[Level of expression of gene CTSL and its correlation with natural killer T-Cells in mexican pediatric patients with recent-onset type 1 diabetes]. / Asociación de células NKT con la expresión del gen CTSL en población pediátrica mexicana con diabetes tipo 1 de reciente diagnóstico.

OBJECTIVE: To compare the level of expression of the gene CTSL and its correlation with NKT cells in patients with recent-onset type 1 diabetes (T1D), their siblings, and healthy controls. METHODS: Analytical cross-sectional design. Patients with T1D < 3 months evolution, their siblings, and healthy controls were included. Percentages and absolute numbers of NKT cells were measured with expression of the CTSL gene. RESULTS: 124 subjects: with T1D (n = 48), siblings (n = 44) and controls (n = 32) were included. HbA1c was greater and C-peptide lower in T1D than the other groups and sibling age was higher (p < 0.001). There were no differences in NKT cells between T1D (0.176 ± 0.202) and controls (0.118 ± 0.133), but the percentage was higher in siblings (0.246 ± 0.188; p = 0.002). Lower level of expression of the CTSL gene associated with both absolute number (r: 0.4607; 95% CI: -0.08425 to -0.7935; p = 0.043) and percentage of NKT cells (r: 0.4540; 95% CI: -0.0927 to -0.7903; p = 0.045) in the T1D group. CONCLUSIONS: Patients with T1D have lower percentage and absolute number of NKT cells compared to their siblings. NKT cells absolute numbers are correlated with the expression of CTSL in T1D patients.

[Diagnosis and treatment guideline for primary hypothyroidism in adulthood]. / Guía de práctica clínica. Diagnóstico y tratamiento del hipotiroidismo primario en adultos.

Our objective was to develop clinical guidelines based on the best clinical evidence to help the staff of medical setting of all levels (first, second and third medical attention levels) to provide evidence based care and diagnosis of hypothyroidism in adults nationwide. The guidelines were built using structured and relevant clinical questions. A strategy was developed to identify the main clinical guidelines for hypothyroidism in adult patient. The working group selected six documents. For aspects not considered in those documents, structured searches using Pubmed, Medical Disability Advisor, and Cochrane Library Plus were done. The results were qualified according its level of evidence and grade of recommendation. The diagnosis of hypothyroidism should be done precisely and without delay. Specialized care should be used rationally, using primary care units as the main resource for the treatment of hypothyroidism. This is the reason why the first primary care physicians should understand and apply a guideline for the diagnosis and treatment of hypothyroidism in adulthood.

Association between glycemic control and dietary patterns in patients with type 2 diabetes in a Mexican institute.

OBJECTIVE: The aim of this study was to evaluate the association between glycemic control (hemoglobin (Hb) A1c <7%) and the dietary patterns identified in Mexican patients with type 2 diabetes mellitus (T2DM). METHODS: This was a secondary analysis conducted with 4838 patients with T2DM in Mexico. Biochemical blood profiles, socioeconomic level, anthropometric measurements, and dietary data were obtained. Dietary data from a food frequency questionnaire were used to derive dietary patterns. Factor analysis was conducted to ascertain dietary patterns, and multivariate analysis was fitted to assess the relationship between glycemic control and consumption of dietary patterns. RESULTS: Three dietary patterns were identified. After control for potential cofounders (age, sex, duration of T2DM, body mass index, pharmacologic treatment, intensity of physical activity, socioeconomic level, and kcal/kg ideal weight), we found that consuming a Western-style diet (odds ratio [OR], 1.533, 95% confidence interval [CI], 1.253-1.875; P < 0.000), and the sweets and dairy diet (fats and sugars; OR, 1.444; 95% CI, 1.133-1.841; P = 0.003) patterns were associated with HbA1c ≥7%, whereas consuming a healthy dietary patter (OR, 0.800; 95% CI, 0.642-0.998; P = 0.048) was associated with HbA1c <7%. CONCLUSIONS: Consuming a healthy diet was associated with glycemic control; whereas the Western-style or sweets and dairy patterns promoted a lack of metabolic control. These results support the promotion of a healthy pattern in the Mexican population with T2DM.

