Glucemia de ingreso asociada a mortalidad y estancia hospitalaria en un servicio multidisciplinario de un hospital nacional peruano

Objetivo: Evaluar la asociación entre glucemia de ingreso y desenlaces adversos en pacientes hospitalizados con COVID-19 en un hospital nacional peruano. Métodos: Estudio observacional tipo cohorte retrospectiva. Se revisaron historias clínicas electrónicas de pacientes hospitalizados por COVID-19 en un servicio de especialidades. Los pacientes se clasificaron según niveles de glucemia al ingreso: ≤ y >140mg/dL; el desenlace primario fue mortalidad y el secundario un compuesto que incluyó mortalidad, shock séptico, ventilación mecánica o traslado a UCI. Se evaluó la estancia hospitalaria y se realizó un subanálisis de regresión logística multivariada en pacientes diabéticos. Resultados: Se evaluaron 169 pacientes, media de edad 61 años, 64.5% varones. 71% presentaban alguna comorbilidad, siendo las más frecuentes: hipertensión arterial (34%), obesidad (30%), diabetes (26%). El 70% presentó gravedad tomográfica. La mediana de glucemia de ingreso fue 126.5mg/dL (RIC: 109-157mg/dL), uno de cada 3 presentó glucemia >140mg/dL. La tasa de mortalidad fue 9700 muertes por cada 100 000 personas-semana, con frecuencia de 21.3%. No se encontró diferencia significativa entre hiperglucemia y normoglucemia, tanto en mortalidad como desenlace compuesto. Los pacientes con hiperglucemia de ingreso presentaron mayor estancia hospitalaria que los normoglucémicos (19 días vs 13 días, p180mg/dL presentó OR de 6.42 (IC95%: 1.07-38.6), ajustado a edad y a gravedad clínica de ingreso. Conclusiones: La hiperglucemia al ingreso se asoció a mayor estancia hospitalaria, y los pacientes diabéticos con hiperglucemia >180mg/dL presentaron un riesgo 6 veces mayor de presentar desenlace adverso.

Objective: Evaluate the association between glycemia on admission and adverse outcomes in hospitalized patients with COVID19 in a Peruvian national hospital. Methods: Retrospective, observational cohort study. We collected data from electronic medical records of COVID19 patients in a medical specialties service. Patients were classified according to blood glucose levels on admission: ≤ and >140mg/dL. Primary outcome was mortality, and the secondary a composite that included mortality, septic shock, mechanical ventilation, or transfer to ICU. We also evaluated hospital stay and a multivariate logistic regression sub analysis was performed in diabetic patients. Results: 169 patients were evaluated. The mean age was 61 years, 64.5% were male. 71% had at least one comorbidity, the most frequent: arterial hypertension (34%), obesity (30%) and diabetes (26%). 70% presented tomographic gravity. Median blood glucose at admission was 126.5mg/dL (IQR: 109-157mg/dL), one of every 3 had blood glucose levels >140mg/dL. Mortality rate was 9700 deaths per 100000 person-weeks, with a frequency of 21.3%. No significant difference was found between hyperglycemia and normoglycemia, mortality and in composite outcome. Patients with hyperglycemia on admission had longer hospital stay than normoglycemic patients (19 vs 13 days, p180mg/dL presented OR of 6.42 (95% CI: 1.07-38.6) for composite outcome, adjusted for age and clinical severity at admission. Conclusions: Hyperglycemia at admission was associated with a longer hospital stay and diabetic patients with hyperglycemia >180mg/dL had a 6-fold increased risk of presenting an adverse outcome.

Carcinoma de paratiroides en un paciente con hiperparatiroidismo terciario / Parathyroid carcinoma in a patient with tertiary hyperparathyroidism

Introducción: La mayoría de los pacientes con enfermedad renal crónica terminal en hemodiálisis desarrollan hiperparatiroidismo secundario. Algunas veces este tipo de hiperparatiroidismo secundario suele ser severo y refractario al tratamiento médico, inclusive algunos desarrollarán hiperparatiroidismo terciario, el tratamiento de ambas situaciones suele ser la paratiroidectomía subtotal o total. Reporte de Caso: Presentamos el caso de un paciente de 29 años, con enfermedad renal terminal en hemodiálisis durante 13 años, quien desarrolló hiperparatiroidismo terciario por lo que fue sometido a paratiroidectomía subtotal con autotrasplante de media glándula; el estudio patológico informó la presencia de un carcinoma de paratiroides en una de las cuatro glándulas paratiroides extirpadas. Conclusión: El carcinoma de paratiroides es una neoplasia rara que causa hiperparatiroidismo primario en menos de 1% de todos los casos, y se ha reportado en algunos pacientes operados por hiperparatiroidismo terciario.

