Thrombotic risk assessed by PAI-1 in patients with COVID-19: The influence of hyperglycemia and diabetes mellitus.

OBJECTIVE: To assess thrombotic risk with PAI-1 levels in patients with COVID-19, to evaluate PAI-1 differences between hyperglycemic and/or Type 2 Diabetes Mellitus (T2DM) versus non-hyperglycemic patients, and to analyze the association of plasminogen activator inhibitor-1 (PAI-1) with hyperglycemia and T2DM. METHODS: A cross-sectional study carried out in 181 patients hospitalized for COVID-19. Two groups were formed: the patients with hyperglycemia at admission and/or previously diagnosed T2DM group and the non-hyperglycemic group. Fibrinolysis was assessed by measuring PAI-1 levels by ELISA. RESULTS: The mean age was 59.4±16.1 years; 55.8% were male 54.1% of patients presented obesity, 38.1% had pre-existing T2DM and 50.8% had admission hyperglycemia and/or pre-existing T2DM. The patients with admission hyperglycemia and/or preexisting T2DM had higher PAI-1 compared with non-hyperglycemic patients [197.5 (128.8-315.9) vs 158.1 (113.4-201.4) ng/mL; p=0.031]. The glucose levels showed a positive correlation with PAI-1 levels (r=0.284, p=0.041). A multivariate logistic regression analysis showed association of PAI-1 level and hyperglycemia and pre-existing T2DM with severity of COVID-19. CONCLUSION: Patients hospitalized for COVID-19 infection with preexisting T2DM or hyperglycemia detected during their hospitalization presented a greater increase in PAI-1 levels, which suggests that hyperglycemia contributes directly to the hypercoagulable state and probably a worse outcome from the patients.

Strategies to prevent, diagnose and treat kidney disease related to systemic arterial hypertension: a narrative review from the Mexican Group of Experts on Arterial Hypertension.

This narrative review highlights strategies proposed by the Mexican Group of Experts on Arterial Hypertension endorsed to prevent, diagnose, and treat chronic kidney disease (CKD) related to systemic arterial hypertension (SAH). Given the growing prevalence of CKD in Mexico and Latin America caused by SAH, there is a need for context-specific approaches to address the effects of SAH, given the diverse population and unique challenges faced by the region. This narrative review provides clinical strategies for healthcare providers on preventing, diagnosing, and treating kidney disease related to SAH, focusing on primary prevention, early detection, evidence-based diagnostic approaches, and selecting pharmacological treatments. Key-strategies are focused on six fundamental areas: 1) Strategies to mitigate kidney disease in SAH, 2) early detection of CKD in SAH, 3) diagnosis and monitoring of SAH, 4) blood pressure targets in patients living with CKD, 5) hypertensive treatment in patients with CKD and 6) diuretics and Non-Steroidal Mineralocorticoid Receptor Inhibitors in Patients with CKD. This review aims to provide relevant strategies for the Mexican and Latin American clinical context, highlight the importance of a multidisciplinary approach to managing SAH, and the role of community-based programs in improving the quality of life for affected individuals. This position paper seeks to contribute to reducing the burden of SAH-related CKD and its complications in Mexico and Latin America.

Lung Ultrasound Elastography by SWE2D and "Fibrosis-like" Computed Tomography Signs after COVID-19 Pneumonia: A Follow-Up Study.

The aim of this study was to assess the shear wave velocity by LUS elastography (SWE2D) for the evaluation of superficial lung stiffness after COVID-19 pneumonia, according to "fibrosis-like" signs found by Computed Tomography (CT), considering the respiratory function. Seventy-nine adults participated in the study 42 to 353 days from symptom onset. Paired evaluations (SWE2D and CT) were performed along with the assessment of arterial blood gases and spirometry, three times with 100 days in between. During the follow-up and within each evaluation, the SWE2D velocity changed over time (MANOVA, p < 0.05) according to the extent of "fibrosis-like" CT signs by lung lobe (ANOVA, p < 0.05). The variability of the SWE2D velocity was consistently related to the first-second forced expiratory volume and the forced vital capacity (MANCOVA, p < 0.05), which changed over time with no change in blood gases. Covariance was also observed with age and patients' body mass index, the time from symptom onset until hospital admission, and the history of diabetes in those who required intensive care during the acute phase (MANCOVA, p < 0.05). After COVID-19 pneumonia, SWE2D velocity can be related to the extent and regression of "fibrotic-like" involvement of the lung lobes, and it could be a complementary tool in the follow-up after COVID-19 pneumonia.

