Consumption of health resources in older people with differentiated thyroid carcinoma: a multicenter analysis

OBJECTIVE

There is hardly any information on the consumption of healthcare resources by older people with differentiated thyroid cancer (DTC). We analyzed these consumptions in older patients with DTC and compared patients 75 years and older with subjects aged 60-74 years.

METHODS

A multicenter, retrospective analysis was designed. We recorded three groups of health resources consumption (visits, diagnostic procedures, and therapeutic procedures) and identified a subgroup of patients with high consumption of resources. We compared patients aged between 60-74 years (group 1) with patients aged 75 and over (group 2).

RESULTS

We included 1654 patients (women, 74.4%), of whom 1388 (83.9%) belonged to group 1 and 266 (16.1%) to group 2. In group 2, we found a higher proportion of patients requiring emergency department visits (7.9 vs. 4.3%, P = 0.019) and imaging studies (24.1 vs. 17.3%; P = 0.012) compared to group 1. However, we did not find any significant difference between both groups in the consumption of other visits, diagnostic procedures, or therapeutic procedures. Overall, 340 patients (20.6%) were identified as high consumers of health resources, 270 (19.5%) in group 1 and 70 (26.3%) in group 2 (P = 0.013). Multivariate logistic regression analysis showed that the risk of recurrence and mortality, radioiodine treatment, tumor size, and vascular invasion were significantly related to the high global consumption of resources. However, the age was not significantly related to it.

CONCLUSION

In patients with DTC over 60 years of age, advanced age is not an independent determining factor in the consumption of health resources.

The NDDG criteria versus the IADPSG or the ADA criteria for diagnosing early-onset gestational diabetes mellitus or abnormal glucose tolerance

OBJECTIVE

To analyze the effects of substituting the National Diabetes Data Group (NDDG) criteria with the International Association of Diabetes and Pregnancy Study Groups (IADPSG) or American Diabetes Association (ADA) criteria for the diagnosis of early-onset gestational diabetes mellitus (Early-GDM) or first trimester abnormal glucose tolerance (1 t-AGT).

METHODS

A retrospective cohort study was conducted of 3200 women: 400 with Early-GDM, 800 with GDM, and 2000 with Non-GDM, according to the NDDG criteria. Rates of women with missed and new Early-GDM according to the IADPSG or ADA criteria were calculated. Multivariate logistic regression analysis was used to compare perinatal outcomes between groups.

RESULTS

Using the IADPSG criteria, 61.6% of women with Early-GDM according to the NDDG were undiagnosed (Missed-Early-GDM group), and 25.9% of women with GDM and 15.7% of women with Non-GDM were diagnosed with Early-GDM (New-Early-GDM groups). Perinatal outcomes were worse in Missed-Early-GDM than in Non-GDM and better in New-Early-GDM groups than in the Early-GDM group. According to the ADA recommendations, only 11.8% of women with Early-GDM according to the NDDG criteria were diagnosed.

CONCLUSION

Replacing the NDDG recommendations for the diagnosis of Early-GDM with the IADPSG or ADA criteria would mean depriving a large number of women with AGT and higher risk of adverse perinatal outcomes from early treatment and treating others with lower risk.

DNA Methylation in Gestational Diabetes and its Predictive Value for Postpartum Glucose Disturbances

CONTEXT

DNA methylation in the diagnosis of gestational diabetes.

OBJECTIVE

To assess the value of DNA methylation in the diagnosis of gestational diabetes (GDM) and in the prediction of maternal postpartum glucose disturbances.

METHODS

Two-stage observational study performed between July 2006 and December 2010, at University Hospital. Forty-eight randomly selected pregnant women formed the discovery cohort (24 with GDM and 24 controls) and 252 pregnant women (94 with GDM and 158 controls) formed the replication cohort. GDM women were re-evaluated 4 years postpartum. The main outcome measures were GDM, type 2 diabetes or prediabetes at 4 years postpartum.

RESULTS

We identified 3 CpG sites related to LINC00917, TRAPPC9, and LEF1 that were differentially methylated in women with GDM and abnormal glucose tolerance; and sites associated with LINC00917 and TRAPPC9 were independently associated with an abnormal glucose tolerance status 4 years postpartum after controlling for clinical variables. Moreover, the site associated with LINC00917 and the combination of the 3 sites had the highest predictive values.

CONCLUSION

Our results suggest that some of these sites may be implicated in the development of GDM and postpartum abnormal glucose tolerance.

Differentiated thyroid carcinoma in the elderly: influence of age on disease-free and overall survival

PURPOSE

We investigated whether age at diagnosis of differentiated thyroid carcinoma (DTC) may be a risk factor for structural disease and mortality after primary treatment in aging patients.

METHODS

A multicenter, retrospective analysis including patients older than 60 years at DCT diagnosis was designed. All subjects were treated by surgery with or without radioiodine adjuvant therapy and had a minimum follow-up of one year. We compared elderly patients (group 1, 60-74 years) with very old patients (group 2, ≥75 years).

RESULTS

The study involved 1668 patients (74.3% women, median age 67 years, 87.6% papillary thyroid cancer, 73.3% treated with radioiodine), including 1397 in group 1 and 271 in group 2. Patients in group 2 had larger tumor size (1.8 [0.8-3.0] vs 1.5 [0.7-2.8] cm; P = 0.005), higher proportions of tumors with vascular invasion (23.8 vs 16.4%; P = 0.006), and lower proportion of lymphocytic thyroiditis (18.6 vs 24.9%; P = 0.013) than subjects in group 1. Kaplan-Meier survival analysis showed that patients in group 2 had significantly lower structural disease-free survival (DFS) and overall survival (OS) than patients in group 1 (P = 0.035 and <0.001, respectively). In multivariate Cox regression analysis, age was a risk factor significantly associated with OS. However, age was significantly associated with DFS in unadjusted analysis and in analysis adjusted by gender and risk classification variables, but not when pathological and therapy-related variables were introduced in the model. On the other hand, patients who received radioiodine had worse DFS (P < 0.001) compared to those who did not.

