24 h urinary free cortisol (UFC) analysis constitutes one of the three first level recommended tests in Cushing's syndrome (CS) diagnostic confirmation work up. However, it occasionally leads to inaccurate results due to the use of immunoassays (IAs) or the concomitant administration of exogenous glucocorticoids, among others. This study aimed to develop a rapid and accurate LC-MS/MS method which may ultimately replace the use of IAs, and also provide relevant clinical information through the simultaneous monitoring of UFC, cortisone, and dexamethasone. An LC-MS/MS method based on direct injection approach was developed and fully characterized for the quantitation of the target analytes. A population-based reference range was established, and the potential supporting role of cortisone and cortisol/cortisone ratio was comprehensively assessed in patients under CS follow-up or clinical suspicion for hypercortisolism. The presence of dexamethasone was also assessed in order to exclude invalid samples from evaluation. Significant differences were observed for cortisone and cortisol/cortisone ratio between the control group and patients with hyper-/hypocortisolism, and an ideal level of biochemical agreement was observed with UFC LC-MS/MS values when the combination of both biomarkers was considered. Dexamethasone was detected in up to 7.7% of the studied population. The herein presented LC-MS/MS approach not only offers the possibility of discontinuing the use of IAs, but also provides additional biomarkers which are significantly relevant in CS management, thus enhancing the overall clinical performance of UFC analyses.

Obstructive sleep apnea (OSA) is common during pregnancy and linked to adverse outcomes. While oxidative stress is a proposed pathogenic mechanism, evidence in pregnant populations remains limited. This multicenter, prospective study evaluated oxidative stress through protein carbonyl levels in 171 pregnant women and 86 cord blood samples. Polysomnography (PSG) performed during pregnancy categorized participants with the apnea–hypopnea index (AHI) in OSA, rapid eye movement (REM) OSA, and supine OSA. Protein carbonyl levels were measured by the dinitrophenyl hydrazine (DNPH) method. No significant differences were found in maternal or cord blood protein carbonyl levels between OSA and non-OSA groups, or between REM and supine OSA subgroups. Interestingly, women with shorter apnea–hypopnea (AH) length showed both higher maternal and cord blood protein carbonyl levels and lower nocturnal oxygen saturation. Overall, OSA in pregnancy was not associated with increased oxidative stress as measured by protein carbonyl levels. However, apnea–hypopnea duration and nocturnal hypoxia may influence oxidative stress, pointing to a complex relationship between OSA and oxidative stress during pregnancy, beyond traditional metrics like AHI. Future studies should explore additional biomarkers and diverse molecular pathways that could play a role, with special attention to emerging factors such as apnea–hypopnea length and hypoxic burden to elucidate the interrelationships between OSA and pregnancy more comprehensively.

24-h urinary free cortisol (UFC) measurements are fundamental in the diagnosis and follow-up of Cushings syndrome (CS) and immunoassays (IA) are the most widely used tests for its quantification in clinical laboratory practice. However, their suitability has been questioned mainly due to their limitations concerning analytical specificity. The aim of this research project was to evaluate a novel algorithm for CS diagnosis and follow-up in the clinical laboratory, based on the combination of IA tests with liquid chromatography-tandem mass spectrometry (LC-MS/MS) for UFC quantification. A quantitative LC-MS/MS approach based on liquid-liquid extraction for sample preparation was developed and fully characterized. A population-based reference range was established and the level of agreement for UFC values when compared to IA approach was assessed in patients under CS follow-up or clinical suspicion for hypercortisolism. Significantly higher UFC values were observed for IA when compared to LC-MS/MS approach, therefore population-based reference range was established for the latter (i.e. 4 - 41 mu g/day). The clinical application of the herein presented LC-MS/MS approach to be used as a confirmation procedure for CS management was assessed and a high level of agreement with IA UFC values, except in the case of IA undetectable results, was observed. However, IA potential false negative (FN) and false positive (FP) findings were also noted. Higher clinical sensitivity for CS diagnosis / follow-up was observed for LC-MS/MS when compared to IA, supporting the advantage and necessity of implementing LC-MS/MS as a confirmation procedure in the clinical laboratory.

