Tratamiento dietético de la ascitis quilosa postquirúrgica: caso clínico y revisión de la literatura / Postsurgical chylousascites: Case report and literature review

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal debido a la ruptura u obstrucción de los conductos linfáticos abdominales. Clínicamente se manifiesta por distensión abdominal. El criterio diagnóstico más útil es el aumento de los triglicéridos en el líquido ascítico. Las neoplasias son la causa más frecuente, aunque también deben considerarse etiologías menos comunes como la cirugía abdominal. El tratamiento consiste en dieta hiperproteica con restricción de la grasa y suplementos de triglicéridos de cadena media. En caso de no respuesta o contraindicación de la vía oral- enteral se opta por nutrición parenteral reservándose la cirugía para las situaciones refractarias al tratamiento conservador. Presentamos un caso de ascitis quilosa secundaria a linfadenectomía retroperitoneal (AU)

Chylous ascites derives from chyle leakage into the peritoneal cavity, either due to rupture or obstruction of abdominal lymphatic vessels. The main clinical sign is abdominal distention, while diagnosis requires the presence of triglycerides in ascitic fluid. Neoplasms are the most common cause of chylous ascites, although less common causes, such as abdominal surgery, should also be considered. The mainstay of therapy is hyperproteic diet with fat restriction and middle-chain triglycerides. Parenteral nutrition is reserved for cases in which dietary treatment fails to restore an optimal nutritional status or is contraindicated, whereas surgery is considered for patients that are deemed refractory to conservative therapy. We present a case of chylous ascites secondary to retroperitoneal lymphadenectomy (AU)

[Metabolic syndrome and insulin resistance: prevalence in women with prior gestational diabetes, using two different classifications]. / Síndrome metabólico y resistencia insulínica: prevalencia según distintas clasificaciones en mujeres con diabetes gestacional previa.

OBJECTIVE: To determine the metabolic syndrome prevalence using the ATPIII and the IDF definitions and that of each criterion and to study the differences. To relate the presence of insulin resistance with metabolic syndrome diagnostic. MATERIALS AND METHODS: A total of 1,080 women diagnosed of gestational diabetes who came to follow up were studied. Prevalence of the metabolic syndrome was determined using the ATPIII and the IDF classification and prevalence of each criterion independently. The HOMA insulin resistance index was determined in 575 patients. RESULTS: Metabolic syndrome prevalence was 9.3% according to the ATPIII classification and 17.4% according to the IDF, this coinciding in 94 cases. Only the IDF classification criteria were fulfilled in 94 cases due to abdominal obesity in 13.8%, to fasting glucose in 17% and to both criteria in 69.8%. Six cases only met the ATPIII classification due to absence of abdominal obesity. The HOMA index value was 4.9 (+/- 3.5) and 4.0 (+/- 3) for women diagnosed of metabolic syndrome using the ATPIII or the IDF classification, respectively. Insulin resistance prevalence was 13.7%. The Kappa index of agreement was 0.411 between metabolic syndrome diagnostic by ATPIII and insulin resistance and 0.352 for IDF. CONCLUSIONS: Metabolic syndrome prevalence is almost double when the IDF classification is used than with the ATPIII due to the more strict value of fasting glucose and abdominal obesity. The ATPIII classification better identifies insulin resistance presence than that of IDF.

Valor predictivo del índice tobillo-brazo, el índice dedo-brazo y la presión arterial del dedo en el paciente con diabetes / Predictive value of ankle brachial index, toe brachial index and toe arterial pressure in patients with diabetes

Introducción: La enfermedad vascular periférica es muy frecuente en pacientes con diabetes. Objetivos: Evaluar, en el paciente diabético, la utilidad del índice tobillo-brazo, el índice dedo-brazo y la presión arterial del dedo para predecir el riesgo de aparición de un evento vascular en las extremidades inferiores. Material y métodos: Se evaluaron 123 pacientes diabéticos. Se midieron el índice tobillo-brazo (ITB), el índice dedo-brazo (IDB) y la presión arterial (PA) del primer dedo del pie. Se compararon los valores medios de los parámetros en los pacientes con y sin evento. Se analizó su valor predictivo y la contribución independiente de cada uno. Resultados: Los valores medios de ITB, IDB y PA en el primer dedo fueron menores en los pacientes con evento vascular. La isquemia por ITB, la isquemia por IDB y el menor valor de PA en el primer dedo aumentaron el riesgo de presentar un evento vascular. Se demostraron, como predictores independientes, la isquemia por ITB y la PA del dedo. Conclusiones: Se demuestra la utilidad del IDB, el ITB y la PA del dedo a la hora de predecir el mayor riesgo de aparición de un evento vascular en las extremidades inferiores en el paciente con diabetes, presentando un valor predictivo independiente el ITB y la PA del dedo (AU)