CONCLUSION

Although age is a conditioning factor for OS, very old patients do not have a greater risk of developing structural disease throughout the follow-up than elderly patients with DTC.

The Gut Microbiota Metabolite Succinate Promotes Adipose Tissue Browning in Crohn's Disease

BACKGROUND AND AIMS

Crohn's disease [CD] is associated with complex microbe-host interactions, involving changes in microbial communities, and gut barrier defects, leading to the translocation of microorganisms to surrounding adipose tissue [AT]. We evaluated the presence of beige AT depots in CD and questioned whether succinate and/or bacterial translocation promotes white-to-beige transition in adipocytes.

METHODS

Visceral [VAT] and subcutaneous [SAT] AT biopsies, serum and plasma were obtained from patients with active [n = 21] or inactive [n = 12] CD, and from healthy controls [n = 15]. Adipose-derived stem cells [ASCs] and AT macrophages [ATMs] were isolated from VAT biopsies.

RESULTS

Plasma succinate levels were significantly higher in patients with active CD than in controls and were intermediate in those with inactive disease. Plasma succinate correlated with the inflammatory marker high-sensitivity C-reactive protein. Expression of the succinate receptor SUCNR1 was higher in VAT, ASCs and ATMs from the active CD group than from the inactive or control groups. Succinate treatment of ASCs elevated the expression of several beige AT markers from controls and from patients with inactive disease, including uncoupling protein-1 [UCP1]. Notably, beige AT markers were prominent in ASCs from patients with active CD. Secretome profiling revealed that ASCs from patients with active disease secrete beige AT-related proteins, and co-culture assays showed that bacteria also trigger the white-to-beige switch of ASCs from patients with CD. Finally, AT depots from patients with CD exhibited a conversion from white to beige AT together with high UCP1 expression, which was corroborated by in situ thermal imaging analysis.

CONCLUSIONS

Succinate and bacteria trigger white-to-beige AT transition in CD. Understanding the role of beige AT in CD might aid in the development of therapeutic or diagnostic interventions.

Cord Blood Advanced Lipoprotein Testing Reveals an Interaction between Gestational Diabetes and Birth-Weight and Suggests a New Early Biomarker of Infant Obesity

Abnormal lipid metabolism is associated with gestational diabetes mellitus (GDM) and is observed in neonates with abnormal fetal growth. However, the underlying specific changes in the lipoprotein profile remain poorly understood. Thus, in the present study we used a novel nuclear magnetic resonance (NMR)-based approach to profile the umbilical cord serum lipoproteins. Two-dimensional diffusion-ordered 1H-NMR spectroscopy showed that size, lipid content, number and concentration of particles within their subclasses were similar between offspring born to control (n = 74) and GDM (n = 62) mothers. Subsequent data stratification according to newborn birth-weight categories, i.e., small (n = 39), appropriate (n = 50) or large (n = 49) for gestational age (SGA, AGA and LGA, respectively), showed an interaction between GDM and birth-weight categories for intermediate-density lipoproteins (IDL)-cholesterol content and IDL- and low-density lipoproteins (LDL)-triglyceride content, and the number of medium very low-density lipoproteins (VLDL) and LDL particles specifically in AGA neonates. Moreover, in a 2-year follow-up study, we observed that small LDL particles were independently associated with offspring obesity at 2 years (n = 103). Collectively, our data demonstrate that GDM disturbs triglyceride and cholesterol lipoprotein content across birth-weight categories, with AGA neonates born to GDM mothers displaying a profile more similar to that of adults with dyslipidemia. Furthermore, an altered fetal lipoprotein pattern was associated with the development of obesity at 2 years.

Recovery of parathyroid function in patients with thyroid cancer treated by total thyroidectomy: An analysis of 685 patients with hypoparathyroidism at discharge of surgery

OBJECTIVE

We aimed to study the predictive factors for recovery of parathyroid function in hypoparathyroid patients after total thyroidectomy for thyroid cancer.

METHODS

We designed a retrospective, multicentre and nation-wide analysis of patients with total thyroidectomy who were seen in twenty endocrinology departments from January to March 2018. We selected patients with histologically proven thyroid cancer and retrieved information related to surgical procedure and thyroid cancer features. Survival analysis and Cox regression analysis were used to study the relationship between these variables and the recovery of parathyroid function.

RESULTS

From 685 patients with hypoparathyroidism at discharge of surgery, 495 (72.3%) recovered parathyroid function over time. Kaplan-Meier analysis showed that this recovery was significantly related to the presence of specialized surgical team (P<0.001), identification of parathyroid glands at surgery (P<0.001), papillary histopathology (P=0.040), and higher levels of postoperative calcium (Ca) (P<0.001) and parathyroid hormone (PTH) (P<0.001). Subjects with gross extrathyroidal extension (P=0.040), lymph node metastases (P=0.004), and surgical re-intervention after initial surgery (P=0.024) exhibited a significant risk of persistence of hypoparathyroidism. Multivariate Cox regression analysis showed that the significant and independent factors for recovery of parathyroid function were postoperative concentrations of Ca (P=0.038) and PTH (P=0.049). The presence of lymph node metastases was a negative predictor of recuperation of parathyroid function (P=0.042) in this analysis.

CONCLUSION

In patients with thyroid cancer, recovery of parathyroid function after total thyroidectomy was directly related to postoperative Ca and PTH concentrations, and inversely related to lymph node metastases.