Objective Global thyroid cancer (TC) incidence is growing worldwide, but great heterogenicity exists among published studies, and thus, population-specific epidemiological studies are needed to adequate health resources and evaluate the impact of overdiagnosis. Methods We conducted a Public Health System database retrospective review of TC incident cases from 2000 to 2020 in the Balearic Islands region and evaluated age-standardized incidence rate (ASIR), age at diagnosis, gender distribution, tumor size and histological subtype, mortality rate (MR), and cause of death. Estimated annual percent changes (EAPCs) were also evaluated and data from the 2000–2009 period were compared to the 2010–2020 period when neck ultrasound (US) was routinely performed by clinicians at Endocrinology Departments. Results A total of 1387 incident cases of TC were detected. Overall, ASIR (×105) was 5.01 with a 7.82% increment in EAPC. A significant increase in the 2010–2020 period was seen for ASIR (6.99 vs 2.82, P < 0.001) and age at diagnosis (52.11 vs 47.32, P < 0.001) compared to the 2000–2009 period. A reduction in tumor size (2.00 vs 2.78 cm, P < 0.001) and a 6.31% increase in micropapillary TC (P < 0.05) were also seen. Disease-specific MR remained stable at 0.21 (×105). The mean age at diagnosis for all mortality groups was older than survivors (P < 0.001). Conclusion The incidence of TC has grown in the 2000–2020 period in the Balearic Islands, but MR has not changed. Beyond other factors, a significant contribution of overdiagnosis to this increased incidence is likely due to changes in the routine management of thyroid nodular disease and increased availability of neck US.

Mechanisms involved in thyroid dysfunction in critically ill coronavirus disease 2019 (COVID-19) patients are not clear. Our objective was to correlate the thyroid response with the pro- and anti-inflammatory cytokines profile in critically ill COVID-19 patients. This was a prospective single-center study. We studied the relationship between continuous variables by using Pearson correlation and simple linear regression. Multiple logistic regression analysis was performed to analyze the factors independently associated with mortality. Seventy-eight patients were included in the study at intensive care unit (ICU) admission and 72 had a measurement of the thyroid and inflammatory profile at day 5. No significant correlations were found between thyroid stimulating hormone (TSH), free triiodothyronine (fT3) and free thyroxine (fT4) and inflammatory cytokines at ICU admission. At day 5, fT4, was inversely correlated with IL-10 (p = 0.035). IL-10 was associated with maximum lactate (p < 0.001) and SOFA score values (p = 0.012). The multiple logistic regression analysis showed that there was a significant relationship between IL-10 (day 5) and in-hospital mortality after adjusting by age and severity of illness. In conclusion, we found that the thyroid hormone profile and inflammatory cytokines had a weak correlation at ICU admission. Associations of interest between fT4 and IL-10 were found at day 5. IL-10 at day 5 was found to be correlated with low fT4 and markers of organ failure and death.

Introduction and objective: The evaluation of liver fibrosis is of vital importance in the assessment of patients with any chronic liver disease for therapeutic decision making, prognosis and evaluation of response to treatment. Liver biopsy is currently the gold standard for identification and staging, but has several limitations. Non-invasive approaches based on serum biomarkers or assessment of liver stiffness by elastography are increasingly being incorporated in clinical practice replacing biopsy. Our objective is to evaluate the concordance between some of these non-invasive tests: FIB-4 index, Enhanced Liver Fibrosis (ELF) test and transient elastography, in patients with chronic hepatitis of diverse etiology with high prevalence of fibrosis, to determine their simultaneous or sequential usefulness in clinical practice.Methods: Retrospective study in which 179 patients were included and the bivariate concordance between FIB-4, ELF score and Fibroscan with the cut-off points considered was tested.Results: The concordance between FIB-4 value and ELF score was found to be 29.94%, when the concordance between FIB4 value and Fibroscan was compared it was found to be 50.46% and the concordance between ELF score and Fibroscan was 29.38%.Conclusions: The concordance for detecting the cut-off points considered between the non-invasive tests studied is poor, suggesting the need to use several non-invasive markers with different cut-off points for various clinically relevant thresholds according to the best detection rate for each pathology

