Hipertiroidismo por enfermedad de Graves posterior a vacuna contra SARS-CoV-2: reporte de 2 casos / Graves' disease hyperthyroidism following SARS-CoV-2 vaccination: a two cases report

Luego del inicio de las campañas de vacunación masiva contra la infección por COVID-19, se han publicado una serie de reportes que muestran la posible asociación entre la vacuna y alteraciones de la función tiroidea. Desde entonces, múltiples teorías han intentado explicar este hallazgo, en su mayoría de índole autoinmune. Dentro de estas destaca el síndrome autoinmune-autoinflamatorio secundario a adyuvantes (ASIA), que podría generar desórdenes tiroideos de novo o exacerbar los ya existentes. Presentamos dos casos de enfermedad de Graves Basedow posterior al uso de Coronavac. Ambas pacientes presentaron características similares a las descritas en la literatura y cumplen con los criterios de ASIA. No obstante, los beneficios de las vacunas superan los posibles riesgos asociados.

After the beginning of COVID-19 vaccination campaigns, a number of reports have shown the potential association between vaccines and thyroid disfunction. Since then several theories have tried to explain this finding, mostly autoinmmune. One of them is the autoimmune/inflammatory syndrome induced by adjuvants, that could trigger or exacerbate thyroid disease. We present two cases of Graves' disease post Coronavac vaccination. Both pacients share similar features than cases published previously and meet criteria for ASIA syndrome. Nevertheless, the benefts of vaccination largely outweigh any adverse events associated.

Cetoacidosis diabética como debut de diabetes mellitus inmunomediada en paciente en tratamiento con inhibidores de checkpoint / Diabetic ketoacidosis as debut of immune-mediated diabetes mellitus in a patient in treatment with immune checkpoint inhibitors

Los inhibidores de checkpoint (ICP) son anticuerpos usados en inmunoterapia contra el cáncer. Uno de sus blancos de acción es el receptor de muerte celular programada-1 (PD-1), el cual es importante para mantener la tolerancia inmunitaria. Sin embargo, este mecanismo se asocia a riesgo de eventos adversos relacionados a la inmunidad que pueden afectar a múltiples órganos incluyendo el sistema endocrino. Se describe el caso inhabitual de un paciente que a los 18 meses de terapia con ICP debutó con cetoacidosis diabética (CAD).

Immune checkpoint inhibitors consist in antibodies used in immunotherapy against cancer. One of their targets is the programmed cell death-1 (PD-1) receptor, which is important in maintaining self-tolerance. However, this mechanism is associated with a risk for immune-related adverse events potentially affecting multiple organs, including the endocrine system. We describe the unusual case of a patient who, after 18 months of treatment with an immune checkpoint inhibitor, debuted with diabetic ketoacidosis

Cetoacidosis diabética posterior a vacuna contra SARS-CoV-2: reporte de un caso / Diabetic ketoacidosis following SRS-CoV-2 vaccination: a one case report

Las emergencias hiperglicémicas como la cetoacidosis diabética (CAD) y el síndrome hiperglicémico hiperosmolar (SHH) se han descrito en el contexto de infección por SARS-CoV-2, como también secundarias a las múltiples vacunas desarrolladas contra el virus. La fisiopatología que explicaría esta asociación aún no está clara, pero existen diversas teorías que incluyen la destrucción directa de los islotes pancreáticos por el virus o secundario a mecanismos inmuno-inflamatorios. Presentamos el caso de un paciente que debutó con CAD al tercer día de la primera dosis de CoronaVac, y que posteriormente presentó hiperglicemia sin cumplir criterios de CAD luego de la segunda y tercera dosis de CoronaVac y Pfizer respectivamente. La temporalidad, como la falta de gatillante y la evolución del cuadro, apuntan a la vacuna como el principal precipitante. Por lo anterior, es importante mantener una vigilancia estricta de los efectos adversos de las vacunas y educar sobre los síntomas sugerentes de una crisis hiperglicémica para pesquisarla a tiempo y actuar oportunamente.

Hyperglycemic emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) have been reported in SARS-CoV-2 infections and after vaccination. The pathophysiology behind this association is still unclear, several theories have been described that include the direct destruction of the pancreatic islets by the virus, and some immuno-inflammatory mechanisms. We present the case of a patient who develope DKA the third day after the first dose of CoronaVac vaccine, and then hypergycemia after the second and third dose of CoronaVac and Pfizer repectively. The temporal relation, lack of a trigger and evolution of the disease, point the vaccine as the main precipitant. The strict surveillance of vaccines adverse effects and education of symptoms suggestive of hyperglicemic emergency are critical to prevent and treat promptly this kind of situations.