Background: Most patients with terminal chronic kidney disease on hemodialysis develop secondary hyperparathyroidism. Sometimes this type of secondary hyperparathyroidism becomes severe and refractory to medical treatment, some will even develop tertiary hyperparathyroidism, the treatment of both situations is usually subtotal or total parathyroidectomy. Case Report: We present the case of a 29-year-old patient with end-stage kidney disease on hemodialysis for 13 years, who developed tertiary hyperparathyroidism, for which he underwent subtotal parathyroidectomy with half gland autotransplantation; the pathological study reported the presence of a parathyroid carcinoma in one of the four excised parathyroid glands. Conclusion: Parathyroid carcinoma is a rare neoplasm that causes primary hyperparathyroidism in less than 1% of all cases, and has been reported in some patients operated on for the development of tertiary hyperparathyroidism.

Síndrome poliuria - polidipsia de causa autoinmune en el posparto de una mujer de 27 años

La hipofisitis autoinmune es un cuadro caracterizado por la infiltración linfocítica de la hipófisis que produce deficiencia de una o más hormonas, tanto de la adenohipófisis como de la neurohipófisis. Para el diagnóstico, es necesario un alto índice de sospecha, más aún considerando la relación temporal con el embarazoo el parto. Las características clínicas e imagenológicas sugieren el diagnóstico. A pesar que el diagnóstico definitivo es por biopsia, esta no se suele realizar por los potenciales efectos adversos del procedimiento. Presentamos un caso que describe la forma de manifestación de la enfermedad y las características imagenológicas típicas en la resonancia magnética nuclear.

Autoimmune hypophysitis is a condition characterized by lymphocytic infiltration of the pituitary resulting in deficiency of one or more hormones of both the adenohypophysis and the neurohypophysis. For diagnosis, a high index of suspicion is necessary, even more so considering the temporal relationship with pregnancy or childbirth. Clinical and imaging features are suggestive of the diagnosis. Although the definitive diagnosis is by biopsy, this is not usually performed because of the potential adverse effects of the procedure. We present a case describing the form of manifestation of the disease and the typical imaging features on magnetic resonance imaging.

Utilidad del carbonato de litio, yoduro inorgánico y plasmaféresis en una paciente con hipertiroidismo severo y agranulocitosis por tiamazol en tiempos de COVID-19 / Usefulness of lithium carbonate, inorganic iodide and plasmapheresis in a patient with severe hyperthyroidism and agranulocytosis due to thiamazole in times of COVID-19

RESUMEN Mujer de 43 años con diagnóstico reciente de enfermedad de Graves-Basedow ingresa a urgencias por infección de tejidos blandos, agranulocitosis por tiamazol e hipertiroidismo descompensado. La paciente requería tratamiento definitivo para hipertiroidismo, pero dado el contexto de la pandemia por SARS-CoV-2 no se contaba con yodo radioactivo (131I) por lo que se planteó la tiroidectomía total. Se necesitaba una preparación preoperatoria rápida y eficaz por lo que se decidió compensar su hipertiroidismo con lugol, carbonato de litio, dexametasona y finalmente plasmaféresis antes de cirugía. Con ello se logró disminuir los niveles de hormonas tiroideas en el tiempo deseado y se procedió al tratamiento quirúrgico definitivo. Se presenta el caso por lo anecdótico y por ser necesario el conocimiento del manejo en escenarios, como esta pandemia, donde no haya acceso a 131I.

