Type 2 diabetes in latin America: recommendations on the flash glucose monitoring system.

OBJECTIVE: To establish recommendations through the consensus of a Latin American experts panel on the use of the flash glucose monitoring system (fCGM) in people living with type 2 diabetes mellitus (T2DM) regarding the benefits and challenges of using the fCGM. METHODS: An executive committee of experts was created, comprised by a panel of fifteen physicians, including endocrinologists and internal medicine physicians, with expertise in management of adult patients with T2DM. The experts were from various countries: Colombia, Chile, Peru, Mexico, Argentina, and Brazil. The modified Delphi method was used, considering a consensus level of at least 80% of the participants. A seventeen-item instrument was developed to establish recommendations on the use of fCGM in patients with T2DM in Latin American. RESULTS: The number of glucose scans recommended per day with the fCGM for patients managed with oral antidiabetic drugs or basal insulin was a median of 6 scans per day, and for those managed with multiple insulin doses, a median of 10 scans per day was recommended. Additionally, a holistic and individualized management approach was recommended, taking into account new treatment directions and identifying patients who would benefit from the use of the fCGM. CONCLUSION: Continuous use of the fCGM is recommended for people living with T2DM, regardless of their type of treatment. These metrics must be evaluated individually for each patient profile.

Nationwide prevalence and clinical characteristics of inpatient diabetic foot complications: A Peruvian multicenter study.

OBJECTIVE: To evaluate the burden of diabetic foot complications amongst inpatients in Peru. MATERIALS AND METHODS: Cross-sectional multicenter study, performed in public hospitals, in one-day enrollment between October and December 2018. RESULTS: We included 8346 patients from 39 national hospitals. Diabetic foot (DF) inpatient point prevalence was 2.8% (CI 95% 2.4-3.1), and DF point prevalence among Diabetes Mellitus (DM) inpatients was 18.9% (CI 95% 16.7-21.1). DF prevalence was higher in jungle and coastal hospitals than highlands ones, and there was no difference according to its care complexity level. Of the 234 patients with DF, 73% were males, age average was 62 ± 12 years, with DM mean time duration of 15 ± 9.9 years. Regarding to DF etiology, 91% and 68% had some degree of peripheral neuropathy and peripheral artery disease, respectively. According to the Infectious Diseases Society of America criteria, 61% presented moderate to severe infections, and 40% had bone involvement. Debridement within 48 h was performed in 36% of sepsis cases. CONCLUSION: Peru has a substantial burden of DF disease, with a greater share of that burden falling on less equipped hospitals in the country's jungle and coastal regions. Interdisciplinary teams and pathways may improve the time of surgical debridement in the highest risk patients.

Foot thermometry with mHeath-based supplementation to prevent diabetic foot ulcers: A randomized controlled trial.

Background: Novel approaches to reduce diabetic foot ulcers (DFU) in low- and middle-income countries are needed. Our objective was to compare incidence of DFUs in the thermometry plus mobile health (mHealth) reminders (intervention) vs. thermometry-only (control). Methods: We conducted a randomized trial enrolling adults with type 2 diabetes mellitus at risk of foot ulcers (risk groups 2 or 3) but without foot ulcers at the time of recruitment, and allocating them to control (instruction to use a liquid crystal-based foot thermometer daily) or intervention (same instruction supplemented with text and voice messages with reminders to use the device and messages to promote foot care) groups, and followed for 18 months. The primary outcome was time to occurrence of DFU. A process evaluation was also conducted. Results: A total of 172 patients (63% women, mean age 61 years) were enrolled; 86 to each study group. More patients enrolled in the intervention arm had a history of previous DFU (66% vs. 48%). Follow-up for the primary endpoint was complete for 158 of 172 participants (92%). Adherence to ≥80% of daily temperature measurements was 87% (103 of 118) among the study participants who returned the logbook. DFU cumulative incidence was 24% (19 of 79) in the intervention arm and 11% (9 of 79) in the control arm. After adjusting for history of foot ulceration and study site, the hazard ratio (HR) for DFU was 1.44 (95% CI 0.65, 3.22). Conclusions: In our study, conducted in a low-income setting, the addition of mHealth to foot thermometry was not effective in reducing foot ulceration. Importantly, there was a higher rate of previous DFU in the intervention group, the adherence to thermometry was high, and the expected rates of DFU used in our sample size calculations were not met. Trial registration: ClinicalTrials.gov NCT02373592 (27/02/2015).

Type B Insulin Resistance in Peru.