Nivel de actividad física y su motivación en estudiantes de medicina de la Universidad de Valparaíso en contexto de pandemia por COVID-19: un estudio de corte transversal / Level of physical activity and its motivation in medical students of the Universidad de Valparaíso during the COVID-19 pandemic: a cross-sectional study

INTRODUCCIÓN: Desde el año 2020 el mundo ha sido afectado por la pandemia por COVID-19, dentro de sus consecuencias se ha descrito la disminución de actividad física realizada por estudiantes universitarios. OBJETIVOS: Determinar el nivel de actividad física y sus motivaciones en estudiantes de medicina de una universidad chilena en el contexto de pandemia por COVID-19. MÉTODOS: Estudio transversal que incluyó a los estudiantes de medicina de primer a séptimo año de la Universidad de Valparaíso en enero del 2021. Se emplearon los cuestionarios International Physical Activity Questionnaire-Short Form (IPAQ-SF) y Motives for Physical Activities Measure - Revised (MPAM-R) de forma online. Se realizó la descripción de las variables y un análisis entre ellas mediante el cálculo de Odds Ratios. RESULTADOS: La muestra fue de 297 estudiantes. Un 53,2% eran mujeres y un 24,2% de los estudiantes eran internos. El 62,3% de los participantes realizaban moderada o alta actividad física. El sexo masculino y el internado fueron factores asociados a un mayor nivel de actividad física. No se demostró una asociación entre la cuarentena y el nivel de actividad física. Las principales motivaciones para realizar actividad física fueron salud y diversión, independiente del sexo de los participantes. CONCLUSIONES: La mayoría de los estudiantes de medicina presentaron al menos un nivel moderado o alto de actividad física, lo que es mayor a lo reportado previamente. Respecto a las motivaciones, el orden de prioridad fue similar entre ambos sexos. Los estudiantes consideran útil tener un horario protegido para realizar actividad física.

INTRODUCTION: The world has been affected by the COVID-19 pandemic since the year 2020, within its consequences it has been described the decrease in physical activity by university students. OBJECTIVES: To determine the level of physical activity and its motivations in medical students from a Chilean university in the context of the COVID-19 pandemic. METHODS: We conducted an observational, cross-sectional study that included first to seventh year medical students from the Universidad de Valparaíso in January 2021. We used the International Physical Activity Questionnaire -Short Form (IPAQ-SF) and the Motives for Physical Activities Measure-Revised (MPAM-R) questionnaire, applied online. We described the variables and conducted an analysis by calculating Odds Ratios. RESULTS: The sample was 297 students. 53.2% were women and 24.2% of the students were interns. 62.3% of the participants performed moderate or high physical activity. Being male and interns were factors associated with a higher level of physical activity. An association between quarantine and level of physical activity was not shown. The main motivations for physical activity were Health and Fun, regardless of the sex of the participants. CONCLUSIONS: Most of the medical students presented at least a moderate or high level of physical activity, which is higher than previously reported. Regarding motivations, the priorities were similar between both sexes. Students find it helpful to have reserved hours in the academic schedule for physical activity.

Diabetes relacionada con la fibrosis quística / Cystic fibrosis-related diabetes

Los avances en el campo de la fibrosis quística han aumentado la esperanza de vida de estos pacientes, por lo que cada vez es más prevalente la Diabetes Relacionada con la Fibrosis Quística (DRFQ) y sus complicaciones. La DRFQ se asocia a mayor morbimortalidad, deterioro de la función pulmonar y del estado nutricional. Por lo mismo, el manejo óptimo de esta patología depende de un diagnóstico precoz, tratamiento individualizado y vigilancia de las complicaciones diabéticas. El screening de DRFQ debe realizarse anualmente a partir de los 10 años, mediante una Prueba de Tolerancia a la Glucosa Oral (PTGO), lo cual permite el diagnóstico. El manejo de esta patología tiene por objetivo estabilizar y mejorar la función pulmonar y el estado nutricional y metabólico de los pacientes. Actualmente, la insulina es el tratamiento farmacológico de elección para controlar la hiperglicemia y el esquema de uso debe ser individualizado para cada persona. En caso de enfermedades agudas pueden existir mayores requerimientos de insulina. Además, se deben tener consideraciones especiales en cuanto a la dieta y la insuficiencia pancreática exocrina que presentan estos pacientes. Para la vigilancia de complicaciones microvasculares se debe realizar una monitorización anual a partir de los 5 años desde el diagnóstico de DRFQ. Debido a la complejidad de estos pacientes, para alcanzar el mejor cuidado posible se necesita un enfoque multidisciplinario con distintos profesionales de la salud coordinados, incluyendo en la toma de decisiones al paciente y su familia.

Advances made in the field of cystic fibrosis have increased the life expectancy of these patients, which is why Cystic Fibrosis-Related Diabetes (CFRD) and its complications are becoming more and more prevalent. CFRD is associated with increased morbidity and mortality, lower lung function and inadequate weight maintenance. Therefore, the optimal management of this pathology depends on an early diagnosis, individualized treatment and monitoring of diabetic complications. For CFRD, routine screening with an Oral Glucose Tolerance Test (OGTT) should be carried out yearly from the age of 10, which allows to diagnose it. The treatment goals in CFRD are to stabilize and improve lung function and obtain adequate weight gain. Currently, insulin is the pharmacological treatment of choice to control hyperglycemia and the insulin regimen must be personalized for each person. In acute illnesses, there may be higher insulin requirements. In addition, special considerations must be taken regarding diet and exocrine pancreatic insufficiency that these patients present. For the surveillance of microvascular complications, annual monitoring should be carried out 5 years after the diagnosis of CFRD. Due to the complexity of these patients, in order to achieve the best possible care, a multidisciplinary approach is needed with different coordinated health professionals, including the patients and their family in the decision-making process.