ABSTRACT A 43-year-old woman with a recent diagnosis of Graves-Basedow disease was admitted to the emergency room due to soft tissue infection, thiamazole agranulocytosis, and severe hyperthyroidism. The patient required definitive treatment for hyperthyroidism, but given the context of the SARS-COV-2 pandemic, radioactive iodine was not available, so she prepared for total thyroidectomy. A rapid and effective preoperative preparation was required, so it was decided to compensate her hyperthyroidism with lugol, lithium carbonate, dexamethasone and finally plasmapheresis before surgery. Thyroid hormone levels normalized in a short time, and the thyroidectomy was performed. The case is presented because of the anecdotal and because knowledge of management in scenarios, such as this pandemic, where there is no access to 131I.

Disfunción tiroidea inducida por amiodarona en la práctica clínica: [revisión] / Thyroid dysfunction induced by amiodarone in clinical practice: [review]

La amiodarona (AMD) es una droga antiarrítmica potente (clase III) usada en la práctica clínica para la profilaxis y el tratamiento de muchos disturbios del ritmo cardiaco, desde la fibrilación auricular paroxística hasta las taquiarritmias ventriculares que amenazan la vida. Frecuentemente causa cambios en las pruebas de función tiroidea principalmente relacionados a la inhibición de la actividad de la 5'-deiodinasa, resultando en una disminución de la generación de T3 desde T4 y el consecuente incremento en la producción de T3 reversa y una disminución de su aclaramiento. En 14 a 18 por ciento de pacientes tratados con AMD hay una disfunción tiroidea manifiesta, ya sea tirotoxicosis inducida por amiodarona (TIA) o hipotiroidismo inducido por amiodarona (HIA). Tanto TIA como HIA pueden desarrollarse en glándulas aparentemente normales o en glándulas con anormalidades preexistentes clínicamente silentes. La TIA está primariamente relacionada a la síntesis de hormonas tiroideas inducida por el exceso de yodo en una glándula tiroidea anormal (TIA tipo 1) o a una tiroiditis destructiva relacionada a la amiodarona (TIA tipo 2), aunque frecuentemente ocurren formas mixtas. La tiroiditis de Hashimoto preexistente es un factor de riesgo definido para la ocurrencia de HIA. La patogenia del HIA es la falla para escapar del efecto agudo de Wolff-Chaikoff inducido por el yodo, debido a los defectos en la hormonogénesis tiroidea y, en pacientes con pruebas de autoanticuerpos tiroideos positivos, para tiroiditis de Hashimoto concomitante. La TIA es más común en zonas deficientes de yodo mientras que el HIA es usualmente visto en zonas suficientes en yodo. En contraste al HIA, la TIA es una condición difícil de diagnosticar y tratar, y usualmente se recomienda la descontinuación de la amiodarona. En esta revisión se analiza, de acuerdo a los datos actuales, las alteraciones en las pruebas de función tiroidea vistas en pacientes eutirodeos bajo tratamiento con AMD así como la epidemiología y opciones de tratamiento disponibles para ambos tipo de disfunción tiroidea inducida por amiodarona, TIA e HIA.

Amiodarone is a potent class III anti-arrhythmic drug used in clinical practice for the prophylaxis and treatment of many cardiac rhythm disturbances, ranging from paroxismal atrial fibrillation to life threatening ventricular tachyarrhythmias. Amiodarone often causes changes in thyroid function tests mainly related to inhibition of 5'-deiodinase activity resulting in decrease in the generation of T3 from T4 with consequent increase in rT3 production and decrease in its clearance. In 14-18 per cent of amiodarone-treated patients, there is overt thyroid dysfunction, either amiodarone-induced thyrotoxicosis (AIT) or amiodarone-induced hypothyroidism (AIH). Both AIT and AIH may develop either in apparently normal thyroid glands or in glands with preexisting clinically silent abnormalities. AIT is primarily related to excess iodine-induced thyroid hormone synthesis in an abnormal thyroid gland (type I AIT) or to amiodarone-related destructive thyroiditis (type II AIT). AIH pathogenesis is related to escape failure from the acute Wolff-Chaikoff effect due to defects in thyroid hormonogenesis or, in patients with positive thyroid autoantibody test, to concomitant Hashimoto's thyroiditis. AIT is more common in iodine-deficient regions of the world, whereas AIH is usually seen in iodine-sufficient areas. In contrast to AIH, AIT is a condition difficult to diagnose and treat, and discontinuation of amiodarone is usually recommended. In this review discusses, according to data from current literature, alterations in thyroid laboratory tests seen in euthyroid patients under treatment with amiodarone and the epidemiology and treatment options available of amiodarone-induced thyroid dysfunctions (AIT and AIH).

