[Autoimmune pancreatitis associated with diabetes mellitus. Report of one case]. / Diabetes mellitus asociada a pancreatitis autoinmune: Caso clínico.

Autoimmune pancreatitis is uncommon, responds to steroids and is usually associated with diabetes mellitus. We report a 73 year-old male who, two months after a diagnosis of diabetes mellitus, presented with obstructive jaundice and weight loss. Abdominal magnetic resonance imaging was suggestive of an autoimmune pancreatitis and serum IgG4 was 339 mg/dl (normal range 3-201). The patient was treated with prednisone 40 mg/day with a good clinical and laboratory response. During outpatient care, the dose of prednisone was tapered.

Diabetes mellitus asociada a pancreatitis autoinmune: caso clínico / Autoimmune pancreatitis associated with diabetes mellitus: report of one case

Autoimmune pancreatitis is uncommon, responds to steroids and is usually associated with diabetes mellitus. We report a 73 year-old male who, two months after a diagnosis of diabetes mellitus, presented with obstructive jaundice and weight loss. Abdominal magnetic resonance imaging was suggestive of an autoimmune pancreatitis and serum IgG4 was 339 mg/dl (normal range 3-201). The patient was treated with prednisone 40 mg/day with a good clinical and laboratory response. During outpatient care, the dose of prednisone was tapered.

[Declaration of the Chilean Academy of Medicine of Law 20.850 “On clinical trials of pharmaceutical products and medical devices” and of the bylaw that will regulate its application]. / Declaración de la Academia Chilena de Medicina sobre el Título V de la Ley 20.850 (Ley Ricarte Soto) y su proyecto de reglamento “De los ensayos clínicos de productos farmacéuticos y elementos de uso médico”.

In Chile, high cost treatments required by selected medical conditions are financed by the State, according to Law 20.850. A bylaw under discussion by the Senate regulates clinical trials, posing complex issues that will endanger local interest in front-line research: 1. The exclusive and mandatory control bestowed to the Institute of Public Health during all stages of the trials and also the surveillance of institutions performing clinical trials, overriding their Clinical Research Review Boards; 2.The 10 year period during which any adverse event is assumed to have been caused by the medication or devise evaluated by the trial, unless the contrary is proven in a judicial process; 3. Individuals submitted to the trials are entitled to free post trial access to the treatment received during the study, financed by the trial supporting entities and as long as the drug or devise is considered to be useful. While agreeing with the need to have a National Registry of Clinical Trials, we predict that the mentioned critical issues in the bylaw will lead to difficulties and unnecessary judicial processes, thus limiting clinicians’ interest in performing research. We propose to modify the bylaw, excluding responsibilities on events associated with the natural evolution of the medical condition, with patients’ ageing or with comorbidities and clinical events considered unpredictable when the protocol was accepted. We recommend that the free post trial access should be a joint decision involving the patient and the attending physician, taking in consideration that the volunteer has been exposed to risks and burdens, or when discontinuation of treatment entails a vital risk until the treatment under study has been approved and becomes available in the national market.

Declaración de la Academia Chilena de Medicina sobre el Título V de la Ley 20. 850 (Ley Ricarte Soto) y su proyecto de reglamento “De los ensayos clínicos de productos farmacéuticos y elementos de uso médico” / Declaration of the Chilean Academy of Medicine of Law 20. 850 On clinical trials of pharmaceutical products and medical devices” and of the bylaw that will regulate its application

In Chile, high cost treatments required by selected medical conditions are financed by the State, according to Law 20.850. A bylaw under discussion by the Senate regulates clinical trials, posing complex issues that will endanger local interest in front-line research: 1. The exclusive and mandatory control bestowed to the Institute of Public Health during all stages of the trials and also the surveillance of institutions performing clinical trials, overriding their Clinical Research Review Boards; 2.The 10 year period during which any adverse event is assumed to have been caused by the medication or devise evaluated by the trial, unless the contrary is proven in a judicial process; 3. Individuals submitted to the trials are entitled to free post trial access to the treatment received during the study, financed by the trial supporting entities and as long as the drug or devise is considered to be useful. While agreeing with the need to have a National Registry of Clinical Trials, we predict that the mentioned critical issues in the bylaw will lead to difficulties and unnecessary judicial processes, thus limiting clinicians’ interest in performing research. We propose to modify the bylaw, excluding responsibilities on events associated with the natural evolution of the medical condition, with patients’ ageing or with comorbidities and clinical events considered unpredictable when the protocol was accepted. We recommend that the free post trial access should be a joint decision involving the patient and the attending physician, taking in consideration that the volunteer has been exposed to risks and burdens, or when discontinuation of treatment entails a vital risk until the treatment under study has been approved and becomes available in the national market.

