Jaime Villena

Thyroid hormone levels improve the prediction of mortality among patients admitted to the intensive care unit.

ObjectiveAs hormones are strongly associated with mortality in critically ill patients, we investigated whether mortality prediction based on the Acute Physiology and Chronic Health Evaluation (APACHE) is improved by combining this score with hormone measurements.Design and settingIntensive care units in three hospitalsPatients and participants113 patients admitted to.MeasurementsWithin the first hour after ICU admission we measured total triiodothyronine, total thyroxine, free thyroxine, thyrotropin, cortisol, growth hormone, dehydroepiandrosterone, and prolactin levels and administered the APACHE. Patients were followed until they died or were discharged from the ICU.ResultsThe best logistic regression model for ICU mortality included the APACHE score and thyroid-stimulating hormone and triiodothyronine levels. This model had an area under the receiver operating characteristic curve of 0.88, significantly higher than the APACHE score alone with 0.75. The model with hormone levels and APACHE score was also significantly better calibrated than the model with only the APACHE score.ConclusionsThe addition of thyroid hormones to the APACHE score improves the prediction of mortality for ICU patients

Prevalence of diabetic retinopathy in Peruvian patients with type 2 diabetes: results of a hospital-based retinal telescreening program.

OBJECTIVE To estimate the prevalence of diabetic retinopathy (DR) in patients with type 2 diabetes and to determine any association with clinical factors. METHODS This hospital-based screening project was designed to prospectively detect the presence of DR in patients with type 2 diabetes by grading images acquired with a digital retinal camera. RESULTS Of 1 311 patients screened, appropriate retinal images were obtained in 1 222 subjects (93.2%). DR was detected in 282 patients (23.1%) [95% confidence interval (CI): 20.71-25.44]; 249 patients (20.4%) (95% CI: 18.1-22.6) had nonproliferative DR and 33 (2.7%) (95% CI: 1.8-3.6) had proliferative DR. In 32 patients (11.3%), DR was unilateral. The frequency of DR was the same in both sexes. Prevalence of blindness was twice as frequent in patients with DR as in those without it (9.4% and 4.6%, respectively) (P = 0.001). The frequency of DR at diagnosis was 3.5% and it increased with the duration of diabetes. DR was more frequent in patients with arterial hypertension, macrovascular or microvascular complications, and hemoglobin A1c (HbA1c) > 7.0% and in those treated with insulin or sulfonylureas. It was less prevalent in those with HbA1c < 7.0%, with greater body mass index, and who had been treated with metformin. CONCLUSIONS The prevalence of DR in these patients with type 2 diabetes was 23.1%. Nonproliferative retinopathy accounted for 77.0% of cases. Although less prevalent than in a previous report, it doubled the frequency of blindness in the people affected. A national screening DR program should be considered in order to detect this prevalent condition early and treat it in a timely fashion.

Hyperglycemic hyperosmolar state and rhino-orbital mucormycosis

Rhino-orbital mucormycosis is a fatal infection. Decompensated diabetes is the most common predisposing factor. Two male adults were admitted because of newly diagnosed diabetes with hyperglycemic hyperosmolar state and CT scan showed extensive pansinusitis and orbital inflammation. Treatment included surgical debridement and antifungal therapy. One patient died from a severe sepsis.

Diabetic KetoaciDosis in Peruvian Patients With tyPe 2 Diabetes Mellitus

OBJECTIVE To describe the clinical and laboratory characteristics of diabetic ketoacidosis (DKA) in adult Peruvian patients with type 2 diabetes mellitus. METHODS In this cross-sectional analysis, we reviewed clinical charts of type 2 diabetic patients with DKA admitted to Cayetano Heredia Hospital between 2001 and 2005 for data on demographics, previous treatment, previous hospital admissions for DKA, family history of diabetes, precipitating factors, hospital course, mortality, and insulin use 3 and 6 months after the index DKA episode. Patients older than 18 years who had confirmed DKA were included. Patients with type 1 diabetes mellitus were excluded. RESULTS We report on 53 patients with DKA for whom complete clinical and laboratory data were available. Of the 53 patients, 39 (74%) were men; mean age (+/- SD) was 45 +/- 12 years; and 22 (42%) had no previous diagnosis of type 2 diabetes. The following mean (+/- SD) laboratory values were obtained at DKA diagnosis: glucose, 457 +/- 170 mg/dL; pH, 7.15 +/- 0.14; bicarbonate, 7.73 +/- 6 mEq/L; and anion gap, 24.45 +/- 7.44 mEq/L. Of the 53 DKA episodes, 35 (66%) were severe (arterial pH <7.0 and/or serum bicarbonate <10 mEq/L). The following precipitating factors were discerned: discontinuation of treatment in 21 (40%), infections in 16 (30%), intercurrent illness in 3 (6%), and no identifiable cause in 13 (25%). Mortality rate was 0%. Three and 6 months after the index DKA episode, insulin was used by 65% and 56% of patients, respectively. CONCLUSION In countries with a low incidence of type 1 diabetes, DKA is frequently reported in patients with type 2 diabetes. In this study, 42% of patients had new-onset disease. Most DKA episodes were severe and were related to infection or noncompliance with treatment.