Objectives Neck recurrence of papillary thyroid cancer (PTC) is frequently detected after initial surgery. The management of these lesions may include rescue surgery (RS) or minimally invasive techniques in selected patients, but comparative studies evaluating the effectiveness and safety of these techniques are lacking. In this paper, we compared ultrasound-guided ethanol ablation (EA) in selected patients to RS in a matched cohort. Methods We retrospectively compared 41 patients and 41 matched PTC patients without known distant metastases, who underwent ultrasound-guided EA or RS (matched reference group), who had 63 and 75 thyroid bed and/or lymph node confirmed PTC recurrences during a median follow-up of 72.8 and 89.6 months, respectively. The primary outcome was time until structural recurrence, compared using Kaplan-Meier survival curves. The secondary outcomes included time until biochemical recurrence, plasma thyroglobulin (Tg) levels, American Thyroid Association (ATA) response-to-therapy categories by the last available observation, and treatment-derived complications in each group. Results No significant differences were found between the EA and RS groups for time until structural recurrence (log-rank test, P=0.94). The time until biochemical recurrence was also similar (P=0.51); and the plasma Tg concentration reduction and proportions of patients in the ATA reclassification categories were also similar. A significantly higher proportion of patients in the RS group presented treatment-derived complications (29.27% vs. 9.75%, P<0.05). Conclusion In this retrospective analysis, the treatment of PTC neck recurrence with EA in selected patients was comparable to RS in a matched reference group for the long-term risk of structural or biochemical relapse, but with a lower risk of treatment-derived complications. These results support the effectiveness and safety of this minimally invasive technique in the management of selected patients with recurrent PTC.

Background Although some evidence suggests an association between obstructive sleep apnea (OSA) and gestational diabetes mellitus (GDM), its consequences still remain largely unknown. We sought to determine whether OSA is associated with higher inflammation and sympathetic levels in GDM, and to relate them with insulin resistance and perinatal outcomes. Methods OSA was identified by polysomnography and defined as an apnea–hypopnea index of ≥ 5 h −1 . Plasma cytokines (TNF-α, IL-1β, IL-6, IL-8, IL-10), metanephrine, and normetanephrine were determined by immunoassays. Results We included 17 patients with GDM and OSA and 34 without OSA. Women with GDM and OSA had higher normetanephrine concentrations [81 IQR (59–134) vs. 68 (51–81) pg/mL]. No differences in the inflammatory profile were found, while IL-1β was higher in patients with mean nocturnal oxyhemoglobin saturation ≤ 94%. We found positive correlations between increased sympathetic activation and IL-1β, with obstructive apneas, while time in REM showed an inverse relationship with IL-1β and metanephrine. Furthermore, IL-10 was inversely related with time in sleep stages 1–2, and with the arousal index, and it was positively related with time in slow-wave sleep. Significant correlations were also found between IL-1β and insulin resistance. There were no significant differences in neonatal characteristics; however, we found inverse relationships between IL-10 and birth weight (BW), and percentile of BW. Conclusions OSA increased sympathetic activity, and IL-1β concentration was higher in patients with GDM with lower nocturnal oxygenation, all of which were related with obstructive events, and time in REM. Moreover, IL-1β was related with insulin resistance, and IL-10 inversely correlated with neonatal BW.