[Severe post-COVID-19 dialysis dependence and inpatient acute kidney injury]. / Dependencia a diálisis posterior a COVID-19 grave y lesión renal aguda intrahospitalaria.

Background: COVID-19 challenged our health system, within the broad clinical spectrum acute kidney injury was presented as a catastrophic event, acute kidney injury and the risk of dependency after dialysis constitute a clinical problem with high repercussions in the funcionality. Objective: To identify risk factors for dialysis dependence after acute kidney injury from COVID-19. Material and methods: A retrospective observational cohort study was carried out at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI, of the Mexican Institute of Social Security, from March 2020 to March 2021. 317 patients were included, we performed descriptive statistics, we compared differences between the stages of acute kidney injury, finding a difference in obesity with a frequency of 2.2% in stage 1, 20.82% stage 2 and 14.51% stage 3, with p value = 0.018. Results: We found dialysis dependence one year after hospital-acquired acute kidney injury induced by COVID-19 in 58 patients (18.9%), we analyzed by KDIGO stage, in those patients who had AKI KDIGO 1 (2.83%) it depended on dialysis at one year, in the KDIGO stage 2 (3.78%), in the KDIGO stage 3 (11.67%). Conclusions: Our study allowed us to identify that the risk factors associated with dialysis dependence are: male gender, type 2 diabetes mellitus, obesity, cardiovascular disease.

Introducción: la COVID-19, retó a nuestro sistema de salud, dentro del amplio espectro clínico la lesión renal aguda se presentó como un evento catastrófico, la lesión renal aguda y el riesgo de dependencia posterior a diálisis constituye un problema clínico con alta repercusión en la funcionalidad. Objetivo: identificar los factores de riesgo para la dependencia a diálisis posterior a lesión renal aguda por COVID-19. Material y métodos: se realizó un estudio de cohorte observacional retrospectivo en el Hospital de Especialidades del Centro Médico Nacional Siglo XXI, del Instituto Mexicano del Seguro Social, del periodo de marzo del 2020 a marzo del 2021. Se incluyeron 317 pacientes, realizamos estadística descriptiva, comparamos diferencias entre los estadios de lesión renal aguda encontrando diferencia en obesidad con frecuencia de 2.2% en estadio 1, de 20.82% estadio 2 y de 14.51% estadio 3, con valor p = 0.018. Resultados: encontramos la dependencia a diálisis a un año posterior a lesión renal aguda intrahospitalaria inducida por COVID-19 en 58 pacientes (18.9%), analizamos por estadio de KDIGO, en aquellos pacientes que cursaron con LRA KDIGO 1 (2.83%) dependió de diálisis a un año, en el estadio KDIGO 2 (3.78%), en el estadio KDIGO 3 (11.67%). Conclusiones: nuestro estudio permitió identificar que los factores de riesgo que se asocian con dependencia a diálisis son: sexo masculino, diabetes mellitus tipo 2, obesidad, enfermedad cardiovascular.

Potential biomarkers for fatal outcome prognosis in a cohort of hospitalized COVID-19 patients with pre-existing comorbidities.

The difficulty in predicting fatal outcomes in patients with coronavirus disease 2019 (COVID-19) impacts the general morbidity and mortality due to severe acute respiratory syndrome-coronavirus 2 infection, as it wears out the hospital services that care for these patients. Unfortunately, in several of the candidates for prognostic biomarkers proposed, the predictive power is compromised when patients have pre-existing comorbidities. A cohort of 147 patients hospitalized for severe COVID-19 was included in a descriptive, observational, single-center, and prospective study. Patients were recruited during the first COVID-19 pandemic wave (April-November 2020). Data were collected from the clinical history whereas immunophenotyping by multiparameter flow cytometry analysis allowed us to assess the expression of surface markers on peripheral leucocyte. Patients were grouped according to the outcome in survivors or non-survivors. The prognostic value of leucocyte, cytokines or HLA-DR, CD39, and CD73 was calculated. Hypertension and chronic renal failure but not obesity and diabetes were conditions more frequent among the deceased patient group. Mixed hypercytokinemia, including inflammatory (IL-6) and anti-inflammatory (IL-10) cytokines, was more evident in deceased patients. In the deceased patient group, lymphopenia with a higher neutrophil-lymphocyte ratio (NLR) value was present. HLA-DR expression and the percentage of CD39+ cells were higher than non-COVID-19 patients but remained similar despite the outcome. Receiver operating characteristic analysis and cutoff value of NLR (69.6%, 9.4), percentage NLR (pNLR; 71.1%, 13.6), and IL-6 (79.7%, 135.2 pg/mL). The expression of HLA-DR, CD39, and CD73, as many serum cytokines (other than IL-6) and chemokines levels do not show prognostic potential, were compared to NLR and pNLR values.