Diabetes Mellitus in Peru

BACKGROUND Peru is an upper medium-income developing country with an increasing prevalence of chronic diseases, including diabetes. OBJECTIVE To review and describe the epidemiology, drivers, and diabetes care plan in Peru. METHODS The medical literature was reviewed based on systematic searching of PubMed, Scielo, and various gray literature from the International Diabetes Federation, World Health Organization, and local Peruvian agencies. FINDINGS In Peru, diabetes affects 7% of the population. Type 2 diabetes accounts for 96.8% of outpatients visits with this condition. Type 1 diabetes has an incidence of 0.4/100,000 per year, and gestational diabetes affects 16% of pregnancies. The prevalence of glucose intolerance is 8.11% and that of impaired fasting glucose 22.4%. The prevalence of overweight, obesity, and metabolic syndrome in adults is 34.7%, 17.5%, and 25%, respectively. Metabolic syndrome prevalence is greater in women and the elderly and at urban and low-altitude locations. Diabetes is the eighth cause of death, the sixth cause of blindness, and the leading cause of end-stage kidney disease and nontraumatic lower limb amputation. In Peru, diabetes accounts for 31.5% of acute myocardial infarctions and 25% of strokes. Infections, diabetic emergencies, and cardiovascular disorders are the main causes for admissions, with a mortality rate < 10%, mainly as a result of infections, chronic kidney disease, and stroke. Sixty-two percent of the population has health insurance coverage, with inequities in the distribution of health care personnel across the country. Less than 30% of treated patients have a hemoglobin A1c < 7%. CONCLUSIONS Diabetes is a major health care issue in Peru that exposes difficult challenges and shortcomings. The national strategy for tackling diabetes includes promotion of healthy lifestyles; training primary care physicians and providing them with evidence-based clinical practice guidelines, safe and effective medications, and tools for monitoring treatment; and, finally, construction of a comprehensive health care network for early referral in order to prevent, detect, and treat diabetic complications.

Diabetic ketoacidosis during gestational diabetes. A case report.

Diabetic ketoacidosis is an infrequent complication of gestational diabetes but results in fetal loss. It usually occurs in the later stages of pregnancy. We report two young pregnant women who were admitted because of newly diagnosed diabetes with ketoacidosis. One patient presented with intrauterine fetal demise.

Asociación de la neuropatía autonómica cardiovascular y el intervalo QT prolongado con la morbimortalidad cardiovascular en pacientes con diabetes mellitus tipo 2

In order to evaluate the relationship between cardiovascular autonomic neuropathy and corrected QT interval (QTc) with cardiovascular morbidity and mortality in patients with type 2 diabetes mellitus, we followed up for 5 years 67 patients attending the outpatient Endocrinology Service. 82% completed follow-up and cardiovascular events occurred in 16 patients. We found that long QTc interval was the only variable significantly associated with cardiovascular morbidity and mortality in the multiple logistic regression analysis (RR: 13.56, 95% CI: 2.01-91.36) (p = 0.0074).

SIGMOID VOLVULUS IN MYXEDEMA MEGACOLON

ABSTRACT Objective: To report a case of myxedema megacolon complicated with sigmoid volvulus that was successfully managed with surgery and intensive thyroid hormone replacement therapy (THRT). Methods: The clinical presentation, laboratory and imaging results, treatment of the myxedema megacolon episode, and post-surgical evolution with THRT are presented. Results: We present the case of a 17-year-old woman with history of congenital hypothyroidism, chronic constipation, and irregular treatment with levothyroxine, who was admitted to the emergency room following 7 days of abdominal pain, nausea, and vomiting. She presented with marked abdominal distention and without bowel sounds. An abdominal computerized tomography scan showed a severe colon enlargement. Thyroid-stimulating hormone (TSH) was 222 μIU/mL, total thyroxine was <1 μg/dL, and total triiodothyronine was <40 ng/dL. Exploratory laparotomy was performed. Sigmoid volvulus was found and sigmoidectomy was performed. No evidence of colonic obstructi...