The incidence of thyroid disfunction has not been analyzed in critically ill COVID-19 patients. Our objective was to analyze the relationship of the thyroid profile and in-hospital mortality in critically ill COVID-19 patients. This was a prospective single-center study involving critically ill COVID-19 patients admitted to the ICU of a tertiary University Hospital. Thyroid hormones were measured through drawing blood samples from a central venous catheter at ICU admission and on the fifth day. A multiple logistic regression analysis was performed to analyze the variables associated with mortality. The ability of the different thyroid hormones to predict in-hospital mortality was evaluated by calculating the receiver operating characteristics (ROCs) and the area under the curve (AUC). A total of 78 patients were included in the study at ICU admission; 72 had their thyroid profile measured at day 5. In-hospital mortality reached 29.5%. Multiple logistic regression analysis showed that variables associated with mortality were age and prior beta-blocker therapy at ICU admission and age fT4 at day 5. The AUC for in-hospital mortality predictions of fT4 at day 5 was 0.69. Thyroid responses are commonly observed in critically ill COVID-19 patients. fT4 at day 5 after ICU admission was associated with mortality.

BACKGROUND-AIMThe prevalence of cobalamin and folate deficit ranges around 2.9%, reaching up to 35% among elderly people.This fact leads to an increase in the demand for both tests.However, the NICE does not recommend the repetition of cobalamin and folate in the follow-up of patients with replacement treatment, and suggests the complete blood count (CBC) instead.Others scientific societies recommend checking cobalamin levels every six months for patients treated with metformin or patients whose cobalamin deficiencies have been corrected.In accordance with international guidelines, our laboratory established a measure of demand adequacy for primary care (PC).The laboratory information system (LIS) retains the determinations of cobalamin and/or folate with normal previous results within a six-month period.The decision on its processing is based on: diagnostic suspicion, CBC results, iron status panel.For the repetition of folate, previous cobalamin values are also considered.Our aim was to evaluate the adequacy of the rule implemented, through the number of tests avoided. METHODSRetrospective observational study performed in a tertiary care hospital between 12/04/2019-31/07/2019.Requests from PC including cobalamin and/or folate were considered.Requests with normal previous results for at least one of the two tests (B12: 138-652pmol/L; folate: 7.05-46.59nmol/L)within a six-monthperiod, were retained by the LIS.The percentages of B12 and folate determinations retained and not performed were evaluated. RESULTSThis study included 2033 requests from PC containing only cobalamin, 1368 only folate and 12779 with both tests.The adequacy rule (retention) was activated for 1141 requests (7.1%).791 requests showed normal prior results in less than six months for both tests (69.3%).Cobalamin was responsible for the retention of 199 requests (17.4%) and in 151 the cause was folate (13.3%).Among all requests retained by the LIS, 480 cobalamin tests were rejected and not performed (48.5%), along with 453 folate tests (48.1%), in accordance with the abovementioned items. CONCLUSIONSGiven the increasing demand of cobalamin and folate from PC, clinical laboratories need to offer not only true results, but also become the cornerstone in the optimization of resources.

INTRODUCTION:Obstructive sleep apnea (OSA) increases the risk of type 2 diabetes, and hyperinsulinemia. Pregnancy increases the risk of OSA; however, the relationship between OSA and gestational diabetes mellitus (GDM) is unclear. We aimed (1) to evaluate OSA prevalence in GDM patients; (2) to assess the association between OSA and GDM; and (3) to determine the relationships between sleep parameters with insulin resistance (IR).METHODS:A total of 177 consecutive women (89 with GDM, 88 controls) in the third trimester of pregnancy underwent a hospital polysomnography. OSA was defined when the apnea-hypopnea index (AHI) was ≥5h-1.RESULTS:Patients with GDM had higher pregestational body mass index (BMI) and neck circumference than controls, but no differences in snoring or OSA-symptoms, or AHI (3.2±6.0 vs. 1.9±2.7h-1, p=.069). OSA prevalence was not significantly different in both groups. We did not identify OSA as a GDM risk factor in the crude analysis 1.65 (95%CI: 0.73-3.77; p=.232). Multiple regression showed that total sleep time (TST), TST spent with oxygen saturation<90% (T90), and maximum duration of respiratory events as independent factors related with homeostasis model assessment of IR, while T90 was the only independent determinant of quantitative insulin sensitivity check index.CONCLUSION:OSA prevalence during the third trimester of pregnancy was not significantly different in patients with GDM than without GDM, and no associations between OSA and GDM determinants were found. We identified T90 and obstructive respiratory events length positive-related to IR, while TST showed an inverse relationship with IR in pregnant women.