Physicians' Distress Related to Moral Issues and Mental Health In-Between Two Late Waves of COVID-19 Contagions.

In addition to the sanitary constrains implemented due to the pandemic, frontline physicians have faced increased workloads with insufficient resources, and the responsibility to make extraordinary clinical decisions. In 108 physicians who were at the forefront of care of patients with COVID-19 during the first two years of the pandemic, mental health, moral distress, and moral injury were assessed twice, in between two late waves of COVID-19 contagions, according to their adverse psychological reactions, in-hospital experience, sick leave due to COVID-19, quality of sleep, moral sensitivity, clinical empathy, resilience, and sense of coherence. Three months after the wave of contagions, the adverse emotional reactions and moral distress decreased, while moral injury persisted. Moral distress was related to clinical empathy, with influence from burnout and sick leave due to COVID-19, and moral injury was related to the sense of coherence, while recovery from moral distress was related to resilience. The results suggest that measures to prevent physician infection, as well as strengthening resilience and a sense of coherence, may be helpful to prevent persistent mental damage after exposure to a sanitary crisis.

Potential of ATR-FTIR-Chemometrics in Covid-19: Disease Recognition.

The COVID-19 pandemic has caused major disturbances to human health and economy on a global scale. Although vaccination campaigns and important advances in treatments have been developed, an early diagnosis is still crucial. While PCR is the golden standard for diagnosing SARS-CoV-2 infection, rapid and low-cost techniques such as ATR-FTIR followed by multivariate analyses, where dimensions are reduced for obtaining valuable information from highly complex data sets, have been investigated. Most dimensionality reduction techniques attempt to discriminate and create new combinations of attributes prior to the classification stage; thus, the user needs to optimize a wealth of parameters before reaching reliable and valid outcomes. In this work, we developed a method for evaluating SARS-CoV-2 infection and COVID-19 disease severity on infrared spectra of sera, based on a rather simple feature selection technique (correlation-based feature subset selection). Dengue infection was also evaluated for assessing whether selectivity toward a different virus was possible with the same algorithm, although independent models were built for both viruses. High sensitivity (94.55%) and high specificity (98.44%) were obtained for assessing SARS-CoV-2 infection with our model; for severe COVID-19 disease classification, sensitivity is 70.97% and specificity is 94.95%; for mild disease classification, sensitivity is 33.33% and specificity is 94.64%; and for dengue infection assessment, sensitivity is 84.27% and specificity is 94.64%.

[Integrated Care Protocol: Prevention, diagnosis and treatment of diabetes mellitus 2]. / Protocolo de Atención Integral: prevención, diagnóstico y tratamiento de diabetes mellitus 2.

Background: Type 2 diabetes mellitus (DM2) represents one of the ten non- transmissible chronic diseases that constitute the main causes of death and disability in Mexico. It is the leading cause of disability and the second cause of death. The IMSS serves 4.2 million people living with this disease. Objective: Establish lines of action that allow standardizing the substantive activities to be carried out by the multidisciplinary health team, promoting healthy lifestyles, establishing timely diagnoses, providing adequate and intensified care and treatments, preventing complications, and providing comprehensive care and of quality for the benefit of the beneficiaries. Material and methods: The process of development of the Integrated Care Protocols consisted of: 1) Prioritization of the health problem, 2) Conformation of an interdisciplinary work group, 3) Development of content and systematic search for information 4) Analysis, review and discussion of interventions, 5) Review and validation by regulatory areas, 6) Dissemination and implementation. Conclusions: Promotion and prevention actions must be carried out at all levels and by all health personnel, likewise, the incorporation of new treatments for DM2 in the IMSS, requires the homologation of the criteria in risk stratification, diagnosis, profile risk of hypoglycemia and adverse effects to limit the complications of the disease and reduce the burden of disease (disability and premature death).

