Relevancia de la nutrición artificial domiciliaria: incidencia, características e impacto económico en el área sanitaria de Santiago de Compostela

Programa Oficial de Doutoramento en Ciencias da Saúde. 5007V01[Resumen] INTRODUCCIÓN La desnutrición representa un problema grave de salud pública, por su frecuencia, morbimortalidad e implicaciones socioeconómicas. En las últimas décadas, una de las estrategias para combatir este problema ha sido el desarrollo de la nutrición artificial, especialmente domiciliaria (NAD). A pesar del crecimiento de la NAD existe una notable carencia de información, que se explicaría tanto por la ausencia de registros de NAD obligatorios, como por las grandes diferencias en su organización en los distintos países o regiones. El objetivo del presente estudio fue evaluar la situación de la NAD en nuestra área sanitaria en cuanto a su incidencia, características o impacto económico y elaborar un proyecto de mejora. MÉTODOS Se diseñó un estudio observacional y prospectivo con una duración de 2 años, que incluyó a todos los pacientes que iniciaron NAD en el Servicio de Endocrinología y Nutrición en un año (del 15 de Octubre de 2009 hasta el 14 de Octubre de 2010). Además de la recogida de datos basales de los pacientes, se realizó un seguimiento durante al menos otro año (hasta el 15 de Octubre de 2011), evaluando la evolución epidemiológica, funcional y nutricional de los enfermos. Para el cálculo de la incidencia de la NAD en el área se tuvieron en consideración también los pacientes con NAD prescrita por otros servicios. Finalmente, realizamos una estimación del gasto en NAD en el período de estudio. RESULTADOS La incidencia de NAD calculada en nuestra área ascendió a 229 casos/100.000 habitantes/año. La población en tratamiento con NAD en nuestro medio se caracteriza por un marcado envejecimiento (78,6% de los pacientes ≥65 años) y una alta frecuencia de polimedicación, pluripatología y limitación funcional (80%). Un tercio de los pacientes precisaba cuidador, aunque la sobrecarga generada por la NAD en estos cuidadores fue baja (más de la mitad no presentaban sobrecarga). Las indicaciones habituales (patología neurológica y oncológica) representaron el 50%. El resto de casos correspondieron a ancianos malnutridos que recibieron períodos cortos de NAD tras un ingreso hospitalario o en el perioperatorio de fractura de cadera. Los suplementos por vía oral (60%) y las fórmulas estándar e hipercalóricas fueron los más empleados. El porcentaje de gastrostomías fue llamativamente bajo (5% al inicio y 12% al final). Al inicio el 75% de los pacientes presentaban desnutrición, principalmente proteica o mixta. Durante el seguimiento se logró una ganancia de peso de 1,6 Kg, un aumento en el porcentaje de pacientes con normo/sobrepeso (del 74% al 82,7%; p=0,001) y una reducción en el porcentaje de úlceras por presión (15,7% vs 10,3%, p<0,001). La mediana de la duración de la NAD fue de 8,5 meses y sólo una cuarta parte experimentó alguna complicación, siendo la mayoría gastrointestinales y leves. El índice de ingresos por complicaciones de la NAD fue de 0,083 episodios/paciente/año. El 56,8% de los pacientes habían fallecido al final del período de estudio. El gasto estimado en NAD fue de 3,65 euros/día (NAD oral) y 8,86 euros/día (NAD por sonda/ostomía). El gasto diario por 1.000 Kcal de dieta fue superior en la NAD oral que en los pacientes con sondas (5,13 euros vs 4,52 euros, p<0,001). El gasto por tratamiento completo finalizado se calculó en 186,60 euros en NAD oral y 531,99 euros en NAD por sonda. El gasto total estimado en todos los pacientes que iniciaron NAD en el período de estudio rondaría el millón de euros. CONCLUSIONES La NAD en el área de Santiago presenta una incidencia muy superior a la descrita en la literatura. Es una terapia segura, con escasas complicaciones que permite mejorar el estado nutricional de los pacientes, incluso con períodos cortos de administración. El gasto estimado diario se sitúa por debajo de lo reflejado en otros estudios, probablemente por la elevada frecuencia de NAD oral, respecto a otros registros. En base a las limitaciones detectadas, se ha propuesto un proyecto de mejora que incluiría medidas para aumentar la detección de la desnutrición, favorecer la coordinación entre los servicios prescriptores de NAD, la Farmacia Hospitalaria y Atención Primaria, protocolizar la información entregada al paciente con NAD, aumentar el porcentaje de gastrostomías e introducir indicadores de calidad.