Mortality in Acromegaly Diagnosed in Older Individuals in Spain Is Higher in Women Compared to the General Spanish Population

CONTEXT

There are no data on mortality of acromegaly diagnosed in older individuals.

OBJECTIVE

This work aimed to compare clinical characteristics, growth hormone-related comorbidities, therapeutic approaches, and mortality rate of patients diagnosed before or after 2010 and to assess overall mortality rate compared with the general Spanish population.

METHODS

A retrospective evaluation was conducted among Spanish tertiary care centers of 118 patients diagnosed with acromegaly at age 65 or older. Kaplan-Meier curves were constructed to trace survival, and Cox proportional hazard models were used to assess the risk factors associated with mortality. We also compared mortality with that of the Spanish population by using age- and sex-adjusted standardized mortality ratios (SMRs).

RESULTS

No differences were found in first-line treatment or biochemical control, between both periods except for faster biochemical control after 2010. Twenty-nine (24.6%) patients died, without differences between groups, and had a median of follow-up 8.6 years (103, [72.3] months). Overall SMR was 1.02 (95% CI, 0.57-1.54), (0.60; 95% CI, 0.35-1.06) for men and (1.80; 95% CI, 1.07-2.94) for women. The most common cause of death was cardiovascular disease (CVD).

CONCLUSION

The mortality in patients with acromegaly diagnosed in older individuals was no different between both periods, and there was no overall SMR difference compared with the general Spanish population. However, the SMR was higher in women. As CVD is the leading cause of mortality, it seems advisable to initiate an intense CVD protective treatment as soon as acromegaly is diagnosed, particularly in women, in addition to tight acromegaly control to prevent excess mortality.

Factors associated with therapeutic response in acromegaly diagnosed in the elderly in Spain

CONTEXT

Some reports suggest that acromegaly in elderly patients has a more benign clinical behavior and could have a better response to first-generation long-acting somatostatin receptor ligands (SRL). However, there is no specific therapeutic protocol for this special subgroup of patients.

OBJECTIVE

This study aimed at identifying predictors of response to SRL in elderly patients.

DESIGN

Multicentric retrospective nationwide study of patients diagnosed with acromegaly at or over the age of 65 years.

RESULTS

One-hundred and eighteen patients (34 men, 84 women, mean age at diagnosis 71.7 ± 5.4 years old) were included. Basal insulin-like growth factor type 1 (IGF-1) above the upper limit of normal (ULN) and growth hormone (GH) levels (mean ± SD) were 2.7 ± 1.4 and 11.0 ± 11.9 ng/ml, respectively. The mean maximal tumor diameter was 12.3 ± 6.4 mm, and up to 68.6% were macroadenoma. Seventy-two out of 118 patients (61.0%) underwent surgery as primary treatment. One-third of patients required first-line medical treatment due to a rejection of surgical treatment or non-suitability because of high surgical risk. After first-line surgery, 45/72 (63.9%) were in disease remission, and 16/34 (46.7%) of those treated with SRL had controlled disease. Patients with basal GH at diagnosis ≤6 ng/ml had lower IGF-1 levels and had smaller tumors, and more patients in this group reached control with SRL (72.7% vs. 33.3%; p < 0.04) [OR: 21.3, IC: 95% (2.4-91.1)], while male patients had a worse response [OR: 0.09, IC 95% (0.01-0.75)]. The predictive model curve obtained for SRL response showed an AUC of 0.82 CI (0.71-0.94).

CONCLUSIONS

The most frequent phenotype in newly diagnosed acromegaly in the elderly includes small adenomas and moderately high IGF-1 levels. GH at diagnosis ≤6 ng/ml and female gender, but not age per se, were associated with a greater chance of response to SRL.

Craniopharyngioma in the Elderly: A Multicenter and Nationwide Study in Spain

BACKGROUND

Craniopharyngioma (CP) is a rare tumor in the elderly whose clinical features and prognosis are not well known in this population.

AIM

To evaluate the clinicopathological features and therapeutic outcomes of CP diagnosed in the elderly.

PATIENTS AND METHODS

This was a retrospective, multicenter, national study of CP patients diagnosed over the age of 65 years and surgically treated.

