Perfiles de hipoglicemiantes e insulinas en pacientes con diabetes mellitus tipo 2 y su efecto en control metabólico, hipoglicemia y otros efectos adversos / Profile of glucose lowering drug use in outpatients with type 2 diabetes mellitus

BACKGROUND: The use of glucose lowering agents with favorable weight profile is a growing practice in Diabetology. AIM: To characterize medication combinations in patients with type 2 Diabetes (T2D) and their effect on metabolic control. MATERIAL AND METHODS: Review of medical records of 249 outpatients with T2D with a median age of 66 years, cared for at a medical network. Clinical characteristics, glycated hemoglobin (HbA1c), details of Diabetes treatment (types of drugs or insulin), renal function, lipids and B12 vitamin levels were registered. RESULTS: The median disease duration was 16 years. The most recent HbA1c was 7.4%. No patient was using sulfonylureas, 45 were using Dipeptidyl peptidase 4 inhibitors, 113 were using Sodium-glucose Cotransporter-2 (SGLT2i) Inhibitors, 21 used Glucagon-like Peptide-1 Receptor Agonists (GLP1ra), 158 used basal insulin and 61 on basal plus bolus insulin. The use of SGLT2i or GLP1ra was associated with a metabolic control similar to those patients not using them, while patients on rapid insulin had a significantly worse metabolic control and a tendency to greater body mass index. The use of basal insulin and rapid insulin was significantly associated with more hypoglycemia events. CONCLUSIONS: The use of SGLT2i and GLP1ra in patients with T2D is associated with better metabolic control than rapid insulin with less risk of hypoglycemia. The use of these therapies should be prioritized in the future.

Reduced burnout and higher mindfulness in medical students after a self-care program during the COVID-19 pandemic / Reducción del agotamiento en estudiantes de medicina mediante auto-cuidado durante la pandemia COVID-19

ABSTRACT Background: Medical students experience high levels of psychological stress during clinical training. However, most medical curricula do not teach self-care skills. The COVID-19 pandemic has disrupted medical education causing increased distress among students. Aim: To report the implementation and impact of an eight-week multifaceted mindfulness-based self-care program on medical students' distress and well-being during the COVID-19 pandemic. Material and Methods: One hundred twenty-three fourth-year medical students attended the program as part of a mandatory course from April to May 2020, during the rising phase of COVID-19 in Chile. They were evaluated using validated tests before and immediately after the program. The measures included burnout, dispositional mindfulness, perceived stress, traumatic stress reactions, general well-being, resilience, and stress coping strategies. Results: Burnout prevalence decreased from 48% to 24%, whereas students with high dispositional mindfulness increased from 25% to 44%. Burnout reduction was mostly due to decreased emotional exhaustion. Additionally, students reported lower levels of stress, self-blaming, and traumatic stress reactions alongside an increased use of active coping strategies and resilience levels after the program. Conclusions: A formal educational intervention, teaching self-awareness and self-regulation skills can help reduce medical students' distress and promote their well-being even amidst a pandemic.

Antecedentes: Los estudiantes de medicina experimentan altos niveles de estrés y burnout durante la formación clínica. Sin embargo, la mayoría de los planes de estudios médicos no enseñan habilidades de autocuidado. La pandemia de COVID-19 ha conmocionado la educación médica provocando mayor distrés entre los estudiantes. Objetivo: Informar sobre la implementación y el impacto de un programa multifacético de autocuidado -basado en mindfulness (atención consciente)-sobre el distrés y el bienestar de los estudiantes de medicina durante la pandemia de COVID-19. Material y Métodos: Ciento veintitrés estudiantes de medicina de cuarto año asistieron al programa como parte de un curso obligatorio de abril a mayo de 2020, durante la fase ascendente de COVID-19 en Chile. Fueron evaluados mediante pruebas validadas antes e inmediatamente después del programa. Las medidas incluyeron burnout, mindfulness disposicional, estrés percibido, reacciones de estrés traumático, bienestar general, resiliencia y estrategias de afrontamiento del estrés. Resultados: La prevalencia del burnout disminuyó del 48% al 24%, mientras que los estudiantes con alto mindfulness aumentaron del 25% al 44%. La reducción del burnout se debió principalmente a la disminución del agotamiento emocional. Además, los estudiantes informaron niveles más bajos de estrés, autoinculpación y reacciones de estrés traumático junto con un mayor uso de estrategias activas de afrontamiento y mayores niveles de resiliencia, después del programa de autocuidado. Conclusiones: Una intervención educativa formal que enseñe habilidades de autoconciencia y autorregulación puede ayudar a reducir el burnout de los estudiantes de medicina y promover su bienestar incluso en medio de una pandemia.

