Underutilization of insulin and better metabolic control. A NOVA clinic experience.

OBJECTIVE: To present the results of metabolic control in patients with type 2 Diabetes Mellitus from a private clinic in Northern Mexico. METHODS: This cross-sectional study used retrospective data obtained from electronic records from a private outpatient clinic at the end of 2018. Inclusion criteria were a diagnosis of T2DM and age ≥ 18 years. Baseline characteristics (age, gender, drug use) were reported. The achievement of glycated hemoglobin goals was established as <7%. RESULTS: A total of 3820 patients were evaluated. Their mean age was 59.86 years (+/-15.01). Of the population, 46.72% were men, and 53.28% were women. Glycated hemoglobin goals were adequate in 1872 (54%) patients. There were 3247 patients (85%) treated with oral medications, of which 1948 (60%) reported glycated hemoglobin less than 7%. Insulin use was reported in 573 (15%) patients, with 115 (20%) reporting glycated hemoglobin less than 7%. The most frequently used basal insulin was glargine in 401 (70%) patients. CONCLUSIONS: Our findings are clearly higher than the control rate reported by our national health surveys of 25% with glycated hemoglobin < 7%, but similar to that reported in other countries. The most commonly used therapeutic scheme was the combination of oral hypoglycemic agents. The percentage of cases that include insulin in their treatment was lower. Clinical inertia to insulin initiation and intensification has been defined as an important cause of this problem.

Underutilization of insulin and better metabolic control. A NOVA clinic experience

SUMMARY OBJECTIVE To present the results of metabolic control in patients with type 2 Diabetes Mellitus from a private clinic in Northern Mexico, METHODS This cross-sectional study used retrospective data obtained from electronic records from a private outpatient clinic at the end of 2018. Inclusion criteria were a diagnosis of T2DM and age ≥ 18 years. Baseline characteristics (age, gender, drug use) were reported. The achievement of glycated hemoglobin goals was established as <7%. RESULTS A total of 3820 patients were evaluated. Their mean age was 59.86 years (+/-15.01). Of the population, 46.72% were men, and 53.28% were women. Glycated hemoglobin goals were adequate in 1872 (54%) patients. There were 3247 patients (85%) treated with oral medications, of which 1948 (60%) reported glycated hemoglobin less than 7%. Insulin use was reported in 573 (15%) patients, with 115 (20%) reporting glycated hemoglobin less than 7%. The most frequently used basal insulin was glargine in 401 (70%) patients. CONCLUSIONS Our findings are clearly higher than the control rate reported by our national health surveys of 25% with glycated hemoglobin < 7%, but similar to that reported in other countries. The most commonly used therapeutic scheme was the combination of oral hypoglycemic agents. The percentage of cases that include insulin in their treatment was lower. Clinical inertia to insulin initiation and intensification has been defined as an important cause of this problem.

RESUMO OBJETIVO Apresentar os resultados do controle metabólico de pacientes com Diabetes Mellitus tipo 2 em uma clínica privada no norte do México, MÉTODOS Este estudo transversal utilizou dados retrospectivos obtidos em prontuários eletrônicos de um ambulatório privado no final de 2018. Os critérios de inclusão foram o diagnóstico de DM2 e idade ≥ 18 anos. Características basais (idade, sexo, uso de drogas) foram relatadas. A realização de metas de hemoglobina glicada foi estabelecida como <7%. RESULTADOS Um total de 3820 pacientes foram avaliados. A média de idade foi de 59,86 anos (+/- 15,01). Da população, 46,72% eram homens e 53,28% eram mulheres. Objetivos de hemoglobina glicada foram adequados em 1872 (54%) pacientes. Havia 3247 pacientes (85%) tratados com medicamentos orais relatando em 1948 (60%) menos de 7%. O uso de insulina foi relatado em 573 (15%) pacientes, com 115 (20%) relatando menos de 7%. A insulina basal mais utilizada foi a glargina, em 401 (70%) pacientes. CONCLUSÕES Nossos resultados são claramente mais altos do que a taxa de controle relatada por nossos levantamentos nacionais de saúde de 25% com hemoglobina glicada <7%, mas semelhante à relatada em outros países. O esquema terapêutico mais utilizado foi a combinação de hipoglicemiantes orais. A porcentagem de casos que incluem insulina no tratamento foi menor. A inércia clínica à iniciação e intensificação da insulina tem sido definida como uma importante causa desse problema.