RESULTS

From a total of 384 adult CP patients, we selected 53 (13.8%) patients (27 women [50.9%], mean age 72.3 ± 5.1 years [range 65-83 years]) diagnosed after the age of 65 years. The most common clinical symptoms were visual field defects (71.2%) followed by headache (45.3%). The maximum tumor diameter was 2.9 ± 1.1 cm. In most patients, the tumor was suprasellar (96.2%) and mixed (solid-cystic) (58.5%). The surgical approach most commonly used was transcranial surgery (52.8%), and more than half of the patients (54.7%) underwent subtotal resection (STR). Adamantinomatous CP and papillary CP were present in 51 and 45.1%, respectively, with mixed forms in the remaining. Surgery was accompanied by an improvement in visual field defects and in headaches; however, pituitary hormonal hypofunction increased, mainly at the expense of an increase in the prevalence of diabetes insipidus (DI) (from 3.9 to 69.2%). Near-total resection (NTR) was associated with a higher prevalence of DI compared with subtotal resection (87.5 vs. 53.6%, p = 0.008). Patients were followed for 46.7 ± 40.8 months. The mortality rate was 39.6% with a median survival time of 88 (95% CI: 57-118) months. DI at last visit was associated with a lower survival.

CONCLUSION

CP diagnosed in the elderly shows a similar distribution by sex and histologic forms than that diagnosed at younger ages. At presentation, visual field alterations and headaches are the main clinical symptoms which improve substantially with surgery. However, surgery, mainly NTR, is accompanied by worsening of pituitary function, especially DI, which seems to be a predictor of mortality in this population.

Efficacy of sodium glucose cotransporter 2 inhibitors as an adjunct treatment for patients with diabetes type 2

OBJECTIVE

To analyze the effect of sodium glucose cotransporter 2 (SGLT2) inhibitors in a group of insulin-dependent type 2 diabetes mellitus (T2D) patients.

PATIENTS AND METHODS

One hundred and five insulin treated T2D patients were enrolled. Primary endpoints were: fasting plasma glucose, HbA1c, weight, total insulin doses (TDI), total basal insulin (TDB) and total rapid insulin (TDR). Secondary variables were: total cholesterol, LDL cholesterol (cLDL), HDL cholesterol (cHDL), triglycerides and systolic (SBP) and diastolic (DBP) blood pressure. Safety and tolerance were evaluated through the appearance of severe hypoglycemia, ketoacidosis and infections.

RESULTS

After 4 months follow-up, a 0.7 (1.0)% HbA1c reduction was found, accompanied by a -2.8 (11.5) UI/day TDI decrease. Weight dropped for 73.7% of patients, with an average -2.0 (2.7) kg reduction. A global cHDL increase was noted after treatment, while no differences were observed for total cholesterol, triglycerides or cLDL. SBP dropped significantly, but no change in DBP was observed.

CONCLUSION

The use of SGLT2 inhibitors in insulin treated T2D patients resulted in reduction of HbA1c, which was associated to weight loss, cHDL increase and SBP decrease.

Mortality risk in adults according to categories of impaired glucose metabolism after 18 years of follow-up in the North of Spain: The Asturias Study

People who develop type 2 diabetes (T2D) are known to have a higher mortality risk. We estimated all-cause, cardiovascular, and cancer mortality-risks in our patient cohort according to categories of impaired glucose metabolism. This 18-year retrospective analysis included a region-wide, representative sample of a population aged 30-75 years. Age- and sex-stratified hazard ratios (HRs) were calculated for 48 participants with diagnosed T2D, 83 with undiagnosed T2D (HbA1c ≥6.5%, fasting glycemia ≥126 mg/dL, or glycemia after 75 g glucose load ≥200 mg/dL); 296 with prediabetes (HbA1c 5.7%-6.4%, fasting glycemia 100-125 mg/dL, or glycemia after 75 g glucose load 140-199 mg/dL), and 607 with normoglycemia. Over 18,612 person-years, 32 individuals with undiagnosed T2D, 30 with diagnosed T2D, 62 with prediabetes, and 80 with normoglycemia died. Total sample crude mortality rate (MR) was 10.96 deaths per 1,000 person-years of follow-up. MR of the diagnosed T2D group was more than 3-times higher and that of newly diagnosed T2D was 2-times higher (34.72 and 21.42, respectively) than total sample MR. Adjusted HR for all-cause mortality was 2.02 (95% confidence interval 1.29-3.16) and 1.57 (95% CI 1.00-2.28) in the diagnosed T2D group and the newly diagnosed T2D group, respectively. Adjusted HR for cardiovascular mortality in the T2D group was 2.79 (95% CI 1.35-5.75); this risk was greatly increased in women with T2D: 6.72 (95% CI 2.50-18.07). In Asturias, age- and sex-standardized all-cause mortality is more than 2-times higher for adults with T2D than for adults without T2D. The HR for cardiovascular mortality is considerably higher in T2D women than in normoglycemic women.

