Seguimiento y características clínicas de los pacientes con nódulos tiroideos en nuestra práctica clínica antes de 2015 / Follow-up and clinical characteristics of patients with thyroid nodules in our clinical practice before 2015

INTRODUCCIÓN: Los nódulos tiroideos son una consulta muy prevalente en Endocrinología. Las guías de la Asociación Americana de Tiroides (2015) animaban a realizar estudios a largo plazo. El objetivo de este estudio fue revisar las características, el seguimiento y la evolución de los nódulos de tiroides seguidos en nuestras consultas hasta 2015. MATERIAL Y MÉTODOS: Estudio retrospectivo de pacientes con al menos dos ecografías o cirugía. Los datos clínicos, ecográficos y de punción, así como la evolución y los resultados histológicos de aquellos operados, se analizaron con métodos descriptivos, bivariados y de regresión. RESULTADOS: 1.420 pacientes seguidos en Endocrinología a largo plazo fueron incluidos. 20 se excluyeron por tener una sola ecografía. El 71,2% presentaban normofunción, 9,6% hipertiroidismo subclínico, 9,5% hipotiroidismo subclínico, 5,7% hipotiroidismo clínico y 4% hipertiroidismo clínico. Del total de nódulos seguidos (n= 1400), 64,1%, 15,6% y 20,3% permanecieron estables, aumentaron y disminuyeron respectivamente. Los que crecieron no tuvieron más características sospechosas en las ecografías. De los intervenidos (457 casos (32,6% del total), 207 fueron malignos (45,2%). 57% de ellos fueron diagnosticados e intervenidos durante el primer año, en la primera evaluación. La aparición de nódulos malignos en el resto de pacientes fue de 89 casos (6,3% de todos los nódulos seguidos, 38,3% de ellos, incidentalomas). La ecografía y la citología empleadas antes de la homogenización de los criterios diagnósticos tuvieron una baja sensibilidad y especificidad en nuestro medio. CONCLUSIONES: Más de la mitad de los cánceres de tiroides fueron diagnosticados en la evaluación inicial del nódulo tiroideo. Más de la mitad de los nódulos no operados en el primer año mantienen el mismo tamaño a largo plazo. No encontramos predictores clínicos del aumento de tamaño. El valor diagnóstico de la ecografía y PAAF sin unos criterios estandarizados homogéneos es bajo.

INTRODUCTION: Thyroid nodules are a very prevalent consultation in endocrinology. Guidelines from the American Thyroid Association (2015) encouraged to conduct follow-up studies in the long term. This study object was to review the clinical characteristics, follow-up and evolution of thyroid nodules visited in our consultations till 2015. MATERIAL AND METHODS: Retrospective study of patients that had at least two thyroid ultrasounds or had been operated. Clinical, ultrasound and FNA (fine needle aspiration) data as well as the evolution and histology results of those operated, were analyzed with descriptive, bivariated and regression analyses. RESULTS: 1.420 patients followed in Endocrinology in the long term were included. 20 were excluded for having only one ecography. 71,2% had normal function, 9,6% subclinical hyperthyroidism, 9,5% subclinical hypothyroidism, 5,7% clinical hypothyroidism and 4% clinical hyperthyroidism. Of all the nodules followed (n=1400), 64,1%, 15,6% and 20,3% remained the same size, grew and decreased respectively. Nodules that grew didn´t have more suspicious sonographic characteristics. Of the operated nodules (457 cases (32,6% of all), 207 were cáncer (45,2%). 57% of them were diagnosed and intervened during the first year, in the first evaluation. Malignant nodules were detected in the rest of patients in 89 cases (6,3% of all the followed nodules, 38,3% of them were incidental cases). The ultrasound and citology diagnoses used before the homogenization of diagnoses criteria had a low senitivity and specificity in our clinical environment. CONCLUSIONS: More than half of the thyroid cancers were diagnosed in the initial evaluation of the thyroid nodule. More than half of nodules non operated in the first year remained the same size long term. We could not find clinical predictors of growth. The diagnostic value of the ultrasound and FNA is low without standardized and homogenous criteria.