[Resumo] INTRODUCCIÓN A desnutrición representa un problema grave de saúde pública, pola súa frecuencia, morbimortalidade e implicacións socioeconómicas. Nas últimas décadas, unha das estratexias para combater este problema foi o desenvolvemento da nutrición artificial, especialmente domiciliaria (NAD). A pesar do crecemento da NAD existe unha notable carencia de información, que se explicaría tanto pola ausencia de rexistros de NAD obrigatorios, coma polas grandes diferenzas na súa organización nos distintos países ou rexións. O obxectivo do presente estudo foi avaliar a situación da NAD na nosa área sanitaria en canto á súa incidencia, características ou impacto económico e elaborar un proxecto de mellora. MÉTODOS Deseñouse un estudo observacional e prospectivo cunha duración de 2 anos, que incluíu a todos os doentes que iniciaron NAD no Servizo de Endocrinoloxía e Nutrición nun ano (do 15 de Outubro de 2009 ata o 14 de Outubro de 2010). Ademais da recollida de datos basais dos doentes, realizouse un seguimento durante polo menos outro ano (ata o 15 de Outubro de 2011), avaliando a evolución epidemiolóxica, funcional e nutricional dos enfermos. Para o cálculo da incidencia da NAD na área tivéronse en consideración tamén os doentes con NAD prescrita por outros servizos. Finalmente, realizamos unha estimación do gasto en NAD no período de estudo. RESULTADOS A incidencia de NAD calculada na nosa área ascendeu a 229 casos/100.000 habitantes/ano. A poboación en tratamento con NAD no noso medio caracterízase por un marcado envellecemento (78,6% dos pacientes ≥65 anos) e unha alta frecuencia de polimedicación, pluripatoloxía e limitación funcional (80%). Un terzo dos doentes precisaba coidador, aínda que a sobrecarga xerada pola NAD nestes coidadores foi baixa (máis da metade non presentaban sobrecarga). As indicacións habituais (patoloxía neurolóxica e oncolóxica) representaron o 50%. O resto de casos corresponderon a anciáns malnutridos que recibiron períodos curtos de NAD tras un ingreso hospitalario ou no perioperatorio de fractura de cadeira. Os suplementos por vía oral (60%) e as fórmulas estándar e enerxéticas foron os máis empregados. A porcentaxe de gastrostomías foi moi baixa (5% ao inicio e 12% ao final). No inicio o 75% dos doentes presentaban desnutrición, principalmente proteica ou mixta. Durante o seguimento logrouse unha ganancia de peso de 1,6 Kg, un aumento na porcentaxe de doentes con normo/sobrepeso (do 74% ao 82,7%; p=0,001) e unha redución na porcentaxe de úlceras por presión (15,7% vs 10,3%, p<0,001). A mediana de duración da NAD foi de 8,5 meses e só unha cuarta parte experimentou algunha complicación, sendo a maioría gastrointestinais e leves. O índice de ingresos por complicacións da NAD foi de 0,083 episodios/doente/ano. O 56,8% dos doentes faleceran ao final do período de estudo. O gasto estimado en NAD foi de 3,65 euros/día (NAD oral) e 8,86 euros/día (NAD por sonda/ostomía). O gasto diario por 1.000 Kcal de dieta foi superior na NAD oral que nos pacientes con sondas (5,13 euros vs 4,52 euros, p<0,001). O gasto por tratamento completo finalizado calculouse en 186,60 euros na NAD oral e 531,99 euros na NAD por sonda. O gasto total estimado en todos os pacientes que iniciaron NAD no período de estudo roldaría o millón de euros. CONCLUSIÓNS A NAD na área de Santiago presenta unha incidencia moi superior á descrita na literatura. É unha terapia segura, con escasas complicacións que permite mellorar o estado nutricional dos doentes, mesmo con períodos curtos de administración. O gasto diario sitúase por debaixo do reflectido noutros estudos, probablemente pola elevada frecuencia de NAD oral, respecto a outros rexistros. Sobre a base das limitacións detectadas, propúxose un proxecto de mellora que incluiría medidas para aumentar a detección da desnutrición, favorecer a coordinación entre os servizos que prescriben NAD, a Farmacia Hospitalaria e Atención Primaria, protocolizar a información entregada ao doente con NAD, aumentar a porcentaxe de gastrostomías e introducir indicadores de calidade.