[Association between depression and hearing loss in patients with type 2 diabetes]. / Asociación entre depresión e hipoacusia en pacientes con diabetes tipo 2.

BACKGROUND: The association between diabetes, hearing loss and depression is unknown, and needs to be understood clearly and precisely. Our objective was to estimate the association between depression and hearing loss in patients with type 2 diabetes. METHODS: Cross-sectional analytical study. Patients of 40 years or older with type 2 diabetes were studied. Anthropometric measurements and biochemical parameters were recorded. The Beck Depression Inventory and a pure tone audiometry were applied. Groups were compared with chi squared test and logistic regression for confounders. RESULTS: 150 patients were included (76 % women). Average age was 56 ± 9.3 years, with 12.4 ± 6.5 years of progression of diabetes, weight 67.4 ± 11.6 kg; 31 % were obese; 25.5 % hypertensive (126.3 ± 19.3 / 79.4 ± 19.7 mm Hg) and 80.7 % had poor metabolic control (HbA1c ≥ 7 %). Of all the patients, 45.3 % presented hearing loss and 32.4 % depression. Diagnosis of depression in patients with hearing loss remained significant after adjusting for confounders (odds ratio [OR] = 2.3; 95 % confidence interval [CI] = 1.051-5.333, p = 0.037). Women had greater risk of depression, difference that remained significant (OR = 3.2; 95 % CI = 1.268-8.584, p = 0.014) after adjustment. CONCLUSIONS: Almost half of the patients with diabetes presented hearing loss and more than three times the risk of depression. Subjects with depression and diabetes presented more hearing loss (> 20 dB) than those without diabetes and/or without depression.

Introducción: se desconoce y es necesario entender con mayor claridad y precisión cuál es la asociación entre la diabetes, la hipoacusia y la depresión. Nuestro objetivo fue estimar la asociación entre depresión e hipoacusia en pacientes con diabetes tipo 2 (DT2). Métodos: estudio transversal analítico. Se estudiaron pacientes con DT2 mayores de 40 años. Se registraron medidas antropométricas y parámetros bioquímicos. Se aplicó el cuestionario de depresión de Beck y un estudio audiológico tonal. Se compararon los grupos con chi cuadrada y regresión logística. Resultados: se incluyeron 150 pacientes (76 % mujeres). El promedio de edad fue de 56 ± 9.3 años, con 12.4 ± 6.5 años de evolución de diabetes, con peso de 67.4 ± 11.6kg; fueron obesos el 31 %; 25.5 % hipertensos (126.3 ± 19.3/79.4 ± 19.7 mm Hg) y el 80.7 % presentó descontrol metabólico (HbA1c ≥ 7 %). El 45.3 % presentó hipoacusia y el 32.4 % depresión. El diagnóstico de depresión en pacientes con hipoacusia permaneció significativo después de ajustar para conseguir confusores (razón de momios [RM] = 2.3; intervalo de confianza [IC] al 95 % 1.051-5.333, p = 0.037). Las mujeres tuvieron mayor riesgo de padecer depresión, diferencia que permaneció significativa al ajustarse (RM = 3.2; IC 95 % 1.268-8.584, p = 0.014). Conclusiones: casi la mitad de los pacientes con diabetes presentaron hipoacusia y más de tres veces el riesgo de depresión. Los sujetos con depresión y diabetes mostraron mayor hipoacusia (> 20 dB) que aquellos sin diabetes o sin depresión.

Lower Plasma Ghrelin Levels are Found in Women with Diabetes-Complicated Pregnancies.

