[Brain characteristics of transgender individuals and consequences of gender assignment treatment]. / Características cerebrales de las personas transexuales y consecuencias del tratamiento de asignación de género.

The differences between the male and female brain in cisgender individuals, those in whom there is no incongruence between the so-called biological sex and the perceived sex, are known. The genetic basis that underlies the differences observed in the brains of transgender individuals compared to cisgender individuals is also becoming known. In transgender individuals, there is a fundamental change in the connectivity of neurons in the body perception network, which may give rise to gender dysphoria. This knowledge allows for the characterization of the transgender condition and distinguishes it from transgender identities such as non-binary gender, gender fluidity, or genderqueer. Articles published assume, from the perspective of depathologization imposed by Gender Ideology, that these differences are due to a different sexual development. The societal acceptance of this perspective over the last two decades paved the way for medical interventions aimed at affirming the perceived gender, different from the genetic sex, through the continuous administration of cross-sex hormones and, in some cases, mutilating surgery. In adolescents and children, affirmation treatment of the perceived gender begins with puberty blockers, which have negative consequences for ossification and growth. The importance and irreversibility of these 'side effects' require the utmost rigor and complete information about them. Spanish law pushes the ideology to the maximum, infringing on the rights of transgender individuals. Medical ethics emphasize the necessity - the right - of a medical and psychological diagnosis, free from ideological approaches, before initiating what is being called treatment. This includes the right to information, prior to consent, about the positive and negative effects of hormonal administration. It also includes the right to the recognition of diversity among transgender individuals, especially the right to research that allows for treating the brain without altering the body. These rights must be recognized and demanded by the laws.

La paradoja diabética: densidad mineral ósea y fractura en la diabetes tipo 2 / The diabetic paradox: bone mineral density and fracture in type 2 diabetes

La diabetes mellitus tipo 2 es una patología con una enorme prevalencia y morbilidad, que van en aumento. La fractura osteoporótica se encuentra entre las denominadas complicaciones «no clásicas» de la diabetes y ha sido durante tiempo ignorada, tal vez por su complejo abordaje tanto diagnóstico como terapéutico. Las herramientas habituales para la prevención de la fractura por fragilidad, como el FRAX y la densitometría ósea, no han demostrado la suficiente eficacia en estos pacientes, ya que infraestiman el riesgo. Nuevas técnicas de evaluación ósea, como el trabecular bone score o los marcadores de remodelado óseo, podrían ser de utilidad, aunque requieren una mayor evidencia científica para recomendar su uso en la práctica clínica habitual. Las características especiales de su fisiopatología condicionan la aparición de fracturas sin existir alteraciones densitométricas, en lo que podemos calificar de «paradoja diabética» (AU)

Type 2 diabetes mellitus prevalence and morbidity are increasing. Osteoporotic fractures are among the ‘non-classical’ complications of diabetes and been overlooked for a long time, maybe because of their complex diagnostic and therapeutic approach. The usual tools for preventing fragility fractures (such as the fracture risk assessment tool and bone densitometry) underestimate risk of fractures in type2 diabetic patients. New techniques, such as trabecular bone score or bone turnover markers, could be useful, but greater scientific evidence is required to recommend their use in clinical practice. The special characteristics of their pathophysiology result in decreased bone remodeling with normal or even increased bone mineral density, but with low quality. These changes lead to the occurrence of osteoporotic fractures without evidence of densitometric changes, which could be called ‘the diabetic paradox’ (AU)

The diabetic paradox: Bone mineral density and fracture in type 2 diabetes. / La paradoja diabética: densidad mineral ósea y fractura en la diabetes tipo 2.

Type 2 diabetes mellitus prevalence and morbidity are increasing. Osteoporotic fractures are among the 'non-classical' complications of diabetes and been overlooked for a long time, maybe because of their complex diagnostic and therapeutic approach. The usual tools for preventing fragility fractures (such as the fracture risk assessment tool and bone densitometry) underestimate risk of fractures in type2 diabetic patients. New techniques, such as trabecular bone score or bone turnover markers, could be useful, but greater scientific evidence is required to recommend their use in clinical practice. The special characteristics of their pathophysiology result in decreased bone remodeling with normal or even increased bone mineral density, but with low quality. These changes lead to the occurrence of osteoporotic fractures without evidence of densitometric changes, which could be called 'the diabetic paradox'.