Experience after switching from insulin glargine U100 to glargine U300 in patients with type 1 diabetes mellitus. A study after one year of treatment in real life

INTRODUCTION

Current treatment of type 1 diabetes mellitus (T1DM) does not always achieve metabolic control because, among other things, the ocurrence of hypoglycemic events associated to insulin use.

MATERIAL AND METHODS

A descriptive real life study of 247 T1DM patients, 55.5% male, aged 46.53 ± 16.23 years, and with a mean diabetes duration of 21.89 ± 11.99 years, who were switched from basal insulin glargine U100 to glargine U300. The primary endpoints were changes in Hba1c and number of hypoglycemic events, while secondary endpoints included changes in weight and insulin dose after 6 and 12 months.

RESULTS

After one year, no changes were seen in HbA1c, but the proportion of patients with HbA1c values <7.5% increased at 6 months (33.5 vs. 40.5%; P<0.05) and remained stable during one year of follow-up. Hypoglycemic events significantly decreased after one year of treatment in patients with previous hypoglycemic events. No changes were seen in body weight. Total insulin dose (U/kg) increased 7.24% at 6 months of treatment and by 8.69% at one year, mainly due to basal insulin. No changes were seen between the doses given at 6 and 12 months. These changes were similar in the different metabolic control groups and in patients with or without hypoglycemia. This increase was not related with prior basal insulin dose, baseline HbA1c level, number of hypoglycemic events or baseline weight.

DISCUSSION

Glargine U300 is a good basal insulin alternative to treat T1DM, improving metabolic control in patients with HbA1c levels >7,5 and decreasing hypoglycemic events in patients with history of hypoglycemia without increasing body weight.

Gestational Diabetes Mellitus (GDM): Relationship Between Higher Cutoff Values for 100 g Oral Glucose Tolerance Test (OGTT) and Insulin Requirement During Pregnancy

Objectives To study if there is any relationship about higher cutoff values for 100 g oral glucose tolerance test and the need for insulin in women diagnosed with gestational diabetes. Materials and Methods This is a retrospective population-based study of 201 women diagnosed with Gestational Diabetes Mellitus (GDM) between January 2012 and June 2014 in the area of Oviedo, Asturias, Spain. According to diagnostic criteria recommended by GEDE, NDDG, gestational diabetes is diagnosed if two or more plasma glucose levels meet or exceed the following threshold: fasting glucose of 105 mg/dl, 1-h 190 mg/dl, 2-h 165 mg/dl, or 3-h 145 mg/dl. We aim to know if there is any relationship between higher cutoffs and insulin requirement. Results 36 out of 201 patients (17.91%) needed insulin to achieve the targets of blood glucose control. There were no differences in mean maternal age and birthweights. Fasting blood glucose levels were significantly higher in women with further need for insulin than those who only needed diet and exercise (p < 0.001). Also, blood glucose levels 2 h after the oral glucose intake were statistically different between the two groups (p 0.032). AUC for fasting glucose value was the highest according to ROC curve. Conclusions Fasting cutoff vales for 100 g oral glucose tolerance test are consistently higher in women diagnosed with Gestational Diabetes that further needed insulin to achieve adequate blood glucose control. The positive predictive value of fasting glucose value 105 mg/dl on OGTT was 81.1%, whereas for the cut-off 95 mg/dl it was 54.0%.

