Héctor Eloy Tamez-Pérez

Steroid hyperglycemia: Prevalence, early detection and therapeutic recommendations: A narrative review

Steroids are drugs that have been used extensively in a variety of conditions. Although widely prescribed for their anti-inflammatory and immunosuppressive properties, glucocorticoids have several side effects, being hyperglycemia one of the most common and representative. In the present review, we discuss the main epidemiologic characteristics associated with steroid use, with emphasis on the identification of high risk populations. Additionally we present the pathophysiology of corticosteroid induced hyperglycemia as well as the pharmacokinetics and pharmacodynamics associated with steroid use. We propose a treatment strategy based on previous reports and the understanding of the mechanism of action of both, the different types of glucocorticoids and the treatment options, in both the ambulatory and the hospital setting. Finally, we present some of the recent scientific advances as well as some options for future use of glucocorticoids.

Clinical course of diabetic ketoacidosis in hypertriglyceridemic pancreatitis.

Objectives Hypertriglyceridemic pancreatitis (HP) is an uncommon condition accounting for 1% to 4% of cases of acute pancreatitis, mostly associated with poor glycemic control. Diabetic ketoacidosis (DKA) may complicate the clinical course of HP. Our objective was to identify clinical and demographic differences between HP and DKA patients compared with those without DKA. Methods Fifty-five patients with HP were included. Diabetic ketoacidosis was diagnosed in 8 patients. We analyzed the severity, hospital stay, delay in oral intake, duration of insulin infusion, complete blood cell count, and triglyceride levels. Results Diabetic ketoacidosis was associated with a more severe HP. There were no differences in hospital stay, delay in oral intake, or duration of insulin treatment in both groups. Serum amylase, lipase, and triglyceride levels were similar. Previous diagnosis of diabetes mellitus, higher Ranson and APACHE II scores, and higher serum glucose level at admission were the only predictive risk factors for DKA and HP. Conclusions Coexistence of DKA does not modify the clinical course of HP, although a more severe episode of HP in DKA patients. Diabetic ketoacidosis was associated with higher insulin doses, without impact in triglyceride levels. Diabetic ketoacidosis and HP should be considered when a previous diagnosis of diabetes mellitus and a severe HP are present.

Continuous glucose monitoring in acute coronary syndrome

BACKGROUND Diabetes mellitus is an independent risk factor for cardiovascular disease. OBJECTIVE To compare the efficacy of devices for continuous glucose monitoring and capillary glucose monitoring in hospitalized patients with acute coronary syndrome using the following parameters: time to achieve normoglycemia, period of time in normoglycemia, and episodes of hypoglycemia. METHODS We performed a pilot, non-randomized, unblinded clinical trial that included 16 patients with acute coronary artery syndrome, a capillary or venous blood glucose ≥ 140 mg/dl, and treatment with a continuous infusion of fast acting human insulin. These patients were randomized into 2 groups: a conventional group, in which capillary measurement and recording as well as insulin adjustment were made every 4h, and an intervention group, in which measurement and recording as well as insulin adjustment were made every hour with a subcutaneous continuous monitoring system. Students t-test was applied for mean differences and the X(2) test for qualitative variables. RESULTS We observed a statistically significant difference in the mean time for achieving normoglycemia, favoring the conventional group with a P = 0.02. CONCLUSION Continuous monitoring systems are as useful as capillary monitoring for achieving normoglycemia.

Acute Pancreatitis and Diabetic Ketoacidosis following L-Asparaginase/Prednisone Therapy in Acute Lymphoblastic Leukemia

Acute pancreatitis and diabetic ketoacidosis are unusual adverse events following chemotherapy based on L-asparaginase and prednisone as support treatment for acute lymphoblastic leukemia. We present the case of a 16-year-old Hispanic male patient, in remission induction therapy for acute lymphoblastic leukemia on treatment with mitoxantrone, vincristine, prednisone, and L-asparaginase. He was hospitalized complaining of abdominal pain, nausea, and vomiting. Hyperglycemia, acidosis, ketonuria, low bicarbonate levels, hyperamylasemia, and hyperlipasemia were documented, and the diagnosis of diabetic ketoacidosis was made. Because of uncertainty of the additional diagnosis of acute pancreatitis as the cause of abdominal pain, a contrast-enhanced computed tomography was performed resulting in a Balthazar C pancreatitis classification.