Utilidad para médicos no radiólogos de la clasificación tirads y las características ecográficas de los nódulos tiroideos / Usefulness for non radiologist physicians of tirad classification and ecographic characteristics of thyroid nodules

Dada la mayor accesibilidad a la ecografía tiroidea, se diagnostican más nódulos de forma incidental aumentando su prevalencia al 65% en las tres últimas décadas. Todo ello ha supuesto un aumento de punciones innecesarias. El objetivo de nuestro estudio es identificar la utilidad de la clasificación TIRADS y de las características ecográficas de los nódulos tiroideos para establecer la probabilidad de malignidad de los mismos y seleccionar aquellos sospechosos para realizar la punción y aspiración con aguja fina (PAAF). Se encontró una relación estadísticamente significativa entre la malignidad y nódulo sólido, hipoecogenicidad, márgenes irregulares y microcalcificaciones. Sin embargo, no se encontró relación estadísticamente significativa entre malignidad y número de nódulos, tamaño nodular, diámetro craneocaudal y vascularización central. Asimismo, un 26.1% de los nódulos TIRADS-2 (todos ellos microcarcinomas), un 30% de los TIRADS-3 y un 54 % de los TIRADS-4 fueron malignos (p 0.027). Tanto el TIRADS como las características ecográficas aisladas son útiles para identificar nódulos sugerentes de malignidad.

Owed to the easier accessibility to thyroid ecography, more incidental nodules are discovered reaching their prevalence the 65 % of population in the last three decades. All of it has resulted in a growth of unnecessary fine needle aspirations (FNA). Our study objective is to identify the TIRADS classification utility and the nodules sonographic characteristics to establish their probability of malignancy and to select those suspicious susceptible of FNA. We found a statistically significant relationship between malignancy and solid nodule, hypoechogenicity, irregular margins and microcalcifications. However we didn´t find a relation between malignancy and number, size, shape (taller than wide) and central vascularity. With respect to TIRADS classification, 26,1% of TIRADS-2 (all of them microcarcinomas), 30% of TIRADS-3 and 54% of TIRADS-4 were malignant (p: 0,027). Both of them, TIRADS and individual sonographic characteristics are useful to identify nodules suspicious of malignancy.

Slightly elevated thyrotropin levels in pregnancy in our clinical practice / Tirotropina discretamente elevada en la gestación en nuestra práctica clínica

Objective: The aim of this study was to assess the incidence of obstetric and neonatal complications in pregnant women with "normal" thyroid-stimulating hormone (TSH) levels in the first trimester (group A) and to compare them with those with "slightly elevated" TSH (SET) levels treated with levothyroxine (group B2) or not treated (group B1). Methods: A total of 2375 women who had been performed laboratory tests in their first trimester of pregnancy were detected at our hospital between April 2015 and August 2017. Of these, 469 patients with SET were prospectively detected and randomized to groups B1 (227) and B2 (242). They were monitored prospectively until 6 months after delivery. Data of the control group (n = 1906, group A) were retrospectively reviewed. A total of 1745 women were analyzed. Variables assessed included demographic and clinical characteristics and complications of pregnancy and delivery. Results: A, B1, and B2 had similar clinical characteristics. There were no statistically significant differences in complications between the three groups during pregnancy, except in that natural deliveries were more common in group A as compared to group B1 (76.8% vs. 68.7%, p 0.017) and group B2 (66.3%), p < 0.002). There were more induced deliveries in groups B1 (35.8%), and B2 (36.2%) than in group A (18.4%), p < 0.01. Although the recommended TSH level was achieved in the second and third trimesters, no benefit could be found of treatment of SET. Conclusion: Although there were less natural deliveries and more induced deliveries in patients with SET, treatment with levothyroxine could not reverse this situation, despite achievement of levels considered appropriate in the second and third trimester

Objetivo: El propósito de este estudio fue investigar la incidencia de complicaciones obstétricas y neonatales en mujeres embarazadas con una tirotropina (TSH) «normal» en el primer trimestre (grupo A) y compararlas con aquellas con una TSH «discretamente elevada» (SET) tratadas con levotiroxina (grupo B2) o no (grupo B1). Métodos: Dos mil trescientos setenta y cinco gestantes con analítica en el primer trimestre fueron detectadas en nuestro hospital entre abril de 2015 y agosto de 2017. Cuatrocientos sesenta y nueve pacientes con SET se detectaron prospectivamente y randomizaron a los grupos B1 (227) y B2 (242). Se siguieron prospectivamente hasta 6 meses posparto. Los datos del grupo control (n = 1.906, grupo A) se revisaron retrospectivamente. Se analizaron 1.745 pacientes. Las variables incluyeron características demográficas, clínicas y complicaciones de la gestación y el parto. Resultados: A, B1 y B2 eran comparables en sus características clínicas. Los partos eutócicos fueron más frecuentes en el grupo A que en el B1 (76,8 vs. 68,7%, p0,017) y B2 (66,3%, p < 0,002). Hubo más partos inducidos en los grupos B1 (35,8%) y B2 (36,2%) que en A (18,4%), p < 0,01. Aunque se alcanzó el nivel de TSH recomendado en el segundo y tercer trimestres, no pudimos encontrar ningún beneficio en el tratamiento de SET. Conclusión: Aunque hemos encontrado menos partos eutócicos y más partos inducidos en las gestantes con SET, el tratamiento con levotiroxina no pudo revertirlo, pese a alcanzar un valor considerado apropiado en el segundo y tercer trimestre

Slightly elevated thyrotropin levels in pregnancy in our clinical practice.