Who Discovered the Binary System and Arithmetic? Did Leibniz Plagiarize Caramuel?

Gottfried Wilhelm Leibniz (1646-1716) is the self-proclaimed inventor of the binary system and is considered as such by most historians of mathematics and/or mathematicians. Really though, we owe the groundwork of today's computing not to Leibniz but to the Englishman Thomas Harriot and the Spaniard Juan Caramuel de Lobkowitz (1606-1682), whom Leibniz plagiarized. This plagiarism has been identified on the basis of several facts: Caramuel's work on the binary system is earlier than Leibniz's, Leibniz was acquainted-both directly and indirectly-with Caramuel's work and Leibniz had a natural tendency to plagiarize scientific works.

Altered intragenic DNA methylation of HOOK2 gene in adipose tissue from individuals with obesity and type 2 diabetes

Aims/Hypothesis

Failure in glucose response to insulin is a common pathology associated with obesity. In this study, we analyzed the genome wide DNA methylation profile of visceral adipose tissue (VAT) samples in a population of individuals with obesity and assessed whether differential methylation profiles are associated with the presence of type 2 diabetes (T2D).

Methods

More than 485,000 CpG genome sites from VAT samples from women with obesity undergoing gastric bypass (n = 18), and classified as suffering from type 2 diabetes (T2D) or not (no type 2 diabetes, NT2D), were analyzed using DNA methylation arrays.

Results

We found significant differential methylation between T2D and NT2D samples in 24 CpGs that map with sixteen genes, one of which, HOOK2, demonstrated a significant correlation between differentially hypermethylated regions on the gene body and the presence of type 2 diabetes. This was validated by pyrosequencing in a population of 91 samples from both males and females with obesity. Furthermore, when these results were analyzed by gender, female T2D samples were found hypermethylated at the cg04657146-region and the cg 11738485-region of HOOK2 gene, whilst, interestingly, male samples were found hypomethylated in this latter region.

Conclusion

The differential methylation profile of the HOOK2 gene in individuals with T2D and obesity might be related to the attendant T2D, but further studies are required to identify the potential role of HOOK2 gene in T2D disease. The finding of gender differences in T2D methylation of HOOK2 also warrants further investigation.

[Chylous asctites post abdominal laparotomy; revision and report of a case]

We describe the case of a 23 year old man who had undergone laparoscopic surgery in order to remove a residual mass secondary to a testicular embryonal carcinoma. 15 days after he attended the emergency department complaining about abdominal bloating and copious drainage via the two laparoscopic surgery incisions. Biochemical analysis was consistent with chylous ascites. Although this is uncommon, it is well known that there is more likely to develop chylous ascites after oncologic surgery if retroperitoneal lymph nodes dissection is performed1. We decide to start with conservative treatment (dietary modifications) but, as it is not enough, then we decide stop any oral intake and treat him with parenteral nutrition, achieving then total resolution of the ascites.

Repair of erosions in patients with rheumatoid arthritis treated with etanercept: magnetic resonance imaging findings after 1 year of follow-up

OBJECTIVES

To monitor repair of bone erosions using magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA) during etanercept combination therapy.

METHOD

The study population comprised 29 RA patients [biologic-naïve, 28-joint Disease Activity Score (DAS28) ≥ 3.2] starting etanercept combination therapy with disease-modifying anti-rheumatic drugs (DMARDs) and completing the 1-year study period with the same treatment. Clinical and laboratory assessments and MRI of the hand were performed at baseline and at 1 year. MRI findings were scored by two readers using the Rheumatoid Arthritis MRI Scoring System (RAMRIS). Both readers were blind to the chronological order of the MRI scans, the identity of the patients, and clinical and other imaging data. Tenosynovitis was also scored. The intra- and inter-reader intraclass correlation coefficients (ICCs) were calculated, along with the sensitivity to change with the smallest detectable difference (SDD). Repair of erosions was defined as a RAMRIS score of at least 1 point lower than baseline.

RESULTS

The mean RAMRIS score for erosions did not change but all other inflammatory MRI parameters decreased significantly. In 19 patients, the RAMRIS score for erosions remained unchanged after 1 year. In five patients the score decreased after 1 year, although the decrease exceeded the SDD in only one patient (3.4%).

