Estado actual de los sistemas de infusión subcutánea continua de insulina y monitorización continua de glucosa en la Comunidad de Madrid / Current status of continuous subcutaneous insulin infusion and continuous glucose monitoring systems in the Community of Madrid

OBJETIVO: Analizar la información disponible sobre el estado de los sistemas de infusión subcutánea continua de insulina (ISCI) y de monitorización continua de glucosa (MCG) en la red pública sanitaria de la Comunidad Autónoma de Madrid (CAM). MATERIAL Y MÉTODOS: Se remitió una encuesta a los 28 servicios de endocrinología de los hospitales públicos de la CAM con 31 preguntas sobre los sistemas ISCI y MCG, que incluían registros de pacientes y aspectos asistenciales, administrativos y logísticos. Entre marzo y mayo de 2014 se recibieron respuestas de los centros y se recabó la información de los 20 servicios que realizaban este tipo de procedimientos en nuestra comunidad. Los datos sobre pacientes pediátricos se recibieron mayoritariamente a través de los servicios de adultos, con la excepción de 2 servicios de pediatría de los que la información se recibió directamente. RESULTADOS: En la CAM hay contabilizados un total de 1.256 sistemas ISCI en la población diabética. Los usuarios son mayoritariamente adultos (1.089 pacientes), mientras que 167 corresponden a pacientes pediátricos. Durante 2013 se instauraron 151 nuevos tratamientos (12% del total) mientras que se retiraron un total de 14 bombas. La disponibilidad de recursos asistenciales y la proporción de facultativos de plantilla encargados de estos tratamientos son muy desiguales entre distintos centros. Un 85% de los hospitales incluye entre sus prestaciones sistemas MCG retrospectivos, y un 40% los utiliza habitualmente al inicio de los tratamientos ISCI. Trece centros (65%) utilizan MCG a tiempo real (MCG-TR) a largo plazo en casos seleccionados, contabilizándose un registro acumulado de 67 pacientes. CONCLUSIONES: La implantación de las tecnologías en diabetes en la CAM es desigual en los distintos centros madrileños, y continúa siendo inferior a otros países de nuestro entorno, aunque parece observarse una discreta tendencia a recortar esas diferencias

OBJECTIVE: To analyze the available information about continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems in the public health care system of the Community of Madrid. MATERIAL AND METHODS: A survey consisting of 31 items was sent to the 28 endocrinology department of the Madrid public hospitals. Items focused on CSII and CGM and included patients' registrations, as well as data regarding healthcare, administrative, and logistic aspects. Responses from a total of 20 hospitals where these procedures are used were received from March 2013 to May 2014. Data about pediatric patients were obtained from adult endocrinology departments, except for two hospitals which directly reported the information. RESULTS: A total of 1256 CSII pumps were recorded in the Madrid region, of which 1089 were used by adults, and the remaining 167 by pediatric patients. During 2013, 151 new CSII systems were implanted (12% of the total), while 14 pumps were withdrawn. Availability of human resources (medical assistance) and the number of staff practitioners experienced in management of these systems widely varied between hospitals. Eighty-five percent of hospitals used retrospective CGM systems, and 40% routinely placed them before starting an insulin pump. Thirteen hospitals (65%) used long-term, real-time CGM systems in selected cases (a total of 67 patients). CONCLUSIONS: Use of these technologies in diabetes is unequal between public health care hospitals in Madrid, and is still significantly lower as compared to other countries with similar incomes. However, there appears to be a trend to an increase in their use

[Current status of continuous subcutaneous insulin infusion and continuous glucose monitoring systems in the Community of Madrid]. / Estado actual de los sistemas de infusión subcutánea continua de insulina y monitorización continua de glucosa en la Comunidad de Madrid.

