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Introduction Thyrotoxicosis with hyperthyroidism is treated with these classical approaches (i) antithyroid drugs to blockade thyroid hormone release and normalize thyroid hormone production and (ii) destruction of the thyroid using radioiodine or surgical removal of the thyroid. The optimal medical therapy, especially for Graves´ disease, remains a subject of debate and there has been little progress in Graves' disease therapeutics over the last decade. Areas covered Novel treatments of thyrotoxicosis with hyperthyroidism. This includes (i) small molecules such as synthetic thyroid hormone receptor antagonists and environmental molecules and (ii) molecules with interaction between thyroid stimulating hormone (TSH) receptor and TSH receptor antibodies such as M22, ANTAG3, org274179-0, 5C9, and K1-70. Other approaches to Graves´ disease treatment includes immunosuppressive treatment, glucocorticosteroids, rituximab, and intrathyroid injection of dexamethasone. Optimal iodine and selenium supplementation can also be considered. Expert opinion Clinical trials results suggest that novel thyroid treatments involving small molecule therapy, may predict a good future in Graves' disease treatment; however, a greater understanding of these antagonists is needed. Other treatments comprising immunosuppressives have demonstrated a significant reduction of relapse of the disease, but are not recommended by international guidelines.

Sunitinib is an oral oxindol derivative and a potent inhibitor of vascular endothelial growth factor receptor and platelet-derived growth factor receptor and a multitargeted tyrosine-kinase inhibitor, which has antitumor and antiangiogenic activity due to the selective inhibition that can stabilize progressive metastatic disease. The aim of this review is to expose whether the drug could be considered as a new promising therapy compared with other tyrosine-kinase inhibitors. Areas covered: In seven open-label studies carried out with sunitinb, the drug showed its anti-tumoral activity in advanced differentiated thyroid carcinoma and in medullary thyroid carcinoma. The reported objectives in advanced differentiated thyroid carcinoma, partial response ranges 13% to 55.5%, stable disease ranges 44.4% to 68%, progressive disease ranges 10% to 21% of patients, progression free survival ranges 3 to 13.3% months. In medullary thyroid carcinoma, PR ranges 0% to 55%, SD ranges 44.4% to 87.5%, PD ranges 7% to 18.8% and progression free survivalranges seven to 21 months. Expert opinion: Sunitinib has demonstrated a potent anti-tumoral activity in differentiated thyroid carcinoma and in medullary thyroid carcinoma, but the results of the open-label trials single arm are limited. Further investigations with this agent with randomized trials are warranted.

Anaplastic thyroid cancer (ATC) is the most aggressive solid tumor and almost uniformly lethal in humans. The Boards of the Thyroid Cancer Group of the Spanish Society of Endocrinology and Nutrition and the Grupo Español de Enfermedades Huérfanas e Infrecuentes of the Spanish Society of Oncology requested that an independent task force draft a more comprehensive consensus statement regarding ATC. All relevant literature was reviewed, including serial PubMed searches together with additional articles. This is the first, comprehensive Spanish consensus statement for ATC and includes the characteristics, diagnosis, initial evaluation, treatment goals, recommendations and modalities for locoregional and advanced disease, palliative care options, surveillance, and long-term monitoring. Newer systemic therapies are being investigated, but more effective combinations are needed to improve patient outcomes. Though more aggressive radiotherapy has reduced locoregional recurrences, median overall survival has not improved in more than 50 years., The Board of the Thyroid Cancer Group of the Spanish Society of Endocrinology and Nutrition (SEEN) and the GETHI (Grupo Español de Enfermedades Huérfanas e Infrecuentes) of the Spanish Society of Oncology (SEOM) staff whose support made this review possible.

Background Approximately one third of the patients with differentiated thyroid cancer (DTC) who develop structurally-evident metastatic disease are refractory to radioactive iodine (RAI). Most deaths from thyroid cancer occur in these patients. The main objective of this consensus is to address the most controversial aspects of management of these patients. Methods On behalf of the Spanish Society of Endocrinology & Nutrition (SEEN) and the Spanish Group for Orphan and Infrequent Tumors (GETHI), the Spanish Task Force for Thyroid Cancer, consisting of endocrinologists and oncologists, reviewed the relevant literature and prepared a series of clinically relevant questions related to management of advanced RAI-refractory DTC. Results Ten clinically relevant questions were identified by the task force. In answering to these 10 questions, the task force included recommendations regarding the best definition of refractoriness; the best therapeutic options including watchful waiting, local therapies, and systemic therapy (e.g. kinase inhibitors), when sodium iodide symporter (NIS) restoration may be expected; and how recent advances in molecular biology have increased our understanding of the disease. Conclusions In response to our appointment as a task force by the SEEN and GHETI, we developed a consensus to help in clinical management of patients with advanced RAI-refractory DTC. We think that this consensus will provide helpful and current recommendations that will help patients with this disorder to get optimal medical care.