Late Recovery of Parathyroid Function After Total Thyroidectomy: A Case-Control Study

The clinical characteristics of patients with postoperative hypoparathyroidism who recover parathyroid function more than 12 months after surgery have not been studied. We aimed to evaluate whether the intensity of replacement therapy with calcium and calcitriol is related to the late recovery of parathyroid function. We compared the demographic, surgical, pathological, and analytical features of two groups of patients: cases, i. e., late recovery patients (those who recover parathyroid function>1 year after thyroidectomy, n=40), and controls, i. e., patients with permanent hypoparathyroidism (n=260). Replacement therapy with calcium and calcitriol was evaluated at discharge of surgery, 3-6 months, 12 months, and last visit. No significant differences were found in clinical, surgical, pathological, or analytical characteristics between cases and controls. The proportion of cases who required treatment with calcium plus calcitriol at 12 months was significantly lower than that found in controls (p<0.001). Furthermore, daily calcium and calcitriol doses in controls were significantly higher than those in cases at 3-6 months (p=0.014 and p=0.004, respectively) and at 12 months (p<0.001 and p=0.043, respectively). In several models of logistic regression analysis therapy with calcium and calcitriol at 12 months was negatively related to late recovery of parathyroid function. Although delayed recuperation of parathyroid function after total thyroidectomy is uncommon (13%), follow-up beyond 12 months is necessary in patients with postoperative hypoparathyroidism, especially in those whose needs of treatment with Ca and calcitriol are reducing over time.

Early identification of metabolic syndrome risk: A review of reviews and proposal for defining pre-metabolic syndrome status

AIMS

a) To analyze the relationship of known and emerging biomarkers/indicators for early risk identification of cardiometabolic health risk; b) to identify early risk markers to be used in both clinical and nonclinical settings; and c) to propose a definition of early risk identification in terms of pre-metabolic syndrome (PreMetSyn).

DATA SYNTHESIS

Pubmed/Medline, Web of Science, Embase, and Cochrane were searched for Systematic Reviews and Meta-analysis. Selected studies were evaluated, and relevant data were extracted and synthesized.

CONCLUSIONS

Serum uric acid is a good predictive biomarker of metabolic syndrome (MetSyn) and has been associated with non-alcoholic liver fat disease (NAFLD) and type 2 diabetes. NAFLD emerges as an early risk indicator of PreMetSyn by itself. Muscle strength should also be included as an early risk marker of cardiometabolic health. High serum triglycerides and waist circumference confirm their predictive value regarding MetSyn. Indicators related to an inflammatory/pro-inflammatory status usually linked to MetSyn showed limited evidence as robust biomarkers for PreMetSyn. Authors suggest defining PreMetSyn related to cardiometabolic risk. It is also necessary to determine how close people are to the cut-off point of MetSyn components, including emerging indicators proposed by our review. Some biomarkers could be used as indicators of PreMetSyn, before any of the MetSyn components appear, allowing early health interventions to prevent its development. Defining a PreMetSyn status might consider both emerging indicators and those variables already included in the definition of MetSyn. New indicators should be considered to create a new risk score specifically meant for PreMetSyn.

Permanent postoperative hypoparathyroidism: an analysis of prevalence and predictive factors for adequacy of control in a cohort of 260 patients

Background

Recent guidelines for the treatment of hypoparathyroidism emphasize the need for long-term disease control, avoiding symptoms and hypocalcaemia. Our aim has been to analyze the prevalence of poor disease control in a national cohort of patients with hypoparathyroidism, as well as to evaluate predictive variables of inadequate disease control.

Methods

From a nation-wide observational study including a cohort of 1792 patients undergoing total thyroidectomy, we selected 260 subjects [207 women and 53 men, aged (mean ± SD) 47.2±14.8 years] diagnosed with permanent hypoparathyroidism. In every patient demographic data and details on surgical procedure, histopathology, calcium (Ca) metabolism, and therapy with Ca and calcitriol were retrospectively collected. A patient was considered not adequately controlled (NAC) if presented symptoms of hypocalcemia or biochemical data showing low serum Ca levels or high urinary Ca excretion.

Results

Two hundred and twenty-one (85.0%) patients were adequately controlled (AC) and 39 (15.0%) were NAC. Comparison between AC and NAC patients did not show any significant difference in demographic, surgical, and pathological features. Rate of hospitalization during follow-up was significantly higher among NAC patients in comparison with AC patients (35.9% vs. 10.9%, P<0.001). Dose of oral Ca and calcitriol were also significantly higher in NAC subjects. In a subgroup of 129 patients with serum parathyroid hormone (PTH) levels available, we found that NAC patients exhibited significantly lower postoperative PTH concentrations than AC patients [median (interquartile range) 3 (1.9-7.8) vs. 6.9 (3.0-11) pg/mL; P=0.009].

Conclusions

In a nation-wide cohort of 260 subjects with definitive hypoparathyroidism, 15% of them had poor disease control. These patients required higher doses of oral Ca and calcitriol, had higher rate of hospitalization during follow-up and showed lower PTH concentrations in the postoperative period.

Impaired Succinate Response to a Mixed Meal in Obesity and Type 2 Diabetes Is Normalized After Metabolic Surgery

OBJECTIVE

To explore the meal response of circulating succinate in patients with obesity and type 2 diabetes undergoing bariatric surgery and to examine the role of gastrointestinal glucose sensing in succinate dynamics in healthy subjects.

RESEARCH DESIGN AND METHODS

Cohort I comprised 45 patients with morbid obesity and type 2 diabetes (BMI 39.4 ± 1.9 kg/m²) undergoing metabolic surgery. Cohort II was a confirmatory cohort of 13 patients (BMI 39.3 ± 1.4 kg/m²) undergoing gastric bypass surgery. Cohort III comprised 15 healthy subjects (BMI 26.4 ± 0.5 kg/m²). Cohorts I and II completed a 2-h mixed-meal tolerance test (MTT) before the intervention and at 1 year of follow-up, and cohort II also completed a 3-h lipid test (LT). Cohort III underwent a 3-h oral glucose tolerance test (OGTT) and an isoglycemic intravenous glucose infusion (IIGI) study.