CONCLUSIONS

Etanercept combined with DMARDs stopped the progression of erosions, as measured by the RAMRIS, in 82.8% of our RA patients and occasional repair of bone erosions occurred after 1 year of treatment.

Development of a web-based support system for both homogeneous and heterogeneous air quality control networks: process and product

The Environmental Laboratories Automation Software System or PALMA (Spanish abbreviation) was developed by a multidisciplinary team in order to support the main tasks of heterogeneous air quality control networks. The software process for PALMA development, which can be perfectly applied to similar multidisciplinary projects, was (a) well-defined, (b) arranged between environmental technicians and informatics, (c) based on quality guides, and (d) clearly user-centred. Moreover, it introduces some interesting advantages with regard to the classical step-by-step approaches. PALMA is a web-based system that allows 'off-line' and automated telematic data acquisition from distributed inmission stations belonging not only to homogeneous but also to heterogeneous air quality control networks. It provides graphic and tabular representations for a comprehensive and centralised analysis of acquired data, and considers the daily work that is associated with such networks: validation of the acquired data, alerts with regard to (periodical) tasks (e.g., analysers verification), downloading of files with environmental information (e.g., dust forecasts), etc. The implantation of PALMA has provided qualitative and quantitative improvements in the work performed by the people in charge of the considered control network.

Minimum variance centroid thresholding

Image-processing thresholding algorithms are extended segmentation tools that are suitable for tracking applications. The centroid of the tracked image distribution is a good point of reference for the location of the image. We describe a new thresholding technique that is based on the estimation of the optimum threshold for achieving minimal variance in the centroid of the processed image. Experimental proofs for evaluating the technique's performance are given. The direct extension of these results to Shack-Hartmann wave-front sensors is also shown.

Effective noise in thresholded intensity distribution: influence on centroid statistics

It is usual to preprocess data before reduction, but it is not so common to study how this operation affects the final results. Determination of the centroid is a relevant task for many optical measurement devices, and the centroid is very often calculated over thresholded data. The influence of preprocessing thresholding algorithms on the statistical properties of intensity data affected by additive Gaussian noise is described as a different effective additive signal perturbation. Theoretical, simulated, and experimental analyses of the model of the effective noise were performed, and good agreement among the analyses was obtained. Direct extension of the analyses from the influence of preprocessing to centroid determination is also presented.

Position and displacement sensing with shack-hartmann wave-front sensors

The use of a Shack-Hartmann wave-front sensor as a position-sensing device is proposed and demonstrated. The coordinates of a pointlike object are determined from the modal Zernike coefficients of the wave fronts emitted by the object and detected by the sensor. The position of the luminous centroid of a moderately extended incoherent flat object can also be measured with this device. Experimental results with off-the-shelf CCD cameras and conventional relay optics as well as inexpensive diffractive microlens arrays show that axial positioning accuracies of 74 microm rms at 300 mm and angular accuracies of 4.3 microrad rms can easily be achieved.

Traumatic lung cyst

We report a patient with a traumatic lung cyst, documenting its radiological evolution: the formation of the pneumatocele, the appearance posteriorly of an intracavitary hematoma, and the spontaneous resolution of the radiological abnormalities.

Interaction of permanently uncharged dopamine analogs with the D-2 dopaminergic receptor

