Asociación entre el índice de amputación por pie diabético y los indicadores de atención y manejo de diabetes mellitus tipo 2 en los Centros de Salud del Servicio Metropolitano Oriente, entre 2014 y 2018 / Association between the diabetic foot amputation index and metabolic compensation in diabetes mellitus

BACKGROUND: Diabetic foot amputation is a public health challenge due to the increasing prevalence of type 2 diabetes mellitus (T2D). Although there are many health indicators aimed at the management and control of T2D and its complications, amputations persist. Aim: To evaluate the association between diabetic foot amputation index and indicators of care and management of T2D in primary care centers of the eastern section of Santiago, Chile. MATERIAL AND MATHODS: We conducted a mixed ecological study and included information from the Monthly Statistical report of different public health centers from 2014 to 2018. We also analyzed the hospital discharge records from an individual tertiary public health center. The annual index for diabetic foot amputation per 100,000 diabetic patients was used as a response variable. The diabetic compensation percentage was calculated as the proportion of adults with a glycosylated hemoglobin below 7% or the proportion of older people with a value below 8%. The diabetic decompensation percentage was calculated as the proportion of people with a glycosylated hemoglobin over 9%. RESULTS: A high variability in demographic and management indicators was observed between communes and centers in the study period. Bivariate analysis showed a significant correlation between the amputation index, decompensation, and insulin use. In a regression analysis, the amputation index was significantly associated with the diabetic compensation percentage (β = -3.5; p < 0.05) and a high decompensation percentage (β = 12.3; p < 0.005). Conclusions: The diabetic foot amputation index was associated with diabetic compensation and decompensation indicators.

[Association between the diabetic foot amputation index and metabolic compensation in diabetes mellitus]. / Asociación entre el índice de amputación por pie diabético y los indicadores de atención y manejo de diabetes mellitus tipo 2 en los Centros de Salud del Servicio Metropolitano Oriente, entre 2014 y 2018.

BACKGROUND: Diabetic foot amputation is a public health challenge due to the increasing prevalence of type 2 diabetes mellitus (T2D). Although there are many health indicators aimed at the management and control of T2D and its complications, amputations persist. AIM: To evaluate the association between diabetic foot amputation index and indicators of care and management of T2D in primary care centers of the eastern section of Santiago, Chile. MATERIAL AND METHODS: We conducted a mixed ecological study and included information from the Monthly Statistical report of different public health centers from 2014 to 2018. We also analyzed the hospital discharge records from an individual tertiary public health center. The annual index for diabetic foot amputation per 100,000 diabetic patients was used as a response variable. The diabetic compensation percentage was calculated as the proportion of adults with a glycosylated hemoglobin below 7% or the proportion of older people with a value below 8%. The diabetic decompensation percentage was calculated as the proportion of people with a glycosylated hemoglobin over 9%. RESULTS: A high variability in demographic and management indicators was observed between communes and centers in the study period. Bivariate analysis showed a significant correlation between the amputation index, decompensation, and insulin use. In a regression analysis, the amputation index was significantly associated with the diabetic compensation percentage (ß = -3.5; p < 0.05) and a high decompensation percentage (ß = 12.3; p < 0.005). CONCLUSIONS: The diabetic foot amputation index was associated with diabetic compensation and decompensation indicators.

Angiectasias yeyunales como causa de sangrado intestinal oculto: identificación con cápsula endoscópica / Jejunal angiectasis as a cause of hidden intestinal bleeding: identification with endoscopic capsule

Una paciente de 83 años, con antecedentes de hipertensión arterial y diabetes mellitus bajo tratamiento, fue ingresó al hospital por un cuadro de sangrado digestivo, caracterizado por melenas y rectorragia, con compromiso hemodinámico. La endoscopia alta y colonoscopia no encontraron el origen del sangrado, por lo cual se empleó una cápsula endoscó- pica. El examen reveló a nivel de yeyuno medio y distal la presencia de sangrado activo proveniente de varios vasos pequeños y tortuosos, ligeramente elevados de diferentes tamaños, lesiones compatibles con múltiples angiodisplasias (foto 1 y 2). Además, a las dos horas del estudio, se visualizó imagen de una lesión ulcerada comprometiendo la luz yeyunal y cubierta con fbrina, sin sangrado activo, que como consecuencia generaba una estenosis luminal, por lo que la cápsula permaneció a este nivel por el lapso de 5 horas (foto 3). La paciente evolucionó con deterioro de su condición médica, fue ingresada a la Unidad de Terapia Intensiva y posteriormente falleció por una falla multiorgánica.