Macro TSH como causa de hipotiroidismo refractario: a propósito de dos casos clínicos / Macro TSH as a cause of refractory hypothyroidism: based on two clinical cases

Se presenta el caso de dos mujeres con hipotiroidismo, con TSH persistentemente elevada, lo que hacía aumentar la dosis de levotiroxina y llegar a un hipertiroidismo clínico con TSH anormalmente alto. Se realizó un seguimiento de los niveles de TSH y T4 libre, durante un período de 20 y 10 meses respectivamente. En ambas situaciones no hubo una respuesta esperable a las dosis de levotiroxina ascendentes. Después de descartar causas posibles que explicaran esta situación, se sospechó y confirmó la presencia de Macro TSH, que es un complejo biológicamente inactivo de TSH e Inmunoglobulina G. Se obtiene como resultado la estabilidad de ambas pacientes siendo su seguimiento prioritariamente clínico y con mediciones de T4L, comprendiendo por qué la TSH persiste elevada. Nos pareció interesante la comunicación de estos casos, que permite recordar causas atípicas de refractariedad al tratamiento con levotiroxina, como es la macro TSH, indispensable pesquisar para el manejo adecuado de estos pacientes.

An inadequate response to levothyroxine treatment in a patient with hypothyroidism suggests lack of intake, lack of absorption, nephrotic syndrome, thyroid hormone resistance among other reasons. We present the case of two women with hypothyroidism and a persistently elevated level of TSH, which required increasing the dose of levothyroxine, resulting in a clinical hyperthyroidism with an abnormally high TSH. A TSH and free T4 follow up was performed during a period of 20 and 10 months respectively, in both situations there was not an adequate response to rising levothyroxine treatment. After ruling out other possible causes that could explain this situation, it was suspected and then confirmed the presence of Macro TSH, which is a biologically inactive complex of TSH and Immunoglobulin G. Therefore, both patients achieved disease stability once controlled by clinical state and free T4 measurements, understanding why THS persited high. We present these interesting cases, because this allows us to remember atypical causes of refractory treatment with levothyroxine, such as the Macro TSH, indispensable to search for the proper management of these patients.

Efectos de la ingesta de los edulcorantes estevia y D-tagatosa sobre el metabolismo de la glucosa, ácido úrico y apetito-saciedad / Effects of stevia and D-tagatose sweeteners intake om glucose, uric acid metabolism and appetite-satiety

INTRODUCCIÓN: Si bien, los edulcorantes no nutritivos (ENN) estevia y D-tagatosa han sido reportados como seguros, han demostrado tener algunos efectos metabólicos tras su ingesta. OBJETIVO: Describir los efectos de la ingesta de estevia y D-tagatosa sobre el metabolismo de la glucosa y ácido úrico, y del apetito-saciedad, a partir de la evidencia disponible. MÉTODOS: Revisión descriptiva. Se realizó búsqueda en PubMed utilizando los siguientes términos y palabras clave: "stevia rebaudiana", "tagatose", "D-tagatose", "blood glucose", "insulin", "metabolic processes", "uric acid", "hyperuricemia", "appetite" o "satiety". El análisis de los estudios seleccionados fue discrecional. RESULTADOS: Existen estudios que demuestran efectos beneficiosos tras el consumo de estevia o D-tagatosa sobre el control glicémico, apetito y saciedad tanto en sujetos sanos como con alteraciones en el metabolismo de la glucosa. Por otra parte, un número importante de estudios que evalúan la ingesta de estevia reportan efectos nulos sobre dichos parámetros. En relación al ácido úrico, solo un estudio en sujetos con enfermedad renal crónica reporta aumento en la concentración de ácido úrico plasmático tras la ingesta de 500 mg/día de estevia. Pocos estudios han evaluado el efecto de la ingesta de D-tagatosa sobre uricemia, en sujetos sanos y diabéticos, reportando un aumento transitorio y significativo en los niveles de ácido úrico sérico, sin embargo, no se ha logrado demostrar un efecto hiperuricémico asociado. Es importante destacar que la metodología de los estudios revisados es heterogénea, especialmente en relación al tamaño muestral, tiempo, dosis y vía de adminitración del edulcorante. CONCLUSIÓN: La ingesta de estevia y D-tagatosa ha demostrado efectos beneficiosos sobre el metabolismo de la glucosa, el apetito y la saciedad. El efecto del consumo de D-tagatosa sobre ácido úrico sérico requiere mayor evidencia para demostrar su significancia clínica.

