Retinal Sensitivity in Patients with Type I Diabetes without Retinopathy or with Minor Retinal Changes.

Objective: To evaluate the ability of short-wavelength automated perimetry (SWAP) for the detection of visual impairment in patients with type I diabetes without retinopathy or with minor retinal vascular changes. Design: Comparative cross-sectional study. Participants: 30 eyes of 30 healthy subjects and 73 eyes of 73 patients with type I diabetes mellitus were studied. Methods: Ophthalmic examination of diabetic patients showed no retinopathy or minimal changes (less than 5 microaneurisms in each eye) with no previous laser treatment. All patients were examined by means of the SWAP 24-2 strategy. Mean Deviation (MD) and Pattern Standard Deviation (PSD) were compared between both groups. Results: There were differences in the clusters of altered points between both groups (p=0.004). SWAP MD was lower in the diabetic group than in the controls (-2.89 dB vs. -0.20 dB, p<0.001). SWAP PSD also differed between both groups (2.50 dB in control group, 3.12 dB in the diabetic group, p=0.003). In the diabetic group, mean period from the onset of diabetes was 12.6±6.7 years and minimal vascular changes were observed in the retina of 18 eyes (24.7%), while 55 had no lesions (75.3%). No differences in SWAP changes were found between patients without and with minimal diabetic retinopathy. Conclusions: Retinal sensitivity assessed by SWAP is depressed in patients with type I diabetes regardless of the presence of retinal vascular changes.

Medical and surgical treatment of primary divergent strabismus.

PURPOSE: To evaluate the long-term effectiveness of different therapies applied in the past 30 years, both medical and surgical, and results, with the ultimate aim of determining which are the most appropriate criteria to indicate when and how to perform medical and surgical treatment in these patients. METHOD: A retrospective randomized study was conducted on 198 patients with primary divergent strabismus first seen in our clinic (IOC) in the last 36 years (1976-2012), with a mean follow-up of 8.38 years. Demographic and clinical characteristics, as well as the various treatments performed, and motor and sensory outcome were collected. They were finally divided into 3 groups of 70, 71 and 56 patients, respectively, according to their first visit, in order to compare the therapies applied. RESULTS: Half (50%) of our patients debuted before 2 years of age (P50=24 months), and 26.3% had optimal binocular vision at the beginning of the study. Medical treatment was used as exclusive therapy in 29.3% of cases (occlusion therapy, applying negative lenses, botulinum toxin), and 70.7% required surgery (61.2% by double retro-insertion of lateral rectus, and 38.8% monolateral retro-resection). There was a recurrence in 26.7% of patients, and 40 re-interventions were performed (70% due to recurrence of divergent strabismus, 12.5% due to surgical over-correction, and 17.5% for other reasons). In the end, 61.1% of patients had perfect binocular vision (TNO=60"), and the proportion was higher in patients who showed proper control of their strabismus at the beginning (P=.003). However, no differences were found in the other variables studied. When the patients were divided into 3 groups (which are demographically comparable), an increased number of patients in Group 3 were found to be treated using negative lenses and botulinum toxin (P<.001 and P=.003). This group was found to have had a higher proportion of bilateral surgery (P=.032), seeking greater immediate postoperative over-correction, thus reducing the number of re-interventions from 40.5 to 19%, although it did not reach statistical significance (P=.093). It was also found that there was a significantly increased number of injections of botulinum toxin in the middle rectum for treatment of excessive postoperative overcorrection (P=.028). No other differences in final binocular vision was found between the 3 groups (P=.703). CONCLUSIONS: In cases of clear ocular dominance, occlusion therapy must be applied twice daily on the dominating eye, in order to encourage divergent strabismus control and improve sensoriality. An attempt should be made to wait until patients reach four years of age before indicating surgical treatment, except in cases of a significant worsening of motor or sensory component. Bilateral surgery on both lateral rectus should be attempted, provided that patient characteristics allow this. A slight post-surgical overcorrection should be looked for in the immediate postoperative period, as this, in our experience, reduces the total amount of re-operations. When working on the middle rectus, remember that the elasticity of this muscle is the key factor for obtaining a proper post-surgical outcome, but a reliable measurement of this still cannot be made. In cases of excessive post-surgical over-correction, an injection of botulinum toxin should be applied to these poor elasticity muscles, in order to reduce the number of re-operations.

Psychosocial support groups for patients with multidrug-resistant tuberculosis: five years of experience.