RESULTS

In cohort I, succinate response to MTT at follow-up was greater than before the intervention (P < 0.0001). This response was confirmed in cohort II with a greater increase after 1 year of surgery (P = 0.009). By contrast, LT did not elicit a succinate response. Changes in succinate response were associated with changes in the area under the curve of glucose (r = 0.417, P < 0.0001) and insulin (r = 0.204, P = 0.002). In cohort III, glycemia, per se, stimulated a plasma succinate response (P = 0.0004), but its response was greater in the OGTT (P = 0.02; OGTT versus IIGI).

CONCLUSIONS

The meal-related response of circulating succinate in patients with obesity and type 2 diabetes is recovered after metabolic surgery.

Gestational diabetes impacts fetal precursor cell responses with potential consequences for offspring

Fetal programming has been proposed as a key mechanism underlying the association between intrauterine exposure to maternal diabetes and negative health outcomes in offspring. To determine whether gestational diabetes mellitus (GDM) might leave an imprint in fetal precursors of the amniotic membrane and whether it might be related to adverse outcomes in offspring, a prospective case‐control study was conducted, in which amniotic mesenchymal stem cells (AMSCs) and resident macrophages were isolated from pregnant patients, with either GDM or normal glucose tolerance, scheduled for cesarean section. After characterization, functional characteristics of AMSCs were analyzed and correlated with anthropometrical and clinical variables from both mother and offspring. GDM‐derived AMSCs displayed an impaired proliferation and osteogenic potential when compared with control cells, accompanied by superior invasive and chemotactic capacity. The expression of genes involved in the inflammatory response (TNFα, MCP‐1, CD40, and CTSS) was upregulated in GDM‐derived AMSCs, whereas anti‐inflammatory IL‐33 was downregulated. Macrophages isolated from the amniotic membrane of GDM mothers consistently showed higher expression of MCP‐1 as well. In vitro studies in which AMSCs from healthy control women were exposed to hyperglycemia, hyperinsulinemia, and palmitic acid confirmed these results. Finally, genes involved in the inflammatory response were associated with maternal insulin sensitivity and prepregnancy body mass index, as well as with fetal metabolic parameters. These results suggest that the GDM environment could program stem cells and subsequently favor metabolic dysfunction later in life. Fetal adaptive programming in the setting of GDM might have a direct negative impact on insulin resistance of offspring.

Prevalence and risk factors for hypoparathyroidism following total thyroidectomy in Spain: a multicentric and nation-wide retrospective analysis

PURPOSE

The prevalence of postoperative hypoparathyroidism has been studied in registries and in surgical series with highly variable and imprecise results. However, the frequency of this hormonal deficiency in the clinical practice of endocrinologists is not known with accuracy. We aimed to assess the prevalence and risk factors of hypoparathyroidism in patients undergoing total thyroidectomy in Spain.

METHODS

We designed a retrospective, multicentre and nation-wide protocol including all patients with total thyroidectomy who were seen in the endocrinology clinic of the participant centers from January to March 2018. Prevalence of hypoparathyroidism was evaluated at discharge of surgery, 3-6 months after surgery, 12 months after surgery and at last visit. Twenty hospitals participated in the study.

RESULTS

Of 1792 patients undergoing total thyroidectomy, 866 (48.3%) developed postoperative hypoparathyroidism at discharge of surgery. Most of them recover parathyroid function over time. Prevalence of hypoparathyroidism at 3-6 months, 12 months and at last visit was 22.9%, 16.7% and 14.5%, respectively. The risk of developing definitive hypoparathyroidism was related to the presence of parathyroid tissue at histology, lymph node dissection, and two-stage thyroidectomy. Patients with thyroid cancer, with higher postoperative calcium levels and treated by expert surgical teams exhibited lower risk of developing permanent hypoparathyroidism.

CONCLUSIONS

Although most patients with postsurgical hypoparathyroidism recover parathyroid function, the prevalence of permanent disease in clinical practice is non negligible (14.5%). Postoperative calcium, extent and timing of surgery, the presence of cancer, expert surgical team, and parathyroid tissue at histology are predictors of permanent hypoparathyroidism.

Correction to: Prevalence and risk factors for hypoparathyroidism following total thyroidectomy in Spain: a multicentric and nation-wide retrospective analysis

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Preoperative Circulating Succinate Levels as a Biomarker for Diabetes Remission After Bariatric Surgery

OBJECTIVE

To determine the potential use of baseline circulating succinate to predict type 2 diabetes remission after bariatric surgery.

RESEARCH DESIGN AND METHODS

Forty-five obese patients with diabetes were randomly assigned to Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or laparoscopic greater curvature plication. Anthropometric parameters were evaluated, and a complete biochemical analysis including circulating serum succinate concentrations was performed at baseline and 1 year after surgery. The results were externally validated in a second cohort including 88 obese patients with diabetes assigned to RYGB or SG based on clinical criteria.

RESULTS

Succinate baseline concentrations were an independent predictor of diabetes remission after bariatric surgery. Patients achieving remission after 1 year had lower levels of baseline succinate (47.8 [37.6-64.6] µmol/L vs. 64.1 [52.5-82.9] µmol/L; P = 0.018). Moreover, succinate concentrations were significantly decreased 1 year after surgery (58.9 [46.4-82.4] µmol/L vs. 46.0 [35.8-65.3] µmol/L, P = 0.005). In multivariate analysis, the best logistic regression model showed that baseline succinate (odds ratio [OR] 11.3, P = 0.031) and the type of surgery (OR 26.4, P = 0.010) were independently associated with remission. The C-statistic for this model was 0.899 (95% CI 0.809-0.989) in the derivation cohort, which significantly improved the prediction of remission compared with current available scores, and 0.729 (95% CI 0.612-0.846) in the validation cohort. Interestingly, patients had a different response to the type of surgery according to baseline succinate, with significant differences in remission rates.

CONCLUSIONS

Circulating succinate is reduced after bariatric surgery. Baseline succinate levels have predictive value for diabetes remission independently of previously described presurgical factors and improve upon the current available scores to predict remission.