Transexualidad: una alteración cerebral que comienza a conocerse / Transsexualism: a brain disorder that begins to known

La transexualidad describe la condición de una persona cuyo sexo psicológico difiere del biológico. Las personas con trastorno de identidad de género sufren de forma persistente por esta incongruencia y buscan un cambio de la anatomía sexual, mediante tratamiento hormonal y quirúrgico. Esta revisión, desde una perspectiva ética, ofrece una visión de las correlaciones neurobiológicas estructurales y funcionales de la transexualidad y los procesos de cambio cerebrales por la administración de las hormonas del sexo deseado. Varios estudios demuestran un aumento de la conectividad funcional entre regiones de la corteza cerebral, que son huellas de la angustia psicosocial generada por la discordancia entre el sexo psicológico y el biológico. Tal angustia se puede atribuir a una imagen corporal incongruente debida a los cambios en la conectividad funcional de los componentes clave de la red de representación del cuerpo. Parte de los cambios de la conectividad suponen un mecanismo de defensa puesto que disocia la emoción sentida de la imagen corporal. Las personas transexuales presentan signos de feminización o masculinización de estructuras y procesos cerebrales con dimorfismo sexual y que durante la administración hormonal se desplazan parcialmente aún más hacia las correspondientes al sexo deseado. Estos cambios permiten una reducción de la angustia psicosocial. Sin embargo, un modelo de 'reasignación del sexo' no resuelve el problema, puesto que no se trata la alteración cerebral que lo causa. Se trata de una grave cuestión de ética médica. La liberación de los prejuicios para conocer lo que ocurre en el cerebro de los transexuales es una necesidad médica, tanto para definir lo que es y no es un tratamiento terapéutico, como para guiar las acciones legales

Transsexualism describes the condition when a person’s psychological gender differs from his or her biological sex. People with gender identity disorder suffer persistently from this incongruence and they search hormonal and surgical sex reassignment to the desired anatomical sex. This review, from an ethical perspective, intends to give an overview of structural and functional neurobiological correlations of transsexualism and their course under cross-sex hormonal administration. Several studies demonstrate an increased functional connectivity between cortex regions reaffirming psychosocial distress of psychologicalbiological sex incongruity. Such distress can be ascribed to a disharmonic body image due to changes in the functional connectivity of the key components of body representation network. These brain alterations seem to imply a strategic mechanism dissociating bodily emotions from bodily images. For a number of sexually dimorphic brain structures or processes, signs of feminization or masculinization are observable in transsexual individuals, who during hormonal administration seem to partly further adjust to characteristics of the desired sex. These changes allow a reduction of psychosocial distress. However, a model leading to a 'gender affirmation' does not solve the problem, since brain disorders causing it are not corrected. This is a serious medical ethics issue. Prejudices should be left aside. To know what happens in the brain of transsexuals is a medical need, both to define what is and what is not, and so to choose an adequate treatment, and to decide and guide legal actions

Guías de práctica clínica para la evaluación y tratamiento de la osteoporosis asociada a enfermedades endocrinas y nutricionales / Clinical practice guidelines for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions

Objetivo Proporcionar unas recomendaciones prácticas para la evaluación y tratamiento de la osteoporosis asociada a diferentes enfermedades endocrinas y alteraciones nutricionales. Participantes Miembros del Grupo de Metabolismo Mineral de la Sociedad Española de Endocrinología y Nutrición, un metodólogo y un documentalista. Métodos Las recomendaciones se formularon de acuerdo al sistema Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) para establecer tanto la fuerza de las recomendaciones como el grado de evidencia. Se realizó una búsqueda sistemática en Medline de la evidencia disponible para cada patología usando las siguientes palabras clave asociadas al nombre de cada patología: AND osteoporosis, fractures, bone mineral density, bone markers y treatment. Se revisaron artículos escritos en inglés con fecha de inclusión hasta 18 de octubre de 2011, y cada tema fue revisado por dos personas del Grupo. Un metodólogo resolvió las diferencias que surgieron durante el proceso de revisión de bibliografía y formulación de recomendaciones. Tras la formulación de las recomendaciones estas se discutieron en una reunión conjunta del Grupo de Trabajo. Conclusiones El documento establece unas recomendaciones prácticas basadas en la evidencia acerca de la evaluación y tratamiento de la osteoporosis en las enfermedades endocrinas y nutricionales que asocian baja masa ósea o aumento del riesgo de fractura. Para cada patología, se señala el riesgo de osteoporosis y fracturas asociado, se formulan recomendaciones en cuanto a la evaluación de masa ósea y se enumeran las opciones terapéuticas que han demostrado eficacia en aumentar la densidad mineral ósea y/o reducir el riesgo de fractura (AU)

Objective To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions. Participants Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist. Methods Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts, related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group. Conclusions The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed (AU)

[Clinical practice guidelines for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions. Bone Metabolism Working Group of the Spanish Society of Endocrinology]. / Guías de práctica clínica para la evaluación y tratamiento de la osteoporosis asociada a enfermedades endocrinas y nutricionales. Grupo de Metabolismo Mineral de la Sociedad Espa˜nola deEndocrinología y Nutrición.

OBJECTIVE: To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions. PARTICIPANTS: Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist. METHODS: Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group. CONCLUSIONS: The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.