Resumen Objetivo Actualizar las recomendaciones previas formuladas por el Grupo de trabajo de osteoporosis y metabolismo mineral de la Sociedad Espanola de Endocrinologia y Nutricion (SEEN) para la evaluacion y el tratamiento de la osteoporosis asociada a diferentes enfermedades endocrinas y alteraciones nutricionales. Participantes Miembros del Grupo de trabajo de osteoporosis y metabolismo mineral de la SEEN. Metodos Las recomendaciones se formularon de acuerdo al sistema Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) para establecer tanto la fuerza de las recomendaciones como el grado de evidencia. Se realizo una busqueda sistematica en PubMed de las nuevas acerca de cada enfermedad usando las siguientes palabras clave asociadas al nombre de cada proceso patologico: AND osteoporosis, fractures, bone mineral density, bone markers y treatment . Se revisaron articulos escritos en ingles con fechas de inclusion comprendidas entre el 18 de octubre de 2011 y el 30 de octubre de 2014. Tras la formulacion de las recomendaciones estas se discutieron de forma conjunta por el Grupo de trabajo. Conclusiones Esta actualizacion resume los nuevos datos acerca de la evaluacion y tratamiento de la osteoporosis en las enfermedades endocrinas y nutricionales que se asocian a baja masa osea o a un aumento del riesgo de fractura.

Background In Spain medullary thyroid carcinoma (MTC) would not exceed 80 new cases per year and less than half of them would be good candidates for systemic treatment with novel agents. Methods Relevant literature was reviewed, including PubMed searches supplemented with additional articles. Results The consensus summarizes the clinical outcomes in terms of activity and toxicity of each of the available drugs. A brief summary of the minimum requirements in terms of follow up and genetic counseling around MTC is also included. Conclusions Only those patients with objective imaging progression in the last 12–14 months with large volume of disease are clear candidates to start systemic treatment. However, those patients with low disease volume should be considered for ‘wait and see’ strategy until symptoms of the disease appear. Multidisciplinary approach for the management of MTC patient is mandatory nowadays.

Objective To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions. Participants Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist. Methods Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group. Conclusions The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.

Objective To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions. Participants Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist. Methods Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND “osteoporosis”, “fractures”, “bone mineral density”, and “treatment”. Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts, related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group. Conclusions The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.

s/. 27. de Groot JW, Zonnenberg BA, van Ufford-Mannesse PQ, de Vries MM, Links TP, Lips CJ, et al. A phase II trial of imatinib therapy for metastatic medullary thyroid carcinoma. J Clin Endocrinol Metab. 2007;92:3466--9. 28. Cohen EE, Rosen LS, Vokes EE, Kies MS, Forastiere AA, Worden FP, et al. Axitinib is an active treatment for all histologic subtypes of advanced thyroid cancer: results from a phase II study. J Clin Oncol. 2008;26:4708--13. 29. Keefe SM, Troxel AB, Rhee S, Puttaswamy K, O’Dwyer PJ, Loevner LA, et al. Phase II trial of sorafenib in patients with advanced thyroid cancer. J Clin Oncol. 2011;29 Suppl [abstract 5562]. 30. Adjei AA, Cohen RB, Franklin W, Morris C, Wilson D, Molina JR, et al. Phase I pharmacokinetic and pharmacodynamic study of the oral, small-molecule mitogen-activated protein kinase kinase 1/2 inhibitor AZD6244 (ARRY-142886) in patients with advanced cancers. J Clin Oncol. 2008;26: 2139--46. 31. Pennell NA, Daniels GH, Haddad RI, Ross DS, Evans T, Wirth LJ, et al. A phase II study of gefitinib in patients with advanced thyroid cancer. Thyroid. 2008;18:317--23. 32. Hong DS, Sebti SM, Newman RA, Blaskovich MA, Ye L, Gagel RF, et al. Phase I trial of a combination of the multikinase inhibitor er 385 sorafenib and the farnesyltransferase inhibitor tipifarnib in advanced malignancies. Clin Cancer Res. 2009;15:7061--8. 33. Wells Jr SA, Gosnell JE, Gagel RF, Moley J, Pfister D, Sosa JA, et al. Vandetanib for the treatment of patients with locally advanced or metastatic hereditary medullary thyroid cancer. J Clin Oncol. 2010;28:767--72. 34. Cleary JM, Sadow PM, Randolph GW, Palmer EL, Lynch TP, Nikiforov YE, et al. Neoadjuvant treatment of unresectable medullary thyroid cancer with sunitinib. J Clin Oncol. 2010;28