Arterial stiffness is highly correlated with the scores obtained from the Steno Type 1 Risk Engine in subjects with T1DM

Objectives

Currently used risk scores for type 2 diabetes mellitus (T2DM) clearly underestimate cardiovascular risk in type 1 diabetes (T1DM). Hence, there is a need to develop novel and specific risk-estimation tools for this population. We aimed to assess the relationship between the Steno Type 1 Risk Engine (ST1RE) and arterial stiffness (AS), and to identify potential cut-off points of interest in clinical practice.

Design and methods

A total of 179 patients with T1DM (50.8% men, mean age 41.2±13.1 years), without established cardiovascular disease, were evaluated for clinical and anthropometric data (including classical cardiovascular risk factors), and AS measured by aortic pulse-wave velocity (aPWV). The ST1RE was used to estimate 10-year cardiovascular risk and patients were classified into 3 groups: low- (<10%; n = 105), moderate- (10–20%; n = 53) and high-risk (≥20%; n = 21).

Results

When compared with the low- and moderate-risk groups, patients in the high-risk group were older, had higher prevalence of hypertension, dyslipidemia and insulin-resistance, and had higher body-mass index and HbA_1c. aPWV increased in parallel with estimated cardiovascular risk (6.4±1.0, 8.4±1.3 and 10.3±2.6m/s; p<0.001). As an evaluation of model performance, the C-statistic of aPWV was 0.914 (95% confidence interval [CI]:0.873–0.950) for predicting moderate/high-risk and 0.879 (95%CI:0.809–0.948) for high-risk, according to the ST1RE. The best cut-off points of aPWV were 7.3m/s (sensitivity:86%, specificity:83%) and 8.7m/s (sensitivity:76%, specificity:86%) for moderate/high- and high-risk, respectively.

Conclusions

AS is highly correlated with the scores obtained from the ST1RE. We have identified two cut-off points of AS that can clearly discriminate moderate/high- and high-risk T1DM patients, which could be of great value in clinical practice.

A descriptive study of the characteristics of differentiated thyroid cancer in Catalonia during the period 1998-2012. The CECaT registry

INTRODUCTION

The consortium for the study of thyroid cancer (CECaT), including 20 hospitals and one research institute, was recently created in Catalonia (Spain). One of the first initiatives of the group was to perform a descriptive analysis of the characteristics of patients with differentiated thyroid carcinoma (DTC).

PATIENTS AND METHODS

The cohort included 1,855 patients from 11 hospitals treated over a period of 15 years (1998-2012).

RESULTS

In this series, 1.470 (79.2%) patients were women. Mean age was 47.7 (15.7) years old. Age was significantly higher in male than in female patients, 49.3 (15) versus 47.3 (15.8); p=0.02. Papillary thyroid carcinoma accounted for 88.9% of cases. Mean tumor size was 21.5 (16) mm, and was significantly lower in females than in males, 20.1 (14.5) mm and 26.6 (20.3) mm respectively (p<0.001). After a follow-up period of 5.5 (3.7) years, information was available for 1,355 patient, of whom 1065 (78.6%) were free of disease, 239 (17.6%) had no tumor persistence, and 51 (3.8) % had died. The risk of persistent or recurrent disease was significantly associated to older age at diagnosis, male gender, larger tumor size, lymph node metastases at surgery, no signs of thyroiditis in the remaining thyroid tissue, and presence of vascular and/or extraglandular invasion.

CONCLUSIONS

Patient characteristics analyzed are similar to those reported in other parts of the world.

Reduced circulating levels of TWEAK are associated with gestational diabetes mellitus

BACKGROUND

To evaluate the inflammatory axis mediated by tumour necrosis factor-like weak inducer of apoptosis (TWEAK) and its scavenger receptor CD163 during pregnancy and their influence on insulin sensitivity in normal pregnancy and in gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

One hundred and thirty seven women with one singleton pregnancy, 71 with normal glucose tolerance (NGT) and 66 with GDM were studied. Glucose metabolism was assessed by oral glucose tolerance test. Serum concentrations of soluble TWEAK (sTWEAK) and CD163 (sCD163) and insulin resistance (HOMA-IR index) were determined in maternal blood drawn at recruitment, in the early third trimester. Offspring weight and height were assessed at birth.

RESULTS

Women with GDM had lower circulating sTWEAK concentrations than control NGT group (237·8 (192·1-301·0) pg/mL vs. 277·2 (206·4-355·7) pg/mL; P = 0·013). sTWEAK was negatively associated with the presence of GDM (r = -0·212; P = 0·013), HOMA-IR index (r = -0·197; P = 0·021) and ponderal index of the newborn (r = -0·196; P = 0·025), but positively with HDL cholesterol (r = 0·283; P = 0·001). In multiple regression analysis, sTWEAK concentration emerged as one of the main predictors of insulin resistance, along with BMI, triglycerides and low concentrations of HDL cholesterol (R(2)  = 0·486; P < 0·001). No relationship was found between HOMA-IR index and sCD163 or sCD163/sTWEAK ratio.

CONCLUSIONS

sTWEAK concentrations are lower in patients with GDM compared with healthy pregnant women, and low concentrations of sTWEAK are associated with insulin resistance. These findings suggest that insulin resistance during pregnancy is closely linked to inflammatory imbalance and sTWEAK may represent a new candidate associated with GDM.

Plasma visfatin concentrations increase in both hyper and hypothyroid subjects after normalization of thyroid function and are not related to insulin resistance, anthropometric or inflammatory parameters

OBJECTIVE

The objective of this study was to evaluate plasma visfatin levels in thyroid dysfunction and its relationship with inflammatory, anthropometric and insulin resistance parameters.

DESIGN AND PATIENTS

Twenty-four hyperthyroid and 27 hypothyroid patients were studied before and after treatment. Forty-five euthyroid subjects were used as control group.