Adequate restitution in primary hypothyroidism depending on levothyroxine formulations / Restitución adecuada en hipotiroidismo primario según las presentaciones de levotirotiroxina

Background: The prevalence of primary hypothyroidism (PH) is around 3.8%-4.6% in general population. Out of patients under treatment with levothyroxine, approximately 40% show altered levels of thyroid-stimulating hormone (TSH). Objective: To determine the prevalence of euthyroid sick syndrome in patients under treatment for PH in two local clinics, considering that the number of formulations of levothyroxine could be a contributing factor to the inadequate restitution. Methods: Descriptive, comparative cohort conducted with PH patients who were treated with a stable dose of levothyroxine for at least six months. Patients treated with mixtures of liothyronine/levothyroxine, with postsurgical hypothyroidism, pregnant, breastfeeding or mentally ill were discarded. Medical clinic 1 was a public center that had only access to levothyroxine of 100 µg, and medical clinic 2 was a private clinic with access to 25, 50, 75 and 100 µg levothyroxine formulations. Results: A total of 350 patients were evaluated. 190 patients were obtained at clinic 1, and 160 patients at clinic 2. At clinic 1, only 63% received the appropriate dose, while at clinic 2, 75% were medicated with the correct dose (p = 0.033). Conclusion: In the public center, 39% of patients did not receive appropriate dose of levothyroxine; however, in the private clinic, which had more drug formulations, the percentage of patients lowered to 25%. Therefore, the number of formulations could be a factor for the risk of inadequate restitution.

Introducción: La prevalencia de hipotiroidismo primario (HP) en la población general oscila entre 3.8 y 4.6%. De los pacientes que están bajo tratamiento con levotiroxina, aproximadamente 40% muestra una hormona estimulante de la tiroides (TSH) anormal. Objetivo: Conocer la prevalencia de eutiroidismo en pacientes tratados por HP en dos clínicas de nuestra localidad, considerando que las presentaciones de levotiroxina pudiesen ser un factor contribuyente. Métodos: Cohorte comparativa de pacientes con HP tratados con levotiroxina en dosis estable por más de seis meses. Se descartaron los pacientes tratados con mezclas de liotironina/levotiroxina, hipotiroidismo postquirúrgico, embarazadas o en lactancia e individuos con enfermedades mentales. La clínica 1 (entidad pública) contó con levotiroxina de 100 µg y la clínica 2 (entidad privada) con pastillas de 25, 50, 75 y 100 µg. Resultados: Evaluamos 350 pacientes. De la clínica 1 se obtuvieron 190 y de la clínica 2 fueron 160. En la clínica 1, el 63% recibió la dosis adecuada, mientras que en la clínica 2, el 75% eran medicados con la dosis correcta (p = 0.033). Conclusiones: En la entidad pública, 39% no recibió la dosis adecuada de levotiroxina; sin embargo, en la entidad privada, con más presentaciones del medicamento, el número disminuye a 25%. Por lo tanto el número de presentaciones podría ser un factor influyente para lograr el eutiroidismo.

Glucose disturbances in non-diabetic patients receiving acute treatment with methylprednisolone pulses.