Introduction: Patients with diabetes have a higher frequency of vascular peripheral disease. Objective: To evaluate, in patients with diabetes, the usefulness of the ankle brachial index, the toe brachial index and the toe blood pressure to predict the risk of later appearance of a vascular event in lower extremities. Material and methods: We measured the ankle brachial index (ITB), the toe brachial index (IDB) and the toe blood pressure in 123 patients with diabetes. We compared the mean value of these parameters between patients with and without vascular event. We analyzed the predictive value of this parameters and the independent contribution of each one of them. Results: The mean value of ITB, IDB and toe blood pressure were signifi cantly lower in patients who had a vascular event. The patients with ischemia by ITB, ischemia by IDB and with lower value of toe blood pressure have an increased risk of presenting a vascular event. Only ischemia by ankle brachial index and toe blood pressure were independent predictors of later appearance of a vascular event. Conclusions: The usefulness of ankle brachial index, toe brachial index and toe blood pressure to predict a vascular event in patients with diabetes had been demonstrated. In addition, ankle brachial index and toe arterial pressure have and independent predictive value (AU)

Síndrome metabólico y resistencia insulínica: prevalencia según distintas clasificaciones en mujeres con diabetes gestacional previa / Metabolic syndrome and insulin resistance: prevalence in women with prior gestational diabetes, using two different classifications

Objetivos. Determinar la prevalencia del síndrome metabólico según las definiciones del ATPIII y de la IDF y la de cada criterio y estudiar las discrepancias. Relacionar la presencia de resistencia insulínica con el diagnóstico de síndrome metabólico. Material y métodos. Se estudiaron 1.080 pacientes diagnosticadas de diabetes gestacional que acudían a revisión. Se determinó la prevalencia de síndrome metabólico utilizando las dos definiciones y la de cada criterio. En 575 pacientes se determinó el índice de resistencia insulínica HOMA. Resultados. La prevalencia de síndrome metabólico fue del 9,3% según la clasificación del ATPIII y de 17,4% con la de la IDF coincidiendo en 94 casos. Noventa y cuatro casos cumplían únicamente los criterios de la IDF debido a la obesidad central en un 13,8%, a la glucemia basal en el 17% y a los dos criterios en 69,8%. Seis casos sólo cumplían los criterios del ATPIII debido a la ausencia de obesidad central. El valor del índice HOMA fue de 4,9 (± 3,5) y de 4,0 (± 3) en las que presentaban síndrome metabólico por el ATPIII y la IDF respectivamente. La prevalencia de resistencia insulínica fue del 13,7%. Resultó un índice de concordancia kappa de 0,411 entre el diagnóstico de síndrome metabólico por el ATPIII y la presencia de resistencia a la insulina y de 0,352 para la IDF. Conclusión. La prevalencia de síndrome metabólico es casi el doble con la definición de la IDF que con la del ATPIII condicionado por los criterios de GBA (glucemia basal alterada) y obesidad central. La definición del ATPIII identifica mejor la presencia de resistencia insulínica que la de la IDF (AU)

Objective. To determine the metabolic syndrome prevalence using the ATPIII and the IDF definitions and that of each criterion and to study the differences. To relate the presence of insulin resistance with metabolic syndrome diagnostic. Materials and methods. A total of 1,080 women diagnosed of gestational diabetes who came to follow up were studied. Prevalence of the metabolic syndrome was determined using the ATPIII and the IDF classification and prevalence of each criterion independently. The HOMA insulin resistance index was determined in 575 patients. Results. Metabolic syndrome prevalence was 9.3% according to the ATPIII classification and 17.4% according to the IDF, this coinciding in 94 cases. Only the IDF classification criteria were fulfilled in 94 cases due to abdominal obesity in 13.8%, to fasting glucose in 17% and to both criteria in 69.8%. Six cases only met the ATPIII classification due to absence of abdominal obesity. The HOMA index value was 4.9 (± 3.5) and 4.0 (± 3) for women diagnosed of metabolic syndrome using the ATPIII or the IDF classification, respectively. Insulin resistance prevalence was 13.7%. The Kappa index of agreement was 0.411 between metabolic syndrome diagnostic by ATPIII and insulin resistance and 0.352 for IDF. Conclusions. Metabolic syndrome prevalence is almost double when the IDF classification is used than with the ATPIII due to the more strict value of fasting glucose and abdominal obesity. The ATPIII classification better identifies insulin resistance presence than that of IDF (AU)

[Postsurgical chylous ascites: case report and literature review]. / Tratamiento dietético de la ascitis quilosa postquirúrgica: caso clínico y revisión de la literatura.

