mutation. We performed serum calcitonin screening until 1999 and subsequently RET genetic testing was obtained. Carriers underwent total thyroidectomy and periodic determination of calcitonin, urinary metanephrines, calcium, phosphorus and neck and abdominal imagingte chniques. Results: Five patients were diagnosed by calcitonin familial screening and all of them have highcalcitonin by now. Three patients were diagnosed by genetic testing (an adult and two children)and they are free of disease. Calcitonin was closely monitored in children and they underwentsurgery when it started to raise, at 6 and 10 years old respectively, finding nodular C-cellhyperplasia in both. Of 8 carriers 3 developed pheochromocytomas, bilateral and asynchronous,one-half had normal urinary metanephrines and two of them were simultaneous with MTC. Nopatient had biochemical data suggesting hyperparathyroidism although in one patient multipleparathyroid adenomas were found at thyroidectomy. Conclusions: RET genetic analysis has achieved an early diagnosis and treatment with nodevelopment of MTC in our patients, adjusting the time and type of surgery and allowing agenotype-phenotype correlation. It demonstrates how a genetic alteration is associated with apathology that we can prevent and manage improving the prognosis of our patients (AU)

Treatment of Graves' hyperthyroidism with thionamides-derived drugs: review.

Thionamide-derived antithyroid drugs (ATD) have been in use for over half a century and much is now known about their mechanism of action, pharmacokinetics and clinical pharmacology. Candidates for first option ATD therapy are young adults, without large goitre. The recommended initial dose for patients without big goitre and mild hyperthyroidism is 20 mg of MMI/CBZ. The recommended maintenance doses are 5-10 mg of MMI/CBZ. In cases of big goitre and/or severe hyperthyroidism the recommended initial dose is 30 to 40 mg/day. PTU use should be restricted to first trimester of pregnancy, doses should be as low as possible (150 to 200 mg/day) and then changing to MMI is recommended. Treatment Duration should be of 12-18 months. ATD plus thyroxine combination therapy have not advantage on ATD alone. ATD plus L-Thyroxine regimens should be used to avoid hypothyroidism when patients are with maintenance doses of ATD drugs in order to relax monitoring. In this case a low dose of T4 50-75 µg per day is used. Breast feeding women with hyperthyroidism can be treated with MMI/CBZ. ATD will not stop until serum stimulating TSH-receptors antibodies values are within the normal range. We are waiting for results of ongoing studies of biochemical and/or genetic markers that will permit us to predict the outcome of these patients after ATD treatment is stopped.

Time trends for thyroid cancer in northwestern Spain: true rise in the incidence of micro and larger forms of papillary thyroid carcinoma.

BACKGROUND: Thyroid cancer incidence is increasing throughout the world. Most studies attribute this rise entirely to the increase in papillary carcinoma, the most common thyroid malignancy in iodine-sufficient areas. A variety of nonetiological factors such as changes in clinical practice may affect the incidence of thyroid cancer and some researchers have suggested that this rise is only apparent due to an increase in diagnostic activity. Since data on the epidemiology of thyroid cancer in Spain are scarce, the main goal of this study was to analyze changes in thyroid cancer presentation, incidence, and prevalence in Vigo (northwestern Spain) between 1978 and 2001, and to investigate the relationship between the incidence rates and trends in tumor size and thyroid surgery. METHODS: In this descriptive epidemiologic study, an analysis was carried out on new thyroid cancer cases obtained from the Pathology Registry of the University Hospital of Vigo (500,000 inhabitants). Trends in age, sex, thyroid surgery, histological type, tumor size, and incidence rates were calculated. The prevalence of thyroid cancer was determined in three cross-sectional surveys. RESULTS: The rate of population undergoing thyroid surgery significantly increased over time. Out of 322 new primary thyroid cancers, papillary thyroid cancer (PTC) was the predominant type (76%). The age-standardized incidence rate shows a significant increase in females: 1.56 per 100,000 year (1978 to 1985) to 3.83 (1986 to 1993) and 8.23 (1994 to 2001); and in males: 0.33, 1.19, and 2.65, respectively. PTC was mainly responsible for this pattern and was the result of both the increase in micropapillary thyroid carcinoma (MPTC) incidence and in PTC measuring more than 1 cm. Besides MPTC cases, no significant variations were observed in tumor size over time. CONCLUSIONS: In northwestern Spain, the incidence of thyroid cancer is increasing. These data should be taken into account when planning health resources for these patients. Our results may reflect the contribution that other factors, besides increased diagnostic activity, have made to the rise in thyroid cancer incidence in our region. Additional studies are needed to explain the rise in PTC incidence throughout the world and to search for potential risk factors that are currently unrecognized.