OBJECTIVE: To analyze the available information about continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems in the public health care system of the Community of Madrid. MATERIAL AND METHODS: A survey consisting of 31 items was sent to the 28 endocrinology department of the Madrid public hospitals. Items focused on CSII and CGM and included patients' registrations, as well as data regarding healthcare, administrative, and logistic aspects. Responses from a total of 20 hospitals where these procedures are used were received from March 2013 to May 2014. Data about pediatric patients were obtained from adult endocrinology departments, except for two hospitals which directly reported the information. RESULTS: A total of 1256 CSII pumps were recorded in the Madrid region, of which 1089 were used by adults, and the remaining 167 by pediatric patients. During 2013, 151 new CSII systems were implanted (12% of the total), while 14 pumps were withdrawn. Availability of human resources (medical assistance) and the number of staff practitioners experienced in management of these systems widely varied between hospitals. Eighty-five percent of hospitals used retrospective CGM systems, and 40% routinely placed them before starting an insulin pump. Thirteen hospitals (65%) used long-term, real-time CGM systems in selected cases (a total of 67 patients). CONCLUSIONS: Use of these technologies in diabetes is unequal between public health care hospitals in Madrid, and is still significantly lower as compared to other countries with similar incomes. However, there appears to be a trend to an increase in their use.

Factores de riesgo de complicaciones vasculares en extremidades inferiores en los pacientes con diabetes / Risk factors of vascular complications in lower limbs in diabetic patients

Fundamento y Objetivo: Evaluar en el paciente con diabetes los factores de riesgo que se asocian a la aparición de complicaciones vasculares en extremidades inferiores. Pacientes y método: Estudio longitudinal retrospectivo en el que se evalúan 270 pacientes con diabetes seguidos en el Hospital la Paz desde 2000 hasta 2008. Medimos el índice tobillo-brazo (ITB), índice dedo-brazo (IDB) y presión arterial (PA) del primer dedo. Definimos evento vascular en extremidades inferiores. Comparamos distintas variables clínicas y epidemiológicas entre los pacientes con y sin evento vascular. Con un modelo de regresión de Cox se valora qué variables presentan asociación independiente con la aparición de evento. Resultados: Los valores medios de ITB, IDB y PA del primer dedo son significativamente menores en los pacientes con evento (ITB medio [DE] de 0,92 [0,30] frente a 0,78 [0,46], p=0,007; IDB medio de 0,86 [4,40] frente a 0,42 [0,22], p=0,001; PA media de 72,08 [30,62] frente a 56,25 [29,51], p=0,014). Resulta significativa la asociación de evento vascular con alteraciones biomecánicas (p=0,022), úlceras activas (p=0,000), antiguas (p=0,000) e insensibilidad (p=0,023). En la regresión de Cox demostraron tener valor independiente el IDB (hazard ratio [HR] 0,05; intervalo de confianza del 95% [IC 95%] 0,00-0,52; p=0,013), alteraciones biomecánicas (HR 4,92; IC 95% 1,13-18,75; p=0,019), úlceras activas (HR 3,26; IC 95% 1,37-7,79; p=0,008) y previas (HR 5,55; IC 95%1,85-16,59; p=0,002). Conclusión: Los factores que nos sirven para predecir de forma independiente la aparición de eventos vasculares en extremidades inferiores en el futuro son el IDB, la existencia de alteraciones biomecánicas en los pies y el haber presentado úlceras. Son independientes de la edad, tipo de diabetes o existencia de otras complicaciones micro o macrovasculares de la misma (AU)

Background and Objetive: To evaluate the risk factors of complications in lower limbs in diabetic patients. Patients and methods: We evaluated 270 patients with diabetes followed in Hospital la Paz from 2000 to 2008.We measured the ankle-brachial index (ABI), toe-brachial index (TBII), and toe blood pressure (BP). We defined vascular complications in lower limbs. We compared some epidemiological and clinical variables between patients with and without a vascular event. We analyzed which variables have an independent association with the later appearance of a vascular event with Cox regression model. Results: The mean value of ITB, IDB and toe blood pressure were significantly lower in patients who had a vascular event compared to those who had not presented it (ITB mean 0.92±0.30 vs 0.78±0.46, P=.007; IDB mean 0.86±4.40 vs 0.42±0.22, P=.001; PA mean 72.08±30.62 vs 56.25±29.51, P=.014).The association of vascular event and biomechanical abnormalities (P=.022), active and old ulcers (P=.000), and insensivity (P=.023) were significantly. In the Cox regression model the toe brachial index (HR 0.05; IC:0.00-0.52; P=.013), the active (HR 3.26; IC:1.37-7.79; P=.008) and old ulcers (HR 5.55; IC:1.85-16.59; P=.002). and the biomechanical abnormalities (HR 4.92; IC:1.13-18.75; P=.019) had an independent value.Conclusions: Toe brachial index, biomechanical abnormalities and ulcers have an independent value to predict the later appearance of vascular events. In addition, they are independent of the age, type of diabetes and others diabetic complications (AU)