Our findings suggest a high prevalence of OSA among the family members studied with an increased association of childhood OSA with paternal OSA. Prediction of OSA risk among children can be significantly improved by adding data on paternal OSA status.

Background: Twenty years after the first publication of the landmark Chronic Care Model by Wagner and collaborators, it still guides interventions and evaluation aiming to improve patient chronic disease outcomes. Chronic care can be influenced by stakeholders who are user of the collected data, but health providers and patient have also a major impact on the success or failure of intervention aiming to improve quality of care. The Assessment of Chronic Illness Care (ACIC) and Patient Assessment of Chronic Illness Care (PACIC) are tools that have been used with success to evaluate care for a number of chronic diseases from the point of view of providers and patients respectively. In Brazil, chronic diseases are the leading cause of mortality accounting for more than 70% of deaths. Diabetes and cardiovascular diseases accounted for 13% and 5% of discounted disability-adjusted life years (DALYs) in 2007. Aim: The objective of this study was to evaluate care for diabetes and hypertension from the point of view of the patient, providers, and managers in primary and secondary care clinics of the city of Juiz de For a, Minas Gerais, Brazil. Material and Methods: Three different tools were used to evaluate care, named the Assessment of Chronic Illness Care (ACIC) and the Patient Assessment of Chronic Illness Care (PACIC) both designed and tested by the MacColl Institute for Health Improvement as well as the questionnaire Chronic Care Structure Survey designed by the Pan American Health Organization and based on the Physician Practice Connection and Readiness Survey (PPC-RS). In the evaluation participated 1,664 patients with diabetes or hypertension, as well as 323 health providers from public primary and secondary care clinics. Patients and providers were interviewed using ACIC and PACIC; and the CCSS was completed by medical managers from each clinic. Clinical data from patients were abstracted from electronic records. Results: Scores for all the three questionnaires were scaled to 100 percentage points. The evaluation of the structure for chronic care scored 49 and 94 percentage points for primary and secondary care respectively. All PACIC and ACIC scores for primary care clinics were lower than scores for the secondary care clinic. Patients and providers rated care at 45 and 48, and 73 and 68 percentage points for primary and secondary care clinics. The secondary care clinic was evaluated with very high scores by patients and providers. Among the activities explored by the PACIC questionnaire, patient considered the lowest score for activation, followed by care coordination for both primary and secondary care clinics; while providers considered that the weakest aspects were the Health Care Organization. This research showed that using the PACIC, ACIC and CCSS were helpful understanding capacity and identifying chronic care areas for improvement in primary and secondary care settings. The capacity and clinic outcomes of the secondary care clinic proved to be better than the one exhibited by the primary care clinics for the management of diabetes and hypertension.

