Bioethics in medical care rationing during the coronavirus disease-19 pandemic

ABSTRACT Background: Coronavirus (CoV) disease (COVID)-19 poses difficult situations in which the ethical course of action is not clear, or choices are made between equally unacceptable responses. Methods: A web search was performed using the terms “bioethics; COVID-19; ethics; severe acute respiratory syndrome CoV-2; emergent care; pandemic; and public health emergencies.” Results: Protection from COVID-19 has resulted in the cancellation of necessary medical interventions, lengthened suffering, and potential non-COVID-19 deaths. Prolonged lockdown reduced well-being, triggering or aggravating mental illnesses and violence, and escalated medical risks. Collateral damage includes restrictions on visitations to hospitals, alienation from the deceased relative, or lack of warm caring of patients. Finally, in a public health crisis, public health interest overrides individual rights if it results in severe harm to the community. Conclusion: Balancing ethical dilemmas are one more challenge in the COVID-19 pandemic. (REV INVEST CLIN. 2021;73(1):1-5)

Prevalence of thyroid dysfunction in healthy adults according to the estimated iodine intake in 24-hour urine samples: The SALMEX cohort.

PURPOSE: The aim of this study was to evaluate the prevalence of thyroid dysfunction in a cohort of healthy individuals in Mexico City, as well as to investigate the potential associations of these results with their estimated iodine intake (EII) as reflected by their 24-hour urinary iodine excretion (24-h UIE). METHODS: From the SALMEX cohort, 683 adults provided an appropriate 24-h urine sample. Thyroid function tests and thyroid antibody concentrations were determined in the participants' sera. We analyzed discrepancies between the commonly used urinary parameters to determine the iodine intake status and the performance of thyroglobulin (Tg) as a biomarker of its status in the adult population. RESULTS: The prevalence of dysthyroidism was high, being similar to other studies. Subclinical hypothyroidism was detected in 5.0% of individuals, clinical hypothyroidism in 1.8% of individuals, and sub-clinical hyperthyroidism in 2.8% of individuals. The median EII was 285 µg/d (IQR 215.0-369.0); 94% of individuals had EII >150 µg/d recommended daily allowance (RDA) in adults. The urinary iodine concentration (UIC) and the UIE had relative biases in their averages of 34.4%. The Tg median was 7.21 ng/mL. The prevalence of increased Tg was 6.15%. There was no correlation between Tg and EII (r= 0.019, p= 0.606). CONCLUSIONS: Thyroid dysfunction was highly prevalent in this population. Our cohort revealed a slight discrepancy between dysthyroidism manifestations and iodine intake markers; the latter represent a population with adequate iodine intake. Further studies are necessary to clearly define the prevalence of thyroid dysfunction as well as the iodine nutritional status in Mexico.

Tocilizumab in glucocorticoid-resistant graves orbitopathy. A case series report of a mexican population.

PURPOSE: To describe pre- to post-treatment changes in clinical activity score (CAS) and exophthalmometry in patients with Graves orbitopathy treated with tocilizumab (TCZ). MATERIAL AND METHODS: Eight Mexican patients presenting with active Graves orbitopathy (CAS>3/7) previously treated with glucocorticoids received 1 monthly dose of TCZ for 6 months. CAS, EUGOGO severity assessment and exophthalmometry were used to evaluate clinical status, with serum measurement of thyroid-stimulating hormone receptor antibodies (TR-Ab) for biochemical evaluation before and after application of TCZ. RESULTS: Eight patients were analyzed: 6 male (75%), 2 female (25%): mean age, 45.9±11.2 years; mean weight, 85±18.3 kg. Mean TR-Ab level at treatment outset was 291.9±96.4%, mean CAS 4.1±0.3 and mean exophthalmometry 21.2±3.2 mm. After TCZ treatment, mean TR-Ab level fell to 172.7±54% (P=0.001), mean CAS to 1.1±0.6 (P=0.001) and mean exophthalmometry to 19.3±2 mm (P=0.02). CONCLUSIONS: TCZ is a therapeutic option for glucocorticoid-resistant orbitopathy, and should be considered in second line due to the cost of treatment or in first line in patients with contraindications to intravenous GC pulse therapy.

Bioethics in Medical Care Rationing During the Coronavirus Disease-19 Pandemic.

BACKGROUND: Coronavirus (CoV) disease (COVID)-19 poses difficult situations in which the ethical course of action is not clear, or choices are made between equally unacceptable responses. METHODS: A web search was performed using the terms "bioethics; COVID-19; ethics; severe acute respiratory syndrome CoV-2; emergent care; pandemic; and public health emergencies." RESULTS: Protection from COVID-19 has resulted in the cancellation of necessary medical interventions, lengthened suffering, and potential non-COVID-19 deaths. Prolonged lockdown reduced well-being, triggering or aggravating mental illnesses and violence, and escalated medical risks. Collateral damage includes restrictions on visitations to hospitals, alienation from the deceased relative, or lack of warm caring of patients. Finally, in a public health crisis, public health interest overrides individual rights if it results in severe harm to the community. CONCLUSION: Balancing ethical dilemmas are one more challenge in the COVID-19 pandemic.