Introducción: la diabetes mellitus tipo 2 (DM2) es una de las diez enfermedades crónicas no transmisibles que constituyen las principales causas de muerte y discapacidad en México, es la principal causa de invalidez y la segunda de muerte. El Instituto Mexicano del Seguro Social (IMSS) atiende a 4.2 millones personas que viven con esta enfermedad. Objetivo: establecer líneas de acción que permitan homologar las actividades sustantivas que debe llevar a cabo el equipo multidisciplinario de salud, promoviendo estilos de vida saludables, estableciendo diagnósticos oportunos, otorgando atención y tratamientos adecuados e intensificados, previniendo complicaciones y brindando atención integral y de calidad para el beneficio de los derechohabientes. Material y métodos: el proceso de desarrollo de los Protocolos de Atención Integral consistió en: 1) Priorización del problema de salud; 2) Conformación de grupo de trabajo interdisciplinario; 3) Desarrollo del contenido y búsqueda sistemática de información; 4) Análisis, revisión y discusión de las intervenciones; 5) Revisión y validación por las áreas normativas, y 6) Difusión e implementación. Conclusiones: las acciones de promoción y prevención deben realizarse en todos los niveles y por parte de todo el personal de salud; asimismo, la incorporación de nuevos tratamientos para DM2 en el IMSS requiere de la homologación de los criterios en estratificación de riesgo, diagnóstico, perfil riesgo de hipoglucemia y efectos adversos, con el objetivo de limitar las complicaciones de la enfermedad y disminuir la carga de enfermedad (discapacidad y muerte prematura).

Effect of Antiviral Agents on Atherosclerosis in Patients with Chronic Hepatitis C.

BACKGROUND: Chronic hepatitis C is an independent risk factor for atherosclerosis and is associated with cardiovascular events. Mechanisms include inflammatory cytokines, endothelial dysfunction, and increased oxidative stress. AIM OF THE STUDY: The objective was to evaluate the response of carotid atherosclerosis to treatment with direct-antiviral agents. METHODS: We developed a prospective cohort study that included patients with chronic hepatitis C treated with direct-acting antiviral agents (DAAs), without cardiovascular disease, diabetes mellitus, significative chronic kidney disease or coinfections. Clinical characteristics, laboratory values and carotid ultrasound to measure carotid intima-media thickness (CIMT) and look for established atherosclerosis were performed at baseline and 3 months after completing treatment with DAAs. RESULTS: A total of 24 patients were included. The mean age was 60 years and 79% were women. The prevalence of smoking was 41.7%, obesity 25% and hypertension 20.8%. Age, arterial hypertension, genotype, AST, glomerular filtration rate and cirrhosis were significantly associated with established carotid atherosclerosis. After treatment with DAAs, an overall significant reduction of C-reactive protein (CRP) levels was found (p = 0.004). A trend towards reduction of significant CIMT (>0.9 mm) (20.8 vs. 8.3%, RR 1.18, IC 95% 0.75-1.86, p = 0.29) and a statistically significant resolution of atherosclerotic plaque (45.8 vs. 41.7% RR 0.09, IC 95% 0.01-0.63, p = 0.001) was found. CONCLUSIONS: Treatment of chronic hepatitis C with DAAs decrease carotid thickening, atheromatous plaques, and inflammatory markers like CRP. More studies are needed to confirm this finding and its impact on long-term cardiovascular outcomes.

Acute Stress in Health Workers during Two Consecutive Epidemic Waves of COVID-19.

The COVID-19 pandemic has provoked generalized uncertainty around the world, with health workers experiencing anxiety, depression, burnout, insomnia, and stress. Although the effects of the pandemic on mental health may change as it evolves, the majority of reports have been web-based, cross-sectional studies. We performed a study assessing acute stress in frontline health workers during two consecutive epidemic waves. After screening for trait anxiety/depression and dissociative experiences, we evaluated changes in acute stress, considering resilience, state anxiety, burnout, depersonalization/derealization symptoms, and quality of sleep as cofactors. During the first epidemic wave (April 2020), health workers reported acute stress related to COVID-19, which was related to state anxiety. After the first epidemic wave, acute stress decreased, with no increase during the second epidemic wave (December 2020), and further decreased when vaccination started. During the follow-up (April 2020 to February 2021), the acute stress score was related to bad quality of sleep. However, acute stress, state anxiety, and burnout were all related to trait anxiety/depression, while the resilience score was invariant through time. Overall, the results emphasize the relevance of mental health screening before, during, and after an epidemic wave of infections, in order to enable coping during successive sanitary crises.

Burnout, depersonalization, and anxiety contribute to post-traumatic stress in frontline health workers at COVID-19 patient care, a follow-up study.