[Antipituitary antibodies in patients with suspected autoimmune hypophysitis]. / Anticuerpos antihipófisis en pacientes con sospecha de hipofisitis autoimmune.

INTRODUCTION: Definitive diagnosis of autoimmune hypophysitis (AH) is histological. However, a presumptive diagnosis can be made through clinical, biochemical and imaging data. OBJECTIVE: The objective of this study was to review the presence of antipituitary antibodies (APA) and antithyroid antibodies (ATA) in patients with suspected AH in order to determinate the utility of APA in the diagnosis of AH. MATERIAL AND METHODS: We studied 36 patients divided into seven groups according to the data suggesting AH (isolated corticotropin deficiency, other idiopathic pituitary deficiencies, idiopathic hyperprolactinemia, empty sella, sellar mass with thickened stalk, proven histological hypophysitis) or because of previous autoimmune endocrine diseases. Twenty-four controls without endocrinological disease were also included. In all subjects, APA were determined by immunofluorescence over primate pituitary gland and ATA by an agglutination technique. RESULTS: None of the controls and only 9 patients, all of them women, were APA-positive. Of the 9 APA-positive patients, 43% belonged to the group of patients with isolated ACTH deficiency. In 8 patients, APA were determined again during the follow-up; 6 remained APA-negative, but one patient became APA-positive and another became APA-negative. ATA were positive in 12 patients, 22.2% of whom were also APA-positive, and in one control. CONCLUSIONS: The prevalence of APA positivity among the study patients was low. These antibodies were found only in women, mostly with isolated corticotropin deficiency. APA and ATA coexisted in only 22% of the patients studied.

Anticuerpos antihipófisis en pacientes con sospecha de hipofisitis autoimmune / Antipituitary antibodies in patients with suspected autoimmune hypophysitis

Introducción El diagnóstico definitivo de la hipofisitis autoinmune es histológico; sin embargo, puede sospecharse en base a criterios clínicos, bioquímicos y radiológicos. Objetivo El objetivo de nuestro estudio fue revisar la presencia de anticuerpos antihipófisis (AAH) y anticuerpos antitiroideos en pacientes con sospecha de hipofisitis autoinmune por si la presencia de los primeros pudiera ayudar en el diagnóstico de la enfermedad. Material y métodos Estudiamos 36 pacientes divididos en 7 grupos por datos que hicieran sospechar una hipofisitis autoinmune (insuficiencia suprarrenal secundaria aislada, deficiencias hormonales sin causa justificada, hiperprolactinemia idiopática, silla turca vacía, masa selar con engrosamiento del tallo, confirmación histológica de hipofisitis) o por historia de autoinmunidad endocrina. Incluimos también 24 controles sin patología endocrina conocida. En todos se determinaron AAH mediante inmunofluorescencia indirecta sobre sustrato de glándula pituitaria de primate y anticuerpos antitiroideos mediante técnica de aglutinación. Resultados Los AAH fueron positivos en 9 pacientes, todos ellos mujeres, y en ningún control, perteneciendo el 43% de los pacientes con AAH positivos al grupo de pacientes con insuficiencia suprarrenal aislada. En 8 pacientes se determinaron de nuevo AAH durante el seguimiento, en 6 se mantuvieron negativos, en una se positivizaron y en otra se hicieron negativos. Los anticuerpos antitiroideos fueron positivos en 12 pacientes, de los cuales el 22,2% también tenían AAH positivos y en un control. Conclusiones La prevalencia de AAH fue baja, siendo todos los casos mujeres y en su mayoría con insuficiencia suprarrenal secundaria aislada. Solo en el 22% de los pacientes estudiados coexistieron AAH y anticuerpos antitiroideos (AU)