Cetoacidosis diabética normoglicémica en el embarazo: caso clínico / Normoglycemic diabetic ketoacidosis in pregnancy: report of one case

Normoglycemic diabetic ketoacidosis should be suspected in pregnant women presenting nausea, vomiting, abdominal pain and anorexia. We report a 39 years old woman with a 32 weeks pregnancy who sought emergency care due to hyperemesis. She was hospitalized with the following diagnoses: pregnancy hypertension syndrome, gestational diabetes, morbid obesity and poor prenatal control. The evaluation of the feto-placental unit showed perception of fetal movements, non-reactive non-stress baseline record and a biophysical profile of 6/8. Fetal maturation was initiated. Laboratory tests showed a metabolic acidosis, a low pH, an increased Gap anion, elevated ketonemia and a blood glucose of 172 mg/dl. A diagnosis of normoglycemic diabetic ketoacidosis was formulated and treatment with hydration and regular insulin according to capillary blood glucose levels was started. An emergency caesarean section was performed. The newborn weighed 2.650 kg, had a length of 46 cm, was large for gestational age, had an Apgar score of 2.7, had perinatal asphyxia, convulsive syndrome and a possible congenital cardiopathy. Once the ketoacidosis was resolved during the immediate puerperium, slow acting insulin was initiated.

[Normoglycemic diabetic ketoacidosis in pregnancy: Report of one case]. / Cetoacidosis diabética normoglicémica en el embarazo: Caso clínico.

Normoglycemic diabetic ketoacidosis should be suspected in pregnant women presenting nausea, vomiting, abdominal pain and anorexia. We report a 39 years old woman with a 32 weeks pregnancy who sought emergency care due to hyperemesis. She was hospitalized with the following diagnoses: pregnancy hypertension syndrome, gestational diabetes, morbid obesity and poor prenatal control. The evaluation of the feto-placental unit showed perception of fetal movements, non-reactive non-stress baseline record and a biophysical profile of 6/8. Fetal maturation was initiated. Laboratory tests showed a metabolic acidosis, a low pH, an increased Gap anion, elevated ketonemia and a blood glucose of 172 mg/dl. A diagnosis of normoglycemic diabetic ketoacidosis was formulated and treatment with hydration and regular insulin according to capillary blood glucose levels was started. An emergency caesarean section was performed. The newborn weighed 2.650 kg, had a length of 46 cm, was large for gestational age, had an Apgar score of 2.7, had perinatal asphyxia, convulsive syndrome and a possible congenital cardiopathy. Once the ketoacidosis was resolved during the immediate puerperium, slow acting insulin was initiated.

Estudio del control metabólico en pacientes diabéticos en hemodiálisis crónica: hemoglobina glicosilada, fructosamina y glicemias capilares / Study of metabolic control in diabetic patients on chronic hemodialysis: glycated hemoglobin, fructosamine and capillary glycemia