Marcadores inmunológicos de diabetes tipo 1: análisis de 4.164 perfiles en un centro de salud de Chile / Analysis of 4, 164 type 1 diabetes antibody profiles in a Chilean health centre

Background: Previous studies have assessed the role of Type 1 diabetes (DM1) antibodies as predictors of the natural history of disease. Aim: To determine the frequency and combinations of positivity for DM1 antibodies in patients with DM1 and the relationship between antibody positivity and the age of the patient. To explore the relationship between history of insulin therapy or diabetic ketoacidosis (DKA) at the onset of the disease with antibody positivity in a subsample. Material and Methods: Data was gathered from every sample processed for DM1 antibodies in our laboratory between January 2015 and September 2019. Medical records from 84 patients who tested positive for at least one antibody were revised to study the relationship between insulin therapy or DKA at the onset of the disease with antibody positivity. Results: Forty percent of DM1 antibody tests were positive. Among positive tests, 1, 2, 3 or 4 DM1 antibodies were detected in 48%, 33%, 17% and 3% of cases, respectively. The likelihood of testing positive was inversely related with age for ICA, GAD, IA-2, ZnT8 and directlyproportionalforIAA (p= −0,012; −0,013; −0,014; −0,009; 0,005 respectively). An association between DKA at the onset of the disease and IA-2 positivity was observed (Odds ratio (OR) 5.38 95% confidence intervals (CI) 1.79 − 16.16, P < 0.01). No association was found between IAA positivity and history of insulin therapy (OR 2.25 95%CI 0.63 − 7.90, P = 0.2403). The results obtained from this study represent a novel local profile of DM1 antibody data, highlighting a relationship between antibody positivity and age.

Prevalencia de hiperglicemia y su relación con el tiempo de estadía en un hospital terciario / Association of hyperglycemia with the length of stay in hospitalized patients

Background: Hyperglycemia during hospital stay is associated with adverse outcomes. Aim: To characterize the frequency of hyperglycemia in a tertiary hospital and to correlate it with length of hospital stay (LOS). Material and Methods: Review of medical records of hospitalized patients. Demographic data and laboratory data, previous diabetes mellitus (DM) history, current main diagnosis, unit of hospitalization and the two highest capillary blood glucose values from the analyzed period were recorded for each patient. LOS was obtained from electronic clinical records. Results: 210 subjects, aged 60 ± 19 years (104 women) were included. 113 patients (54%) developed hyperglycemia ≥ 140 mg/L. Thirty one percent of these had a previous history of diabetes and 29% had stress hyperglycemia (SHG). Patients with a history of DM had a higher average blood glucose than those with SHG (238.9 and 178.2 mg/dL, respectively, p < 0.01) and a greater percentage of cases with a blood glucose above 180 mg/dL (72 and 40.0%, respectively, p < 0.01). Hospital LOS was significantly longer in patients with hyperglycemia ≥ 140 mg/dL as compared with those with normoglycemia (29.3 and 12.8 days, respectively, p < 0.01). This association remained significant when introduced in a linear regression analysis including diagnosis, decreased glomerular filtration rate (GFR) and hospitalization unit (p < 0.01). Conclusions: Hyperglycemia during hospitalization affects more than half of hospitalized patients and is associated with a longer length of stay.

Tratamiento de quilotórax y quiloascitis refractaria en paciente cirrótico. Caso clínico

Chylous Ascites (CA) and chylothorax (CTx) are associated with obstruction, disruption or insufficiency of the lymphatic system. We report a 68-year-old male, with a history of alcoholic cirrhosis, who had recurrent events of CTx and CA. After a complete study, no other etiologies other than portal hypertension were found. Therapy with diuretics, nothing per mouth, parenteral feeding plus octreotide did not relieve symptoms. A transjugular intrahepatic portosystemic shunt (TIPS) was successfully placed and pleural effusion subsided. This case shows that CA and CTx can be caused by portal hypertension and they may subside employing a multimodal management strategy.

Experiencia de uso de inhibidores del cotransportador sodio-glucosa 2 en diabéticos tipo 2 / Use of sodium-glucose cotrasporter 2 inhibitors in type 2 diabetics: experience in 77 patients

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a new pharmacological alternative for the treatment of diabetes. Aim: To report our experience with the use of this type of drugs in type 2 diabetics treated in an outpatient clinic. Material and Methods: We selected 77 type 2 diabetic patients aged 59 ± 11 years (45 men) who started SGLT2i, based on the advice of their treating physician. We registered their demographic characteristics and changes in metabolic parameters, weight, blood pressure, albuminuria and adverse effects, during a follow-up of at least three months. Results: We observed a decrease of glycosylated hemoglobin A1c of 0.8 ± 1.14% (p < 0.01) and a weight decrease of 2.5 ± 2.24 kg (p < 0.01). The proportion of patients with a glycosylated hemoglobin A1c of less than 7% increased from 7.2% to 30.9% (p = 0.002). In addition, a relative decrease in albuminuria of 39.9% was observed (p = 0.07). The treatment was well tolerated with a rate of adverse effects of 21%, all of them being categorized as mild. Of these, most of them corresponded to genital mycotic infections. Conclusions: The effects observed in this study are comparable and of similar magnitude to randomized studies of SGLT2i reported in the international literature.