Recurrent Papillary Thyroid Carcinoma to the Cervical Lymph Nodes: Outcomes of Compartment-Oriented Lymph Node Resection.

INTRODUCTION: Recurrence of papillary thyroid carcinoma after initial treatment is challenging. Surgical reintervention is recommended, but cure after surgery in uncertain and surgical morbidity may be high. This study evaluates the effect of compartment-oriented lymph node dissection (LND) on clinical and biochemical cure rate as well as the related complications. PATIENTS AND METHODS: All patients who underwent LND for recurrent papillary thyroid carcinoma between 2000 and 2015 were included. Demography, the extent of the initial surgery, usage of 131I, the pattern of recurrence, diagnosis, details of the surgical reintervention, histological findings, surgical morbidity, and clinical and biochemical outcomes were analyzed. RESULTS: There were 11 (12.7%) males and 75 (87.2%) females with a mean age of 42.8 ± 14.6 years. Seventy-seven patients had undergone total thyroidectomy and in 67 (77.9%) some type of LN resection. In 76 (88.3%), 131I was administered after the initial surgery. We localized suspicious lymph nodes by US in all patients, and metastases were documented before surgery by FNA in 63. Seven (8.13%) patients underwent central LND, 63 (73.2%) lateral LND and 16 (18.6%) both, central and lateral LND. Major complications occurred in 6 patients (6.9%). Sixty-two (72.0%) patients received 131I after surgery. A second surgical re-exploration was performed in 30 (34.8%) patients, and 7 patients required 3 or more additional LND. In a mean follow-up of 59.4 ± 39 months, 51 (59.3%) patients are clinically, radiologically and biochemically free of disease. CONCLUSIONS: In this series, compartment-oriented lymph node resection of recurrent papillary thyroid carcinoma leads to a final clinical and biochemical disease-free status of 59.3% with 6.9% of major complications.

[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.

Frontiers in internal medicine

Clinical research in Internal Medicine has provided may scientific advances during the past few years. However, the newly generated information overrides the time available to read all of the medial literature regarding advances in Internal Medicine. The goal of this review is to summarize some of the most relevant improvements in clinical practice published over the last few years. From Cardiology to Pulmonary, the authors of this review expose in a succinct way what they and many of their peers consider to be the most trascendental information gathered from thousands of publications. The authors of this review article have attempted to avoid sensationalism by incluiding facts instead of just simply optimistic preliminary findings that can mislead clinicians' decision making. The review is focused on information obtained through well-designed, prospective clinical trials and cohorts where the effectiveness of medical interventions and diagnostic procedures were tested

Diabetic ketoacidosis in adults: clinical and laboratory features

In this retrospective study, we report the clinical and biochemical features of diabetic ketoacidosis (DKA) in adult patients who were managed at the Instituto Nacional de la Nutricion during a 6.5 year period. There were 98 episodes in 46 patients: 22 females (48 per cent) and 24 males (52 per cent). Six patients (13 per cent) had four or more episodes of DKA were the initial manifestation of diabetes. We compared our results with those from other reported series, finding no differences among them. The mean anion gap in our series was 30.4. Main complications identified were hypokalemia in five cases, hypoglycemia in four cases hypernatremia in four cases, and acute pulmonary edema, ventricular fibrillation, neurological deficit and coma in one case each. There were three death (6.5 per cent) in the whole group. To our knowledge, this is the largest series on adult patients with DKA reported in our country in the last decade. The obtained results may help evaluate prospectively the impact of different diagnostic and therapeutic strategies in the management of DKA

Transferencia de insulinas en 198 pacientes de seis países latinoamericanos / Transference of insulins in 198 patients of six Latinoamerican countries

Es un estudio multicéntrico, comparativo, ciego, aleatorio y prospectivo que evaluó la eficacia y seguridad de la transferencia de insulinas de origen animal a insulina humana biosintética en 198 pacientes de seis países latinoamericanos. Todos los pacientes recibían insulinas de origen animal al menos dos meses antes de su inclusión al estudio. Este tuvo una duración de seis semanas, con evaluaciones al inicio, y a las dos y seis semanas. La eficacia se determinó por cambios inicial-final en la glucemia de ayunas y hemoglobina glucosilada, y la seguridad por la aparición de efectos adversos. De los 198 pacientes, 94 se asignaron al grupo de insulina bovina y 104 al de humana. Al ingreso, ambos grupos fueron similares en sus características. El único cambio al final del estudio fue una disminución en la glucemia en ayunas en el grupo de insulina humana (bovina 212 ñ 95.3 vs 193 ñ 78.8 mg/dL, p= 0.18; humana 198 ñ 86.8 vs 169 ñ 71.7, p= 0.025). El resto de los parámetros no tuvieron modificaciones estadísticamente significativas, aunque la tendencia fue hacia la mejoría en las cifras de hemoglobina glucosilada en ambos grupos. Se presentaron episodios de hipoglucemia leve con mayor frecuencia en el grupo de insulina humana, y hubo un episodio de hipoglucemia grave sin síntomas premonitorios con insulina humana. Concluimos que la transferencia de insulina de origen animal a insulina humana biosintética, en pacientes diabéticos insulinorrequirientes latinoamericanos, es eficaz y razonablemente segura (con ajuste de las dosis de insulina al hacer el cambio)