Background: In conditions that may change red blood cell survival, such as hemodialysis, the accuracy of A1c glycosylated hemoglobin (HbA1c) to assess metabolic control can be hampered. Other glycosylated proteins such as fructosamine, could accomplish the role of HbA1c. Aim: To assess if HbA1c is a good metabolic control parameter in diabetic patients on chronic hemodialysis. To compare fructosamine, HbA1c and serial capillary glucose levels in the same patients. Material and Methods: Patients on hemodialysis three times per week were studied. Twenty one subjects with diabetes mellitus and 10 non-diabetic patients were included (70 percent were male). During a period of 14 days, fasting and post prandial capillary glucose levels were measured. Venous glucose, HbA1c and fructosamine were measured at the onset and completion of the monitoring period. Results: Diabetic patients were older than their non-diabetic counterparts (65 and 47 years respectively, p < 0.04). In diabetic and non-diabetic patients respectively, capillary blood glucose levels were 161 +/- 22 and 104 +/- 51 mg/dl, HbA1c levels were 6.8 +/- 1.2 and 5.4 +/- 0.4 percent and fructosamine levels were 282.0 +/- 126.6 and 154.6 +/- 73 umol/L. In all patients there was a positive correlation between blood glucose, HbA1c (r = 0.78 p < 0.01) and fructosamine (r = 0.52, p 0.02). There was a positive correlation between mean capillary glucose, HbA1c (r = 0.77, p < 0.01) and fructosamine (r = 0.69, p < 0.02). Among diabetic patients, the correlation coefficients between mean capillary glucose levels, HbA1c and fructosamine levels were 0.67 (p < 0.01) and 0.51 (NS), respectively. Conclusions: Among diabetic patients on hemodialysis fructosamine levels are not a better indicator of metabolic control than HbA1c.

Frecuencia de periodontitis en una muestra de diabéticos tipo 2 y no diabéticos de Santiago de Chile / Frequency of periodontitis in a sample of type 2 diabetics and non diabetics

Background: Periodontitis is highly prevalent in the general population and some diseases such as diabetes could favor its development, reaching a prevalence of over 60 percent. Aim: To evaluate the prevalence of periodontitis in a sample of DM2 patients and to compare it with non-diabetic subjects. Patients and Methods: We enrolled patients with DM2 and non-diabetic adult subjects. According to periodontal diagnosis, they were classified as healthy, having mild to moderate periodontitis and having severe periodontitis. Anthropometric assessment was performed and a fasting blood sample was obtained to measure blood glucose and lipid profile. In diabetics, HbA1c, creatinine, microalbuminuria, EKG and fundoscopy were evaluated. Results: We studied 62 patients with DM2, aged 55.2 +/- 9.4 years and with 4.7 +/- 4.6 years of diagnosis of diabetes and 65 non-diabetic subjects, aged 50 +/- 9.6 years. Among diabetics, HbA1c values were 7.85 +/- 2.3 percent. The proportion of periodontitis was significantly higher in DM2 than in non-diabetics (98 and 89 percent, p = 0.02). Mild to moderate and severe periodontitis was observed in 39 and 60 percent of diabetic patients, respectively. Among non-diabetics, 11 percent were healthy, 5 percent had gingivitis, 37 percent mild to moderate periodontitis and 48 percent had severe periodontitis. The frequency of chronic complications of diabetes was low, except for positive microalbuminuria, that was present in 42.6 percent of patients. Conclusions: We found a high prevalence of periodontitis in diabetic and no diabetic patients, but among the former, it was near to 100 percent. Periodontal examination should be considered as part of the evaluation of patients with type 2 diabetes.

Maestros de la medicina interna chilena / Masters of internal medicine in Chile

Maestros de la Medicina Interna es la más alta distinción honorífica otorgada a sus miembros por la Sociedad Médica de Santiago-Sociedad Chilena de Medicina Interna. Desde que fue instuido, en 1981, la Sociedad ha otorgado el título a distinguidos internistas chilenos, en una selección que ocurre periódicamente. Los galardoneados son considerados modelos como médicos, educadores y personas, dignos de ser emulados por las futuras generaciones de médicos, con la responsabilidad de mantener el espíritu, prestigio y proyección de la medicina interna. En 2010, en ocasión del XXXII Congreso Chileno de Medicina Interna, se entregó el título de Maestro de la Medicina Interna al Dr. Rodolfo Armas Merino. El Dr. Armas es Profesor de Medicina de la Universidad de Chile, Miembro de Número de la Academia Chilena de Medicina (actualmente su Presidente) y Master del American College of Physicians. Ha sido un colaborador permanente de la Revista Médica de Chile, como revisor externo y Miembro del Comité Editorial Asesor. En su homenaje se publica la presentación que hizo la Dra. Gloria López Stewart, al entregarle la actual distinción. Una síntesis del curriculum vitae del Dr. Armas y su foto se publicaron en el número de junio de la revista (Rev. Méd. Chile 2010; 138: 784-5). (AU)

