Banff 2022 pancreas transplantation multidisciplinary report: Refinement of guidelines for T cell-mediated rejection, antibody-mediated rejection and islet pathology. Assessment of duodenal cuff biopsies and noninvasive diagnostic methods.

The Banff pancreas working schema for diagnosis and grading of rejection is widely used for treatment guidance and risk stratification in centers that perform pancreas allograft biopsies. Since the last update, various studies have provided additional insight regarding the application of the schema and enhanced our understanding of additional clinicopathologic entities. This update aims to clarify terminology and lesion description for T cell-mediated and antibody-mediated allograft rejections, in both active and chronic forms. In addition, morphologic and immunohistochemical tools are described to help distinguish rejection from nonrejection pathologies. For the first time, a clinicopathologic approach to islet pathology in the early and late posttransplant periods is discussed. This update also includes a discussion and recommendations on the utilization of endoscopic duodenal donor cuff biopsies as surrogates for pancreas biopsies in various clinical settings. Finally, an analysis and recommendations on the use of donor-derived cell-free DNA for monitoring pancreas graft recipients are provided. This multidisciplinary effort assesses the current role of pancreas allograft biopsies and offers practical guidelines that can be helpful to pancreas transplant practitioners as well as experienced pathologists and pathologists in training.

Recomendaciones sobre el uso de la telemedicina aplicada a la patología nutricional / Recommendations on the use of telemedicine as applied to nutritional pathology

Introducción: la telemedicina puede mejorar la calidad asistencial y el uso de recursos. La pandemia de COVID-19 ha hecho necesaria su implementación en la práctica habitual. Por ello, un grupo de endocrinólogos de la Comunidad Valenciana, Murcia y Baleares creó un comité para su desarrollo. Objetivos: establecer unas recomendaciones para mejorar la calidad de la consulta de patología nutricional y diseñar unos indicadores para su gestión. Metodología: se siguió la metodología Delphi con participación de 13 profesionales con el fin de alcanzar el mayor consenso. Para ello se circuló un cuestionario de 16 puntos en 3 rondas: en la primera se estableció el grado de consenso; en la segunda, los participantes tuvieron acceso a los resultados de la primera y respondieron a las cuestiones planteadas. Se consideró que había acuerdo si el consenso era ≥ 75 % de los participantes, y que existía acuerdo fuerte si este era ≥ 90 %. Además, se estableció la temática de los indicadores de calidad. En la tercera se desarrollaron dichos indicadores. Resultados: tras 3 rondas y una reunión de revisión se establecieron los sobre aspectos organizativos 5 recomendaciones con acuerdo fuerte; sobre los aspectos administrativos, 6 recomendaciones con acuerdo fuerte y 4 con acuerdo. Se seleccionaron 8 indicadores de calidad que se desarrollaron en formato de fichas. Conclusiones: este documento recopila una serie de recomendaciones sobre cuestiones, necesidades y requisitos a tener en cuenta para una consulta telemática de calidad al paciente con patología nutricional. Así mismo, se han desarrollado unos indicadores para mejorar la calidad asistencial (AU)

Introduction: telemedicine can improve the standards of clinical care and use of resources. The COVID-19 pandemic has required its implementation in routine practice. For this reason, a group of endocrinologists from Valencia, Murcia and the Balearic Islands created a committee for its development. Objectives: to establish recommendations in order to improve the quality of consultation in nutritional disorders, and to create indicators for its management. Methodology: the Delphi methodology was followed with the participation of 13 professionals in order to reach the widest consensus. A 16-item questionnaire was distributed within 3 rounds: in the first round, the degree of consensus was established; in the second round, the participants responded to the posed questions after having access to the first-round results. Agreement was considered if ≥ 75 % participants reached consensus, while strong agreement was considered if consensus was reached by ≥ 90 %. In addition, quality indicators were established. In a third round, these indicators were developed. Results: after 3 rounds and a revision 5 recommendations with strong agreement were established based on organizational aspects. Regarding administrative aspects, 6 recommendations with strong agreement were established while 4 recommendations reached the level of agreement. Eight quality indicators were selected and developed. Conclusions this document compiles a list of recommendations about needs and requirements to be taken into account for a quality telematic consultation in patients with nutritional disorders. In addition, health care quality indicators have been created and developed (AU)

A real-life study of the medium to long-term effectiveness of a hypercaloric, hyperproteic enteral nutrition formula specifically for patients with diabetes on biochemical parameters of metabolic control and nutritional status.