Injerto vascular de aponeurosis con peritoneo en perros / Vascular graft of aponeurosis with peritoneum in dogs

BACKGROUND: Vascular autografts are commonly used to repair damage to blood vessels; however, they can be used only with small-caliber vessels. Although synthetic vascular grafts are good options, there may be a high likelihood of thrombus formation. METHODS: An experimental animal model was used in order to evaluate feasibility and viability of a vascular autograft. Under inhalatory anesthesia, seven mongrel dogs were operated on. A 4-cm vascular autograft was created with the posterior rectus aponeurosis with subjacent peritoneum, leaving the second one as the internal sheath. A 2-cm-long portion of the abdominal aorta was removed and the vascular autograft was inserted by end-end surgical anastomosis. Animals were observed for 7 weeks, evaluating clinical data of vascular insufficiency (intensity of pulse, temperature and trophic changes of the legs). At the end of the experiment, aortography under fluoroscopic visualization was performed. Dogs were sacrificed and autograft removed in order to evaluate permeability. RESULTS: All dogs survived until the end of the procedure. Vascular autograft was easy to create. During surgery, no evidence of bleeding of the anastomosis or the graft suture was noted. At the end of the procedure, no clinical signs of vascular insufficiency were noted; radiographic evaluation of the autograft showed no dye leakage at any level. Autografts were removed and no signs of thrombus formation were noticed. CONCLUSIONS: Feasibility of the vascular autograft was demonstrated with good permeability and no thrombogenicity.

Estudio de la función endotelial mediante tomografía por emisión de positrones en pacientes con hipercolesterolemia / Endothelial function assessment by positron emission tomography in patients with hypercholesterolemia

Hypercholesterolemia prompts to endothelial dysfunction (ED) and ED predisposes to atherogenesis. ED appears early in the course of atherogenesis and it is considered a coronary artery disease (CAD) marker. OBJECTIVES: To assess endothelial function (EF) using Positron Emission Tomography (PET) in asymptomatic patients with recent dyslipidemia diagnosis and without history of ischemic heart disease and previous hypolipemiant treatment. MATERIAL AND METHODS: Fourteen asymptomatic patients with recent dyslipidemia diagnosis (< 6 months) were studied by obtaining a lipid profile, blood glucose, and a three phase 13N-ammonia PET scan: rest, cold pressor test (CPT) and pharmacologic stress with adenosine. EF was assessed by calculating the coronary flow reserve (CFR), endothelial-dependant vasodilatation index (EDVI), and coronary blood flow increase percentage in CPT (% Delta CF). RESULTS: 79% of patients with dyslipidemia had ED and all their values were lower than those previously published as normal: rest coronary flow 0.44 +/- 0.12 vs 0.57 +/- 0.147 (p = 0.002), CPT coronary flow 0.57 +/- 0.17 vs 0.88 +/- 0.26 (p = 0.001), stress coronary flow 1.24 +/- 0.05 vs 1.81 +/- 0.35 (p = 0.005), EDVI 1.28 +/- 0.25 vs 1.53 +/- 0.24 (p 0.017), CRF 2.79 +/- 0.94 vs 3.15 +/- 0.48 (p 0.198) and % Delta CF 29.08 +/- 24.62% vs 53 +/- 24.60% (p 0.022). Conclusions: Asymptomatic patients in early stages of dyslipidemia showed a greater ED prevalence that was detected by 13N-ammonia PET scan.