Bycontrast,itsrelationshiptothyroidfollicular epithelium cancer, such as papillary carcinoma,has been for a long time and continues to be controversial,because theconceptofchronicinflammationleadingtoneo-plasm is also well established in other tissues. Coexistenceof chronicthyroiditisanddifferentiatedthyroidcarcinomaisa real clinical situation whose significance is still unknown

Resumen Introduccion El proposito de este estudio es el de considerar si en Espana la actuacion de los especialistas ante el nodulo tiroideo y carcinoma diferenciado de tiroides esta de acuerdo con la guia norteamericana y el consenso europeo. Material y metodos Estudio transversal con un cuestionario que constaba de preguntas que fueron facilitadas a los endocrinologos clinicos expertos en cancer de tiroides y a algunos miembros de los servicios de medicina nuclear de toda Espana. Resultados Se obtuvieron 177 respuestas, el 85% de los encuestados; de ellas el 74% procedian de endocrinologos y el 26% de especialistas en medicina nuclear; el 82% de las respuestas procedian de hospitales de tercer nivel, el 10% de segundo nivel y el resto de centros privados. La mayoria de los encuestados valora el nodulo tiroideo con ecografia y practica el estudio citologico. La mayoria tambien dispone de un grupo quirurgico experto en cirugia tiroidea y practican la tirodectomia total o casi total en los canceres de tamano superior a 10 mm, asi como la diseccion ganglionar orientada por compartimentos. Menos 43 (24%), practican la diseccion profilactica de los ganglios del compatimento central. En 81 (45%) respuestas se sigue practicando el rastreo corporal total con I131 o I123 previo al tratamiento con I131. En la mayoria de los casos se sigue al paciente basandose en la ecografia cervical y en la tiroglobulina; sin embargo 101 (57%) de los encuestados siguen realizando el rastreo corporal total en el seguimiento. Conclusion La actitud que siguen nuestros especialistas esta bastante de acuerdo con la guia americana y consenso europeo, si bien difiere en el rastreo corporal total con I131 previo al tratamiento ablativo asi como el seguimiento basado tambien en el rastreo corporal total con I131.

The clinical profile of primary hyperparathyroidism (PHPT) has changed considerably, especially since the introduction of autoanalyzers in the laboratory, allowing calcium to be determined more frequently and a large number of cases of hypercalcemia to be detected. The most frequent causes are PHPT and cancer-related hypercalcemia. All of these factors have modified the prevalence of the clinical manifestations and currently the presence of recurrent kidney stones is observed in 20% of patients, while bone lesions, even the most subtle, are infrequent. Differentiating and establishing the limits between symptomatic and asymptomatic PHPT is difficult and many asymptomatic cases will never show disease progression, such as severe hypercalcemia, bone disease, hypercalciuria and/or kidney stones. An important question is whether patients not showing the classical manifestations of PHPT will benefit from surgery. This question is all the more important since, among patients not surgically treated, many are lost to follow-up after 5 to 10 years and the cost of follow-up exceeds that of surgery. Those against intervention base their arguments on the lack of progression in many patients and the possibility of alternative treatments.