MEASUREMENTS

Fasting plasma visfatin, IL-6, C reactive protein, adiponectin, thyroid hormones, waist-to-hip ratio, BMI, percentage of body fat and homeostasis model insulin resistance index (HOMA-IR) were measured.

RESULTS

Hyperthyroid patients showed increased insulin resistance, IL-6 and visfatin levels compared with controls (3.21 +/- 3.0 vs. 1.67 +/- 0.75, P = 0.022; 3.35 +/- 0.41 vs. 2.10 +/- 0.25 pg/ml, P = 0.016; and 37.4 +/- 5.81 vs. 23.79 +/- 4.2 ng/ml, P = 0.061 respectively). After normalization of thyroid function, IL-6 levels and HOMA-IR decreased (2.35 +/- 0.37 vs. 2.10 +/- 0.25 pg/ml, P = 0.045 and 3.21 +/- 0.60 vs. 2.28 +/- 0.38, P = 0.032 respectively), while body weight, adiposity and visfatin levels increased (26.1 +/- 1.2 vs. 26.7 +/- 1.2 kg/m(2), P = 0.049; 30.9 +/- 1.6 vs. 32.2 +/- 1.6%, P = 0.007; and 37.4 +/- 5.81 vs. 63.13 +/- 8.72 ng/ml, P = 0.047 respectively). C reactive protein and adiponectin levels were similar to those of the control group. Hypothyroid patients showed high visfatin levels (40.59 +/- 3.07 vs. 29.34 +/- 4.9 ng/ml, P = 0.049) that increased after treatment (81.4 +/- 9.2 ng/ml, P = 0.001) without changes in anthropometric or insulin resistance parameters. C reactive protein, IL-6 and adiponectin levels were similar to those of the control group. No correlations between visfatin and any analysed parameter were found in either hyper- or hypothyroidism.

CONCLUSION

Visfatin exhibits a marked increase after normalization of thyroid function in both hyper and hypothyroid patients. We suggest that visfatin may play a role in the hormone stabilization process independent of anthropometric, inflammatory or insulin resistance variables.

Adipocyte fatty acid-binding protein as a determinant of insulin sensitivity in morbid-obese women

The aim of the study was to evaluate human plasma circulating levels of adipocyte fatty acid-binding protein (A-FABP) and its relationship with proinflammatory adipocytokines and insulin resistance in a severely obese cohort, before and 1 year after a surgical gastric bypass. Plasmatic levels of A-FABP were measured in 77 morbid-obese women before and 1 year after bariatric surgery. Anthropometrical parameters and body composition by bioelectrical impedance analysis were determined. Circulating levels of soluble tumor necrosis factor receptor 2 (sTNFR2), Interleukin 18 (IL-18), adiponectin, and high-sensitive C-reactive protein (hsCRP) were also analyzed. Insulin resistance by homeostasis model assessment of insulin resistance (HOMA-IR) index was calculated. After massive weight loss, A-FABP plasmatic levels decreased significantly [7.6 (8.9) vs. 4.3 (5.1); P<0,001] but no association with circulating adipokines or proinflammatory cytokines, both at the beginning and at the end of follow-up, was observed. A decrease in sTNFR2, IL-18, hsCRP, and an increase in adiponectin levels (P<0.001 in all cases) were observed after the gastric bypass. HOMA-IR index improved 1 year after surgery and after multiple regression analysis remained associated with A-FABP after controlling for confounding variables (beta=0.322, P=0.014; R2 for the model 0.281). In morbid-obese women, plasma A-FABP concentrations were dramatically reduced after gastric bypass surgery. After weight loss this protein contributed to HOMA-IR index independently of proinflammatory/antinflammatory cytokine profile. Further studies are warranted to elucidate the role of A-FABP in the pathogenesis of insulin resistance in morbid obesity.

Effectiveness of retinoic acid treatment for redifferentiation of thyroid cancer in relation to recovery of radioiodine uptake

BACKGROUND

Retinoic acid (RA) treatment has been used for redifferentiation of metastatic thyroid neoplasia that have lost radioiodine (131I) uptake with heterogeneous results.

AIM

Retrospective analysis of the recovery rate of 131I uptake after RA treatment in patients from 11 Spanish hospitals.

METHODS

Twenty-seven patients (14 men, 13 women) with papillary [21], follicular [4], and oncocytic [2] thyroid cancer initially treated with total thyroidectomy plus 131I, and with 131I negative metastatic disease, were given 13-cis RA (0.66-1.5 mg/kg for 5-12 weeks) followed by a therapeutic 131I dose (3700-7400 MBq); 3 months later thyroglobulin levels and computed tomography imaging were performed.

RESULTS

In 9 out 27 cases (33%) (8 papillary, 1 follicular) optimal positive 131I scan was observed after RA treatment; in the remaining 18, 10 had a suboptimal uptake (7 papillary, 2 follicular, 1 oncocytic) and in the rest there was no 131I uptake recovery (6 papillary, 1 follicular, 1 oncocytic). In 17 positive responses to RA (either optimal or suboptimal) in which image follow-up was available, decrease or stabilization of metastatic growth was observed in 7, while tumor mass increased at short term in the remaining 10. No major side effects were detected.

CONCLUSION

Quite a high rate of 131I uptake recovery after RA treatment may be obtained in advanced differentiated thyroid cancer, but the potential modification of the natural course of the disease is uncertain. A better biological characterization of these tumors allowing the identification of potential responders to RA may improve the outcome of RA coadjuvant therapy.

LMNA mRNA expression is altered in human obesity and type 2 diabetes

OBJECTIVE

The aim of this study was to analyze lamin A/C mRNA levels in abdominal subcutaneous adipose tissue in two conditions-obesity and type 2 diabetes-that share common inflammatory and metabolic features, and to assess their relationship with selected inflammatory and adipogenic genes.