Introduction Definitive diagnosis of autoimmune hypophysitis (AH) is histological. However, a presumptive diagnosis can be made through clinical, biochemical and imaging data. Objective The objective of this study was to review the presence of antipituitary antibodies (APA) and antithyroid antibodies (ATA) in patients with suspected AH in order to determinate the utility of APA in the diagnosis of AH. Material and methods We studied 36 patients divided into seven groups according to the data suggesting AH (isolated corticotropin deficiency, other idiopathic pituitary deficiencies, idiopathic hyperprolactinemia, empty sella, sellar mass with thickened stalk, proven histological hypophysitis) or because of previous autoimmune endocrine diseases. Twenty-four controls without endocrinological disease were also included. In all subjects, APA were determined by immunofluorescence over primate pituitary gland and ATA by an agglutination technique. Results None of the controls and only 9 patients, all of them women, were APA-positive. Of the 9 APA-positive patients, 43% belonged to the group of patients with isolated ACTH deficiency. In 8 patients, APA were determined again during the follow-up; 6 remained APA-negative, but one patient became APA-positive and another became APA-negative. ATA were positive in 12 patients, 22.2% of whom were also APA-positive, and in one control. Conclusions The prevalence of APA positivity among the study patients was low. These antibodies were found only in women, mostly with isolated corticotropin deficiency. APA and ATA coexisted in only 22% of the patients studied (AU)

[Peripheral arterial disease in diabetic patients: utility of the toe-brachial index]. / Arteriopatía periférica en el paciente diabético: utilidad del índice dedo-brazo.

BACKGROUND AND OBJECTIVE: To evaluate the influence of peripheral neuropathy, autonomic neuropathy and arterial wall calcification on the concordance of ankle-brachial index (ABI) and toe-brachial index (TBI) in diabetic patients. PATIENTS AND METHOD: We evaluated in 221 diabetic patients (73.8% type 2; 66.6% male) the presence of: peripheral arterial disease, peripheral neuropathy, autonomic neuropathy and arterial wall calcification. RESULTS: The mean (standard deviation) difference between ABI and TBI in our population was 0.33 (0.25). Patients with arterial wall calcification had a higher mean difference between ABI and TBI than patients without arterial wall calcification -0.87 (0.39) vs 0.30 (0.21) (p < 0.005)-. Mean difference between ABI and TBI was similar for patients with and without autonomic neuropathy -0.36 (0.26) vs 0.30 (0.24) (p = 0.057)- and for patients with and without peripheral neuropathy -0.34 (0.28) vs 0.31 (0.21) (p = 0.423)-. Among all patients there was a significant linear association (r = 0.506; p < 0.001) between ABI and TBI. For patients with arterial wall calcification there was no correlation between both indices (r = -0.070; p = 0,857). CONCLUSIONS: Our findings indicate that in diabetic patients, TBI is the method of choice to evaluate lower limb perfusion in the presence of overt arterial wall calcification.

Arteriopatía periférica en el paciente diabético: utilidad del índice dedo-brazo / Peripheral arterial disease in diabetic patients: utility of the toe-brachial index