[Abstract] INTRODUCTION Malnutrition is a serious public health problem because its frequency, morbidity, and socioeconomic implications. The artificial nutrition field has developed over the past decades to fight this problem, especially home artificial nutrition (HAN). Despite the growing importance of HAN, there is still a notable lack of information, which can be explained both by the absence of obligatory registries and the large differences among HAN organizations in different countries or regions. The aims of this study were to assess the state of HAN in our health area, with regard to its incidence, characteristics, and economic impact, and to develop an improvement project. METHODS An observational, prospective, two-year study was designed that includes all patients who initiated HAN in the Nutrition Unit from October 15, 2009 until October 14, 2010. In addition to this baseline data collection, the patients were followed for at least another year (until October 15, 2011). During this follow-up, we evaluated the epidemiological, functional, and nutritional evolution of the patients. To calculate the incidence of HAN, we also considered the prescriptions in the other hospital departments. Finally, we estimated the economic burden of HAN during the study period. RESULTS The incidence of HAN in our area was 229 cases per 100,000 inhabitants per year. The HAN population in our area is characterized by the aged (78.6% of the patients ≥65 years) and a high frequency of polypharmacy, comorbidity, and functional limitations (80%). A third of these patients needed a caregiver; however, the caregiver burden associated to HAN was low (more than half of the patients had no burden). The usual indications (neurological and oncological diseases) accounted for 50% of the total. The remaining cases were malnourished patients who received short periods of HAN after hospitalization or a hip fracture. The oral supplements (60%) with standard and hypercaloric formulas were used the most. The percentage of gastrostomy was very low (5% at baseline and 12% at the end). At the baseline, 75% of the patients suffered from malnutrition, mainly protein or mixed. During the follow-up, our patients showed a weight gain of 1.6 kg, an increase in the percentage of normal weight and overweight (from 74% to 82.7%, p=0.001) and a reduction in pressure ulcers (15.7% vs. 10.3%, p <0.001). The median duration of HAN was 8.5 months. Only a quarter of the patients experienced complications, in most cases, gastrointestinal or mild complications. The admission rate for complications from HAN was 0.083 episodes per patient-year. Among study population, 56.8% died at the end of the follow-up. The estimated cost of HAN was 3.65 euros per day (oral HAN) and 8.86 euros per day (HAN by tube or ostomy). The daily expenditure per 1,000 kcal of diet was higher for the oral HAN than for patients with tubes (5.13 vs. 4.52 euros, p <0.001). The complete treatment cost was estimated at 186.60 euros and 531.99 euros for oral and tube HAN, respectively. The total estimated cost for all patients who initiated HAN in the study period was around one million euros. CONCLUSIONS In our health area, the incidence of HAN is much higher than is described in the literature. HAN appears to be a safe therapy with few complications that improves the nutritional status of the patients, even with short periods of administration. The estimated daily cost is lower than the costs reported in other registries, probably because of the high frequency of oral HAN that we found. However, the study identified some limitations in our practice. We propose an improvement project that would include measures to increase malnutrition screening; promote coordination among HAN prescribing departments, hospital pharmacy, and primary care; protocolized the information given to patients with HAN; increase the percentage of gastrostomies; and introduce quality indicators