Type B insulin resistance (IR) is a rare autoimmune disease characterized by the presence of insulin receptor autoantibodies, resulting in a marked IR inducing hyperglycemia. Our first case is a 42-year-old female with a history of RA, SLE and Hashimoto-thyroiditis that presented with cachexia, acanthosis-nigricans, hirsutism, negative anti-insulin-ab and glucose level between 400 to 700 mg/dl, despite a total insulin dose of 1000 IU/day. She received pulses of cyclophosphamide along with prednisone. One year later the patient was off insulin and with HbA1c of 5.6%. The second case is a 42-year-old female patient that presented with polyuria, polydipsia, cachexia, acanthosis-nigricans, negative glutamic-acid-decarboxilase-ab and positive TPO-ab. She received IV infusion of regular insulin at a rate of 500 UI/d. Two years later she was off insulin with HbA1C of 5.6%. As summary, we reported a case of a disease remitted after receiving immunosuppressive therapy and a case of disease remitted spontaneously.

Inhospital Mortality in Patients with Type 2 Diabetes Mellitus: A Prospective Cohort Study in Lima, Peru.

Objective. To estimate cause of death and to identify factors associated with risk of inhospital mortality among patients with T2D. Methods. Prospective cohort study performed in a referral public hospital in Lima, Peru. The outcome was time until event, elapsed from hospital admission to discharge or death, and the exposure was the cause of hospital admission. Cox regression was used to evaluate associations of interest reporting Hazard Ratios (HR) and 95% confidence intervals. Results. 499 patients were enrolled. Main causes of death were exacerbation of chronic renal failure (38.1%), respiratory infections (35.7%), and stroke (16.7%). During hospital stay, 42 (8.4%) patients died. In multivariable models, respiratory infections (HR = 6.55, p < 0.001), stroke (HR = 7.05, p = 0.003), and acute renal failure (HR = 16.9, p = 0.001) increased the risk of death. In addition, having 2+ (HR = 7.75, p < 0.001) and 3+ (HR = 21.1, p < 0.001) conditions increased the risk of dying. Conclusion. Respiratory infections, stroke, and acute renal disease increased the risk of inhospital mortality among hospitalized patients with T2D. Infections are not the only cause of inhospital mortality. Certain causes of hospitalization require standardized and aggressive management to decrease mortality.

Beta-cell function and insulin resistance among Peruvian adolescents with type 2 diabetes.

OBJECTIVE: To characterize and compare the beta-cell function and insulin resistance among Peruvian adolescents with type 2 diabetes (T2D) and their non-diabetic, overweight and lean peers. METHODS: Cross-sectional study of 54 adolescents aged 10-19 years, distributed in three sex- and age-matched groups (n = 18): (i) adolescents with T2D; (ii) overweight adolescents without T2D; and (iii) lean adolescents without T2D, at the Diabetes, Obesity and Nutrition Research Center in Lima, Peru. Fasting glucose, insulin, C-peptide, and glycated hemoglobin were measured for all participants. In addition, a two-hour oral glucose tolerance test (OGTT, 1.75 mg of glucose/kg body weight) was performed, during which glucose and C-peptide were quantified. The homeostasis model assessment of insulin resistance (HOMA-IR) and beta-cell function (HOMA-B) were derived for all participants, and beta-cell function was further examined by the area under the curve (AUC) of C-peptide. RESULTS: The median HOMA-IR score was higher in adolescents with T2D compared to lean adolescents (6.1 vs. 2.1; p = 0.002), but was not different from that of overweight adolescents (6.1 vs. 4.0; p = 0.322). The median HOMA-B was higher in overweight adolescents than in lean adolescents (256.9 vs. 134.2; p = 0.015), and adolescents with T2D (256.9 vs. 119.8; p = 0.011). The mean AUC of glucose in adolescents with T2D was 1.8-fold higher than that of overweight adolescents, and 1.9-fold higher than that of lean adolescents (p < 0.001). Although the median AUC of C-peptide in adolescents with T2D was lower than that of overweight and lean adolescents, this difference was not statistically significant (230.7 vs. 336.6 vs. 267.3 nmol/l120 min, respectively; p = 0.215). CONCLUSION: Among Peruvian adolescents with T2D, insulin resistance is the most prominent characteristic, rather than beta-cell dysfunction.