INTRODUCTION: We designed a follow-up study of frontline health workers at COVID-19 patient care, within the same working conditions, to assess the influence of their general characteristics and pre-existing anxiety/depression/dissociative symptoms and resilience on the development of symptoms of post-traumatic stress disorder (PTSD), while monitoring their quality of sleep, depersonalization/derealization symptoms, acute stress, state anxiety, and burnout. METHODS: In a Hospital reconfigured to address the surge of patients with COVID-19, 204 frontline health workers accepted to participate. They completed validated questionnaires to assess mental health: before, during, and after the peak of inpatient admissions. After each evaluation, a psychiatrist reviewed the questionnaires, using the accepted criteria for each instrument. Correlations were assessed using multivariable and multivariate analyses, with a significance level of .05. RESULTS: Compared to men, women reporting pre-existing anxiety were more prone to acute stress; and younger age was related to both pre-existent common psychological symptoms and less resilience. Overall the evaluations, sleep quality was bad on the majority of participants, with an increase during the epidemic crisis, while persistent burnout had influence on state anxiety, acute stress, and symptoms of depersonalization/derealization. PTSD symptoms were related to pre-existent anxiety/depression and dissociative symptoms, as well as to acute stress and acute anxiety, and negatively related to resilience. CONCLUSIONS: Pre-existent anxiety/depression, dissociative symptoms, and coexisting acute anxiety and acute stress contribute to PTSD symptoms. During an infectious outbreak, psychological screening could provide valuable information to prevent or mitigate against adverse psychological reactions by frontline healthcare workers caring for patients.

[Adult-onset Still's disease and the neutrophil-lymphocyte index in the Mexican population. A case series report]. / Enfermedad de Still del adulto y el índice neutrófilo/linfocito en población mexicana. Reporte de serie de casos.

BACKGROUND: In Mexico, adult-onset Still's disease (AOSD) is one of the causes of fever of unknown origin (FUO). The aim of this study is to describe a series of AOSD cases from a FUO cohort in order to know the clinical and biochemical characteristics of the cases, as well as to describe the neutrophil-lymphocyte index (NLI), which is a clinical marker of inflammation in autoimmune diseases. CASE REPORT: An observational study of 24 cases with AOSD; 72 % of them were women, the median age was 43 years (IQR 37.7-59.7), and the most frequent manifestations were classic rash (84 %) and arthralgia (100 %). All of them had tested negative for rheumatoid factor, antinuclear antibodies, and hyperferritinemia; 83 % had NLI > 3.08. The most used treatment was the combination of methotrexate with corticosteroids; seven patients required biological therapy, and one of them presented a hypersensitivity reaction. CONCLUSION: When there's FUO, the existence of AOSD should be suspected; also in the presence of rash, arthralgia, hyperferritinemia, and NLI > 3.08.

Antecedentes: En México, la enfermedad de Still del adulto (ESA) es una causa de fiebre de origen desconocido (FOD). El objetivo de este informe fue describir una serie de casos de ESA de una cohorte de FOD para conocer las características clínicas y bioquímicas, así como describir el índice neutrófilo/linfocito (INL), marcador clínico de inflamación en enfermedades autoinmunes. Caso clínico: Estudio observacional de 24 casos con ESA; 72 % fue del sexo femenino, la edad fue de 43 años (37.7-59.7) y las manifestaciones más frecuentes fueron rash clásico (84 %) y artralgias (100 %). Todos tuvieron factor reumatoide, anticuerpos antinucleares negativos e hiperferritinemia; 83 % tuvo INL > 3.08. El tratamiento más empleado fue la combinación de metotrexato y corticosteroides; siete pacientes ameritaron terapia biológica, uno presentó reacción de hipersensibilidad. Conclusión: Ante fiebre de origen desconocido, debe sospecharse ESA si, además, existe rash, artralgias, hiperferritinemia e INL > 3.08.

Association between metabolic syndrome and breast cancer. / Asociación entre síndrome metabólico y cáncer de mama.

Metabolic syndrome is a set of risk factors associated with cardiovascular disease and diabetes. In Mexico, its prevalence has been reported up to 49.8%, significantly higher than in other countries. In the last 30 years there has been an increase in breast cancer incidence in Mexico, becoming the most frequent and deadly neoplasm in 2018. Since the late 1990s, several observational studies have identified an association between metabolic syndrome and an increased risk of breast cancer. At least 3 interrelated mechanisms that explain the risk increase of cancer associated with metabolic syndrome are postulated: the increase in estrogen levels derived from adipose tissue, hyperinsulinemia and its anabolic effect on epithelial cells and the endocrine effect of abdominal fat. The components of metabolic syndrome associated with an increased risk of breast cancer are: type 2 diabetes with a relative risk of 1.27 (95% CI: 1.16-1.39), obesity in postmenopausal women with a relative risk of 1.39 (95% CI: 1.14-1.70) and low HDL cholesterol levels have demonstrated an increased risk.