METHODS AND PROCEDURES

This is a cross-sectional study involving 52 nondiabetic and 54 type 2 diabetes patients. Anthropometrical and analytical measurements (glycemic, lipidic, and inflammatory profiles) were performed, and mRNA expression was determined using real-time PCR.

RESULTS

Lamin A and C isoforms are expressed differentially. Lamin A/C mRNA levels were increased in obese and in type 2 diabetes patients. We also observed a strong relationship between both isoforms (B = 2.218, P < 0.001) and among lamin C mRNA expression and adipogenic (sterol-responsive element binding protein-1 (SREBP1c)) and inflammatory (interleukin-6 (IL-6)) markers (B = 0.854, P = 0.001, and B = 0.557, P < 0.001, respectively).

DISCUSSION

These data suggest that lamin A/C may be involved in the adipocyte gene profile observed in obesity and type 2 diabetes.

Adult subjects with Prader-Willi syndrome show more low-grade systemic inflammation than matched obese subjects

AIM

Adult subjects with Prader-Willi syndrome (PWS) may show several conditions that are associated with an activation of innate immunity such as obesity, deficient GH secretion or hypogonadism. Our aim was to study whether obese adult PWS subjects show an additional low-grade systemic inflammation (LGSI) in relation to obese adult non-PWS subjects and lean healthy control subjects before and after a standardized liquid meal.

METHODS

Seven obese adult PWS subjects, 7 matched obese non-PWS subjects and 7 lean healthy control subjects were studied for 6 h from the administration of a standard liquid meal.

RESULTS

Compared to non-PWS, PWS subjects showed higher plasma concentrations of C-reactive protein (CRP) (p=0.030), complement component C3 (p=0.018), interleukin(IL)-18 (p=0.048), and IL-6 (p=0.041) that persisted post-prandially elevated for CRP (p<0.0001), C3 (p=0.015), and IL-18 (p=0.003). Tumor necrosis factor(TNF)-alpha did not differ between the 3 groups. These results were independent from IGF-I levels, homeostasis model assessment index, and body mass index (BMI). In male subjects with PWS, testosterone levels correlated to IL-18 (r=-0,646, p=0.041).

CONCLUSIONS

Compared to matched non-PWS subjects, the obese PWS subjects in this study showed an additional LGSI that persisted postprandially and was independent from BMI, insulin resistance, and deficient GH secretion. However, in PWS males, high IL-18 levels were related to low testosterone concentrations.

Human subcutaneous adipose tissue LPIN1 expression in obesity, type 2 diabetes mellitus, and human immunodeficiency virus--associated lipodystrophy syndrome

The aim of this study was to analyze LPIN1 adipose tissue gene expression levels in 3 clinical insulin-resistant conditions-obesity, type 2 diabetes mellitus, and human immunodeficiency virus (HIV)-associated lipodystrophy-and its relationship with adipogenic and inflammatory markers. Subcutaneous adipose tissue samples were obtained from 2 cohorts: 98 subjects with different degrees of adiposity and with or without the presence of type 2 diabetes mellitus and 37 HIV-infected patients. Real-time polymerase chain reaction was used to measure gene expression of LPIN1 and adipogenic (PPARgamma, SREBP1c) and inflammatory markers (IL6, TNFalpha, TNFR1, and TNFR2). LPIN1 messenger RNA expression levels were significantly lower in the obese group (P = .002), were similar in type 2 diabetes mellitus patients and control subjects (P = .211), and were significantly higher in HIV-infected patients (P < .001). LPIN1 messenger RNA levels positively correlated with insulin sensitivity in all subjects. Moreover, an inverse correlation with proinflammatory cytokines was observed.

Monocyte chemoattractant protein-1 in obesity and type 2 diabetes. Insulin sensitivity study

OBJECTIVE

Our goal was to test any association between human plasma circulating levels of monocyte chemoattractant protein-1 (cMCP-1) and insulin resistance and to compare monocyte chemoattractant protein-1 (MCP-1) adipose tissue gene expression and cMCP-1 in relation with inflammatory markers.

RESEARCH METHODS AND PROCEDURES

cMCP-1 was measured in n = 116 consecutive control male subjects to whom an insulin sensitivity (S(i)) test was performed. Circulating levels of soluble CD14, soluble tumor necrosis factor receptor type 2 (sTNFR2), soluble interleukin-6 (sIL-6), and adiponectin also were measured. Subcutaneous adipose tissue samples were obtained from n = 107 non-diabetic and type 2 diabetic subjects with different degrees of obesity. Real-time polymerase chain reaction was used to measure gene expression of MCP-1, CD68, tumor necrosis factor-alpha (TNF-alpha), and its receptor TNFR2.

RESULTS

In the S(i) study, no independent effect of cMCP-1 levels on insulin sensitivity was observed. In the expression study, in non-diabetic subjects, MCP-1 mRNA had a positive correlation with BMI (r = 0.407, p = 0.003), TNF-alpha mRNA (r = 0.419, p = 0.002), and TNFR2 mRNA (r = 0.410, p = 0.003). In these subjects, cMCP-1 was found to correlate with waist-to-hip ratio (r = 0.322, p = 0.048). In patients with type 2 diabetes, MCP-1 mRNA was up-regulated compared with non-diabetic subjects. TNF-alpha mRNA was found to independently contribute to MCP-1 mRNA expression. In this group, CD68 mRNA was found to correlate with BMI (r = 0.455, p = 0.001).

DISCUSSION

cMCP-1 is not associated with insulin sensitivity in apparently healthy men. TNF-alpha is the inflammatory cytokine associated with MCP-1 expression in subcutaneous adipose tissue.