Fundamento y objetivo: Evaluar la influencia de la neuropatía periférica, neuropatía autonómica y calcificaciones arteriales en la concordancia del índice tobillo-brazo (ITB) e índice dedo-brazo (IDB) en pacientes con diabetes. Pacientes y método: Evaluamos en 221 pacientes diabéticos (el 73,8% con diabetes mellitus tipo 2 y un 66,6% varones) la existencia de arteriopatía periférica, neuropatía periférica, neuropatía autonómica y calcificaciones arteriales. Resultados: La diferencia media (desviación estándar) entre el ITB y el IDB en nuestra población fue de 0,33 (0,25). Esta diferencia fue significativamente mayor en los pacientes con calcificaciones arteriales, con una media de 0,87 (0,39), frente a 0,30 (0,21) (p < 0,005). Sin embargo, fue similar en los pacientes con y sin neuropatía autonómica ­0,36 (0,26) frente a 0,30 (0,24) (p = 0,057)­ y en los pacientes con y sin neuropatía periférica ­0,34 (0,28) frente a 0,31 (0,21) (p = 0,423)­. En la población estudiada se obtuvo una relación lineal significativa (r = 0,506; p < 0,001) entre el ITB y el IDB, que desapareció en presencia de calcificaciones arteriales (r = ­0,070; p = 0,857). Conclusiones: Los resultados indican que en los pacientes diabéticos el IDB es el método de elección para evaluar la existencia de arteriopatía periférica en presencia de calcificaciones arteriales

Background and objective: To evaluate the influence of peripheral neuropathy, autonomic neuropathy and arterial wall calcification on the concordance of ankle-brachial index (ABI) and toe-brachial index (TBI) in diabetic patients. Patients and method: We evaluated in 221 diabetic patients (73.8% type 2; 66.6% male) the presence of: peripheral arterial disease, peripheral neuropathy, autonomic neuropathy and arterial wall calcification. Results: The mean (standard deviation) difference between ABI and TBI in our population was 0.33 (0.25). Patients with arterial wall calcification had a higher mean difference between ABI and TBI than patients without arterial wall calcification ­0.87 (0.39) vs 0.30 (0.21) (p < 0.005)­. Mean difference between ABI and TBI was similar for patients with and without autonomic neuropathy ­0.36 (0.26) vs 0.30 (0.24) (p = 0.057)­ and for patients with and without peripheral neuropathy ­0.34 (0.28) vs 0.31 (0.21) (p = 0.423)­. Among all patients there was a significant linear association (r = 0.506; p < 0.001) between ABI and TBI. For patients with arterial wall calcification there was no correlation between both indices (r = ­0.070; p = 0,857). Conclusions: Our findings indicate that in diabetic patients, TBI is the method of choice to evaluate lower limb perfusion in the presence of overt arterial wall calcification

Carcinoma papilar tiroideo asociado a linfoma. A propósito de tres casos / Lymphoma-associated papillary thyroid carcinoma. A report of three cases

El tiroides es una glándula sumamente sensible a la radiación externa. Los estudios epidemiológicos han demostrado que los efectos carcinogénicos de la radiación sobre el tiroides son máximos durante la infancia y decrecen tras 30 años de la exposición, aunque no desaparezcan. El efecto es también dosis-dependiente, aunque pueda producirse a dosis bajas. Los carcinomas que aparecen son generalmente papilares con un comportamiento similar a los no radioinducidos, aunque en muchas ocasiones son multifocales. En el linfoma de Hodgkin, con cierta frecuencia aparece un segundo tumor, ya sea como efecto secundario al tratamiento o bien en el contexto de un síndrome genético. Presentamos 3 casos de carcinoma papilar tiroideo asociados a linfoma. En el primero, el linfoma apareció 18 años antes del cáncer tiroideo y fue tratado con radioterapia, pero no durante la infancia. En los otros 2, el carcinoma papilar tiroideo aparece previamente al linfoma y no existen antecedentes de radiación

The thyroid gland is extremely sensitive to external radiation. Epidemiological studies have demonstrated that the carcinogenic effects of radiation on the thyroid reach a peak during childhood and decrease after 30 years of exposure, although they do not disappear. The effect is also dose-dependent, although it can be produced by low doses. The carcinomas that develop are generally papillary with similar behavior to those not induced by radiation, although they are often multifocal. In Hodgkin´s disease, a second tumor may sometimes develop, either as an adverse effect of treatment or in the context of a genetic syndrome. We present 3 cases of thyroid papillary carcinoma associated with lymphoma. In the first patient, the lymphoma developed 18 years before the thyroid cancer, and was treated with radiotherapy, but not in childhood. In the remaining 2 patients, the papillary carcinoma developed before the lymphoma, with no antecedents of radiation