Consenso elaborado por la Sociedad Chilena de Endocrinología y Diabetes sobre resistencia a la insulina(RI) y síndrome metabólico (SM): aspectos clínicos y terapéuticos / Chilean society of endocrinology and diabetes consensus on clinical and therapeutic aspects of insulin resistance and metabolic syndrome

Background: The concept insulin resistance as the basis for a series of metabolic alterations and diseases was introduced by Gerald Reaven in 1988, when he described a cluster of alterations that named syndrome X. Aim: To review and discuss the present information about insulin resistance (IR) and metabolic syndrome (MS). Material and methods: The IR concept is defined,the affected metabolic ways, its consequences and relationship with different diseases are presented. The importance of central obesity with its metabolic, inflammatory and prothrombotic consequences playing a key role in cardiovascular risk, is discussed. The cluster of factors focused on cardiovascular disease and eventually diabetes is named MS. Several definitions of MS are analyzed and compared. A proposition is made about the definition to be used in the Chilean population. Differences between IR syndrome and MS are discussed. Diagnostic methods of IR and MS are presented, recommendations are made about their usefulness and reliability. Non pharmacological and pharmacological treatments of IR and MS are analyzed. Other related diseases, such as polycystic ovary syndrome, non alcoholic steatohepatitis and sleep apnea are discussed. Conclusions. Until further studies are made to define a local waist circumference cut-off associated with high risk, the ATPIII MS definition is preferred. A clinical approach is recommended for diagnosis. A search for all components of the MS is important. There is no evidence about the benefits of MS treatment on the prevention of cardiovascular diseases or diabetes. Evidence supports the use of lifestyle changes and some drugs, such as metformin on the prevention of diabetes in prediabetic states.

[Assessment and follow up of diabetic patients in hemodialysis]. / Diabetes y hemodiálisis. Caracterización de una cohorte y seguimiento a cuatro años.

BACKGROUND: Despite a better management of the variables that influence the development of diabetic nephropathy there is a progressive increase in the prevalence of terminal renal failure among diabetics, whose cause is not clear. AIM: To study in a group of patients in hemodialysis, the quality of diabetes control previous to the entry to dialysis, their physical condition and their evolution. MATERIAL AND METHODS: Diabetic patients with at least three months of hemodialysis answered a questionnaire about diabetes control quality previous to dialysis and had physical and laboratory assessment. They were followed for at least four years thereafter. RESULTS: Fifty seven patients aged 62+/-11 years were studied. Eighty four percent had some degree of disability. Eighty seven percent had high blood pressure and 73% had to enter dialysis as an emergency. Mean glycosilated hemoglobin was 7.7% and 58% had a dialysis dose with a Kt/Vofless than 1.2. Fifty eight percent died during follow up. No relationship between mortality and age, blood pressure, glycosilated hemoglobin of Kt/V, was observed. CONCLUSIONS: There is an inadequate management of blood glucose and blood pressure of diabetic patients before entry to dialysis. They are referred inverted exclamation markate to the nephrologist, the dialysis dose is insufficient and they have a high mortality.

Diabetes y hemodiálisis. Caracterización de una cohorte y seguimiento a cuatro años / Assessment and follow up of diabetic patients in hemodialysis

Background: Despite a better management of the variables that influence the development of diabetic nephropathy there is a progressive increase in the prevalence of terminal renal failure among diabetics, whose cause is not clear. Aim: To study in a group of patients in hemodialysis, the quality of diabetes control previous to the entry to dialysis, their physical condition and their evolution. Material and methods: Diabetic patients with at least three months of hemodialysis answered a questionnaire about diabetes control quality previous to dialysis and had physical and laboratory assessment. They were followed for at least four years thereafter. Results: Fifty seven patients aged 62±11 years were studied. Eighty four percent had some degree of disability. Eighty seven percent had high blood pressure and 73 percent had to enter dialysis as an emergency. Mean glycosilated hemoglobin was 7.7 percent and 58 percent had a dialysis dose with a Kt/Vofless than 1.2. Fifty eight percent died during follow up. No relationship between mortality and age, blood pressure, glycosilated hemoglobin of Kt/V, was observed. Conclusions: There is an inadequate management of blood glucose and blood pressure of diabetic patients before entry to dialysis. They are referred ¡ate to the nephrologist, the dialysis dose is insufficient and they have a high mortality.