Different TNFalpha expression elicited by glucose in monocytes from type 2 diabetes mellitus patients

Increased plasma concentrations of tumor necrosis factor alpha (TNFalpha) system components appear in type 2 diabetes patients with poor glycemic control. We have analyzed the expression of TNFalpha, TNFR1 and TNFR2 when monocytes and lymphocytes isolated from a group of recent onset type 2 diabetic patients, with fasting glucose levels below 7.0mM and glycated haemoglobin (Hb1Ac) in the normal range, were stimulated with high glucose or LPS endotoxin. We report, that cultured monocytes from these type 2 diabetic patients, in comparison to monocytes from non-diabetic individuals, had an enhanced response to LPS but did not respond to an acute glucose challenge (p<0.05). No differences were observed in the cultured lymphocyte fractions. These results indicate the existence of differences, elicited by LPS or high glucose related stimulus, between monocytes isolated from non-diabetic subjects or from type 2 diabetes patients.

Expression of TWEAK and its receptor Fn14 in human subcutaneous adipose tissue. Relationship with other inflammatory cytokines in obesity

TWEAK, a cytokine of the TNF family, has been found to be expressed under different inflammatory conditions but no data is available concerning the expression of this cytokine and its receptor (Fn14) in human obesity. In the present work we have evaluated the expression of many pro-inflammatory TNF system cytokines (TNF-alpha, TWEAK and their respective receptors, TNFR1, TNFR2 and Fn14) in human adipose tissue of 84 subjects some with different degree of obesity and type 2 diabetes, and its relation with inflammation by also measuring the expression of macrophage marker CD68. We detected expression of TWEAK and Fn14 in isolated mature adipocytes and in the stromovascular fraction. Additionally, we found that LPS upregulates the expression of both genes on THP-1 human monocytic cell line. TWEAK was expressed in adipose tissue of all studied subjects with no differences between obesity group, and was associated with Fn14 expression in morbid obese, mainly in women with type 2 diabetes. The data obtained here also showed that TNF-alpha and TNFR2 mRNAs were significantly more expressed in subcutaneous adipose tissue of subjects with morbid obesity compared to obese and non-obese subjects. In contrast, TNFR1 gene expression was negatively associated with BMI. Our results suggest that the expression of TNF-derived pro-inflammatory cytokines are increased in severe obesity, where macrophage infiltrate could modulate the inflammatory environment through activation of its receptors.

[Our experience in the nutritional treatment of anorexia nervosa (1989-1991)]

The purpose of this study was to assess the evolution in the nutritional situation of patients diagnosed with anorexia nervosa in the Clinical Nutrition Service between January 1 1989 and December 31 1991. Twenty-eight admitted patients (4 men and 24 women) and 38 outpatients (3 men and 35 women) were monitored, with an age of 22.4 +/- 6.4 years and average evolution time of the illness of 3.8 +/- 5 years. Nutritional state was evaluated with anthropometric, biochemical and immunological parameters. Following nutritional therapy, malnutrition and BMI (Body Mass Index) improved significantly over the initial evaluation in all patients, whether admitted or outpatients. All anthropometric parameters improved significantly during the period of treatment of admitted patients, but AMC (arm muscle circumference) rose only in outpatients. An unrestricted diet plus nutritional counselling was the most-used therapeutic procedure in outpatients while most of the admitted patients required dietary supplements. Calorie malnutrition is very common in patients diagnosed with anorexia nervosa: vitamin or trace element deficiencies are very infrequent. Nutritional therapy, suitably coordinated with psychotherapeutic treatment, is effective, enhancing both the nutritional state and anomalous dietary habits.

[Primary empty sella turcica: clinical, radiological and hormonal evaluation]

A retrospective study of 33 patients diagnosed of primary empty sella turcica has been done. Main clinical feature was cephalea, which was present in 51.1% of cases. Diagnosis was done based in Neuroradiologic studies (CAT, Cisternography, Pneumocisternography, Nuclear Magnetic Resonance) finding sellar size being significantly smaller in cases studied after 1980. After Hypophyseal function study, 19 patients did not show any endocrinological disorders, in the other 14 (42.4%), hyperprolactinemia was the most frequent finding (7 patients, 23.3%). 17.8% of cases showed a lowered response of Growth Hormone to insulinic Hypoglycemia. In two cases Panhypopituitarism was found and in case Insipidus diabetes was diagnosed.

[Diabetes and pregnancy. Our experience in pregnancy diabetes (1977-1988)]

The records of 303 females with gestational diabetes (GD) seen from 1977 to 1988 in the Hospital La Paz in Madrid were reviewed. In some respects, two periods were separately considered, period A from 1977 to 1983 and period B from 1983 to 1988, the latter corresponding to the activity of the Diabetes and Pregnancy Unit. Significant differences in fetal mortality (0.65%) with nondiabetic pregnant women or between periods A and B were not found. Macrosomic fetuses (the most common abnormality, 18.5%) were related with maternal age, a macrosomic fetus in previous pregnancies, degree of carbohydrate intolerance at the time of diagnosis of the diabetes and need for insulin therapy. This latter feature indicates a more severe degree of metabolic involvement. Regarding risk factors, the most common were older maternal age, family history of diabetes and obesity. The pancreatic reserve in nonobese women with GD (2.1 +/- 0.8 ng/ml) was lower than in obese women with GD (3.3 +/- 0.9 ng/l) (p less than 0.001), higher than in progestational diabetic women type II (1.1 +/- 0.7 ng/ml) and type I (0.15 +/- 0.1 ng/ml) (p less than 0.001), and it was not different from that in normal pregnant women (2.15 +/- 0.6 ng/ml). Insulin therapy for the control of diabetes was required in 24.5% of pregnant women. During the period B, termination of pregnancy by means of cesarean section (25.3%) was higher than in normal pregnant women (11.2%) (p less than 0.001). After pregnancy, 13.2% of patients in period A and 39.1% in period B (p less than 0.01) complied with the evaluation of carbohydrate metabolism. Overall, 26.2% had carbohydrate intolerance and 5.9% diabetes mellitus. Although the creation of the Diabetes and Pregnancy Unit has provided a better care and follow-up of the diabetic pregnant women, has not resulted in significant differences in fetal mortality.