INTRODUCTION: Although current recommendations suggest the use of specific formulas in enteral nutrition in people with diabetes, there is little evidence of their long-term effectiveness in glycemic control. The main objective of this study is to evaluate the long-term efficacy (24 weeks) of a specific high-protein hypercaloric enteral nutrition formula for people with diabetes in glycemic control and in their improvement in nutritional status. METHODOLOGY: This was a multicenter, prospective, observational, real-life study of patients with long-term enteral nutrition prescription through gastrostomy or nasogastric tube who received a high protein hypercaloric formula specific for diabetes. Once the participant's informed consent was obtained and the inclusion and exclusion criteria were verified, data relating to glycemic control, inflammation parameters, biochemical data, nutritional status and gastrointestinal tolerance at 0, 12 and 24 weeks were collected. RESULTS: 112 patients were recruited, 44.6% women, age 75.0 (12.0) years and a mean time of evolution of diabetes of 18.1 (9.5) years. The percentage of patients with malnutrition according to VGS decreased throughout the treatment from 78.6% to 29.9% (p < 0.001). Glycemic and HbA1c levels were significantly reduced at 12 and 24 weeks (Blood glucose 155.9-139.0-133.9 mg/dl, p < 0.001; HbA1c 7.7-7.3-7.1%, p < 0.001) while no significant changes were observed in cholesterol, triglycerides, creatinine, or glomerular filtration. A significant increase in variables related to nutritional status was observed: weight, the BMI, albumin, prealbumin and transferrin, and CRP levels were significantly reduced and the CRP/Albumin ratio decreased. Gastrointestinal tolerance was good, the number of patients with moderate-severe symptoms was small, and did not change throughout the follow-up. CONCLUSION: Our real-life study suggests that the use of a specific hyperprotein hypercaloric formula for diabetes during a 6-month nutritional treatment allows adequate glycemic control and nutritional evolution, with good gastrointestinal tolerance.

Aetiological diagnosis of hyponatraemia in non-critical patients on total parenteral nutrition: A prospective multicentre study.

BACKGROUND: In patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN. METHODS: Prospective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone. RESULTS: 162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%). CONCLUSIONS: SIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.

[Recommendations on the use of telemedicine as applied to nutritional pathology]. / Recomendaciones sobre el uso de la telemedicina aplicada a la patología nutricional.

Introduction: Introduction: telemedicine can improve the standards of clinical care and use of resources. The COVID-19 pandemic has required its implementation in routine practice. For this reason, a group of endocrinologists from Valencia, Murcia and the Balearic Islands created a committee for its development. Objectives: to establish recommendations in order to improve the quality of consultation in nutritional disorders, and to create indicators for its management. Methodology: the Delphi methodology was followed with the participation of 13 professionals in order to reach the widest consensus. A 16-item questionnaire was distributed within 3 rounds: in the first round, the degree of consensus was established; in the second round, the participants responded to the posed questions after having access to the first-round results. Agreement was considered if ≥ 75 % participants reached consensus, while strong agreement was considered if consensus was reached by ≥ 90 %. In addition, quality indicators were established. In a third round, these indicators were developed. Results: after 3 rounds and a revision 5 recommendations with strong agreement were established based on organizational aspects. Regarding administrative aspects, 6 recommendations with strong agreement were established while 4 recommendations reached the level of agreement. Eight quality indicators were selected and developed. Conclusions: this document compiles a list of recommendations about needs and requirements to be taken into account for a quality telematic consultation in patients with nutritional disorders. In addition, health care quality indicators have been created and developed.

Introducción: Introducción: la telemedicina puede mejorar la calidad asistencial y el uso de recursos. La pandemia de COVID-19 ha hecho necesaria su implementación en la práctica habitual. Por ello, un grupo de endocrinólogos de la Comunidad Valenciana, Murcia y Baleares creó un comité para su desarrollo. Objetivos: establecer unas recomendaciones para mejorar la calidad de la consulta de patología nutricional y diseñar unos indicadores para su gestión. Metodología: se siguió la metodología Delphi con participación de 13 profesionales con el fin de alcanzar el mayor consenso. Para ello se circuló un cuestionario de 16 puntos en 3 rondas: en la primera se estableció el grado de consenso; en la segunda, los participantes tuvieron acceso a los resultados de la primera y respondieron a las cuestiones planteadas. Se consideró que había acuerdo si el consenso era ≥ 75 % de los participantes, y que existía acuerdo fuerte si este era ≥ 90 %. Además, se estableció la temática de los indicadores de calidad. En la tercera se desarrollaron dichos indicadores. Resultados: tras 3 rondas y una reunión de revisión se establecieron los sobre aspectos organizativos 5 recomendaciones con acuerdo fuerte; sobre los aspectos administrativos, 6 recomendaciones con acuerdo fuerte y 4 con acuerdo. Se seleccionaron 8 indicadores de calidad que se desarrollaron en formato de fichas. Conclusiones: este documento recopila una serie de recomendaciones sobre cuestiones, necesidades y requisitos a tener en cuenta para una consulta telemática de calidad al paciente con patología nutricional. Así mismo, se han desarrollado unos indicadores para mejorar la calidad asistencial.