This detailed case history traces the first 5 years of a psychosocial support group intervention aimed to improve adherence to individualized drug regimens for multidrug-resistant tuberculosis (MDR-TB) in Peru. A total of eight groups were established in metropolitan Lima and two provinces of Peru led by teams of psychiatrists and nurses. The intervention consisted of bi-monthly support groups, recreational excursions, symbolic celebrations, and periodic family workshops. Notably, of the 285 patients who participated in this intervention, only 3.5% defaulted from treatment. Details include the description of services, patient data, major psychosocial difficulties faced by this population, key challenges, and implications. Psychosocial support is a crucial component of treatment for MDR-TB in order to ensure completion of complicated treatment regimens and enable psychosocial rehabilitation after treatment.

Psychiatric issues in the management of patients with multidrug-resistant tuberculosis.

INTRODUCTION: Psychiatric issues present a challenge in the treatment of patients with multidrug-resistant tuberculosis (MDR-TB). Both baseline psychiatric disorders and development of psychiatric complications related to anti-tuberculosis drugs and psychosocial factors require aggressive management. SETTING: A community-based non-governmental health organization in Lima, Peru. OBJECTIVE: To review the literature for psychiatric complications associated with anti-tuberculosis medications, to describe the incidence and prevalence of depression, anxiety and psychosis among individuals receiving MDR-TB therapy, and to detail the management approach used in this cohort. METHODS: A retrospective case series was performed among the first 75 patients to receive individualized MDR-TB therapy in Lima, Peru, between 1996 and 1999. RESULTS: Baseline depression and baseline anxiety were observed in respectively 52.2% and 8.7% of this cohort. Most individuals with baseline depression experienced improvement of depressive symptoms during the course of TB therapy. The incidence of depression, anxiety and psychosis during MDR-TB treatment was 13.3%, 12.0% and 12.0%, respectively. While the majority of individuals with depression, anxiety and psychosis required psychiatric pharmacotherapy, cycloserine was successfully continued in all but one case. CONCLUSION: Psychiatric comorbidities are not a contra-indication to MDR-TB therapy. Management of psychiatric complications is possible without compromising anti-tuberculosis treatment.

Child-onset growth hormone deficiency in adulthood. Transfer of patients from pediatric to adult endocrinology units.

Treatment with growth hormone (GH) in adult-onset GH deficiency (AO-GHD) reverses its many metabolic alterations, modifying body composition, bone mass, several cardiovascular risk factors, and improving quality of life. In adult patients with a previous diagnosis of child-onset GH deficiency (CO-GHD), the lack of treatment also produces similar alterations, reversed by GH treatment. In patients with multiple pituitary hormone deficiency, the lack of GH is considered definitive, but in isolated GHD, the need for re-evaluation of the deficit is mandatory. The 'gold standard' test is insulin-induced hypoglycemia, after a wash-out period, and the criterion for GH therapy should be a GH (polyclonal-RIA assay) response less than 3 ng/ml. The initial recommended GH dose is lover than in children, and the dosage must be adjusted to maintain IGF-I levels in the normal range. We propose that decisions about patient recruitment, assessment, confirmation or reevaluation, information about new perspectives, disadvantages and benefits of GH therapy, and the beginning of treatment should be made in cooperation by pediatric and adult endocrinologists, so the patient receives all information from both medical teams, before being transferred to the adult endocrinology department.

Valor diagnóstico de las pruebas de laxitud y de resalte en la inestabilidad glenohumeral / Diagnostic value of the laxity and relocation tests in glenohumeral instability

Para conocer el valor diagnóstico de las pruebas de laxitud y de resalte en la inestabilidad glenohumeral se realizó un estudio prospectivo sobre 225 pacientes (450 hombros): 99 presentaban inestabilidad por luxación recidivante de 1 o ambos hombros; 68 presentaban otra patología de hombro sin signos de inestabilidad y otros 58 fueron intervenidos por otras patologías del aparato locomotor. Se valoraron las diferentes pruebas de aprensión, laxitud y resalte mediante una sistemática exploración en consulta así como bajo anestesia. En base a la misma, se consideró que 67 de los 99 hombros con luxación recidivante presentaban inestabilidad multidireccional. Se describe la realización de las distintas pruebas de 'resalte'. Se encontró un alto índice de especificidad para el diagnóstico de la inestabilidad multidireccional de las pruebas de aprensión y de las de 'resalte' (anterior e inferior) y bajo de la prueba de 'surco'. Valores de especificidad: aprensión anterior, 91 por ciento; aprensión inferior, 98 por ciento; sulcus, 55 por ciento; resalte anterior, 98 por ciento y resalte inferior, 95 por ciento. Este análisis permite diagnosticar las formas de tipo multidireccional, diferenciándolas de las unidireccionales y de la hiperlaxitud inferior sin inestabilidad (AU)

Occurrence of serious adverse effects in patients receiving community-based therapy for multidrug-resistant tuberculosis.

