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Diagnóstico de la acromegalia.
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La acromegalia es una enfermedad crónica multisistémica de relativamente baja prevalencia cuyo diagnóstico y tra-tamiento debe de adecuarse a las realidades socioeco-nómicas locales. En 2004 se publicó en esta misma revis-ta la Guía para el Diagnóstico y Tratamiento de la Acromegalia, producto de un consenso que reunió a va-rios especialistas de to...
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... Therefore, the true probability of the disease among patients submitted to laboratory investigation is variable, with consequences on the predictive value of the tests. Using current assays and excluding known causes of GH suppression failure, nadir GH > 0.4 µg/L after oral glucose overload is indicative of autonomous GH secretion (5,7,8,11,[14][15][16][17]19,22,23,[25][26][27][28][29][30][31][32]). Using one of the algorithm traditionally recommended for the investigation of patients with clinical suspicion of acromegaly (Figure 1), the objective of this prospective study was to determine the frequency of indication of the GH suppression test and pituitary MRI and the probability of an equivocal diagnosis when GH concentrations > 0.4 µg/L despite normal serum IGF-1 are taken into consideration. ...
Objective:
To determine the frequency of indication of the GH suppression test and pituitary magnetic resonance imaging (MRI) in patients with clinical suspicion of acromegaly with GH concentrations > 0.4 µg/L despite normal serum IGF-1.
Subjects and methods:
A total of 160 patients with clinical suspicion of acromegaly with normal IGF-1 were studied.
Results:
Basal GH > 0.4 µg/L was observed in 70/88 women (79.5%). Nadir GH > 0.4 µg/L was found in 21/70 women (30%) and these patients were submitted to MRI, which revealed a microadenoma in 2/21 women (9.5%). In these two women, IGF-1 continued to be normal in subsequent measurements and no clinical progression has been observed so far (time of follow-up until now 4 years). Basal GH > 0.4 µg/L was seen in 33/72 men (45.8%). Nadir GH was < 0.4 µg/L in all of them.
Conclusions:
In patients with clinical suspicion of acromegaly, concern over GH concentration in the presence of normal IGF-1 results in the unwarranted complementary investigation in many cases, and even in possible equivocal diagnoses. It is only in exceptional cases that normal IGF-1 should not rule out acromegaly.
... A meeting held in Mexico City in 2007 led to expert panel recommendations on the management of acromegaly specifically in Latin America, and these were published in 2010 [16]. Guidelines have also been developed at the national level in Mexico and Brazil [17, 18]. All the latest versions of these guidelines and consensus statements generally recommend either surgery or, if there is a low probability of surgical cure, SSAs as primary therapy in acromegaly (seeFig. 1 for the algorithm developed by the Latin American Expert Panel [16] ). ...
Evidence-based treatment guidelines have undoubtedly advanced medical practice and supported optimal management of acromegaly, but their application may be hampered by limited access to the latest treatment options.
In this retrospective, narrative review, the authors revisited existing treatment guidelines for acromegaly in Latin America. These were considered in conjunction with published evidence chosen at the authors' discretion.
In a socially and economically diverse region, such as Latin America, any regional practice guidelines need to appreciate that recommended treatment options, such as surgery by expert pituitary surgical teams and drug therapies, especially somatostatin analogs, are often not available due to limited resources. In these instances, physicians may be obliged to apply less effective therapeutic options.
The current article looks at the practical aspects of acromegaly management in Latin America and discusses this in the context of existing guidelines. Furthermore, we consider potential strategies to make better use of resources through combination and multimodal approaches to treatment.
... Although this test may be sufficient to establish the diagnosis in some centers, if a greater certainty is desired, GH measurement is further recommended in response to an oral glucose tolerance test (OGTT) (75 g) [13–16]. Under normal conditions, with this carbohydrate load, it is expected that GH production will be suppressed to levels <1 ng/mL, although recent “ultrasensitive” assays for GH detection estimate that normal suppression should be <0.4 ng/mL [5, 10, 11, 14, 17, 18]. ...
... Of all primary tumors of the pituitary, between 15, and 20% are GH-secretors. When untreated, acromegalic patients have a high morbidity and mortality because patients with the disease have a decreased life expectancy by at least 10 years when compared with the general population [1, 5, 10]. Causes of death are particularly due to cardiovascular and respiratory problems and to the increased risk of neoplasms. ...
... Patients considered to be in remission shall be followed biochemically (IGF-1 and GH post-OGTT) annually for 5 years [5, 10]. Performing serial MRI is not indicated unless there are data of new visual deficit or evidence of residual tumor in control studies. ...