OBJECTIVE: The aim of this study was to assess the incidence of obstetric and neonatal complications in pregnant women with "normal" thyroid-stimulating hormone (TSH) levels in the first trimester (group A) and to compare them with those with "slightly elevated" TSH (SET) levels treated with levothyroxine (group B2) or not treated (group B1). METHODS: A total of 2375 women who had been performed laboratory tests in their first trimester of pregnancy were detected at our hospital between April 2015 and August 2017. Of these, 469 patients with SET were prospectively detected and randomized to groups B1 (227) and B2 (242). They were monitored prospectively until 6 months after delivery. Data of the control group (n=1906, group A) were retrospectively reviewed. A total of 1745 women were analyzed. Variables assessed included demographic and clinical characteristics and complications of pregnancy and delivery. RESULTS: A, B1, and B2 had similar clinical characteristics. There were no statistically significant differences in complications between the three groups during pregnancy, except in that natural deliveries were more common in group A as compared to group B1 (76.8% vs. 68.7%, p 0.017) and group B2 (66.3%), p<0.002). There were more induced deliveries in groups B1 (35.8%), and B2 (36.2%) than in group A (18.4%), p<0.01. Although the recommended TSH level was achieved in the second and third trimesters, no benefit could be found of treatment of SET. CONCLUSION: Although there were less natural deliveries and more induced deliveries in patients with SET, treatment with levothyroxine could not reverse this situation, despite achievement of levels considered appropriate in the second and third trimester.

Glucemia basal en el primer trimestre como acercamiento inicial al diagnóstico de la diabetes en el embarazo / Fasting glucose in the first trimester: An initial approach to diagnosis of gestational diabetes

Objetivos: 1) Determinar si una glucemia basal en el primer trimestre (GBPT) del embarazo ≥ 92 mg/dl anticipa la aparición de complicaciones materno-fetales de diabetes mellitus gestacional (DMG). 2) Valorar si la GBPT puede sustituir al diagnóstico clásico de DMG mediante sobrecarga oral de glucosa (SOG). Métodos: Estudio retrospectivo de 1.425 embarazos con GBPT y test de ÓSullivan (TOS) en el segundo trimestre más SOG según resultado del TOS. Valoración de la sensibilidad y especificidad de la GBPT respecto al diagnóstico clásico de DMG. Relación de las complicaciones materno-fetales con la GBPT en el grupo total y tras excluir a las madres que realizaron tratamiento médico específico de DMG. Resultados: La sensibilidad y la especificidad de la GBPT ≥ 92mg/dl respecto al diagnóstico de DMG en el segundo trimestre, usando los criterios clásicos basados en la SOG de Carpenter y Coustan, fueron respectivamente del 46,4 y el 88,8%. Respecto a las gestantes con GBPT <92 mg/dl, las gestantes con GBPT ≥ 92 mg/dl tienen mayor peso del recién nacido (3.228±86 versus 3.123±31g; p <0,05) y mayor porcentaje de macrosomía (6,9% versus 3,5%; p <0,05). Esta relación se mantuvo tras excluir a las pacientes diagnosticadas y tratadas por DMG (peso: 3.235 ± 98 versus 3.128 ± 31 g; p < 0,05; porcentaje de macrosomía: 7,2% versus 3,4%; p < 0,05). Conclusiones: 1) La GBPT no es un buen sustituto del diagnóstico clásico de DMG en el segundo trimestre. 2) Las gestantes con GBPT ≥ 92 mg/dl, aun sin diagnóstico posterior de DMG, constituyen un grupo de riesgo de macrosomía fetal y podrían beneficiarse de la instauración de tratamiento nutricional y ejercicio físico