SETTING: A community-based treatment program for multidrug-resistant tuberculosis (MDR-TB) in an urban shantytown of Lima, Peru. OBJECTIVES: To ascertain the occurrence of serious adverse effects associated with therapy for MDR-TB in northern Lima, Peru, where therapy was individualized according to drug-susceptibility testing of patients' infecting strains and delivered through a community-based program. DESIGN: A retrospective record review of 60 patients who had received individualized therapy for MDR-TB between September 1996 and October 1998. RESULTS: Although adverse effects were common, they occurred less frequently than previously reported in the literature and were rarely life-threatening. Effects occurring most frequently in this population included: mild gastritis (100%), dermatological effects (43.3%), peripheral neuropathy (16.7%), depression (18.3%), and anxiety (11.7%). These effects never resulted in the discontinuation of anti-tuberculosis therapy, and only occasionally resulted in the suspension of an agent (11.7%). CONCLUSION: In young patients with little comorbid disease, multidrug, long-course regimens rarely caused life-threatening adverse effects. Common side effects may be managed successfully on an out-patient basis through a community-based treatment program in conjunction with MDR-TB experts, even in resource-poor settings. The very low rate of default in this cohort offers hope that strategies to manage the adverse effects may reduce the incidence of abandonment of therapy and increase rates of cure.

[Idiopathic hypophyseal hyperplasia: diagnosis by magnetic resonance]. / Hiperplasia hipofisaria idiopática: diagnóstico por resonancia magnética.

INTRODUCTION: Hypophyseal hyperplasia is an uncommon disorder in which the gland increase in size due to excessive proliferation of strings of normal cells, which usually secrete prolactin. Different aetiologies may cause this disorder of the hypophyseal gland. However, in a small number of cases the hyperplasia is not due to any of these aetiologies and is therefore known as idiopathic hypophyseal hyperplasia. There are few references in the literature to idiopathic hypophyseal hyperplasia with hyperprolactinaemia. Usually diagnosis is reached after treatment for a hypophyseal adenoma, since the clinical features are similar. CLINICAL CASES: We present three cases seen in our department, in which hormone and endocrine studies were done to exclude known causes of hyperplasia, together with CT and MR scans. We analyzed the behaviour of hypophyseal hyperplasia by using imaging techniques, and the differential aspects with regard to hypophyseal adenomas. Firm diagnosis is only made on anatomopathological study of the hypophysis. However, we consider that sound knowledge of the characteristics of this condition may help to establish the correct diagnosis and thus avoid unnecessary surgery. CONCLUSIONS: We review the information published in the literature on this subject, emphasizing the importance of differential diagnosis by means of imaging techniques.

Adrenal failure due to metastasis both to the hypothalamic-pituitary area and the adrenals.

A 61-year-old white male was admitted to our hospital with a big-cell bronchogenic carcinoma whose first clinical manifestation was diabetes insipidus (DI) secondary to metastasis to the hypothalamic-pituitary area (MHP). In three months, and progressively, he developed anterior pituitary failure, as well as primary adrenal insufficiency (PAI) due to metastasis in both adrenals. Panhypopituitarism or PAI due to both MHP and adrenals has been rarely reported in the literature. A thorough examination of the oncologic patient led us to diagnose hormone insufficiency properly. The absence of reported cases might be due to the fact that the symptoms resulting from hormone insufficiency are veiled by the severe condition of the patients suffering from disseminated cancer.

[Flocculation of NPH insulin]. / Floculación de la insulina NPH.

In the past decade, human insulins have been substituting animal insulins, offering the advantage of its lesser antigenic capacity. One of the most clinically important problems with human NPH insulins is its tendency to flocculate. We present four diabetic patients who, after using flocculated human NPH insulin, encountered a deterioration in the metabolic control of their diabetes, and in two of them, there were bouts of diabetic Ketoacidosis "without any other apparent causal factors". Among those causes favoring flocculation are movement during transport, high temperatures, and probably leaving the vial open for an excessively long period of time, as with the extraction of multiple doses. Physicians, educators, diabetics, and their relatives should be informed of this phenomenon. Diabetics, especially those who carry insulin with them, should carefully inspect their vials before each injection to detect signs of flocculation.