Resultados tras 13 años del inicio del trasplante simultáneo de páncreas-riñón en pacientes con diabetes mellitus tipo 1 en la Comunidad Valenciana / Results after 13 years of kidney-pancreas transplantation in type 1 diabetic patients in Comunidad Valenciana

Introducción: El trasplante simultáneo de páncreas-riñón (SPK, por simultaneous pancreas kidney) es una opción terapéutica válida en pacientes afectos de diabetes mellitus tipo 1 con enfermedad renal crónica terminal que son candidatos a trasplante renal. Se presentan los resultados desde el inicio del programa de trasplante SPK en la Comunidad Valenciana. Métodos: Estudio descriptivo, retrospectivo y unicéntrico de los trasplantes de páncreas realizados en el Hospital Universitari i Politècnic La Fe, desde septiembre de 2002 a diciembre de 2015. Se recogieron variables clínicas de los donantes y receptores, variables peri-operatorias y supervivencia del paciente y del injerto pancreático. Resultados: Ochenta y un pacientes con diabetes mellitus tipo 1 (48 hombres y 33 mujeres, de 37,4±5,7 años, IMC de 24,1±3,4kg/m2, con una duración de su diabetes de 25,5±6,5 años) recibieron un trasplante SPK. La supervivencia global del paciente a uno, 3 y 5 años fue del 91,3, el 91,3 y el 89,5%, respectivamente. Sin embargo, la supervivencia del paciente en los periodos 2002-2008 y 2009-2015 fue del 88,2 y el 93,6% al año, del 88,2 y el 93,7% a los 3 años, y del 85,3 y el 93,7% a los 5 años, respectivamente (p=1). La supervivencia global del injerto pancreático a uno, 3 y 5 años fue del 75,2, el 69,1 y el 63,2%, respectivamente. Por otra parte, la supervivencia del injerto pancreático en los periodos 2002-2008 y 2009-2015 fue del 67,5 y el 80,6% al año, del 64,7 y el 71,8% a los 3 años, y del 58,8 y el 65,3% a los 5 años, respectivamente (p=0,0109). Las complicaciones postrasplante fueron: rechazo del injerto en un 8,6%, trombosis venosa del injerto en un 7,4% y pancreatitis del injerto en un 4,9%. (AU)

Introduction: Simultaneous pancreas-kidney (SPK) transplant is a proven option of treatment for patients with type 1 diabetes mellitus and related end-stage renal disease, who are candidates for kidney transplantation. The results from the beginning of SPK transplant program in Comunidad Valenciana are presented. Methods: Descriptive, retrospective, and single-center study of the pancreas transplant performed at the Hospital Universitari i Politècnic La Fe, from September 2002 to December 2015. Clinical variables from donors and recipients, peri-operative variables, patient survival, and pancreatic graft survival were collected. Results: Eighty-one patients with type 1 diabetes mellitus (48 males and 33 females, mean age 37.4±5.7 years, mean BMI 24.1±3.4kg/m2, mean duration of diabetes 25.5±6.5 years) received SPK transplantation. The overall patient survival at one, 3, and 5 years were 91,3, 91,3 and 89,5%, respectively. However, patient survival in the periods 2002-2008 and 2009-2015 were 88.2 and 93.6% at one year, 88.2 and 93.7% at 3 years, and 85.3 and 93.7% at 5 years, respectively (P=1). The overall pancreatic graft survival at one, 3, and 5 years were 75.2, 69.1 and 63.2%, respectively. On the other hand, pancreatic graft survival in the periods 2002-2008 and 2009-2015 were 67.5 and 80.6% at one year, 64.7 and 71.8% at 3 years, and 58.8% and 65.3% at 5 years, respectively (P=.0109). Postransplant complications were: graft rejection 8.6%, venous graft thrombosis 7.4%, graft pancreatitis 4.9%. (AU)

Results after 13 years of kidney-pancreas transplantation in type 1 diabetic patients in Comunidad Valenciana.