Objectives: To establish whether fasting glucose levels in the first trimester (FGFT)of pregnancy ≥ 92 mg/dL (5.1 mmol/L) (FGFT) anticipate the occurrence of maternal-fetal complications of gestational diabetes mellitus. To assess whether FGFT can replace diagnosis of GDM using the classical two-step oral glucose tolerance test (OGTT). Methods: A retrospective study of 1425 pregnancies with FGFT and O'Sullivan Test (OST) and/or OGTT according to OST results in the second trimester. FGFT sensitivity and specificity were assessed as compared to the conventional diagnosis of GDM. The relationship between maternal-fetal complications and FGFT was assessed in the total group and after excluding mothers who received specific medical treatment for GDM. Results: Sensitivity and specificity of FGFT levels ≥ 92mg/dL were 46.4% and 88.8% as compared to diagnosis of GDM using Carpenter and Coustan criteria. In the total group, a statistically significant relationship was found between FGFT levels ≥ 92 mg/dL and newborn weight (3228±86 versus 3123±31g; P<.05), as well as a higher rate of macrosomia (6.9% versus 3.5%; P<.05). This association persisted after excluding patients diagnosed with and treated for GDM (weight: 3235±98 versus 3128±31 g; P<.05; percentage of macrosomia: 7.2% versus 3.4%; P<.05). Conclusions: FGFT is not a good substitute for conventional diagnosis of GDM in the second trimester. Pregnant women with FGFT levels ≥ 92 mg/dL, even with no subsequent diagnosis of GDM, are a risk group for fetal macrosomia and could benefit from dietary measures and physical exercise

Fasting glucose in the first trimester: An initial approach to diagnosis of gestational diabetes. / Glucemia basal en el primer trimestre como acercamiento inicial al diagnóstico de la diabetes en el embarazo.

OBJECTIVES: To establish whether fasting glucose levels in the first trimester (FGFT)of pregnancy ≥ 92 mg/dL (5.1 mmol/L) (FGFT) anticipate the occurrence of maternal-fetal complications of gestational diabetes mellitus. To assess whether FGFT can replace diagnosis of GDM using the classical two-step oral glucose tolerance test (OGTT). METHODS: A retrospective study of 1425 pregnancies with FGFT and O'Sullivan Test (OST) and/or OGTT according to OST results in the second trimester. FGFT sensitivity and specificity were assessed as compared to the conventional diagnosis of GDM. The relationship between maternal-fetal complications and FGFT was assessed in the total group and after excluding mothers who received specific medical treatment for GDM. RESULTS: Sensitivity and specificity of FGFT levels ≥ 92mg/dL were 46.4% and 88.8% as compared to diagnosis of GDM using Carpenter and Coustan criteria. In the total group, a statistically significant relationship was found between FGFT levels ≥ 92 mg/dL and newborn weight (3228±86 versus 3123±31g; P<.05), as well as a higher rate of macrosomia (6.9% versus 3.5%; P<.05). This association persisted after excluding patients diagnosed with and treated for GDM (weight: 3235±98 versus 3128±31 g; P<.05; percentage of macrosomia: 7.2% versus 3.4%; P<.05). CONCLUSIONS: FGFT is not a good substitute for conventional diagnosis of GDM in the second trimester. Pregnant women with FGFT levels ≥ 92 mg/dL, even with no subsequent diagnosis of GDM, are a risk group for fetal macrosomia and could benefit from dietary measures and physical exercise.

Acidosis láctica, en relación con insuficiencia renal aguda y metformina, tratada con hemodiálisis con bicarbonato / A case of lactic acidosis related to acute renal failure and metformin intake treated with bicarbonate haemodialysis

La acidosis láctica es una rara enfermedad con una mortalidad en torno al 50%. Se caracteriza por una acidosis metabólica con anión gap y ácido láctico elevado. Presentamos un caso de acidosis láctica en una paciente diabética en tratamiento con metformina, que presentó una insuficiencia renal aguda secundario a deshidratación por un cuadro de gastroenteritis. El tratamiento con hemodiálisis venovenosa continua fue exitoso con recuperación gradual de la función renal. Se describe el caso clínico, los mecanismos fisiopatológicos, las diferentes causas y el pronóstico de esta infrecuente y grave complicación (AU)

Lactic acidosis is a rare entity. Mortality is approximately 50%. Lactic acidosis is characterized by metabolic acidosis with elevated blood lactate and anion gap. We present a case of lactic acidosis in a diabetic woman under treatment with metformin. The patient developed acute renal failure due to dehydration and diarrhea. Treatment with continuous venovenoushemodialysis was successful with clinical improvement and recovery of renal function. We describe the case and review the pathophysiological causes and prognosis of this infrequent and severe complication (AU)