OBJECTIVE: Methylprednisolone pulses are used in a variety of disease conditions, both for acute and chronic therapy. Although well tolerated, they increase glucose levels in both non-diabetic and diabetic patients. They may also be considered a significant risk for acute metabolic alterations. The purpose of this report is to determine the metabolic changes in blood glucose levels in non-diabetic patients receiving methylprednisolone pulses and identify the presence of predictive factors for its development. METHODS: Observational, prospective study in 50 non-diabetic patients receiving 1 g intravenous methylprednisolone pulses for three consecutive days as an indication for diverse autoimmune disorders. Demographic, anthropometric, and metabolic variables were analyzed, and glucose, insulin and C-peptide levels after each steroid pulse were identified. Different variables and the magnitude of hyperglycemia were analyzed using Pearson's correlation. RESULTS: 50 patients were included, predominantly women (66%, n = 33). The average age was 41 ± 14 years with a BMI of 26 ± 3 kg/m². Baseline glucose was 83 ± 10 mg/dL. After each steroid pulse, glucose increased to 140 ± 28, 160 ± 38 and 183 ± 44, respectively (p < 0.001). C-peptide and insulin concentrations increased significantly (p < 0.001). The prevalence of fasting hyperglycemia after each pulse was 68%, 94% and 98%, respectively. We found no correlation between the magnitude of hyperglycemia and the studied variables. CONCLUSION: Methylprednisolone pulses produced significant increases in fasting glucose in most patients without diabetes. Further studies are needed to define its role in long-term consequences.

Glucose disturbances in non-diabetic patients receiving acute treatment with methylprednisolone pulses / Distúrbios de glicose em pacientes não diabéticos que recebem tratamento agudo com pulsos de metilprednisolona

OBJECTIVE: Methylprednisolone pulses are used in a variety of disease conditions, both for acute and chronic therapy. Although well tolerated, they increase glucose levels in both non-diabetic and diabetic patients. They may also be considered a significant risk for acute metabolic alterations. The purpose of this report is to determine the metabolic changes in blood glucose levels in non-diabetic patients receiving methylprednisolone pulses and identify the presence of predictive factors for its development. METHODS: Observational, prospective study in 50 non-diabetic patients receiving 1 g intravenous methylprednisolone pulses for three consecutive days as an indication for diverse autoimmune disorders. Demographic, anthropometric, and metabolic variables were analyzed, and glucose, insulin and C-peptide levels after each steroid pulse were identified. Different variables and the magnitude of hyperglycemia were analyzed using Pearson's correlation. RESULTS: 50 patients were included, predominantly women (66 percent, n = 33). The average age was 41 ± 14 years with a BMI of 26 ± 3 kg/m². Baseline glucose was 83 ± 10 mg/dL. After each steroid pulse, glucose increased to 140 ± 28, 160 ± 38 and 183 ± 44, respectively (p < 0.001). C-peptide and insulin concentrations increased significantly (p < 0.001). The prevalence of fasting hyperglycemia after each pulse was 68 percent, 94 percent and 98 percent, respectively. We found no correlation between the magnitude of hyperglycemia and the studied variables. CONCLUSION: Methylprednisolone pulses produced significant increases in fasting glucose in most patients without diabetes. Further studies are needed to define its role in long-term consequences.