Chylous ascites derives from chyle leakage into the peritoneal cavity, either due to rupture or obstruction of abdominal lymphatic vessels. The main clinical sign is abdominal distention, while diagnosis requires the presence of triglycerides in ascitic fluid. Neoplasms are the most common cause of chylous ascites, although less common causes, such as abdominal surgery, should also be considered. The mainstay of therapy is hyperproteic diet with fat restriction and middle-chain triglycerides. Parenteral nutrition is reserved for cases in which dietary treatment fails to restore an optimal nutritional status or is contraindicated, whereas surgery is considered for patients that are deemed refractory to conservative therapy. We present a case of chylous ascites secondary to retroperitoneal lymphadenectomy.

[Diabetic foot and risk factors]. / Factores de riesgo y pie diabético.

OBJECTIVE: To identify clinic and metabolic risk factors for diabetic neuropathy and peripheral arterial disease in patients evaluated in a diabetic foot unit care. METHOD: From 2000 to 2005 we evaluated the presence of diabetic neuropathy (monofilament, tuning fork and Boulton's clinic scale) and peripheral arterial disease (ankle-brachial index and toe-brachial index) in 304 diabetic patients. We classified patients in four groups: patients without pathology (normal group), with neuropathy (neuropathic group), with peripheral arterial disease (vascular group) and with both pathologies (mixed group) and we compared the characteristics of each group. We analysed other poblational characteristics: age, gender, type of diabetes, duration, microvascular and macrovascular complications, hypertension, smoking habit, antiagregation and mean HbA1c in the last year. RESULTS: Age, frequency of hypertension and coronary disease were significantly higher (p < 0.005) in vascular and mixed group than in normal group (63 +/- 13 and 65 +/- 10 vs. 55 +/- 14; 69.2 and 70.3 vs. 45.5%; 46,2% and 39.2% vs 23.8%, respectively). Frequency of retinopathy, nephropathy and HbA1c were significantly higher (p < 0.05) in neuropathic and mix group than in normal group (62.5 and 66.2 vs. 32.7%; 45.3 and 47.3 vs. 24.8%; 8.1 +/- 1.6 and 8.0 +/- 1.3 vs 7.4 +/- 1.2 respectively). CONCLUSION: This study indicates that the development of diabetic neuropathy is related with worse metabolic control and the presence of other microvascular complications; while age, hypertension and coronary disease are risk factors for peripheral arterial disease.

Factores de riesgo y pie diabético / Diabetic foot and risk factors

Objetivo: Identificar factores clínico-metabólicos relacionados con la neuropatía diabética y la enfermedad arterial periférica en pacientes evaluados en una unidad de pie diabético. Método: Desde 2000 a 2005 se evaluó, en una población de 304 diabéticos, la presencia de neuropatía (monofilamento, diapasón graduado y escala clínica de Boulton) y de enfermedad arterial periférica (índice tobillo-brazo y/o dedo-brazo). Se clasificaron los pacientes en cuatro grupos: sin patología (grupo normal), con neuropatía (grupo neuropático), con enfermedad arterial periférica (grupo vascular) y con ambas patologías (grupo mixto). Se compararon las características de los pacientes de cada grupo. Se recogieron las variables: edad, sexo, tipo de diabetes, duración, complicaciones microvasculares y macrovasculares, hipertensión, dislipemia, tabaquismo, antiagregación y HbA1C media del último año. Resultados: Comparado con el grupo normal, la edad media, la frecuencia de hipertensión y la de cardiopatía isquémica fue significativamente mayor (p < 0,005) en el grupo vascular y mixto (55 ± 14 vs. 63 ± 13 y 65 ± 10; 45,5 vs. 69,2 y 70,3%; 23,8 vs. 46,2 y 39,2%, respectivamente). Comparado con el grupo normal, la frecuencia de retinopatía , la de nefropatía y HbA1c media fue significativamente mayor (p < 0,05) en el grupo neuropático y mixto (32,7 vs. 62,5 y 66,2%; 24,8 vs. 45,3 y 47,3%; 7,4 ± 1,2 vs. 8,1 ± 1,6 y 8,0 ± 1,3 respectivamente). Conclusiones: Este estudio indica que el desarrollo de neuropatía diabética está en relación con un peor control metabólico y con la existencia de otras complicaciones microvasculares; mientras que la edad, la hipertensión y la enfermedad coronaria constituyen factores de riesgo para la coexistencia de arteriopatía periférica