To update previous recommendations developed by the Working Group on Osteoporosis and Mineral Metabolism of the Spanish Society of Endocrinology and Nutrition for the evaluation and treatment of osteoporosis associated to different endocrine and nutritional diseases.Members of the Working Group on Osteoporosis and Mineral Metabolism of the Spanish Society of Endocrinology and Nutrition.Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed) using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date between 18 October 2011 and 30 October 2014 were included. The recommendations were discussed and approved by all members of the Working Group.This update summarizes the new data regarding evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions.

d a t t O b b u c r The relationship between chronic autoimmune thyroiditis and mucosa-associated lymphoid tissue (MALT) thyroid lymphoma is well known.1 By contrast, its relationship to thyroid follicular epithelium cancer, such as papillary carcinoma, has been for a long time and continues to be controversial, because the concept of chronic inflammation leading to neoplasm is also well established in other tissues. Coexistence of chronic thyroiditis and differentiated thyroid carcinoma is a real clinical situation whose significance is still unknown2; in addition, thyroiditis itself may sometimes be associated to both papillary thyroid carcinoma and MALT lymphoma.3 The first difficulty lies is that the criteria for defining autoimmune thyroiditis are quite heterogeneous, as are the patient groups studied, which may be surgical series or cytological studies with no subsequent surgery. Differentiation between chronic thyroiditis as a nosological entity and lymphocyte infiltration may be another confounding factor. In this regard, such infiltration represents that the immune system, through lymphocytes, could locate the tumor, and thus prevent recurrence. This potential mechanism has led to consider immunotherapy in advanced thyroid cancer, as there would be a generalized immune defect, and a response to cancer could be triggered by tumor cells or specific tumor antigens. An alternative explanation to lymphocyte infiltration is that the tumor itself acts locally, triggering a

Fundamento El objetivo de este estudio es el analisis de las variables antropometricas y el de los valores de referencia de los parametros de la composicion corporal que tienen interes en la poblacion sana, asi como para su comparacion en diversas enfermedades, ya que no hay estudios poblacionales que los establezcan. Sujetos y metodos Se estudiaron 268 sujetos sanos, 134 varones y 134 mujeres, seleccionados a traves del censo de L'Hospitalet de Llobregat, y representativos de su poblacion en sexo y edad, con una edad media de 41,4 anos los varones y 40,7 anos las mujeres, y se valoraron los datos antropometricos, peso, talla, indice de masa corporal, indice cintura/cadera y los parametros de composicion corporal por bioimpedanciometria: agua corporal total, masa no grasa, masa grasa y porcentaje de grasa. Resultados Veinticuatro varones y 33 mujeres eran obesos; de ellos, dos varones y cuatro mujeres presentaban obesidad morbida. Los parametros antropometricos y de composicion corporal se distribuyeron por sexos y decadas. El indice de masa corporal fue mayor en las ultimas decadas respecto a la primera tanto en varones (p = 0,017) como en mujeres (p = 0,0001), y dicho incremento en mujeres fue a partir de un aumento significativo de la masa grasa (p = 0,0001). El indice cintura/cadera fue de 0,93 (0,08) en varones y de 0,79 (0,07) en mujeres, siendo elevado sobre todo en varones en las ultimas decadas. Conclusiones En el analisis de la composicion corporal de la poblacion sana de L'Hospitalet de Llobregat, destaca el indice de masa corporal elevado en las ultimas decadas, a partir del incremento de masa grasa, y el indice cintura/cadera elevado en varones en las ultimas decadas de la vida.

Myotonic dystrophy (MyD) is a multisystem autosomal dominant disorder associated with progressive muscle wasting and weakness. The striking metabolic abnormality in MyD is insulin resistance. The mechanism by which target tissues are insensitive to insulin action remains uncertain. In a recent study, plasma soluble tumor necrosis factor receptor (sTNFR)2 levels were found to be associated with muscle tissue mass and insulin resistance. Given these associations, we speculated that disorders of the muscle cell membrane could lead simultaneously to insulin insensitivity and sTNFR2 leakage in MyD. To test this hypothesis, we measured the levels of circulating sTNFR1 and sTNFR2 and insulin resistance in MyD patients. We studied 22 MyD patients and 24 age-, BMI-, and fat mass-matched control subjects. Both MyD men and women showed higher plasma insulin levels in the presence of comparable glucose concentrations than did control subjects. sTNFR2, but not sTNFR1, levels were approximately 1.5-fold higher in MyD patients. In parallel with these findings, the fasting insulin resistance index (FIRI) was also higher in MyD patients. In fact, in the whole population, fasting insulin and FIRI strongly correlated with sTNFR2 in both men (r = 0.77 and r = 0.81, P