OBJETIVO: Pulsos de metilprednisolona são usados em diversas doenças, tanto para tratamento agudo quanto crônico. Embora bem tolerados, eles aumentam os níveis de glicose em ambos os pacientes, não diabéticos e diabéticos. Eles também podem ser considerados um risco significativo para alterações metabólicas agudas. O propósito deste estudo é determinar as alterações metabólicas nos níveis de glicose no sangue de pacientes não diabéticos que recebem pulsos de metilprednisolona e identificar a presença de fatores preditivos para seu desenvolvimento. MÉTODOS: Estudo observacional prospectivo em 50 pacientes não diabéticos que recebem pulsoterapia com 1 g de metilprednisolona intravenosa por três dias consecutivos como tratamento para diversas doenças autoimunes. Variáveis demográficas, antropométricas e metabólicas foram analisadas, e glicose, insulina e níveis de peptídeo C foram identificados após cada pulso de esteroide. Diferentes variáveis e a magnitude da hiperglicemia foram analisadas utilizando a correlação de Pearson. RESULTADOS: 50 pacientes foram incluídos, predominantemente mulheres (66 por cento, n = 33). A idade média foi de 41 ± 14 anos com um IMC de 26 ± 3 kg/m². A glicose de base foi de 83 ± 10 mg/dL. Após cada pulso de esteroide, a glicose aumentou para 140 ± 28, 160 ± 38 e 183 ± 44, respectivamente (p < 0,001). Peptídeo C e concentrações de insulina aumentaram significativamente (p < 0,001). A prevalência de hiperglicemia em jejum após cada pulso foi de 68 por cento, 94 por cento e 98 por cento, respectivamente. Não encontramos nenhuma correlação entre a magnitude da hiperglicemia e as variáveis estudadas. CONCLUSÃO: Os pulsos de metilprednisolona produziram aumentos significativos na glicemia de jejum na maioria dos pacientes sem diabetes. Mais estudos são necessários para definir o seu papel nas consequências em longo prazo.

[Thyroid incidentaloma frequency in a university hospital]. / Prevalencia del incidentaloma tiroideo en un hospital universitario.

BACKGROUND: The prevalence of thyroid incidentaloma is variable and always created the dilemma of how to manage them. The objective was to determine the frequency of thyroid incidentalomas in a University Hospital. METHODS: A descriptive, transversal, prospective study was done; a non-probabilistic sample was used with patients who met the following criteria: >18 years, indiscriminate sex, and an image that included neck: ultrasound, computed tomography and/or magnetic resonance. Patients with known or suspected thyroid nodule or any other thyroid disease and pregnant women were excluded. Descriptive statistics were used. RESULTS: 153 patients who had the criterion; 11 patients had an incidentaloma (7.18%). Females were more frequent with seven cases (63.6%), the mean age was 56.9 years. Morphologically only a single thyroid nodule was detected. The nodules were smaller than 1.5 cm. CONCLUSIONS: The prevalence documented in our study is smaller than other reports, it is proposed monitoring patients with thyroid incidentalomas according to current consensus guidelines.

[Prevalence of hypokalemia in patients with methylprednisolone pulse therapy]. / Prevalencia de hipokalemia en pacientes tratados con pulsos de metilprednisolona.

OBJECTIVE: To determine the prevalence of hypokalemia in patients with methylprednisolone pulse therapy. DESIGN: We carried out a descriptive, cross-sectional study. MATERIAL AND METHODS: We enrolled 110 outpatients who received pulse doses of 1 g of intravenous methylprednisolone for three consecutive days. Demographic variables, serum electrolytes and an electrocardiogram were documented. RESULTS: The study group consisted of 31 men (28.2%) and 79 women (71.8%). Average age was 40 +/- 13.6 years. Mild hypokalemia was present in 19 patients (17.27% [95% CI 9.75-24.79]); moderate potassium levels were found in just one patient 0.9% [IC 95 0.023-4.96]); no cases of severe hypokalemia occurred. Total prevalence was 18.18% (95% CI 10.5-25.8). There were no significant electrocardiographic changes. DISCUSSION AND CONCLUSION: Mild and moderate hypokalemia was 18.18% without clinical or electrocardiographic consequences. Since there were no cases of severe hypokalemia, close monitoring of potassium levels should be restricted to those patients with other risk factors.

[NOPHAL Proyect: an integreting vision of hyperglycemia at the hospital]. / Proyecto NOPHAL: una visión integradora de la hiperglucemia en el hospital.

Patients with hyperglycemia are more likely to be hospitalized, and evidence links it with poor outcomes. Recognizing the importance of glycemic control, we develop a multidisciplinary educational program on inpatient glycemic management, with metabolic goals that are reasonable, achievable and safe.