Evaluación de las alteraciones de la perfusión miocárdica y función ventricular derecha con SPECT y ecocardiografía en la transposición corregida de las grandes arterias / Evaluation of myocardial perfusion and right ventricular function alterations by SPECT and echocardiography after great arteries corrected transposition

Antecedentes: La transposición corregida de grandes arterias (TCGA) es una cardiopatía congénita rara, asociada a disfunción ventricular derecha. El objetivo del presente trabajo fue evaluar por técnicas de medicina nuclear como la ventriculografía en equilibrio y SPECT sincronizado utilizando Tc-99m sestamibi reposo-esfuerzo, la función y perfusión del ventrículo derecho en pacientes adultos con TCGA no operados y comparar los resultados con el ecocardiograma convencional (ETT) y de contraste (EC). Material y métodos: Se estudiaron 13 pacientes a quienes se les realizó ventriculografía con radioisótopos para evaluar la función ventricular derecha y SPECT sincronizado para estudiar la perfusión y función del ventrículo derecho. Los resultados obtenidos se compararon con el ETT y EC. Resultados: La fracción de expulsión ventricular derecha calculada por ventriculografía tuvo correlación de 0.67 (p = 0.059) con la fracción de acortamiento de áreas y de 0.84 (p = 0.01) para el método de descenso del anillo tricuspídeo. Conclusiones: El EC y SPECT sincronizado son métodos de gran utilidad en el estudio de la perfusión miocárdica del ventrículo derecho en pacientes en el que dicho ventrículo se comporta como sistémico. El índice de concordancia diagnóstica entre estas dos técnicas obtenido fue de 0.76 (p = 0.005) para identificar defectos fijos y 0.68 (p = 0.009) para defectos reversibles.

BACKGROUND: Great arteries corrected transposition is a rare congenital heart disease associated with right ventricle dysfunction. The objective of this study was to assess by equilibrium ventriculography (EV) and gated SPECT with Tc-99m sestamibi rest-stress protocol, right ventricle function and perfusion in adult patients with CTGA without previous surgery, and to compare the results with the standard transthoracic cross-sectional (TTE) and color coded Doppler echocardiography (CE) techniques. METHODS: We studied 13 patients, who underwent ventriculography to assess right ventricle function and gated SPECT to evaluate myocardial perfusion and right ventricle function. The data obtained were compared with TTE and CE. RESULTS: Right ventricle ejection fraction was measured using nuclear medicine and showed a Pearson correlation coefficient of 0.67 (p = 0.059) with the shortening area fraction and 0.84 (p = 0.01) with the tricuspid ring descendent method. CONCLUSIONS: Gated SPECT and Echo contrast are extremely valuable methods in the assessment of myocardial perfusion of the right ventricle in this group of patients. The diagnostic agreement index of both studies was 0.76 (p = 0.005) to identify non-reversible defects and 0.68 (p = 0.009) for reversible defects.

Comparison of 18FDG PET with thallium SPECT in the assessment of myocardial viability. A segmental model analysis

BACKGROUND: In patients with myocardial infarction and left ventricular dysfunction, the evidence of myocardial viability is primordial. There are some methods to detect the presence of myocardial viability, 201 thallium reinjection SPECT protocol represents the most common radioisotopic technique to evaluate it. Positron emission tomography (PET) using FDG is considered the gold standard. The aim of this study was to compare globally and by segments the value of both techniques in the detection of viable myocardium. METHODS: Twenty-three consecutive patients with previous myocardial infarction and left ventricular dysfunction were studied. All of them underwent into a SPECT perfusion scan and a FDG PET study to asses myocardial viability. Each study was performed in less than one week between the other. For the analysis, the myocardium was divided into 17 segments. A visual semi-quantitative analysis was carried out according to the following score indicating radiotracer uptake: O = normal to 4 = absent. Myocardial viability was defined as the presence of normal, mildly or moderately reduced radiotracer uptake. The scores obtained by PET were compared to those obtained in SPECT. A statistical analysis was performed using the SPSS v. 10. RESULTS: 391 segments were analyzed. PET detected viability in 130 segments that had been defined as non-viable by SPECT. No differences in the analysis by vascular territories were found. Thirty percent of the segments that were defined as non viable by SPECT were viable by PET, meanwhile only 1% of the segments detected viable by SPECT were considered non viable with PET. CONCLUSIONS: FDG PET study represents a better technique to detect myocardial viability, compared to thallium reinjection SPECT protocol. By this study we have demonstrated that more of 3 of each 10 studies may be diagnosed as non viable where viability is present.