OBJECTIVE: To evaluate the associations of glycemic control and gestational age with ghrelin and proinsulin levels in cord blood and mothers' peripheral blood during pregnancy. METHODS: This is a cross-sectional comparative study of twenty-four pregnant women with gestational diabetes (GD), 18 with type 2 diabetes mellitus (T2DM), and 36 without diabetes, as well as their neonates. Levels of proinsulin, ghrelin, and glycated hemoglobin A1c (HbA1c) were measured from maternal blood during the last week before caesarian delivery and in neonatal umbilical cord blood samples. RESULTS: Mothers with GD and T2DM had significantly lower ghrelin levels compared to the healthy mothers (p<0.001). Maternal proinsulin was lower in women with GD than in women without diabetes (p<0.001). Proinsulin was significantly elevated in the neonates of women with GD and in women with HbA1c ≥6.5% (p<0.001). However, maternal ghrelin levels were higher (p=0.031) and neonate proinsulin levels lower in the pre-term offspring of mothers with GD (p=0.033). There was a negative correlation between HbA1c levels and birth weight (r=-0.407, p<0.001). CONCLUSION: Ghrelin levels were lower in pregnant women with diabetes, although pre-term birth appeared to reverse this trend in GD. Proinsulin levels were also low in pregnant women with diabetes and even lower in pre-term vs. at-term births. Both ghrelin and proinsulin levels were lower in pregnant women with diabetes and HbA1c of <6.5%. Thus, ghrelin participates in the adaptation to the caloric imbalance of diabetic pregnancy and may play a similar role in pregnancy-related complications, since high ghrelin concentrations may be necessary for normal fetal development.

[Childhood obesity and dyslipidemia]. / Obesidad infantil y dislipidemia.

Screening and treatment of plasma lipid abnormalities secondary to obesity are among the interventions that should be implemented in children who are overweight or obese, in order to prevent a cardiovascular event. Dyslipidemias are a group of asymptomatic diseases that are commonly caused by abnormal levels of lipoproteins in blood; they are a comorbidity that is commonly related to obesity, without considering the age of the patient. Among dyslipidemias, hypertriglyceridemia has the highest prevalence. The etiology of the dyslipidemia should be identified; it allows the proper selection of therapy for the patients and their family. The goal is the prevention of cardiovascular complications. Reduced caloric intake and a structured physical activity plan should be considered for initial treatment for all the overweight and obese patients. For adherence to treatment to be successful, the participation of the primary care physician and a multidisciplinary team is required. With treatment, the risks and complications can be reduced. The participation of a specialist in handling the pediatric obese patient with dyslipidemia should be limited to severe cases or those at risk for having pancreatitis.

En todos los niños o adolescentes con sobrepeso u obesidad debe buscarse de manera intencionada la presencia de dislipidemias que sean secundarias a la obesidad, con el fin de poder prevenir un evento cardiovascular. Las dislipidemias son un grupo de enfermedades asintomáticas que comúnmente son causadas por concentraciones anormales de las lipoproteínas sanguíneas; son una comorbilidad que es común en la obesidad, independientemente de la edad del paciente. De estas enfermedades, la que tiene mayor prevalencia es la hipertrigliceridemia. Identificar anormalidades en el perfil de lípidos de la población pediátrica permite seleccionar la intensidad y el tipo de tratamiento para el paciente y su familia. El manejo inicial que debe recibir todo niño y adolescente con obesidad y dislipidemia debe basarse en la promoción de un estilo de vida saludable con la dieta y el ejercicio. Para que la adherencia al tratamiento sea exitosa, es fundamental la participación del médico en combinación con un equipo multidisciplinario. Con el tratamiento se pueden reducir los riesgos de complicaciones. La participación del especialista en el manejo del paciente pediátrico obeso con dislipidemias debe limitarse a los casos con dislipidemias severas o a aquellos en los que se busque prevenir una pancreatitis.

Epidemiology of type 1 diabetes in Latin America.