Thyroid nodules are a common clinical problem and evaluation with neck and thyroid ultrasound and fine-needle aspiration biopsy are the most accurate methods for evaluating and identifying those that require surgical resection. The surgical treatment of differentiated thyroid carcinoma is the most common and recommended approach. Post-operative131I remnant ablation is used to eliminate the post-surgical thyroid remnant and may facilitate the early detection of recurrence. The conclusion of two important recent studies is that the use of recombinant human thyrotropin and low131I dose, 30 mCi, for post-operative ablation may be sufficient for the management of low-risk thyroid cancer. Recently, multi-targeted kinase inhibitors have emerged as promising treatments for metastatic differentiated thyroid cancers based on mutation detection in samples from thyroid cancer. Motesanib, sorafenib, vandetanib, sunitinib, lenvatinib, imatinib and cabozantinib are multi-kinase inhibitors that have the ability of inhibiting the rearranged during transection(RET)and vascular endothelial growth factor receptor (VEGFR), and other kinases, and have been used in advanced differentiated thyroid carcinoma. By contrast, axitinib and pazopanib seem to act only as anti-angiogenic agents. Anaplastic thyroid carinoma is often advanced and metastatic at diagnosis. Patients with localised disease not amenable to surgical resection can be treated with adjuvant chemoradiotherapy.

To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions.Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist.Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group.The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.

The aim of this study was to evaluate and compare the morbidity associated with 2 strategies of treatment of colorectal anastomotic leakage: surgical drainage of anastomosis with loop ileostomy versus anastomotic takedown.An observational study of patients operated on for ileocolic or colorectal anastomotic leakage between 2001 and 2009. Patients were classified into 2 groups: group 1, salvage of the anastomosis, and group 2, anastomotic takedown. Mortality and morbidity were assessed. Morbidity and mortality of bowel restoration were also evaluated.Thirty-nine patients were included into group 1 and 54 into group 2. Mortality was 15% for group 1 and 37% for group 2 (P = .022). The rate of patients suitable for stoma reversal was 91% for loop ileostomy and 38% for end stoma (P.001). Morbidity was 18% after loop ileostomy closure and 71% after end stoma reversal (P = .021). Hospitalization was 10 days and 21 days, respectively (P = .009). There was no mortality.Salvage of anastomosis with loop ileostomy is an effective strategy to control peritoneal sepsis for colorectal anastomotic leakage.

The clinical profile of primary hyperparathyroidism (PHPT) has changed considerably, especially since the introduction of autoanalyzers in the laboratory, allowing calcium to be determined more frequently and a large number of cases of hypercalcemia to be detected. The most frequent causes are PHPT and cancer-related hypercalcemia. All of these factors have modified the prevalence of the clinical manifestations and currently the presence of recurrent kidney stones is observed in 20% of patients, while bone lesions, even the most subtle, are infrequent. Differentiating and establishing the limits between symptomatic and asymptomatic PHPT is difficult and many asymptomatic cases will never show disease progression, such as severe hypercalcemia, bone disease, hypercalciuria and/or kidney stones. An important question is whether patients not showing the classical manifestations of PHPT will benefit from surgery. This question is all the more important since, among patients not surgically treated, many are lost to follow-up after 5 to 10 years and the cost of follow-up exceeds that of surgery. Those against intervention base their arguments on the lack of progression in many patients and the possibility of alternative treatments.

Letter to Editor On behalf of the Thyroid Cancer Committee from the Spanish Society of Endocrinology and Nutrition (SEEN).-- et al.

Primary hyperparathyroidism (PHPT) is a common cause of hypercalcaemia. The most common lesion found in patients is the solitary benign parathyroid adenoma. Multiple parathyroid adenomas have also been reported. Parathyroid carcinomas are an uncommon cause of PHPT. In 15% of patients, all four parathyroid glands are involved and it may be associated with a familial hereditary syndrome, such as multiple endocrine neoplasia, types 1, 2A and 4. PHPT jaw tumour syndrome is associated with fibromas in the mandible and tumours can also be present in the kidneys and the uterus. No predisposing germline DNA variants in parathyroid adenomas have been demonstrated and only a few clonally altered genes that drive parathyroid tumorigenesis have been identified. Frequently parathyroid adenomas haveHRPT2gene mutations that are likely to be of pathogenetic importance. Mutations in theMEN1gene (localised to 11q13) are responsible for multiple endocrine neoplasia 1. Multiple endocrine neoplasia 2A, which can be associated with medullary thyroid cancer, is due to a germline mutation of theRETproto-oncogene located on chromosome 10. In MEN1-like negative patients some of the germline mutations in this new susceptibility gene were due to gene CDKN1B (12p13). This new syndrome was classified as multiple endocrine neoplasia 4. In PHPT jaw tumour syndrome,HRPT2, the gene on the long arm of chromosome 1, is responsible for the syndrome. It is suggested to perform genetic testing in patients with PHPT below the age of 30 years, but at any age in patients presenting with multigland parathyroid disease.