Nondiagnostic thyroid fine needle aspiration cytology: outcome in surgical treatment.

BACKGROUND: Fine-Needle Aspiration (FNA) is the main screening process for distinguishing benign from malignant thyroid nodules. Despite this, by 5-29% of patients, their FNA results are not enough to confirm malign neoplasia, particularly in cases with follicular lesions. The objective of this report is to present the definitive histological results of a group of 41 patients with FNA of Thyroid nodule catalogued as "indeterminate/non diagnostic" sent for surgical treatment. MATERIAL AND METHODS: A retrospective analysis was done on all of the patients who had underwent surgery for thyroid nodule, with a previous diagnosis of "indeterminate/non diagnostic" by FNA. Forty-one patients, three male (7.31%), and 38 female (92.68%), were included in the present study. RESULTS: Fifteen women and one man were positive for malignancies (39.02%). The nodule was bigger than 4 cm in 23 patients in total (56.09%), and of this percentage, 6 were malignant (26.09%). According to age, 24 patients were older than 45 years (58.5%), 8 of whom showed malignant pathology (33.3%). All these variables were non significant. Fifteen of 16 patients had a definitive diagnosis of papillary carcinoma and one follicular carcinoma. CONCLUSIONS: The majority of patients with a diagnosis of "indeterminated/non diagnostic" had benign lesions (60.9%). The usual predictive factors for malignity such as age, sex, size of nodule, did not present a significant support in the differential diagnosis.

[Insulin therapy in patients with severe hypertriglyceridemia]. / Terapia con insulina en pacientes con hipertrigliceridemia severa.

A series of seven patients with severe hypertriglyceridemia (triglyceride levels > 1000 mg/dL) is presented. Four of the patients were diabetics, two of them were in treatment with anti-retroviral drugs, and three of them presented acute pancreatitis. In all patients intravenous infusion of insulin was initiated at a rate of 0.05-2 U/kg/day. Two and a half days after this treatment, the serum triglyceride level remained lower than 400 mg/dL. There were no complications during the treatment. The long treatment included basal insulin, fibrates and avoidance of pharmacotherapy. Insulin therapy for diabetic and non-diabetic patients with severe hypertriglyceridemia is an effective and safe treatment.

[Thyroid cancer in children and adolescents]. / Cáncer de tiroides en niños y adolescentes.

BACKGROUND: Thyroid nodules in children and adolescents may be associated to malignant neoplasms. Although thyroid cancer is a rare event in this age group, delayed diagnosis is associated to metastatic, regional or lung disease, but even in these circumstances appropriate treatment may be followed by good prognosis. We decided to review the clinical course of these patients in our hospital from 1980 to 2001. METHODS: We found fifteen patients younger than 18 years diagnosed with thyroid carcinoma, which had been followed by at least 12 months, with a mean of 95 months and a maximal of 10 years. All patients were treated by surgery and 131 iodine, and followed by scans, ultrasound and thyroglobulin analysis. RESULTS: The patients group were thirteen females and two males. At diagnosis, seven patients (46.7o%) had metastatic regional disease and eight had a thyroid nodule. Total thyroidectomy with a modified neck dissection and 131 iodine was the initial treatment for patients with regional disease and subtotal thyroidectomy and 131 iodine in the follow-up to treat the thyroid bed or metastases was the treatment for patients with localized disease. All patients had a histologic pattern of papillary carcinoma. Nine patients (60%) had local recurrence in a mean follow-up of 37 months, one patient that had been previously treated by total thyroidectomy and all patients that were treated by subtotal thyroidectomy, however, all responded to the complementary treatment. At this moment the mean follow up is 95 months and all the patients have survived. CONCLUSIONS: In our experience thyroid cancer in children and adolescents is a rare event whose delayed diagnosis is associated to regional lymph node or lung metastases. Subtotal thyroidectomy was associated to disease progression to metastases, but complementary treatment was successful and all patients have survived.