Acromegaly is a complex disease that requires the intervention of a multidisciplinary team. The most frequent clinical manifestations are growing of distal parts of the body and some areas of the face. Patients may also present arterial hypertension, diabetes mellitus, colonic polyps, cardiomegaly, neurological and endocrine changes secondary to the presence of a GH-secreting tumor in pituitary or extrapituitary origin, or eutopic hypothalamic GHRH hypersecretion and peripheral GHRH hypersecretion.
Surgery is the first treatment used for most patients, regardless of the cause. In the great majority of cases, pituitary tumor can be removed through a transsphenoidal approach. Craniotomy is reserved for those cases with giant tumors, particularly when they grow toward the middle or posterior cranial fossa. Best surgical results are obtained when the tumor is confined into the sella turcica or if it has a regular suprasellar extension. When the disease cannot be controlled with surgery, medical treatment is indicated. Somatostatin analogues are included as the first line of medication, followed by dopamine agonist and growth hormone receptors antagonists. Radiation therapy can be also indicated in two main forms for residual tumor with medically refractory patients: radiosurgery for small tumors or fractionated stereotactic radiotherapy for larger ones.
... 45 Si ninguno de estos dos parámetros se cumple, se deberá realizar una supresión de hormona de crecimiento con carga oral de glucosa de 75 g; si la hormona de crecimiento no se suprime a menos de 1 µg/l por RIA o a menos de 0.3 µg/l por inmunoensayo ultrasensible, el diagnóstico de acromegalia queda confirmado. 42 ...
Introducción l rápido avance en técnicas de imagen como la tomo-grafía axial computarizada y la resonancia magnética han propiciado el hallazgo incidental de lesiones asintomáti-cas en diversos órganos, 1,2 que implican un desafío desde el punto de vista del abordaje y tratamiento de los pacientes con este tipo de lesiones. 3,4 Es así como surge el término inciden-taloma para referirse a lesiones encontradas al realizar estu-dios rutinarios o con propósitos diferentes a la evaluación ex profeso de un órgano. 5,6 Las glándulas endocrinas en especial las suprarrenales, la tiroides y la hipófisis son particular asiento de estas lesiones. 1,2 Este artículo pretende revisar el abordaje del incidentaloma hipofisario haciendo énfasis en los aspectos de tratamiento y toma de decisiones. Actualmente, el incidentaloma hipofisario representa un dilema para el clínico y para el neurocirujano en el que es necesario equilibrar aspectos de riesgo-beneficio y de costo-efectividad 7 en cuanto al uso de métodos diagnósticos y terapéuticos. Por lo anterior, resulta imperioso conocer la historia natural de esta condición 4,6,8 y desarrollar estrategias de manejo multidisciplinario. Recibido en su versión modificada: 6 de junio de 2007 Aceptado: 8 de junio de 2007 RESUMEN El rápido desarrollo y la gran precisión en las técnicas de imagen han fomentado el hallazgo incidental de lesiones asintomáticas de la hipófisis que imponen un reto de manejo tanto para el clínico como para el neurocirujano. Estas masas llamadas incidentalomas se encuentran en cerca de 10% de las resonancias magnéticas realizadas en individuos sanos. Hasta ahora no se conoce con exactitud la historia natural de estas lesiones. Algunas no se modifican con el tiempo, e incluso disminuyen espontáneamente de tamaño, mientras que otras tienen el riesgo de aumentar de volumen y producir síntomas por efectos de masa o hipersecreción hormonal. Esta revisión pretende dar a conocer el consenso actual en cuanto a las estrategias diagnósticas y terapéuticas en el paciente con incidentaloma hipofisario. Se hace énfasis en los factores, ya sea clínicos, bioquímico-hormonales o imagenológicos, que por sí mis-mos sugieren un alto riesgo de crecimiento tumoral.
Objective
To study the impact of secondary mental disorders in patients affected with acromegaly and correlate them with quality of life (QoL) and disease status.
Design
An observational transversal descriptive and comparative study that evaluates QoL's impact due to secondary mental disorders in affected Mexicans with acromegaly using AcroQoL and SF‐36 instruments. Correlation of the results with the disease's biochemical status was performed. According to Beck's scales, anxiety and depression analyses evaluate QoL's impact, and its gender variability is described.