Latin America is among the regions with the highest diabetes-related burden. Research and treatment programs have increased in number and complexity in recent years, but they are focused in type 2 diabetes, because this condition explains a large proportion of the cases. In contrast, the information regarding the epidemiology of type 1 diabetes is scant in this area. Here, we analyze the available information on this topic and identify potential areas of opportunity to generate new knowledge through the study of type 1 diabetes in Latin Americans. Both, the prevalence and the incidence of type 1 diabetes, are lower in Latin American countries compared to that reported in Europe, North America, southern Asia and northern Africa. Biologic and methodological factors may explain the smaller contribution of type 1. The presence of some putative 'protective' environmental exposures or the absence of those prevalent in a region may explain the lower type 1 diabetes prevalence observed in most Latin American countries. However, the number and quality of the diabetes registries are not enough in this region. During the past decade, the incidence of type 1 diabetes has grown worldwide. The same trend has been reported in Latin America. This epidemiologic transition is a unique opportunity to identify interactions between rapidly changing environmental factors in subjects with different genetic backgrounds (such as the admixed Latin American populations). Finally, on-going therapeutic initiatives in this region are highlighted.

Controversias en el diagnóstico del síndrome metabólico en poblaciones pediátricas / Controversies in diagnosis of the metabolic syndrome in pediatric population

El síndrome metabólico es el concepto clínico que integra los mecanismos mediante los cuales la acumulación de grasa intra-abdominal y la resistencia a la insulina participan en la génesis de la diabetes mellitus tipo 2, la aterosclerosis y otros procesos degenerativos (ej. deterioro cognitivo, neoplasias, esteatohepatitis no alcohólica). Su prevalencia ha aumentado en todas las sociedades occidentales; en paralelo, ha disminuido su edad de aparición, hecho que se relaciona con el aumento en la prevalencia de obesidad infantil. Sin embargo, su identificación en edades pediátricas es motivo de controversia, ya que existe poca evidencia que ligue los componentes conocidos del síndrome metabólico en adultos, con desenlaces cardiovasculares o metabólicos en la infancia o en la adolescencia. Existen varias definiciones que emplean puntos de corte y componentes distintos, situación que ocasiona confusión en su diagnóstico y tratamiento. Por otro lado, los puntos de corte de las diferentes variables del síndrome metabólico, basados en poblaciones de países desarrollados, frecuentemente no se ajustan a la realidad de los países en vías de desarrollo. Ambas situaciones dificultan la obtención de datos epidemiológicos fidedignos, respecto a la magnitud del problema. En este documento se revisan las fortalezas y debilidades de los criterios diagnósticos del síndrome metabólico en edades pediátricas.

The metabolic syndrome is a clinical concept which incorporates the phenotypic expression of intra-abdominal fat and insulin resistance under a single diagnosis. The main end points of the metabolic syndrome are well known, namely type 2 diabetes mellitus and atherosclerosis. The prevalence of the metabolic syndrome has increased in all western societies. Simultaneously, there has been a reduction in diagnosis age, probably related to the increase in prevalence of childhood obesity. However, diagnosis of the metabolic syndrome in pediatric patients has been an area of controversy. There has been little evidence connecting the known components of the metabolic syndrome in adults with either cardiovascular or metabolic end points in children and adolescents. Different definitions with distinct thresholds and components have resulted in confusion regarding diagnosis and treatment in this population. In addition, cut-off points for the components of the metabolic syndrome come from populations from developed countries; they are frequently not adjusted for populations in developing countries. Both situations complicate the possibility of obtaining accurate epidemiological data to evaluate the metabolic syndrome in the pediatric population. In this document, we discuss the strengths and weaknesses of diagnostic criteria for the metabolic syndrome when applied to children and adolescents.