INTRODUCTION: No-nutritive sweeteners stevia and D-tagatose have been reported as safe according to their acceptable daily intake, however, they have been shown to have metabolic effects after their ingestion. OBJECTIVE: To describe the effects of stevia and D-tagatose intake on parameters associated to glucose, uric acid metabolism and on appetite-satiety, considering the available evidence. METHODS: Descriptive review. PubMed search was carried out to identify the totality of the published articles. The following terms and key words were used: "stevia rebaudiana", "tagatose", "D-tagatose", "blood glucose", "insulin", "metabolic processes", "uric acid", "hyperuricemia", "appetite" o "satiety". The analysis of the selected studies was discretionary. RESULTS: studies have shown beneficial effects of stevia and D-tagatose consumption on glycemic control, appetite and satiety in healthy subjects as well as subjects with impairment glucose metabolism. On the other hand, a significant number of studies evaluating estevia intake report null effects on these parameters. In relation to uric acid, only one study in subjects with chronic kidney disease reported an increase in plasmatic uric acid concentration after the intake of 500 mg/day of stevia. Several studies have evaluated the effect of D-tagatose intake on plasmatic uric acid, in healthy and diabetic subjects, reporting a transient and significant increase in serum uric acid levels, however, has not been able to demonstrate an associated hyperuricemic effect. It is important to highlight that the methodology of the studies reviewed is heterogeneous, especially in relation to sample size, dose administered, time and route of exposure to the sweetener. CONCLUSION: Stevia and D-tagatose intake has shown beneficial effects on glucose metabolism, appetite and satiety. The effects of the consumption of both sweeteners on uric acid require further study to demonstrate their clinic significance.

Hipotiroidismo refractario idiopático: un caso clínico / Idiopathic refractory hypothyroidism: case report

Introducción: El hipotiroidismo constituye una patología frecuente, y su tratamiento habitual es el suplemento de levotiroxina (LT4) oral (VO). Sin embargo, existen casos inhabituales donde no es posible corregir esta condición a pesar de la utilización de LT4 en dosis alta. El hipotiroidismo refractario se define como la persistencia del hipotiroidismo a pesar del uso de LT4 > 1,9 ug/kg/día. La prevalencia del hipotiroidismo refractario no ha sido suficientemente documentada hasta ahora. Descripción del caso: Mujer de 53 años con antecedentes de hipotiroidismo, obesidad, dislipidemia, hipertensión arterial e insulinorresistencia. Fue derivada desde APS a nivel terciario por hipotiroidismo persistente a pesar del uso de LT4 800 ug/día y liotironina 80 ug/día. En forma ambulatoria se descartaron distintas causas, como mala adhesión al tratamiento, pseudo-malabsorción, síndromes de malabsorción; interacciones farmacológicas o interacciones alimentarias. Ante esto, y manteniéndose en su condición, se decide hospitalizar. Durante la hospitalización se prueban distintas fórmulas de administración. Finalmente, se logra respuesta adecuada con LT4 por vía rectal 100 ug/día asociado a 100 ug c/12 horas VO. Discusión: A pesar de no contar con herramientas óptimas para enfrentar este caso, se logró aplicar una estrategia sistemática especializada, que permitió un buen manejo de la paciente. Luego de probar distintas formulaciones de hormonas tiroideas, se logró respuesta mediante la administración por vía rectal, lo cual sugiere que esta paciente presentaba algún trastorno celular/bioquímico intestinal alto, que impedía la absorción óptima de LT4 VO. Conclusiones: La principal fortaleza de este trabajo consiste en la demostración de la utilidad práctica, en un contexto de recursos limitados, de una estrategia de estudio y tratamiento sistemático del hipotiroidismo refractario, lo cual ha sido escasamente publicado en la literatura internacional. Además, se recalca la importancia de una intervención especializada oportuna para evitar los riesgos sistémicos asociados a dosis altas de hormonas tiroideas.

Introduction: Hypothyroidism is a common condition, and its usual treatment is the supplement of oral levothyroxine (po). However, there are unusual cases where it is not possible to correct this condition despite the use of high-dose levothyroxine. Refractory hypothyroidism is defined as the persistence of hypothyroidism despite the use of levothyroxine > 1.9 ug/kg/ day. The prevalence of refractory hypothyroidism has not been sufficiently documented so far. Case description: 53 year old woman with a history of hypothyroidism, obesity, dyslipidemia, hypertension and insulin resistance. She was sent from primary care to tertiary level due to persistent hypothyroidism despite the use of 800 ug/day levothyroxine and liothyronine 80 ug/ day. On an outpatient basis, different causes were excluded as poor adherence to treatment, pseudo-malabsorption, malabsorption syndromes; drug interactions or food interactions. Given this, and staying on her condition, it was decided to hospitalize. Different forms of administration were tested during hospitalization. Finally, got adequate response with levothyroxine rectally 100 ug/day associated with 100 ug po bid. Discussion: Despite not having optimum tools to deal with this case, it was succeeded thanks to the implementation of a specialized systematic strategy. After testing different formulations of thyroid hormones, a positive response by rectal administration was achieved, which suggests that this patient presented any high intestinal cell/biochemist disorder that prevented the optimal absorption of levothyroxine po. Conclusions: The main strength of this work consists in demonstrating the practical utility, in a context of limited resources, of a study and systematic treatment strategy of refractory hypothyroidism, which has barely been published in the international literature. It is also highlighted the importance of an early specialized intervention to prevent the systemic risks associated with high doses of thyroid hormones.