Los rápidos cambios tecnológicos, poblacionales, de conocimientos científicos, organizativos, profesionales, económicos y sociales obligan a una adaptación del sistema de formación médica posgraduada. La lentitud en esta adaptación puede ser perjudicial para la próxima profesión. La reconocida credibilidad del sistema MIR no debería actuar como freno de las reformas necesarias. Para implementar las mismas se señalan una serie de problemas detectados como: inadecuación en la cantidad de determinados especialistas, solapamiento de áreas competenciales entre especialidades afines, rigidez en los sistemas de formación, déficit en los programas formativos y evaluativos (tanto a la entrada como durante el propio período de formación), falta de profesionalización de los tutores, formación heterogénea para la investigación y dificultades en la incorporación al trabajo como especialistas. Para poner remedio a estos problemas se proponen una serie de soluciones que, en caso de aplicarse, pueden aproximar a los profesionales especializados a las nuevas necesidades, logrando de esta manera mejoras en la calidad de la atención sanitaria.

Resumen Objetivo Proporcionar unas recomendaciones practicas para la evaluacion y seguimiento de los pacientes con hiperparatiroidismo normocalcemico. Participantes Miembros del Grupo de Trabajo de Metabolismo Mineral de la Sociedad Espanola de Endocrinologia y Nutricion. Metodos Se realizo una busqueda sistematica en MEDLINE de la evidencia disponible usando las siguientes palabras clave: normocalcemic primary hyperparathyroidism y primary hyperparathyroidism. Se revisaron articulos escritos en ingles con fecha de inclusion hasta el 22 de noviembre de 2012. La bibliografia fue revisada por 2 miembros del Grupo de Trabajo de Metabolismo Mineral de la Sociedad Espanola de Endocrinologia y Nutricion, y tras la formulacion de recomendaciones el manuscrito fue revisado por el resto de los integrantes del Grupo con incorporacion de las sugerencias realizadas. Conclusiones El documento establece unas recomendaciones practicas acerca de la evaluacion y seguimiento de los pacientes con hiperparatiroidismo normocalcemico. No obstante, y dada la escasa evidencia disponible acerca de diferentes aspectos de esta situacion (tasa de progresion y repercusiones clinicas, fundamentalmente), son necesarios mas datos antes de poder establecer recomendaciones definitivas.

Objective To provide practical recommendations for evaluation and follow-up of patients with normocalcemic primary hyperparathyroidism. Participants Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology. Methods A systematic search was made in MEDLINE (PubMed), using the terms normocalcemic primary hyperparathyroidism and primary hyperparathyroidism , for articles in English published before 22 November 2012. Literature was reviewed by 2 members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, and after development of recommendations, the manuscript was reviewed by all other members of the Group, and their suggestions were incorporated. Conclusions The document provides practical recommendations for evaluation and follow-up of patients with normocalcemic primary hyperparathyroidism. There is however little evidence available about different aspects of this disease, mainly progression rate and clinical impact. More data are therefore needed before definite recommendations may be made.

Pituitary apoplexy into nonadenomatous tissue is extremely rare. The authors describe a 20-year-old woman with symptomatic pituitary hemorrhage into an apparently intra-sellar malignant teratoma, which caused headache, visual impairment, involvement of III, IV, VI, and 1st division of the V cranial nerves, and hypopituitarism. Diabetes insipidus had developed previously. Magnetic resonance scans had a high-intensity signal in the pituitary on T1-and T2-weighted images, and lack of the signal of the posterior pituitary. Transsphenoidal approach, radiotherapy, and chemotherapy management did not preclude a fatal outcome.