Tratamiento del niño obeso / Obese child treatment

La obesidad, en la niñez y la adolescencia, ha pasado de ser una enfermedad rara a una epidemia emergente, con consecuencias adversas en etapas ulteriores de la vida. En niños con sobrepeso y obesidad, se ha evidenciado incremento de la alteración del metabolismo de los carbohidratos, enfermedad cardiovascular, problemas psicosociales y trastornos alimentarios. El inicio de estrategias de prevención y tratamiento debe ser multidisciplinario, con la intervención no solo de profesionales de la salud sino de todos los involucrados en el ámbito escolar, familiar y gubernamental. Las razones por las que no se tiene éxito tienen que ver con factores culturales, creencias y prejuicios, pero también se relaciona con insuficiente preparación del personal involucrado en su manejo. El tratamiento de la obesidad no debe centrarse sólo en indicaciones de dieta y ejercicio, sino también de convencer al niño o adolescente, para lograr cambios en el área afectiva, lo más difícil de lograr en el ámbito educativo. La prevención constituye la mejor herramienta que contribuirá a modificar la historia natural de la enfermedad y evolución clínica desde etapas tempranas de la vida. En esta revisión, los profesionales de la salud encontrarán respuesta informada y recomendaciones a una serie de interrogantes que plantean la asistencia clínica cotidiana de obesidad en pediatría. La revisión fue desarrollada con la participación de expertos en las diferentes disciplinas de atención de este grupo de pacientes, con el objetivo de alcanzar el mayor impacto positivo en el manejo, tanto de prevención como de tratamiento de obesidad en pediatría.

Childhood obesity is not longer a rare disorder; it has become in a growing epidemic that result in serious consequences later on life. Children who had an excessive body weight have a higher prevalence of metabolic disorders, cardiovascular disease, psy-chosocial pathology and abnormal eating behaviors. Preventive and therapeutic programs against childhood obesity should be multifaceted, including the participation of health professionals, school teachers, relatives and the government. Multiple factors may limit the efficacy of such programs, including, cultural factors, prejudice, misbelieves and inadequate preparation of the personnel in charge. Obesity treatment extends beyond the prescription of the dietary plan and an exercise program. It should modify patient's attitudes and their ability to confront emotions. Prevention is the best approach to change the natural course of the disease. In this review, health professionals will find recommendations for the treatment of childhood obesity. This manuscript was prepared with the participation of several expert clinicians with complimentary points of view. The multi-disciplinary approach has the greater likelihood for being successful in this condition.

Efecto de bezafibrato en la dieta de hipertensos con dislipidemia e hiperfibrinogenemia / Effects of bezafibrate in the diet of hypertensive patients with dyslipidemia and hyperfibrinogenemia

Objetivo. Evaluar la respuesta a bezafibrato en la dieta de sujetos con hipertensión arterial, hiperinsulinemia, hiperlipidemia mixta e hiperfibrinogenemia. Métodos. Se usó un diseño comparativo, doble ciego de placebo (N = 13) ó 400 mg/día de bezafibrato (N = 15) añadidos a una dieta hipolipémica pobre en azúcares refinados durante 90 días de tratamiento. Al inicio y al final del tratamiento se midieron fibrinógeno, lípidos, insulina y péotido C y se hizo una curva de tolerancia a la glucosa. Resultados. Los grupos fueron similares en edad, presión arterial e IMC. Al final de tratamiento hubo disminución de fibrinógeno, colesterol, triglicéridos y LDL-C en ambos grupos, pero sólo en el grupo de bezafibrato hubo: a) una disminución significativa de triglicéridos (64 mg/dL, p 0.01); y b) cambios marginales en fibrinógeno (disminuyó 35 mg/dL, p = 0.09), colesterol (disminuyó 26 mg/dL, p= 0.10) y en la relación glucosa/insulina (aumentó de 4.4 a 5.2, p= 0.09). El bezafibrato disminuyó ligeramente los niveles de insulina pero no afectó al péptido C. La correlación de los cambios de nivel de fibrinógeno versus la insulina de 60 min de la curva de tolerancia fue mayor en el grupo de bezafibrato (r = 0.61) que en el de placebo (r = 0.23). Conclusiones. En pacientes resistentes a insulina y con riesgo cardiovascular elevado, el bezafibrato y el placebo añadidos a una dieta hipolipémica disminuyeron el fibrinógeno plasmático. El bezafibrato bajó significativamente los niveles de triglicéridos en estos pacientes