El síndrome metabólico es un conjunto de factores de riesgo para enfermedad cardiovascular y diabetes mellitus. En México, su prevalencia se ha reportado en un 49.8%, siendo notablemente mayor que en otros países del mundo. En los últimos 30 años se ha observado un incremento en la incidencia de cáncer de mama en México, alcanzando a ser la neoplasia con mayor frecuencia y mortalidad en el año 2018. A finales de la década de los noventa, múltiples estudios observacionales identificaron una asociación entre síndrome metabólico y un incremento en el riesgo de cáncer de mama. Actualmente se postulan, por lo menos, tres mecanismos interrelacionados que explican el incremento en el riesgo de cáncer asociado a síndrome metabólico: el primero de ellos es el aumento en los niveles de estrógenos derivados del tejido adiposo, en segundo lugar la hiperinsulinemia y su efecto anabólico sobre las células epiteliales y, finalmente, el efecto endócrino de la grasa abdominal. Los componentes del síndrome metabólico asociados a un incremento en el riesgo de cáncer de mama son: diabetes mellitus tipo 2 con un riesgo relativo de 1.27 (IC95%: 1.16-1.39), la obesidad en mujeres posmenopáusicas con un riesgo relativo de 1.39 (IC95%: 1.14-1.70) y, finalmente, los niveles bajos de HDL que han mostrado un incremento en el riesgo.

Lung ultrasound: clinical applications and its teaching in medical education. / Ultrasonido pulmonar: aplicaciones clínicas y su enseñanza en la formación médica.

The ultrasound as care at the bedside of the patient, or POCUS (Point-Of-Care Ultrasound), has taken today a primary place as a complementary tool in the diagnosis and monitoring of patients in different intensive care units and health care services. One of these specialties is internal medicine, since in the area of hospitalization patients with complex and critical clinical conditions are treated, who benefit from this tool for diagnostic complementation, monitoring and performing safer procedures. The pulmonary ultrasound is a tool to integrate the signs, symptoms and physical examination, for a better diagnostic accuracy and monitoring of patients. That is why we consider important the training of the internist not only in the pulmonary ultrasound, but also in other areas related to this diagnostic method. For this reason, we performed a review of the basic concepts of pulmonary ultrasound, a practical guide of how to do it, the current state of education and training in this area. As well as the importance in areas of clinical performance of the internist.

El ultrasonido como estrategia de cuidado a la cabecera del enfermo, o POCUS (Point-Of-Care Ultrasound), ha tomado actualmente un lugar primordial como herramienta complementaria en el diagnóstico y el monitoreo de pacientes hospitalizados en las diferentes unidades de terapia intensiva y servicios de atención médica. Una de las especialidades es medicina interna, debido a que en los servicios de hospitalización se atiende a pacientes con cuadros clínicos complejos y críticos, quienes se benefician de esta herramienta tanto para complementación diagnostica como para monitoreo y realización de procedimientos invasivos más seguros. El ultrasonido pulmonar permite integrar el cuadro clínico y la exploración física para una mejor precisión de diagnóstico y monitoreo de los pacientes. Por ello, esta herramienta es importante en la formación del médico internista no solo en el ultrasonido pulmonar, sino también en diversas áreas afines a este método diagnóstico. Por esta razón realizamos una revisión de los conceptos básicos de ultrasonido y anatomía pulmonar, una guía práctica sobre cómo llevarlo a cabo, el estado actual sobre la enseñanza y formación en esta área, y la importancia en áreas de desempeño clínico del médico internista.