Objectives: In children, thyroid hormones are essential for correct physical and neurological development. The recommended process for defining reference intervals (RIs) is the direct approach; however, indirect methods are an effective alternative. This study aimed to explore age- and sex-dependent relationships between serum concentrations of thyroid hormones in a large population-based cohort of healthy Spanish Caucasian children and calculate RIs. Material and Methods: Results of serum thyroid-stimulating hormone (TSH) and free thyroxine (fT4) were collected from laboratory data of N (TSH = 23201; fT4 = 20728) patients aged 1 month - 15 years. These results were validated with a prospective study. Analyses of serum concentrations of TSH and fT4 were performed on ARCHITECT i2000 (Abbott Diagnostics, US). Percentiles (2.5th to 97.5th) were determined for each variable and taken as the RI. Results: No difference was found between serum TSH concentrations in male and female children of all age groups. A difference between serum fT4 concentrations in males and females and an age-dependent correlation for both sexes were found. Conclusion: There is very little consensus on RIs in children. Our data confirm it is possible to use data mining techniques to calculate reliable and clinically useful RIs.

Background Hypovitaminosis D is a common health problem. The purpose of this study was to investigate the inter-relationship between serum 25(OH)D levels and paternal and maternal vitamin D status in a sample of snoring children. Methods We selected 137 participants for whom serum 25(OH)D had been measured and underwent overnight polysomnography evaluation. Serum glucose, lipids, liver enzymes, parathyroid hormone, insulin, and glycated hemoglobin were also measured. Glucose and insulin levels were used to estimate insulin resistance with the homeostasis model assessment (HOMA-IR). Results Vitamin D insufficiency (<30 ng/mL) and deficiency (<20 ng/mL) were found in 40.9 and 17.5% of children, respectively. After adjustments for age, BMI z -score and seasonality, the odds ratio for risk of vitamin D insufficiency according to the vitamin D status of parents were: OR (95% CI): paternal insufficiency 15.1 (2.7–35.7), p = 0.002; maternal insufficiency 7.2 (2.4–22), p = 0.001. When children with vitamin D deficiency were analyzed separately, serum 25(OH)D concentration was found to be associated with the apnea–hypopnea index ( r = −0.647, p = 0.009) and respiratory arousal index ( r = −0.669, p = 0.034). Conclusions Family patterns of vitamin D could be helpful for the early identification of children at risk of metabolic and/or sleep disturbances and when considering strategies to improve vitamin D status. Impact Family patterns of vitamin D could be helpful for the early identification of snoring children at risk of metabolic and/or sleep disturbances. Significant associations were found between serum 25-hydroxyvitamin D (25(OH)D) concentrations in children and their parents. An inverse association between 25(OH)D levels and OSA severity was detected in deficient vitamin D children. Children with insufficient and deficient vitamin D status tended to have a worse metabolic profile, so strategies are needed to improve vitamin D status.

Vitamin D has known effects on the immune system, and its deficiency has been associated with allergen sensitization.

Obstructive sleep apnea (OSA) affects between 2% and 4% in children and there is a search for new biomarkers that can be useful both in the diagnosis and in the evolution of the disease. The surfactant protein D (SP-D) is a collection that is part of the innate immune system exerting an anti-inflammatory and antimicrobial effect. Thus, the objective of this study was to evaluate the concentration of SP-D in the suspect OSA pediatric population. A total of 178 children were recruited in this prospective study. Blood samples, sleep parameters, feeding habits, anthropometric, sociodemographic, and family data were collected. Specific biochemical determinations were made, and the plasmatic concentrations of SP-D were measured by enzyme-linked immunosorbent assay. We found no statistical correlation between the SP-D concentration and the apnea-hypopnea index (AHI) from the data. Nevertheless, the changes in SP-D levels could be correlated to a large extent by the arousals that often go along with hypopneas (r = -0.258, p = 0.011 unadjusted; r = -0.258, p = 0.014 adjusted by age and body mass inded [BMI] Z-score). Intermittent hypoxia was correlated with C-reactive protein levels (r = 0.547, p < 0.001 unadjusted; r = 0.542, p < 0.001 adjusted by age and BMI Z-score). Although AHI and SP-D did not appear to correlate, a secondary analysis suggests that sleep fragmentation, which is produced by arousals, may do, and further research is needed to determine the mechanisms by which changes in SP-D occur in OSA.