Abordaje y tratamiento nutricional precoz en una vía rápida oncológica de cabeza y cuello: ¿Qué aportamos los Dietistas-Nutricionistas?

III Congreso de Alimentación, Nutrición y Dietética. Combinar la nutrición comunitaria y personalizada: nuevos retos

LipoDDx: a mobile application for identification of rare lipodystrophy syndromes

Background: Lipodystrophy syndromes are a group of disorders characterized by a loss of adipose tissue once other situations of nutritional deprivation or exacerbated catabolism have been ruled out. With the exception of the HIV-associated lipodystrophy, they have a very low prevalence, which together with their large phenotypic heterogeneity makes their identification difficult, even for endocrinologists and pediatricians. This leads to significant delays in diagnosis or even to misdiagnosis. Our group has developed an algorithm that identifies the more than 40 rare lipodystrophy subtypes described to date. This algorithm has been implemented in a free mobile application, LipoDDx®. Our aim was to establish the effectiveness of LipoDDx®. Forty clinical records of patients with a diagnosis of certainty of most lipodystrophy subtypes were analyzed, including subjects without lipodystrophy. The medical records, blinded for diagnosis, were evaluated by 13 physicians, 1 biochemist and 1 dentist. Each evaluator first gave his/her results based on his/her own criteria. Then, a second diagnosis was given using LipoDDx®. The results were analysed based on a score table according to the complexity of each case and the prevalence of the disease. Results: LipoDDx® provides a user-friendly environment, based on usually dichotomous questions or choice of clinical signs from drop-down menus. The final result provided by this app for a particular case can be a low/high probability of suffering a particular lipodystrophy subtype. Without using LipoDDx® the success rate was 17 ± 20%, while with LipoDDx® the success rate was 79 ± 20% (p < 0.01).Project financed with an intramural grant from the Xunta de Galicia, ED341b 2017/19. S.S-I was awarded a Research Fellowship, granted by the Asociación Española de Familiares y Afectados de Lipodistrofias (AELIP).S

Unmasking a new prognostic marker and therapeutic target from the GDNF-RET/PIT1/p14ARF/p53 pathway in acromegaly

Most of acromegaly is caused by a sporadic somatotropinoma and a couple of novel gene mutations responsible for somatotropinoma have recently been reported. To determine the cause of sporadic somatotropinoma in Japanese patients, we analyzed 61 consecutive Japanese patients with somatotropinoma without apparent family history. Comprehensive genetic analysis revealed that 31 patients harbored guanine nucleotide-binding protein, alpha stimulating (GNAS) mutations (50.8%) and three patients harbored aryl hydrocarbon receptor interacting protein (AIP) mutations (4.9%). No patients had G protein-coupled receptor 101 (GPR101) mutations. The patients in this cohort study were categorized into three groups of AIP, GNAS, and others and compared the clinical characteristics. The AIP group exhibited significantly younger age at diagnosis, larger tumor, and higher nadir GH during oral glucose tolerance test. In all patients with AIP mutation, macro- and invasive tumor was detected and repetitive surgery or postoperative medical therapy was needed. One case showed a refractory response to postoperative somatostatin analogue (SSA) but after the addition of cabergoline as combined therapy, serum IGF-I levels were controlled. The other case showed a modest response to SSA and the switching to cabergoline monotherapy was also effective. These data suggest that although resistance to SSA has been reported in patients with AIP mutations, the response to dopamine agonist (DA) may be retained. In conclusion, the cause of sporadic somatotropinoma in Japanese patients was comparable with the previous reports in Caucasians, patients with AIP mutations showed unique clinical characteristics, and DA may be a therapeutic option for patients with AIP mutations

Unmasking a new prognostic marker and therapeutic target from the GDNF-RET/PIT1/p14ARF/p53 pathway in acromegaly