Hipotiroidismo subclínico y embarazo / Sub-clinical hypothyroidism and pregnancy

El hipotiroidismo subclínico se define como una concentración sérica elevada de tirotropina (TSH), con T4 libre normal. En el embarazo, se ha descrito efectos deletéreos tales como riesgo aumentado de aborto espontáneo y déficit cognitivo del niño en mujeres con esta condición; además, se debe considerar la posible progresión a hipotiroidismo clínico. Se ha planteado el rol de la autoinmunidad mediante la presencia de anticuerpos anti-tiroperoxidasa (AntiTPO), describiéndose este como factor de riesgo para desenlaces adversos. No se ha comprobado la utilidad del tamizaje universal con TSH, siendo el enfoque actualmente el estudio de pacientes de riesgo. El tratamiento se inicia según los resultados de la cuantificación deTSH y AntiTPO, siendo el fármaco de elección la levotiroxina.El seguimiento es conmediciones deTSH.

Sub-clinical hypothyroidism is defined to be raised plasma thyrotropin (TSH) with normal levels of free T4. Detrimental effects such as increased abortion risk and newborns with cognitive deficit have been reported in pregnancies with this condition. Possible progression to clinical hypothyroidism must be considered. A possible auto-immune mechanism mediated by anti-thyroperoxidase (AntiPO) has been postulated where AntiPO should be considered a risk factor for adverse outcomes. Universal screening using TSH has not been found to be of use and at present only high risk women are screened. Women are treated with levothyroxine, the dose depending on the TSH andAntiPO levels, and follow up is done bymonitoringTSHlevels.

Diabetes mellitus e insuficiencia cardíaca en pacientes hospitalizados / Diabetes and heart failure in impatients

INTRODUCCIÓN: existe asociación entre diabetes mellitus(DM) e insuficiencia cardiaca (IC), planteándose una miocardiopatía inducida por DM, sin embargo, se desconoce la fisiopatología exacta. OBJETIVO: describir la población de pacientes hospitalizados por insuficiencia cardiaca descompensada (ICD). MÉTODOS: estudio descriptivo de cohorte transversal en pacientes hospitalizados con diagnóstico de ICD.Se obtuvieron datos delingreso de la Unidad de Emergencias, anamnesis y epicrisis. Las variables estudiadas fueron: edad, sexo, duración de la hospitalización, comorbilidades, causa de la IC y de su descompensación, evolución clínica y complicaciones adyacentes, realización de ecocardiograma y hospitalizaciones previas por ICD. Se comparó descriptivamente entre subgrupo de pacientes diabéticos y no diabéticos. RESULTADOS: se obtuvo 31 pacientes,todos con diagnóstico previo de IC, 10 de ellos diabéticos.La etiología isquémica fuemásfrecuente en los diabéticos y éstos presentaban mayores hospitalizaciones previas por ICD y mayores complicaciones durante la hospitalización. Los no diabéticos tuvieron más días de hospitalización y fracción de eyección (FE) más baja. Fallecieron 2 pacientes, ninguno diabético. Los pacientes diabéticos tenían un inadecuado control metabólico según valor de hemoglobina glicada. CONCLUSIONES: la población diabética presentó mayor proporción de insuficiencia cardiaca de etiología isquémica y mayores complicaciones durante la hospitalización. Se encontró diferencias a lo descrito en la literatura, en cuanto a días de hospitalización y mortalidad,lo que probablemente se explica por la muestra pequeña y laFE menor en no diabéticos. La DM mal controladaparecióser unfactorinfluyente enla rehospitalización porICD.

INTRODUCTION: diabetes mellitus and heart failure are associated, possibly through a diabetes-induced myocardiopathy, however the precise pathophysiology remains unknown. OBJECTIVE: to describe a population of patients hospitalized for heart failure. METHODS: a descriptive study of a transversal cohort of inpatients diagnosed with heart failure. Data were taken from Aand E admissions, patient histories and discharge papers. The variables studied were: age, sex, length of stay, co-morbidities, cause of heart failure and its exacerbation, clinical course and complications, heart ultrasound findings, and prior hospitalizations for heart failure. The sub-groups diabetic and non-diabetic were compared descriptively. RESULTS: We describe 31 patients already diagnosed with heart failure, 10 being diabetic. Ischemic etiology was more frequent in the diabetic patients and these had had more hospitalizations and presented more complications. The non-diabetics had longer hospital stays and a lower ejection fraction. Two patients died. Neither was diabetic. Glycated hemoglobin levels showed that the diabetics had poor metabolic control. CONCLUSIONS: the diabetic group had a higher incidence of ischemic heart failure and more complications during their stay. Our values for length of stay and mortality differ from those found in the literature, probably because of the small sample size and the low ejection fraction found in non-diabetics. Poorly controlled diabetes seems to be a factor in re-admission for heart failure