Results
Eighty‐five patients with diagnoses of acromegaly were included. The mean age was 43.18 years, 47 being women (55.29%). The mean age at diagnosis was 37.95 years, with no difference between men and women. AcroQoL and SF‐36 global and sub‐domain scores differed significantly between men and women, the latter having lower global and individual sub‐domain scores. The mean score of QoL, according to AcroQoL, is 59.40. In women, the mean values are less (55.13) than men (64.68), p = 0.021. The sub‐domain analyses’ scores in physical, appearance and social relationships were less in women (53.21; 47.34; 62.32) than men (62.68; 56.76; 73.87) p = 0.044, 0.069 and 0.013, respectively. Higher Beck's Depression Inventory (BDI) and Beck's Anxiety Inventory (BAI) scores correlated with lower QoL as assessed by global and individual sub‐domain scores. Women presented significantly higher BDI and BAI mean scores when compared to men regardless of their biochemical status. Anxiety ( p = 0.027) and depression ( p < 0.001) severity were higher in women compared to men.
Conclusion
Correlations between female gender, depression/anxiety scores and QoL require further validation. There is much to be routinely done to improve secondary psychopathology in patients affected by this disease. The need for mental status screening at diagnosis should be emphasized to identify secondary mental illnesses to improve QoL with its treatment.
Acromegaly is a rare condition characterized by the excessive secretion of growth hormone (GH), usually by a pituitary adenoma. The clinical manifestations of acromegaly include enlarged hands, feet and face, headaches, arthralgias, fatigue and hyperhydrosis. This condition is also associated with comorbidities such as hypertension and diabetes in a significant proportion of patients and frequently compromises life quality and life expectancy. The biochemical diagnosis of acromegaly rests on the demonstration of an autonomous secretion of GH by means of the measurement of glucose-suppressed GH levels and the serum concentration of insulin like growth factor type 1 (IGF-1). The localizing method of choice is magnetic resonance image of the selar area, which in 70 % of the cases reveals the presence of a macroadenoma. Even though the primary treatment is usually the transsphenoidal resection of the adenoma, the majority of patients require a multimodal intervention that includes radiotherapy, as well as pharmacological therapy with somatostatin analogs and dopamine agonists. The latter approach has resulted in a significant reduction in mortality and in an improvement in the quality of life.
Objective:
To determine the value of acromegaly screening in adult patients not reporting enlargement of the extremities, but who present arterial hypertension associated with at least one other comorbidity of the disease.
Subjects and methods:
Patients seen by general practitioners at primary health care units were evaluated. Among the patients without extremity enlargement, those with recently diagnosed arterial hypertension associated with at least one other comorbidity were selected.
Results:
A total of 1,209 patients were submitted to laboratory investigation. Elevated IGF-1 was observed in 22 patients. Eighteen patients had adequate suppression of growth hormone (GH). No GH suppression was observed in four women with confirmed elevated IGF-1. In the latter, IGF-1 and nadir GH were only slightly elevated, magnetic resonance showed a normal pituitary, and chest and abdominal computed tomography revealed no tumor, and no intervention was performed.
Conclusion:
In patients with arterial hypertension without known pituitary disease, acromegaly is unlikely in the absence of enlargement of the extremities.
The purpose of this study was to evaluate the safety of the oral glucose tolerance test (OGTT) and its capacity to suppress growth hormone (GH) in diabetic patients without acromegaly. A total of 135 diabetic patients submitted to the OGTT for GH suppression were studied. The following selection criteria were applied: age between 20 and 70 years; body mass index ≥18.5 and ≤27 kg/m(2); absence of kidney, liver, or thyroid disease; no use of estrogens, androgens, corticosteroids, or levothyroxine. Adequate suppression of GH was defined as a nadir below the cut-off established for a sample of 200 normoglycemic subjects (<0.25 µg/L for men, <0.74 µg/L for premenopausal women, and <0.5 µg/L for postmenopausal women). Acromegaly was diagnosed in five patients. Among the 130 diabetic patients without known pituitary disease or a clinical suspicion of acromegaly, 95.5 % of men, 94 % of premenopausal women, and 96.6 % of postmenopausal women presented adequate GH suppression (vs 97.5 % of normoglycemic controls). In all patients without acromegaly, the lowest GH levels (nadir) were achieved after the administration of glucose and not during baseline measurement. None of the patients had acute complications [ketoacidosis, hyperosmolar state, and symptomatic marked hyperglycemia (>300 mg/dL)] on the day of the test and up to 3 days thereafter. We demonstrated the safety of the OGTT and its capacity to suppress GH in diabetic patients without acromegaly. In addition, we suggest the adoption of a protocol to prevent possible risks of the OGTT in patients with diabetes.