Background: Acromegaly is produced by excess growth hormone secreted by a pituitary adenoma of somatotroph cells (ACRO). First-line therapy, surgery and adjuvant therapy with somatostatin analogs, fails in 25% of patients. There is no predictive factor of resistance to therapy. New therapies are investigated using few dispersed tumor cells in acute primary cultures in standard conditions where the cells do not grow, or using rat pituitary cell lines that do not maintain the full somatotroph phenotype. The RET/PIT1/p14ARF/p53 pathway regulates apoptosis in normal pituitary somatotrophs whereas the RET/GDNF pathway regulates survival, controlling PIT1 levels and blocking p14ARF (ARF) and p53 expression. Methods: We investigated these two RET pathways in a prospective series of 32 ACRO and 63 non-functioning pituitary adenomas (NFPA), studying quantitative RNA and protein gene expression for molecular-clinical correlations and how the RET pathway might be implicated in therapeutic success. Clinical data was collected during post-surgical follow-up. We also established new'humanized’ pituitary cultures, allowing 20 repeated passages and maintaining the pituitary secretory phenotype, and tested five multikinase inhibitors (TKI: Vandetanib, Lenvatinib, Sunitinib, Cabozantinib and Sorafenib) potentially able to act on the GDNF-induced RET dimerization/survival pathway. Antibody arrays investigated intracellular molecular pathways. Findings: In ACRO, there was specific enrichment of all genes in both RET pathways, especially GDNF. ARF and GFRA4 gene expression were found to be opposing predictors of response to first-line therapy. ARF cut-off levels, calculated categorizing by GNAS mutation, were predictive of good response (above) or resistance (below) to therapy months later. Sorafenib, through AMPK, blocked the GDNF/AKT survival action without altering the RET apoptotic pathway. Interpretation: Tumor ARF mRNA expression measured at the time of the surgery is a prognosis factor in acromegaly. The RET inhibitor, Sorafenib, is proposed as a potential treatment for resistant ACRO. Fund: This project was supported by national grants from Agencia Estatal de Investigación (AEI) and Instituto Investigación Carlos III, with participation of European FEDER funds, to IB (PI150056) and CVA (BFU2016-76973-R). It was also supported initially by a grant from the Investigator Initiated Research (IIR) Program (WI177773) and by a non-restricted Research Grant from Pfizer Foundation to IB. Some of the pituitary acromegaly samples were collected in the framework of the Spanish National Registry of Acromegaly (REMAH), partially supported by an unrestricted grant from Novartis to the Spanish Endocrine Association (SEEN). CVA is also supported from a grant of Medical Research Council UK MR/M018539/1

Craniopharyngioma in the elderly: a multicenter and nationwide study in Spain

[Abstract] 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

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

ContextSome 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. ObjectiveThis study aimed at identifying predictors of response to SRL in elderly patients. DesignMulticentric retrospective nationwide study of patients diagnosed with acromegaly at or over the age of 65 years. ResultsOne-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). ConclusionsThe 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

Revisiting the usefulness of the short acute octreotide test to predict treatment outcomes in acromegaly

Introduction: We previously described that a short version of the acute octreotide test (sAOT) can predict the response to first-generation somatostatin receptor ligands (SRLs) in patients with acromegaly. We have prospectively reassessed the sAOT in patients from the ACROFAST study using current ultra-sensitive GH assays. We also studied the correlation of sAOT with tumor expression of E-cadherin and somatostatin receptor 2 (SSTR2) .Methods: A total of 47 patients treated with SRLs for 6 months were evaluated with the sAOT at diagnosis and correlated with SRLs' response. Those patients whose IGF1 decreased to = 3SDS, were considered non-responders. The 2 hours GH value (GH2h) after s.c. administration of 100 mcg of octreotide was used to define predictive cutoffs. E-cadherin and SSTR2 immunostaining in somatotropinoma tissue were investigated in 24/47 and 18/47 patients, respectively.Results: In all, 30 patients were responders and 17 were non-responders. GH(2h) was 0.68 (0.25-1.98) ng/mL in responders vs 2.35 (1.59-9.37) ng/mL in non-responders (p<0.001). GH(2h) = 1.4ng/mL showed the highest ability to identify responders (accuracy of 81%, sensitivity of 73.3%, and specificity of 94.1%). GH(2h) = 4.3ng/mL was the best cutoff for non-response prediction (accuracy of 74%, sensitivity of 35.3%, and specificity of 96.7%). Patients with E-cadherin-positive tumors showed a lower GH(2h) than those with E-cadherin-negative tumors [0.9 (0.3-2.1) vs 3.3 (1.5-12.1) ng/mL; p<0.01], and patients with positive E-cadherin presented a higher score of SSTR2 (7.5 +/- 4.2 vs 3.3 +/- 2.1; p=0.01).Conclusion: The sAOT is a good predictor tool for assessing response to SRLs and correlates with tumor E-cadherin and SSTR2 expression. Thus, it can be useful in clinical practice for therapeutic decision-making in patients with acromegaly