[Effect of the smoking habit on carbohydrate metabolism]. / Influencia del hábito de fumar sobre el metabolismo hidrocarbonado.

Mechanism tobacco favours arteriosclerosis aren't clear. Hyperglycemia in smokers would be help factor. On value relationship between tobacco, fasting plasma glucose and hemoglobin A1c in a coal-miner working population, made up of 1,379 males, 38 years old average. We find meaning difference in hemoglobin A1c and fasting plasma glucose values between smokers and non-smokers. Hemoglobin A1c are more elevated in smokers while glycemia are more elevated in non-smokers. We rapport some reason over these divergent results. Hemoglobin A1c elevated in smokers suggest that the tobacco has negative influence on glucose metabolism.

[Metabolic improvement of diabetes mellitus through pamphlets on the norms of self-monitoring control measures]. / Mejoría metabólica de la diabetes mellitus mediante el seguimiento de normas escritas de autocontrol.

OBJECTIVE: To assess whether giving a leaflet containing norms of self-control to diabetics receiving insulin treatment results in a metabolic improvement. The HbA1c was established prior and subsequent to giving out the leaflet. The written norms contained in the leaflet were highlighted from the wider range of instructions obtained from diabetes education. DESIGN: A longitudinal intervention study with no random allocation. SETTING: Hospital care in a specialised Endocrinology clinic. PATIENTS AND OTHER PARTICIPANTS: 122 types 1 and 2 diabetics, treated with various insulin diets, who had received prior diabetes education and carried out blood self-controls. Cases of meta-diabetic syndrome, serious illnesses and those without apparent hypoglycaemia symptoms were excluded. INTERVENTIONS: Giving out of a leaflet with written norms of self-control. MEASUREMENTS AND MAIN RESULTS: The averages, standard deviations and 95% confidence intervals of the basal HbA1c and of those at four-monthly check-ups were calculated. Basal 8.07 (CI 7.75 - 8.39); 4th month 6.88 (CI 6.74 - 7.17); 8th month 6.59 CI 6.29 - 6.90); 12th month 6.60 (CI 6.23 - 6.94); 16th month 6.06 (CI 5.63 - 6.49); 20th month 5.40 (CI 3.04 - 7.75). Averages were compared by the Student T test and all values had p < 0.005 against the basal. CONCLUSIONS: Following the written norms produced a clear metabolic improvement, represented by the significant fall of HbA1c. Therefore, though without ignoring the overall context of treatment and diabetes education, it is proposed that the relationship of the most practical features of insulin dosing to written norms of self-control should be emphasised.

[Does goiter constitute basically a surgical process?]. / Constituye el bocio un proceso fundamentalmente quirúrgico?

Goiter is usually a clinical manifestation present almost in all the thyroid processes. The over-simple idea of a thyroid tumoration demanding surgical resection is, unfortunately, deeply implanted in many medical and, above all, surgical environments. We tried to estimate the incidence of goiter in a series of thyroid processes and how many of them required surgery. We reviewed the surgical indications in several thyroid entities. In a series of 377 thyroidopathies, goiter was present in 345 (91.5%), 50 of which underwent surgery (12.26% of the total and 14.49 of goiters). Some of the patients were operated in other hospitals without adjusting to the aforementioned criteria and, in theory, just 36 of then should had undergone surgery (9.54% of the total and 10.43% of goiters). In conclusion, surgery has a very secondary role in the treatment of goiter.

En-bloc resection of the distal fibula for aneurysmal bone cyst.

A 21-year-old woman who presented with a voluminous aneurysmal bone cyst in the distal left fibula was treated with en-bloc resection. After 30 months of follow-up, the stability and range of motion of the left ankle were similar to that of the contralateral ankle.

Pseudo-analbuminaemia due to the presence of a slow albumin variant moving into the alpha 1 zone.

A serum has been studied, in which direct observation of cellulose acetate electrophoresis may induce misdiagnosis of analbuminaemia. Immunogically, and by saline fractionation, the serum contained albumin, although in a decreased quantity. Gel filtration shows the majority of this albumin is to be in the 4.5 S20 peak and to have a low electrophoretic mobility, overlapping with that of alpha 1 globulins. Possible explanations of the presence of this slow-moving albumin are discussed.