An 83-year-old patient with a history of hypertension arterial and diabetes mellitus under treatment, was admitted to hospital for a picture of digestive bleeding, characterized by mane and rectorragia, with hemodynamic commitment. The high endoscopy and colonoscopy did not find the origin of bleeding, whereby an endoscopic capsule was used pica. The examination revealed at the level of middle and distal jejunum the presence of active bleeding from several vessels small and tortuous, slightly elevated from different sizes, lesions compatible with multiple angiodysplasias (photo 1 and 2). In addition, two hours after the study, it was visualized image of an ulcerated lesion compromising jejunal light and covered with fbrine, without active bleeding, which as consequence generated a luminal stenosis, so the capsule remained at this level for 5 hours (photo 3). The patient evolved with deterioration of her medical condition, she was admitted to the Intensive Care Unit and He subsequently died of a multi-organ failure.

[Primary sclerosing cholangitis: a twelve-year experience]. / Colangitis esclerosante primaria: revisión de 12 años en dos centros de referencia.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic disorder characterized by progressive inflammation and fibrosis of the biliary tract, evolving to cirrhosis. It is commonly associated with inflammatory bowel disease (IBD). AIM: To communicate the clinical characteristics of patient with PSC seen in two reference centers. PATIENTS AND METHODS: Review of medical records of patients with PSC confirmed by liver biopsies. The clinical picture, laboratory abnormalities, imaging studies and treatment were recorded. RESULTS: Thirty three patients (aged 16 to 73 years, 64% female) were identified. They corresponded to 1.7% of liver biopsies done between 1991-2003. Clinical presentation was a cholestatic picture in 40%, right upper abdominal pain in 36%, a dysenteric syndrome in 9% and varied symptoms in 15%. Laboratory tests showed cholestasis in 94% and positive anti ANCA, SMA, ANA and AMA antibodies in 28, 18, 15 and 9% of cases, respectively. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiography were diagnostic in 43 and 58% of patients, respectively. There was an association with ulcerative colitis in 12% of cases. Liver biopsies showed grade I PSC in 76% and grade II-III in 6% of patients. It also showed a concomitant chronic hepatitis and primary biliary cirrhosis in 12 and 6% of cases, respectively. Treatment consisted on ursodeoxycholic acid (UDCA) in 45%, UDCA plus 5-aminosalicylic acid derivatives in 12% and UDCA plus immunosuppresors in 12% of patients. Two patients had to be transplanted. CONCLUSIONS: PSC is an uncommon cause of chronic liver disease. It is suspected in cholestatic patients and confirmed with a liver biopsy. It can be associated with other autoimmune hepatic and extrahepatic diseases.

Tetraparesia fláccida / Flaccid tetraparesis

In this paper we review a clinical case of a man of 66 years old admitted to the medicine service of the Clinical Hospital of the University of Chile, with a clinical setting of flaccid tetraparesis associated with myalgias, dysphagia, dysphonia, reddish-violaceous eruption on the upper eyelids, periungual erythema and erythema distributed over the anterior neck and chest. We take this case to review the cases of flaccid tetraparesis that can be due to systemic, neuromuscular or psychiatric diseases. The clinical approach begins with the anamnesis: drugs consumption, or systemic diseases; continues with the physical examination orientated to stablish compromise of first or second motoneuron. Finally laboratory test as muscle enzymes, endocronologic test, and others like electromyography and muscle biopsy. We also review the actual tratments and the outcome and prognosis with each of them