Inappropriate prescribing in older adults: Critical review of the literature and safety alerts / Prescripción inapropiada en adultos mayores: revisión de la literatura y alertas de seguridad

Background: Prescribing errors are a risk factor for patients to present adverse events and a strategy that has been incorporated into medical care to reduce them is the use of computer tools. The objective was to obtain the scientific basis for the development of prescribing error alerts for four chronic diseases with a higher prevalence in population ≥ 65 years. Methods: We reviewed the literature from 2010 to 2015 to obtain information about adverse events and adverse drug reactions associated with the use of drugs for the treatment of diabetes mellitus type 2 (DM2), hypertension, osteoarticular diseases (OD) and depression; the review included these databases: PubMed, OVID, Cochrane Library, LILACS, MEDES, Portal Mayores and SIETES. A group of physicians reviewed and analyzed the papers that were identified and in a meeting they developed the alerts for the treatments used in the included diseases. Results: We obtained 76 papers, out of which 47 were analyzed by the group of physicians, who eliminated 18. With the remaining 29 were integrated 55 alerts: five for DM2, 16 for hypertension, 15 for OD and 19 for depression. Conclusion: The safety alerts that were developed mainly were drug-drug interactions and adverse reactions.

Introducción: los errores de prescripción son un factor de riesgo para que los pacientes presenten eventos adversos; una estrategia que se ha incorporado a la atención médica para disminuirlos es el uso de herramientas informáticas. El objetivo fue obtener el fundamento científico que sustente la elaboración de alertas de errores de prescripción para cuatro padecimientos de mayor prevalencia en población ≥ 65 años. Métodos: se revisó la literatura del 2010 al 2015 para obtener información de eventos adversos o reacciones ligadas al uso de fármacos empleados en diabetes mellitus (DM), hipertensión arterial sistémica (HAS), enfermedad osteoarticular (EO) y depresión; la revisión incluyó las bases de datos PubMed, OVID, Cochrane Library, LILACS, MEDES, Portal Mayores y SIETES. Se integró un grupo de médicos que analizaron los artículos y elaboraron las alertas de los medicamentos involucrados en los tratamientos de las enfermedades incluidas. Resultados: se obtuvieron 76 artículos in extenso, de los cuales 47 fueron analizados por el grupo de médicos, quienes eliminaron 18 artículos. De los 29 restantes, se integraron 55 alertas: 5 de DM, 16 de HAS, 15 de EO y 19 de depresión. Conclusión: las alertas principalmente fueron interacciones fármaco-fármaco confirmadas y reacciones adversas.

[Vitamin D deficiency associated with insulin resistance in medical residents]. / Hipovitaminosis D asociada a resistencia a la insulina en residentes médicos.

BACKGROUND: Several studies have reported a correlation between vitamin D deficiency and insulin resistance; however, other clinical trials show that vitamin D supplementation do not normalize glucose and insulin levels. We designed a study to show if there is a correlation between serum vitamin D and the homeostatic model assessment 2 (HOMA 2). METHODS: It was designed a cross-sectional, descriptive, and analytical study, which included medical residents. They answered a questionnaire to record the time of sun exposure. We took anthropometric measurements, such as weight, height, and waist circumference, as well as some serum levels: serum vitamin D, serum insulin, fasting blood glucose, triglycerides and high-density lipoprotein-cholesterol. The correlation between serum vitamin D and HOMA 2 was determined by the correlation of Pearson; it was considered significant a p < 0.05. RESULTS: The decreased serum vitamin D levels did not correlate with high concentrations of HOMA 2 (r = -0.11, p = 0.34). A negative correlation between vitamin D levels and index size waist was observed (r = -0.27, p = 0.025). HOMA 2 was positively correlated with waist size index (r = 0.23, p = 0.05) and triglycerides (r = 0.61, p = 0.01) and negatively with high density lipoprotein-cholesterol (r = -0.26, p = 0.02). CONCLUSIONS: We couldn't show the correlation between vitamin D deficiency and insulin resistance.

Introducción: diversos estudios han reportado una correlación entre la deficiencia de vitamina D y la resistencia a la insulina; sin embargo, algunos ensayos clínicos demuestran que la suplementación con vitamina D no normaliza las cifras de glucosa ni las de insulina. Por lo tanto, el objetivo es buscar si existe correlación entre las concentraciones séricas de vitamina D y la resistencia a la insulina a partir de la utilización del índice homeostatic model assessment 2 (HOMA 2). Método: estudio transversal, descriptivo y analítico que incluyó a residentes a los que se les aplicó un cuestionario para conocer su tiempo de exposición al sol. Se tomaron medidas antropométricas como peso, talla y circunferencia de cintura, niveles séricos de vitamina D, insulina sérica, glucosa de ayuno, triglicéridos y colesterol de alta densidad. Se determinó la correlación entre las concentraciones séricas de vitamina D y HOMA 2 mediante el coeficiente de correlación de Pearson; se consideró significativa una p < 0.05. Resultados: la disminución sérica de vitamina D no se correlacionó con concentraciones elevadas del HOMA 2 (r = −0.11, p = 0.34). Se observó una correlación negativa entre las concentraciones de vitamina D y el índice cintura-talla (r = −0.27, p = 0.025). El HOMA 2 se correlacionó positivamente con el índice cintura-talla (r = 0.23, p = 0.05) y los triglicéridos (r = 0.61, p = 0.01) y de forma negativa con el colesterol de alta densidad (r = −0.26, p = 0.02). Conclusión: no observamos la correlación esperada entre hipovitaminosis D y resistencia a la insulina.