Características clínicas del paciente diabético después de un evento de cetoacidosis / Clinical characteristics of the diabetic patient after a ketoacidosis event

Objetivo. Describir las características clínicas y terapéuticas de los pacientes después de un evento de cetoacidosis diabética (CAD). Material y métodos. Estudio descriptivo, tipo serie de casos. Se revisó 127 historias clínicas de pacientes con diagnóstico de crisis hiperglicémicas, 90 de los cuales tuvieron diagnóstico de CAD, en el Hospital Nacional Arzobispo Loayza de Lima. Cuarenta pacientes fueron ubicados, firmaron el consentimiento informado y fueron entrevistados. Se evaluó los siguientes parámetros clínicos y metabólicos: sexo, edad, glicemia, hemoglobina glicosilada (Hb1Ac), nuevo evento de CAD, índice de masa corporal (IMC) y tratamiento postevento (dieta y tratamiento). Resultados. Veintisiete (67,5%) fueron mujeres. La edad promedio fue 49,53 ± 14,88 años. El tiempo de enfermedad de diabetes mellitus (DM) promedio fue 60,5 ± 70,45 meses y el tiempo después del evento de CAD promedio fue 21,3 ± 8,47 meses. En 50% de pacientes fue un debut de DM. La glucosa promedio fue 157,50 ± 83,24 mg/dL, el nivel de Hb1Ac promedio fue 8,05 ± 2%. El IMC promedio fue 28,01 ± 5 kg/m2. La terapia recibida postevento de CAD fue: 9 (22,5%) pacientes con insulinoterapia, 19 (47,5%) antidiabéticos orales (todos tenían DM-2); 2 (5%) recibieron solo dieta y ejercicio y 10 (25%) no seguían ningún tratamiento. Tres (7,5%) presentaron un nuevo evento de CAD (dos pacientes tenían DM-1 y uno tenía DM-2). Conclusión. En el seguimiento, postevento de CAD, la mayoría de los pacientes tenía un comportamiento clínico como de DM-2.

Objetive. To describe the clinical and therapeutic characteristics of patients after an event of diabetic ketoacidosis (DKA). Material and methods. A descriptive, case series. We reviewed 127 medical records with diagnosis of hyperglycemic crisis, 90 of whom had a diagnosis of DKA, in the Hospital Nacional Arzobispo Loayza, Lima. Forty patients were contacted, signed an informed consent and were interviewed. We evaluated the following clinical and metabolic parameters: sex, age, blood glucose, Hb1Ac, new event of DKA, body masss index (BMI) and the treatment after the event of DKA (diet and treatment). Results. Twenty-seven (67,5%) were women. The mean age was 49,53 ± 14,88 years. The mean disease duration of diabetes mellitus (DM) was 60,5 ± 70,45 months and the mean time after the event of DKA 21,3 ± 8,47 months. A debut of DM ocurred in 50% of DKA cases. The mean glucose was 157,50 ± 83,24 mg/dL, the mean BMI was 28,01 ± 5 kg/m2. The therapy given after the event of CAD was: 9 (22,5%) patients with. 19 (47,5%) oral agents (all of whom had DM2), 2 (5%) only diet and exercise and 10 (25%) without any treatment. There (7,5%) had new DKA event, 2 patients had DMI and DM2 1 had. Conclusions. On follow up, after an episode of DKA the majority of patients have a similar clinical behavior as patients with diabetes mellitus type 2.

Hyperglycemic hyperosmolar state and rhino-orbital mucormycosis.

Rhino-orbital mucormycosis is a fatal infection. Decompensated diabetes is the most common predisposing factor. Two male adults were admitted because of newly diagnosed diabetes with hyperglycemic hyperosmolar state and CT scan showed extensive pansinusitis and orbital inflammation. Treatment included surgical debridement and antifungal therapy. One patient died from a severe sepsis.

Crisis hipercalcémica e hiperparatiroidismo primario / Hypercalcemic crisis and primary hyperparathyroidism

Presentamos el caso de una mujer de 45 años de edad con hiperparatiroidismo primario de varios años de evolución debido a un adenoma paratiroideo. Inicialmente ella cursó con nefrolitiasis y estreñimiento pertinaz, luego compromiso neuromuscular y enfermedad ósea caracterizada por osteítis fibrosa quística, osteoporosis severa y fractura patológica. Fue admitida por pancreatitis aguda asociada a crisis hipercalcémica que resolvió. Después de la paratiroidectomía, la paciente desarrolló el síndrome del hueso hambriento, del cual se recuperó. En el seguimiento está asintomática. Se discute el curso clínico, diagnóstico y tratamiento.