Características clínicas, esquemas de tratamiento, grado de control y variables asociadas a este en una cohorte de adultos con diabetes mellitus tipo 1 en un centro terciario / Clinical features and management of 205 adults with type 1 diabetes mellitus

Background: Few studies have evaluated the details of insulin therapy for type 1 diabetes mellitus (T1D) in Chile. Aim: To describe clinical features and treatment details of adults with T1D and its association with metabolic control. Material and Methods: Review of medical records of patients with T1D treated in a clinical network. Demographic and clinical features, types and doses of insulin and glycated hemoglobin levels were registered. The use flash glucose monitors (FGM) and insulin pumps (CSII) were also recorded. Results: 205 records were reviewed, with T1d lasting 12 ± 10 years. Twenty six percent had hypothyroidism, 1% had celiac disease, 12% had hypertension, 20% had dyslipidemia; 13% had diabetic retinopathy, 2% had diabetic nephropathy, 8% had neuropathy and 2% cardiovascular diseases. Mean body mass index was 25 kg/ m2 and mean glycated hemoglobin was 8%. Eighty-two percent used multiple daily injections, 18% used CSII and 24% used FGM. As basal insulin, 35% used slow acting analogs and 65% used ultra-slow analogs. As rapid acting insulin, 69 patients used Lispro, 79 Aspart and 50 Glulisin. Bolus doses were calculated using only capillary glucose in 22%, while 78% also considered carbohydrate consumption. Variables significantly associated to better control were the use of carbohydrates for dosing rapid insulin (A1c 7,85% vs 8,59%, p = 0,008), use of CSII (A1c 7,36% vs 8,16%, p = 0,008), and basal dose < 0,4 U/kg (A1c 7,81% vs 8,58%, p = 0,003). There were no differences regarding insulin type or use of FGM. Conclusions: The use of formulas considering carbohydrates for dosing rapid insulin, use of infusion pumps and physiological doses of basal insulin are significantly associated with a better metabolic control in adults with T1d.

Cetoacidosis diabética: Casuística 2008-2012, epidemiología y fisiopatología / Treatment of diabetic ketoacidosis using 2009 American Diabetes Association guidelines

Background: During 2009, new guidelines for the treatment of diabetic ketoacidosis were published by the American Diabetes Association. Aim: To assess the impact of new treatment guidelines on the evolution of patients treated for diabetic ketoacidosis (KAD). Patients and Methods: Anonymous data was obtained from computational medical records of patients treated for KAD at our institution two years before (“Traditional Protocol”) and TWO years after (“ADA-2009 Protocol”) the publication of the 2009 American Diabetes Association (ADA) KAD guidelines. Results: Twenty three patients aged 36.5 ± 15.1 years were treated with the traditional method and 23 patients aged 44.4 ± 21.1 years were treated following 2009 ADA guidelines. Among patients treated with the traditional protocol and treated following ADA 2009 guidelines, the diabetes type 1/type 2 ratio was18/5 and 19/16 respectively (p = NS), the glycosylated hemoglobin on admission was 12.6 ± 2.5 and 14.3 ± 2.7% respectively (p = 0.03), minimal blood pH was 7.15 ± 0.14 and 7.19 ± 0.09 respectively (p = NS), bicarbonate was required in seven and no patient respectively (p = 0.01), hypokalemia < 3.5 mEq/L occurred in 78.2 and 48.5% of patients (p = 0.03), the lapse until resolution was 28.7 ± 28.0 and 28.8 ± 20.6 hours (p = NS). Only one patient, treated following ADA 2009 guidelines, died. Conclusions: Introduction of the ADA-2009 protocol for the treatment of KAD resulted in decrease in the use of intravenous bicarbonate and a reduction in the incidence of hypokalemia. There was no impact neither in the lapse until resolution or lethality.

Un curso de docencia clínica para residentes mejora la autopercepción de preparación para enseñar / A clinical teaching course for residents improves self-perception about preparation to teach

Background: Medical doctors need to be competent to teach patients, their families, students, and the health care team. In a previous study we determined that although the residents attach great importance to have teaching skills, they do not feel prepared to meet this role. Aim: To assess self-perception of learning in a formal course of training how to teach for residents. Material and Methods: In 2004 we implemented the course "Residents as Clinical Teachers", based on the Stanford Faculty Development Center for Medical Teachers Model (SFDC), for residents of a Medical School. Residents of all the post graduate programs were invited to take the course as an elective during the period 2004-2011. At the end of the course each resident completed the pre/post Seminar Series Housestaff/student Questionnaire; assessing perceptions of learning, expressed in a Likert scale from 1-5. Results: The implementation of the course in 111 residents significantly improved self-perception of general preparation for teaching and improved self-perception of preparedness in each educational category. The personal goals most commonly established by participants were on feedback (52,2%), control of session (44%) and communication of goals (40%). Barriers for teaching most frequently identified were lack of time to do clinical teaching (51,3%) and environmental limitations (16,2%). The main impact of the course reported by residents were acquisition of teaching skills or tools for teaching (39,6%), enhancing of motivation (14%), and a richer understanding of teaching principles (14%). Conclusions: A clinical teaching course for residents improves their self-perception of preparation to teach and enhances motivation for clinical teaching.