Calidad de vida en pacientes con hipotiroidismo / Quality of life in patients with Hypothyroidism

Introduction: Patients with hypothyroidism may have worse quality of life, specially in Hashimoto's Thyroiditis (HT). Objective: Describe differences in the quality of life in patients with HT, compared to other causes of hypothyroidism in ambulatory patients. Method: Cross sectional, observational and descriptive study. The survey SF36 was applied, with prior authorization, to hypothyroid outpatients over 18 years without psychiatric, physical or mental disorder, dividing the sample into two groups: patients with TH and other causes of hypothyroidism. We used QualityMetric Health OutcomesTM Scoring Software 5.0, that gives a descriptive analysis of each area included in the instrument. Results: 53 patients, of whom 30 where diagnosed with TH, and 23 with other causes of hypothyroidism were surveyed. The characteristics were similar in both groups. The total group of hypothyroid patients had mental component under the average. In the specific analysis of the groups, the physical component was within the average general population. The mental component, was decreased in patients with other causes of hypothyroidism, but not in patients with TH. Conclusion: Comparing both groups, there were no differences in the physical component of patients with hypothyroidism. The mental component of the total group of hypothyroid patients compared to the general population was below average, especially in patients with other causes of hypothyroidism. The reason is unclear, but could be related to the absence of endogenous thyroid hormones

Prevalencia de hipotiroidismo subclínico en pacientes con síndrome coronario agudo / Prevalence of subclinical hypothyroidism in patients with acute coronary syndrome

INTRODUCTION: Subclinical hypothyroidism (SH) is characterized by elevation of thyroid stimulating hormone (TSH) with normal free thyroxine (FT4). SH has been associated with cardiovascular risk factors (CVRF) such as increased blood pressure, lipid level and atherosclerosis; however, its association with coronary heart disease is controversial. OBJECTIVES: The primary objective was to know the prevalence of SH in patients with acute coronary syndrome (ACS) in 3 hospitals of the Viña del Mar-Quillota Health Service. The secondary objective was to know the prevalence of CVRF in patients with SH and euthyroidism. MATERIAL AND METHOD: A cross-sectional study that included patients admitted for ACS. CVRF and thyroid hormone levels were recorded. RESULTS: Of the 81 patients recruited, 11 (13.6 percent) had SH. AHT was present in 68.3 percent of euthyroid and 90.9 percent of SH (p = 0.16). 55 percent of euthyroid and 63.6 percent of SH had dyslipidemia (p = 0.74). Overweight or obesity was found in 76.6 percent of euthyroid and 54.5 percent of SH (p = 0.15). The median CVRF was 3 (IQR 2-4) in euthyroid and 3 (IQR 3-4) in SH (p = 0.78). CONCLUSIONS: The prevalence of SH in patients with ACS was not higher than that reported in the general population and there were no differences in CVRF between SH and euthyroid. We require prospective cohort studies with a larger sample size to establish incidence and risk of adverse cardiovascular outcomes in SH.

Cetoacidosis diabética euglicémica asociada a inhibidor de cotransportador de sodio glucosa Tipo 2 en paciente con diabetes Mellitus Tipo 1 / Diabetic ketoacidosis with mild hyperglycemia associated with the use of canagliflozin. report of one case with type 1 diabetes

Diabetic ketoacidosis with mild hyperglycemia is a major complication of sodium-glucose cotransporter 2 inhibitors. Although its use is not approved for patients with type 1 diabetes mellitus, the drug is often prescribed with the hope of optimizing metabolic control. We report a 20 years old female with hypothyroidism and type 1 diabetes consulting for vomiting and abdominal pain. The patient had used canagliflozin during the two previous months. Laboratory showed a blood glucose of 200 mg/dl, a severe metabolic acidosis (pH 7.1) and ketonemia. The patient was successfully treated in the intensive care unit.

Pancreatitis aguda grave por hipertrigliceridemia: Reporte de un caso / Acute severe pancreatitis induced by Hypertriglyceridemia: Case report

La hipertrigliceridemia es la causa del 1-4 % de las Pancreatitis Agudas (PA).Clínicamente se presenta en forma similar a otras etiologías de PA, pero suelen tener una evolución más tórpida.Varios estudios han planteado que esto se debe a la lipotoxicidad producida tras la hidrólisis de los triglicéridos (TG) en el tejido pancreático. Suele presentarse con niveles de TG por sobre los 1000 mg/dL, aumentando el riesgo a medida que se incrementan. Trastornos en el metabolismo de las lipoproteínas pueden desencadenar cuadros de PA graves. Estos desórdenes se clasifican en trastornos primarios (defectos genéticos) y secundarios a otras causas,dentro de las que se encuentran: presencia de patologías subyacentes (obesidad, diabetes), secundarias al uso de fármacos (tratamientos hormonales) o alteraciones de condiciones fisiológicas (embarazo); todas estas condiciones favorecenla acumulación de TG en la circulación periférica. Para el tratamiento de las hipertrigliceridemias severas, se recomienda el uso de bombas de insulina y aféresis, con el objetivo de disminuir los valores de TG en forma precoz, lo que mejora los resultados y aumenta la sobrevida. En este contexto, se presenta el caso de una mujer de 22 años que desarrolla una PA grave por hipertrigliceridemia de más de 4000 mg/dL.