Anacusia súbita neurosensorial bilateral en un paciente con síndrome antifosfolípido primario microangiopático / Bilateral sudden sensorineural hearing loss in a patient with microangiopathic antiphospholipid syndrome

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Esteroides asociados a inmunoglobulina intravenosa en el tratamiento del Síndrome de Stevens-Johnson y necrólisis epidérmica tóxica / Steroids associated with intravenous immunoglobulin in the treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis

Introducción: La necrólisis epidérmica tóxica (NET) y el síndrome de Stevens-Johnson (SSJ) son reacciones cutáneas raras, graves y potencialmente mortales asociadas principalmente al uso de medicamentos; sin embargo, se ha señalado la posible relación entre el SSJ con la infección por Mycoplasma pneumoniae o herpes. El tratamiento consiste en la suspensión del fármaco y cuidados de soporte. No existe tratamiento específico que haya demostrado eficacia. Se ha propuesto el uso de inmunoglobulina intravenosa debido a su potencial anti-Fas in vitro, aunque sus efectos reportados no son concluyentes. Objetivo: Describir la respuesta a inmunoglobulina intravenosa en el tratamiento del SSJ/NET en el Hospital de Especialidades Centro Médico Nacional Siglo XXI. Material y métodos: Se realizó un estudio descriptivo retrospectivo en pacientes con SSJ/NET del servicio de Medicina Interna que recibieron inmunoglobulina intravenosa (IV) en el período de marzo de 2008 y abril de 2014. Resultados: Siete pacientes recibieron de 1-3 g/kg de inmunoglobulina IV, 5 mujeres (87.7%) y 1 hombre (14.2%). Todos se relacionaron con ingesta de fármacos, trimetoprim/sulfametoxazol en el 28.5% de los casos. El 71.4% presentó fiebre, 85.7% presentó afección mayor al 10% de la superficie corporal, 100% presentó afección de 2 o más mucosas y 42.8% requirió manejo avanzado de la vía aérea. La estancia hospitalaria promedio fue de 32 días. No ocurrieron defunciones. Una mujer presentó hipertensión asociada a la infusión de inmunoglobulina, así como cefalea, y otra paciente desarrolló neumonía nosocomial. Conclusiones: La respuesta a inmunoglobulina IV fue satisfactoria logrando abortar la progresión del cuadro en 5 pacientes, 85.7% de los casos, sin efectos adversos relevantes(AU)

Background: Toxic epidermal necrolysis (TEN) and Stevens -Johnson syndrome (SJS) are rare but serious and potentially lifethreatening adverse cutaneous drug reactions. However, a possible relationship between SJS with Mycoplasma pneumoniae infection or herpes has been noted. Treatment consists of drug discontinuation and supportive care as there is no specific therapy that has shown efficacy. Intravenous immunoglobulins have been tested as a consequence of the anti-Fas in vitro potential, although its reported effects are inconclusive. Objective: To describe the response to intravenous immunoglobulin in the management of SJS / TEN in Hospital de Especialidades Centro Médico Nacional SXXI. Material and methods: A retrospective descriptive study was conducted in patients with SJS / TEN in the service of Internal Medicine who received intravenous immunoglobulin (IVIG) from March 2008 until April 2014. Results: Seven patients received 1-3 g/ kg IV immunoglobulin, 5 females (87.7 %) and 1 male (14.2 %), all related to ingestion of drugs, trimethoprim/ sulfamethoxazole in 28.5 % of cases. 71.4% had fever, 85.7 % had skin involvement of greater than 10% of the body surface , 100 % had involvement of 2 or more mucous and 42.8 % required advanced airway management . The average hospital stay was 32 days. No deaths occurred. A woman has hypertension associated with immunoglobulin infusion and headache, and another patient developed nosocomial pneumonia Conclusions: Response to IV immunoglobulin was satisfactory as it was associated with cessation of skin and mucosal detachment in 85.7 % of cases without significant adverse effects.