Natural history and surgical outcomes of Rathke’s cleft cysts: a Spanish multicenter study

Rathke’s cleft cysts (RCC) are a common type of lesion found in the sellar or suprasellar area. They are usually monitored clinically, but in some cases, surgery may be required. However, their natural progression is not yet well understood, and the outcomes of surgery are uncertain. The objective of this study is to evaluate the natural history of Rathke’s cleft cysts in patients who are clinically monitored without treatment, and to determine the outcomes of surgery and the incidence of recurrences over time.Design and patientsNational multicentric study of patients diagnosed of Rathke’s cleft cyst (RCC- Spain) from 2000 onwards and followed in 15 tertiary centers of Spain. A total of 177 patients diagnosed of RCC followed for 67.3 months (6–215) and 88 patients who underwent surgery, (81 patients underwent immediate surgery after diagnosis and 7 later for subsequent growth) followed for 68.8 months (3–235).ResultsThe cyst size remained stable or decreased in 73.5% (133) of the patients. Only 44 patients (24.3%) experienced a cyst increase and 9 of them (5.1%) experienced an increase greater than 3 mm. In most of the patients who underwent surgery headaches and visual alterations improved, recurrence was observed in 8 (9.1%) after a median time of 96 months, and no predictors of recurrence were discovered.ConclusionsRathke’s cleft cysts without initial compressive symptoms have a low probability of growth, so conservative management is recommended. Patients who undergo transsphenoidal surgery experience rapid clinical improvement, and recurrences are infrequent. However, they can occur after a long period of time, although no predictors of recurrence have been identified

Revisiting the usefulness of the short acute octreotide test to predict treatment outcomes in acromegaly

IntroductionWe previously described that a short version of the acute octreotide test (sAOT) can predict the response to first-generation somatostatin receptor ligands (SRLs) in patients with acromegaly. We have prospectively reassessed the sAOT in patients from the ACROFAST study using current ultra-sensitive GH assays. We also studied the correlation of sAOT with tumor expression of E-cadherin and somatostatin receptor 2 (SSTR2) .MethodsA total of 47 patients treated with SRLs for 6 months were evaluated with the sAOT at diagnosis and correlated with SRLs’ response. Those patients whose IGF1 decreased to &lt;3SDS from normal value were considered responders and those whose IGF1 was ≥3SDS, were considered non-responders. The 2 hours GH value (GH2h) after s.c. administration of 100 mcg of octreotide was used to define predictive cutoffs. E-cadherin and SSTR2 immunostaining in somatotropinoma tissue were investigated in 24/47 and 18/47 patients, respectively.ResultsIn all, 30 patients were responders and 17 were non-responders. GH2h was 0.68 (0.25-1.98) ng/mL in responders vs 2.35 (1.59-9.37) ng/mL in non-responders (p&lt;0.001). GH2h = 1.4ng/mL showed the highest ability to identify responders (accuracy of 81%, sensitivity of 73.3%, and specificity of 94.1%). GH2h = 4.3ng/mL was the best cutoff for non-response prediction (accuracy of 74%, sensitivity of 35.3%, and specificity of 96.7%). Patients with E-cadherin-positive tumors showed a lower GH2h than those with E-cadherin-negative tumors [0.9 (0.3-2.1) vs 3.3 (1.5-12.1) ng/mL; p&lt;0.01], and patients with positive E-cadherin presented a higher score of SSTR2 (7.5 ± 4.2 vs 3.3 ± 2.1; p=0.01).ConclusionThe sAOT is a good predictor tool for assessing response to SRLs and correlates with tumor E-cadherin and SSTR2 expression. Thus, it can be useful in clinical practice for therapeutic decision-making in patients with acromegaly