The purpose of this study was to determine if structural analogs of dopamine in which the side chain nitrogen has been replaced by a permanently uncharged monomethylsulfide, monomethylselenide or sulfoxide group are capable of binding to the striatal D-2 dopamine receptor and acting as agonists at this receptor. All the permanently uncharged dopamine analogs were found to bind to the D-2 dopamine receptor as evidenced by their abilities to inhibit significantly [3H]spiperone binding to striatal homogenates. However, the inhibition of [3H]spiperone binding by the uncharged dopamine analogs was incomplete and was almost abolished by the addition of NaCl (125 mM) to the incubation medium or by the addition of dopamine or quinpirole at a concentration that that saturates the high-affinity state of the D-2 dopamine receptor. These effects of NaCl, dopamine and quinpirole suggest that the uncharged dopamine analogs bind primarily to the high-affinity state of the D-2 dopamine receptor. Whether the uncharged monomethylsulfide and sulfoxide analogs could function as dopamine agonists at the striatal D-2 dopamine receptor was assessed by determining the abilities of these compounds to inhibit the K+-evoked release of [3H]acetylcholine from striatal slices. Both the monomethylsulfide and sulfoxide analogs inhibited the K+-evoked release of [3H]acetylcholine, but this inhibitory effect does not appear to be due to the activation of the D-2 dopamine receptor since it was not reversed by the selective D-2 dopamine antagonist, sulpiride. Additionally, the uncharged monomethylsulfide and sulfoxide dopamine analogs were found to antagonize the ability of apomorphine to inhibit the K+-evoked release of [3H]acetylcholine, but this antagonistic effect does not appear to be due to the reversible blockade of the D-2 dopamine receptor since it was not reduced by increasing the concentration of apomorphine. Therefore, while the permanently uncharged analogs of dopamine appear to bind to the high-affinity state of the D-2 dopamine receptor, they are not dopamine agonists or antagonists at the striatal D-2 dopamine receptor involved in regulating the release of acetylcholine. These results suggest that a positive charge may be a requirement for the activation of the striatal D-2 dopamine receptor.

Interaction of permanently charged analogs of dopamine with the D-2 dopaminergic receptor

Dopamine can exist in both charged and uncharged forms at physiological pH. At present it is unclear which of these forms is responsible for dopaminergic agonist activity. The purpose of this study was to determine whether permanently charged structural analogs of dopamine containing either a nitrogen, sulfur, or selenium atom in the side chain can bind to and activate the D-2 dopamine receptor. Binding to and activation of the D-2 dopamine receptor were measured by determining the abilities of the permanently charged dopamine analogs to inhibit [3H]spiperone binding to striatal homogenates and to inhibit K+-stimulated [3H]acetylcholine release from striatal slices respectively. The quaternary ammonium, dimethylsulfonium and dimethylselenonium analogs of dopamine were all found to inhibit [3H]spiperone binding to the same extent and in a manner qualitatively similar to the parent amines, dopamine and dimethyldopamine. Thus, [3H]spiperone inhibition curves for dopamine, dimethyldopamine and the permanently charged dopamine analogs were generally shallow and fit best to a two-site binding model as indicated by computer-assisted analyses. The addition of 125 mM NaCl to the incubation medium resulted in a significant decrease in the proportion of high affinity binding sites for both the permanently charged analogs and the parent amines. Similarly, the permanently charged dopamine analogs were found to maximally inhibit the K+-stimulated release of [3H]acetylcholine to the same extent as dopamine and dimethyldopamine. However, the permanently charged analogs were less potent in inhibiting both [3H]spiperone binding and K+-stimulated [3H]acetylcholine release than dopamine and dimethyldopamine. These results show that dopamine analogs possessing a permanent positive charge in the side chain can bind to and activate the D-2 dopamine receptor. The lower potencies of the permanently charged analogs in binding to and activation of the D-2 dopamine receptor suggest that, while the ability of a compound to exist in an uncharged form is not a requirement, both charged and uncharged forms of the agonist molecule appear to play a role in D-2 dopamine agonist activity.

Dopamine agonists: effects of charged and uncharged analogues of dopamine

Dopamine, at physiological pH, may exist as either an uncharged amine or a charged ammonium species. In order to gain insight as to which species is better suited for interaction with the dopamine receptor, we have synthesized dopamine analogues in which the nitrogen atom is replaced with a neutral methyl sulfide, a neutral methyl selenide, a charged dimethylsulfonium iodide, and a charged dimethylselenonium iodide. These analogues were tested for their ability to inhibit the K+-stimulated release of [3H]acetylcholine from striatal slices. At 30 microM concentration, the charged sulfonium and selenonium salts possessed significant agonist activity while the corresponding neutral species were inactive, suggesting that a charged species is optimal for dopamine agonist activity. In addition, the methyl sulfide was converted into the corresponding sulfoxide and sulfone; however, neither of these oxidation products possessed significant activity as dopaminergic agonists.