Hypertriglyceridemia is the etiology of 1-4% of Acute Pancreatitis (PA). The clinical presentation is similar to other causes of PA, but often has worst outcomes.Several studies have suggested that this is due to the lipotoxicity produced after hydrolysis of triglycerides (TG) in pancreatic tissue. It often is presented with TG levels above 1000 mg/dL, increasing the risk while it gets higher. Abnormality of lipoprotein metabolism can trigger severe cases of PA. These disorders are conventionally classified into primary disorders (genetic defects) and secondary to other causes, in which we can find: underlying pathologies, (obesity, diabetes), secondary to drug use (hormonal treatment) or disruption of physiological conditions (pregnancy). All these conditions favor accumulation of TG in peripheral circulation. For the treatment of severe hypertrigliridemia, the use of insulin bombs and aphaeresis is recommended, in order to reduce levels of TG precociously, which produces better results and enhances survival. It is in this context, that a case of a woman of 22 years old that develops severe PA with hypertriglyderidemia over 4000 mg/dl is presented.

Tiroiditis subaguda con ausencia de captación cintigráfica unilateral inicial / Subacute thyroiditis with initial unilateralabsence of scintigraphic uptake

Subacute thyroiditis is a transient inflammatory process of the thyroid gland and the most common cause of painful thyroiditis. It usually involves the whole thyroid. We present a clinical case of a 45 years old woman developing tachycardia, fever and painful sensation in the left anterior cervical region after an upper respiratory tract infection. In addition the patient presented an enlarged and painful left thyroid lobe. Laboratory analysis demonstrated elevated acute phase reactants, high T4 levels and suppressed thyrotropin with absence of antithyroid antibodies. Thyroid scintigram showed an absent left radioactive iodine uptake. One month later the patient started with malaise, fatigue with an enlarged painful right thyroid lobe. A new scintigram showed complete absence of radioactive iodine uptake. A course of prednisone was initiated with excellent clinical response. Four months later the patient was asymptomatic with normal thyroid function.

Prevalencia, control metabólico y relación con estadía hospitalaria de pacientes diabéticos hospitalizados en el Hospital de Quilpué / Prevalence, metabolic control and relationship with hospital stay in diabetic patients ospitalized in Hospital de Quilpué

Diabetes Mellitus (DM) is a prevalent pathology. It has been noticed that patients tend to have longer stays in the hospital and one of the factors that causes it corresponds to bad metabolic control. AIM:To assess prevalence and different variables related to an erroneous metabolic control and a longer hospital stay. PATIENTS AND METHODS:It is a cross-sectional study on diabetics patients hospitalized at the Internal Medicine service in the Hospital of city of Quilpué, for a period of two months, quantifying epidemiologic data, days of hospital stay and metabolic control. A statistical multivariate correlative study was carried. RESULTS: Patient prevalence with DM was 13.15% (n = 35/266), all of them were type 2 (DM), being the 91.4% (n = 32) hypertensive, 97.1% (n = 34) older than 40 years old, 62.9% (n = 22) with HbA1c ≥ 7%, 17,1% (n = 6) had a bad metabolic control and an average of 22,8 (rank = 6-136) days of hospital stay versus 12,1 days without DM. An association was observed between inadequate previous metabolic control and "bad metabolic hospital control" (p < 0.05). DISCUSSION: Prevalence of DM patients in the hospital was lower than other centers of the region. A statistical association between bad metabolic chronic control with bad metabolic hospital control was found. No associations between bad hospital control and long stays were observed, a possible reason might be the biased values of glycemia's records and different handling of these patients.

Hipoglicemia en el paciente diabético hospitalizado / Hypoglycemia in hospitalized diabetic patiens

Introduction: Hypoglycaemia occurs frequently in hospitalized diabetic patients and increases inpatient morbidity and mortality. In 60 percent of cases, it isn’t managed properly. The goal of this study was to determine prevalence, treatment, complications and length of hospital stay related to hypoglycaemia with local patients. Patients and Methods: This study was designed as a prospective series of cases with diabetic patients, hospitalized in internal medicine and surgical services. Results: 105 cases of hypoglycaemia presented in 47 patients, with a mean of 2,21 +/- 1,68 episodes per patient. 53,32 percent of hypoglycaemic episodes presented in surgical patients. The cause was not determined in 49,52 percent (n = 52) of the episodes, and 41,9 percent (n = 44) of them were asymptomatic. 59,57 percent (n = 28) of patients presented complications during their hospital stay, mainly infectious, with no difference between surgical and medical services. Median inpatient stay in the surgical service was of 28 days (RIQ 19-45), and of 16 days (RIQ 11-28) in the internal medicine service. Treatments were modified in 57,45 percent (n = 27)of patients after their first hypoglycaemic episode occurred, 17 in internal medicine service, and 10 in surgical service (p = 0,003). Conclusions: the majority of patients presented at least two hypoglycaemic events, and only in half of were treatments modified in order to prevent another episode, which is more that reported in literature, particularly in internal medicine service, where diabetologists work. Highlighting the large number of undetermined causes of hypoglycaemia, caused mainly by lack of registry, can lead to the creation of a registry form for these kinds of occurrences in order to successfully prevent more episodes and decrease inpatient stay and complications.