Objective: To identify clinic and metabolic risk factors for diabetic neuropathy and peripheral arterial disease in patients evaluated in a diabetic foot unit care. Method: From 2000 to 2005 we evaluated the presence of diabetic neuropathy (monofilament, tuning fork and Boulton´s clinic scale) and peripheral arterial disease (ankle-brachial index and toe-brachial index) in 304 diabetic patients. We classified patients in four groups: patients without pathology (normal group), with neuropathy (neuropathic group), with peripheral arterial disease (vascular group) and with both pathologies (mixed group) and we compared the characteristics of each group. We analysed other poblational characteristics: age, gender, type of diabetes, duration, microvascular and macrovascular complications, hypertension, smoking habit, antiagregation and mean HbA1c in the last year. Results: Age, frequency of hypertension and coronary disease were significantly higher (p < 0.005) in vascular and mixed group than in normal group (63 ± 13 and 65 ± 10 vs. 55 ± 14; 69.2 and 70.3 vs. 45.5%; 46,2% and 39.2% vs 23.8%, respectively). Frequency of retinopathy, nephropathy and HbA1c were significantly higher (p < 0.05) in neuropathic and mix group than in normal group (62.5 and 66.2 vs. 32.7%; 45.3 and 47.3 vs. 24.8%; 8.1 ± 1.6 and 8.0 ± 1.3 vs 7.4 ± 1.2 respectively). Conclusion: This study indicates that the development of diabetic neuropathy is related with worse metabolic control and the presence of other microvascular complications; while age, hypertension and coronary disease are risk factors for peripheral arterial disease

Adaptación de la tasa basal frente a dosis elevadas de corticoides en mujer con diabetes pregestacional, embarazo gemelar y tratamiento con infusión subcutánea continua de insulina (ISCI) / Adaptation of the basal rate against elevated glucocorticoid doses in a woman suffering pregestational diabetes, twin pregnancy and therapy with continuous subcutaneous insulin infusion

El tratamiento con corticoides puede alterar el control metabólico de las mujeres gestantes con diabetes. El caso que se presenta corresponde al de una mujer con diabetes pregestacional en tratamiento con ISCI que, tras la inyección de 2 dosis de 12 mg betametasona vía im (cada 12 h) para maduración del pulmón fetal, necesitó una adaptación de la tasa basal de insulina de la bomba de infusión. La tasa basal de insulina fue modificada en todos los periodos previamente programados, triplicando las tasas después de aplicada la primera dosis de corticoides durante las 24 h siguientes, duplicándolas el segundo día y aumentando 0,1 UI/hora el tercer y cuarto días. El incremento de insulina que supuso la nueva pauta fue de 39,5 UI/24 h el primer día, 19,75 UI/24 h el segundo, y 2,4 UI/24 h el tercer y cuarto días. Los valores de glucemia media logrados en los 4 días siguientes de las inyecciones de corticoides fueron 152, 99, 108, y 116 mg/dl (65-206), encontrándose más del 75% de las mediciones en un rango aceptable de entre 60 a 140 mg/dl. Falta saber si los buenos resultados obtenidos son reproducibles en el resto de gestantes con diabetes tipo 1 que sigan terapia con ISCI

Corticoid treatment can alter the metabolic control of pregnant women with diabetes. The reported case describes a woman with pregestational diabetes under CSII therapy, who needed an adaptation of basal rate of the insulin pump after the i.m. injection of two doses of 12 mg beclametasone (t.i.d) administered to accelerate fetal lung maturation. The basal rate was modified in each of the previously programmed periods, increasing all of them three times during the first 24 h, twice during the second day, and 0.1 IU./h the third and the forth following days. The insulin increment was the first day 39.5 IU./24 h, the second day 19.75 IU./24 h, and 2.4 IU./24 h the ensuing third and forth days. Mean blood glucose values were achieved these days were 152, 99, 108 and 116mg/dl (range 65-206), being more than 75% of determinations in an acceptable range between 60-140 mg/dl. Our recommendation needs also to be confirmed in other type 1 diabetic women treated with CSII who receive corticoids during pregnancy