Neutral protamine hagedorn/regular insulin in the treatment of inpatient hyperglycemia: Comparison of 3 basal-bolus regimens

AIM To compare the safety and efficacy or 3 basal-bolus regimens of neutral protamine hagedorn (NPH)/regular insulin in the management of inpatient hyperglycemia. METHODS We randomized 105 patients with blood glucose levels between 140 and 400 mg/dL to a basal-bolus regimen of NPH insulin given once (n = 30), twice (n = 40) or three times (n = 35) daily, in addition to pre-meal regular insulin. Major outcomes included were differences in glycemic control, frequency of hypoglycemia and total insulin dose. RESULTS NPH insulin given in a once-daily regimen was associated with better glycemic control (58.3%) compared to twice daily (42.4%) and three times daily (48.9) regimens (P = 0.031). The frequency of hypoglycemia was similar between the three groups (2.0%, 0.7% and 1.2%, P = 0.21). The mean insulin dose at discharge was 0.48 ± 0.14 U/kg in the once-daily group compared to 0.69 ± 0.28 in the twice-daily, and 0.65 ± 0.20 in the three times daily regimens (P < 0.001). CONCLUSION NPH insulin administered in a once-daily regimen resulted in improvement in glycemic control with similar rates of hypoglycemia compared to a twice-daily and a three times-daily regimen. Further studies are needed to evaluate whether this regimen could be implemented in all hospitalized patients with hyperglycemia.

The rate of primary hypothyroidism in diabetic patients is greater than in the non-diabetic population. An observational study

BACKGROUND AND OBJECTIVE The aim of our study was to identify the rate of diabetic patients treated for hypothyroidism and compare them with a group without type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS We reviewed the computerized clinical records of 5161 patients. We identified diabetic patients treated with l-thyroxine. We compared the prevalence of PH with those patients under treatment with levothyroxine without T2DM. We excluded patients with a thyroid neoplasia, thyroid surgery, panhypopituitarism, or surgical complications of multinodular goiter or a thyroid nodule. Subclinical hypothyroidism was not considered. RESULTS We included 1848 adult patients with T2DM in the study group, 58% women and 42% men. For the control group, we included 3313 non-diabetic patients, 55% women and 45% men. The mean age in the study group was 52±7 years, and 47±4 years in the control group (p<.001). The rate of hypothyroidism in the study group was 5.7%, and in the control group 1.8% (odds ratio of 3.45; 95% confidence interval 2.51-4.79) (p<.001). CONCLUSION A strong association between T2DM and hypothyroidism was found. We recommend a thyroid profile in all patients with T2DM, similar to the recommendation in type 1 diabetes mellitus.Background and objective The aim of our study was to identify the rate of diabetic patients treated for hypothyroidism and compare them with a group without type 2 diabetes mellitus (T2DM).

Brief reportThe rate of primary hypothyroidism in diabetic patients is greater than in the non-diabetic population. An observational studyLa proporción de hipotiroidismo primario en pacientes diabéticos es mayor que la de pacientes no diabéticos. Estudio observacional

BACKGROUND AND OBJECTIVE The aim of our study was to identify the rate of diabetic patients treated for hypothyroidism and compare them with a group without type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS We reviewed the computerized clinical records of 5161 patients. We identified diabetic patients treated with l-thyroxine. We compared the prevalence of PH with those patients under treatment with levothyroxine without T2DM. We excluded patients with a thyroid neoplasia, thyroid surgery, panhypopituitarism, or surgical complications of multinodular goiter or a thyroid nodule. Subclinical hypothyroidism was not considered. RESULTS We included 1848 adult patients with T2DM in the study group, 58% women and 42% men. For the control group, we included 3313 non-diabetic patients, 55% women and 45% men. The mean age in the study group was 52±7 years, and 47±4 years in the control group (p<.001). The rate of hypothyroidism in the study group was 5.7%, and in the control group 1.8% (odds ratio of 3.45; 95% confidence interval 2.51-4.79) (p<.001). CONCLUSION A strong association between T2DM and hypothyroidism was found. We recommend a thyroid profile in all patients with T2DM, similar to the recommendation in type 1 diabetes mellitus.Background and objective The aim of our study was to identify the rate of diabetic patients treated for hypothyroidism and compare them with a group without type 2 diabetes mellitus (T2DM).

Galectin Labeling of Cells from Paraffinized Tissues May Serve as a Diagnostic Tool in the Detection and Classification of Thyroid Carcinomas

This study seeks to determine whether the relative levels of attachment to galectins 1 and 3 of cells from thyroid tissues embedded in paraffin blocks can differentiate thyroid tumors from normal tissues. A total of 48 thyroid paraffin sample blocks from 4 groups of patients were analyzed: 12 samples served as controls, 12 samples were from patients with thyroid adenoma, 12 samples were from patients with thyroid follicular carcinoma, and 12 samples were from patients with thyroid papillary carcinoma. The relative attachment of cells to galectins 1 and 3 antigens was determined using the InnoCyte™ ECM Cell Adhesion kit at different cell sample concentrations. All of the samples from thyroid tissue preparations showed attachment to galectins 1 and 3. The samples from tissues with a diagnosis of adenoma, follicular and papillary carcinoma showed an increased adherence to galectins 1 and 3 relative to the controls. Significant differences were found between the means of the adherent cells from the adenomas compared with the follicular and papillary carcinoma samples. When the outcomes from the galectins 1 and 3 cell surface binding were compared, no statistical differences were found. The cells from adenoma and carcinoma samples show more adhesion to galectins 1 and 3 than cells from the control samples. The samples prepared from follicular and papillary carcinomas show more cells adherent to galectins 1 and 3 than those from the adenomas.