Infecciones urinarias en el diabético: parte II / Urinary infections in diabetic patients: part II

Las infecciones urinarias en general son muy comunes especialmente en las mujeres diabéticas con descompensación metabólica. Desde un punto de vista práctico, se les puede clasificar en: infecciones bajas generalmente denominadas cistitis en las que predominan las molestias disúricas y no existen fiebre ni compromiso apreciable del estado general. Infecciones altas o pielonefritis que tienen una evolución febril y dolor en las fosas lumbares, riñón palpable y sensible en los flancos y compromiso del estado general. En ambos tipos de infecciones urinarias, la compensación de la diabetes es un objetivo obligado que no siempre se consigue completamente. Las complicaciones potenciales son las mismas pero son mucho más frecuentes en las pielonefritis que en las cistitis. Ello explica que su pronóstico y su tratamiento sean diferentes. En las infecciones bajas el tratamiento antibiótico es oral y su duración es menor pero noinferior a 7 días. En las infecciones altas el tratamiento antibiótico inicial debe ser parental y de mayor duración (15 a 20 días); debe complementarse con reposo u hospitalización y a veces con cirugía (drenajes y aún nefrectomía). Para evitar las recurrencias muy comunes en las mujeres diabéticas, se recomienda la profilaxis continua y ocacionalmente la postcoital. Los antimicrobianos indicados con estos fines y sus docis se señalan en el texto. En el curso de las infecciones urinarias altas los antidiabéticos orales deben ser reemplazados por insulina

Efecto de la metformina sobre la resistencia insulínica en mujeres obesas y obesas hiperandrogénicas / Effects of metformin on insulin resistance in obese and hyperandrogenic women

Background: Metformin is a biguanide often used in obese diabetics that improves tissue sensitivity to insulin. Aim:To assess the effects of metformin on tissue insulin sensitivity in obese and byperandrogenic women. Patients and methods: Eight obese and eight obese and eight and hyperandrogenic women received metformin 850 mg orally during 12 weeks. Before and at the end of the treatment period, an insulin tolerance test to measure insulin sensitivity was performed and blood was drawn to measure sex hormone binding globulin (SHBG), dehydroepiandrosterone sulphate (DHEAS), testosterone, triglycerides, total and HDL cholesterol. The free androgen index was calculated for each sample. Results: After metformin treatment, the insulin sensitivity index improved from 0.38 (0.05-0.5) to 0.43 (0.25-0.59) in obese and hyperandrogenic women. SHBG increased and total cholesterol and triglycerides decreased significantly in both groups. No other significant changes were observed. Conclusions: Metformin has a favorable effect on tissue sensitivity to insulin, SHBG and serum lipids in obese and hyperandrogenic women

Marcadores bioquímicos y métodos de cuantificación de insulinorresistencia en mujeres normales, obesas e hiperandrogénicas / Biochemical markers and methods to assess insulin resistance in normal, obese and hyperandrogenic women

Six normal, 6 obese and 12 hyperandrogenic women of similar ages, were studied. In two consecutive days, the ITT and the IVGTT were performed and a basal blood sample was obtained to measure SHBG, DHEAS and IGFBP-1. Insulin sensitivity was calculated as the blood glucose slope in the ITT and with the minimal model of Bergman in the IVGTT. Insulin sensitivity, measure with ITT was 0.58 (0.53-0.63) in normal, 0.38(0.05-0.59) in obese and 0.20(0.0-0.36) in hyperandrogenic women. The figures for the IVGTT were 7.97(4.1-15.4), 2.41 )0.81-4.89) and 1.1 (0.46-1.88), respectively. Both methods had a positive correlation coefficient of 0.792 (p 0.09). IGFBP-1 values were 3.0, 2.1 and 1.6 ng/ml respectively (p 0.05). DHEAS values were 132, 190 and 206 ug/dl, respectively (ND). ITT is a sample and reliable method to asses insulin sensitivity. SHBG discriminates subjects with different levels of insulin sensitivity