Pacientes diabéticos hospitalizados en un servicio de medicina interna: características, causas de hospitalización y control metabólico / Diabetic patients hospitalized in a service of internal medicine: characteristics, reasons of hospitalization and metabolic control

Most of patients that present hyperglycemia during hospitalization still have the condition when they are discharged. A good level of metabolic control for hospitalized patients was set at a glycemic value between 70 and 180 mg/dl, taking into account that no statistics exist for the studied population. Aim: To describe reasons for hospitalization and glycemic control of patients with Diabetes Mellitus (DM) hospitalized in the Internal Medicine UNIT (SMI) of Hospital San Martin of Quillota (HSMQ). Patients and methods: Descriptive study of serial cases that included all patients of the SMI of HSMQ during July and August 2014. The information was obtained by daily census, analysis of nursing data, and interviews with patients. The information included general characteristics of the population and in patient management. Results: Of a total of 353 patients, 55 (15.6 percent) corresponded to diabetic patients, of them 92.7 percent had DM type 2. The average duration of hospitalization for not DM was 7 days where as for the DM it was 13.4 days. The principal reason for hospitalization for DM patients was infection: 23.6 percent (13/55). During hospitalization, most of patients’ care was controlled by means of "sliding scale" (28/55), but the schemes were quite variable, predominantly resulting in normal glycemia (63.8 percent) followed by hyperglycemia (33.7 percent). Conclusion: We found a significant percentage of patients with hyperglycemia and a great variability in the managing of DM in this sample, which indicates the importance of implementing a protocol for managing these cases...

Cuando el tiroides habla, el corazón escucha / When the thyroid speaks, the heart listens

Thyroid dysfunction, whether it be from an increase or decrease in the levels of thyroid hormones, has multiple repercussions in the cardiovascular system which have been associated with an increase in mortality and heightened risk of cardiovascular events. This risk must be taken into consideration when evaluating patients with thyroid dysfunction in order to include strategies that assure a timely diagnosis and treatment of the above-mentioned complications. Similarly, it is necessary to evaluate the thyroid function in patients who present cardiovascular events such as heart failure, arrhythmias, coronary acute syndrome or acute stroke. Some of these alterations will cease with the recovery of euthyroidism. Randomized controlled trials are needed to define the best way to treat these patients, especially in cases of subclinical hypothyroidism, where it is still unknown if treatment with L-thyroxin helps reducing cardiovascular risk...

Neumonía grave del adulto adquirida en la comunidad manejada en sala de cuidados generales en un hospital público / Severe community-acquired pneumonia in adult patients managed in a general ward at a public hospital

Introducción: la neumonía grave del adulto adquirida en la comunidad (NAC grave) se caracteriza por requerir manejo en la unidad de cuidados intensivos (UCI), dado su mayor mortalidad y riesgo de complicaciones, por lo cual se han diseñado distintas escalas de predicción de gravedad. Objetivo: identificar apacientes adultos con NAC grave manejados en la sala de cuidados generales. Pacientes y Métodos: estudio clínico descriptivo retrospectivo, se revisaron las fichas clínicas de 131 pacientes adultos egresados del servicio de medicina del hospital de Quilpué con el diagnóstico de NAC entre el 1 de enero y 31 de diciembre del 2010. Se examinaron los criterios de NAC grave de la Sociedad de Tórax Americana (ATS) y se midió el CURB-65 de 89 pacientes que consignaban esta información. Resultados: en 16 pacientes (18 por ciento) se obtuvo una puntuación del CURB-65 > 3 y en 8 pacientes (9 por ciento) se identificaron > 3 criterios menores de la ATSy en 2 de ellos un criterio mayor. Conclusión: se identificaron pacientes con NAC grave manejados en la sala de cuidados generales de un hospital publico.

Introduction: severe community-acquired pneumonia (severe CAP) is characterized by intensive care unit (ICU) requirement, given its higher mortality and complications rate. Different prediction scales have been designed to assess severity. Objective: identify adult patients with severe CAP managed in the general ward of a public hospital. Patients and Methods: retrospective descriptive study, including all adult patients dischargedfrom hospital with CAP diagnosis, from january 1st to december 31st, 2010, with a total of 131 medical records reviewed. The American Thoracic Society criteria (ATS) of severe CAP and CURB-65 scores from 89 medical records were calculated. Results: 16 patients (18 percent) had CURB-65 score > 3, 8 patients (9 percent) had > 3 minor ATS criteria, and 2 of those patients had a major criterion. Conclusion: a significant number of patients with severe CAP were managed on the general ward of a public hospital.