INTRODUCTION: Simultaneous pancreas-kidney (SPK) transplant is a proven option of treatment for patients with type 1 diabetes mellitus and related end-stage renal disease, who are candidates for kidney transplantation. The results from the beginning of SPK transplant program in Comunidad Valenciana are presented. METHODS: Descriptive, retrospective, and single-center study of the pancreas transplant performed at the Hospital Universitari i Politècnic La Fe, from September 2002 to December 2015. Clinical variables from donors and recipients, peri-operative variables, patient survival, and pancreatic graft survival were collected. RESULTS: Eighty-one patients with type 1 diabetes mellitus (48 males and 33 females, mean age 37.4 ± 5.7 years, mean BMI 24.1 ± 3.4 kg/m2, mean duration of diabetes 25.5 ± 6.5 years) received SPK transplantation. The overall patient survival at one, 3, and 5 years were 91.3%, 91.3% and 89.5%, respectively. However, patient survival in the periods 2002-2008 and 2009-2015 were 88.2% and 93.6% at one year, 88.2% and 93.7% at 3 years, and 85.3% and 93.7% at 5 years, respectively (P = 1). The overall pancreatic graft survival at one, 3, and 5 years were 75.2%, 69.1% and 63.2%, respectively. On the other hand, pancreatic graft survival in the periods 2002-2008 and 2009-2015 were 67.5% and 80.6% at one year, 64.7% and 71.8% at 3 years, and 58.8% and 65.3% at 5 years, respectively (P = .0109). Post-transplant complications were: graft rejection 8.6%, venous graft thrombosis 7.4%, graft pancreatitis 4.9%. CONCLUSIONS: In 13 years' experience of SPK transplantation, patient and pancreatic graft survival and the rate of complications after pancreas transplantation were similar to those of other larger series. The medical-surgical team experience improves pancreatic graft survival without influencing patient survival.

Aetiological diagnosis of hyponatraemia in non-critical patients on total parenteral nutrition: A prospective multicentre study.

BACKGROUND: In patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN. METHODS: Prospective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone. RESULTS: 162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%). CONCLUSIONS: SIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.

A real-life study of the medium to long-term effectiveness of a hypercaloric, hyperproteic enteral nutrition formula specifically for patients with diabetes on biochemical parameters of metabolic control and nutritional status. / Estudio en vida real de la efectividad a medio-largo plazo en parámetros bioquímicos de control metabólico y estado nutricional de una fórmula de nutrición enteral hipercalórica hiperproteica específica para pacientes con diabetes.

INTRODUCTION: Although current recommendations suggest the use of specific formulas in enteral nutrition in people with diabetes, there is little evidence of their long-term effectiveness in glycemic control. The main objective of this study is to evaluate the long-term efficacy (24 weeks) of a specific high-protein hypercaloric enteral nutrition formula for people with diabetes in glycemic control and in their improvement in nutritional status. METHODOLOGY: This was a multicenter, prospective, observational, real-life study of patients with long-term enteral nutrition prescription through gastrostomy or nasogastric tube who received a high protein hypercaloric formula specific for diabetes. Once the participant's informed consent was obtained and the inclusion and exclusion criteria were verified, data relating to glycemic control, inflammation parameters, biochemical data, nutritional status and gastrointestinal tolerance at 0, 12 and 24 weeks were collected. RESULTS: 112 patients were recruited, 44.6% women, age 75.0 (12.0) years and a mean time of evolution of diabetes of 18.1 (9.5) years. The percentage of patients with malnutrition according to VGS decreased throughout the treatment from 78.6% to 29.9% (P<.001). Glycemic and HbA1c levels were significantly reduced at 12 and 24 weeks (Blood glucose 155.9-139.0-133.9mg/dl, P<.001; HbA1c 7.7-7.3-7.1%, P<.001) while no significant changes were observed in cholesterol, triglycerides, creatinine, or glomerular filtration. A significant increase in variables related to nutritional status was observed: weight, the BMI, albumin, prealbumin and transferrin, and CRP levels were significantly reduced and the CRP / Albumin ratio decreased. Gastrointestinal tolerance was good, the number of patients with moderate-severe symptoms was small, and did not change throughout the follow-up. CONCLUSION: Our real-life study suggests that the use of a specific hyperprotein hypercaloric formula for diabetes during a 6-month nutritional treatment allows adequate glycemic control and nutritional evolution, with good gastrointestinal tolerance.

Results after 13 years of kidney-pancreas transplantation in type 1 diabetic patients in Comunidad Valenciana. / Resultados tras 13 años del inicio del trasplante simultáneo de páncreas-riñón en pacientes con diabetes mellitus tipo 1 en la Comunidad Valenciana.

INTRODUCTION: Simultaneous pancreas-kidney (SPK) transplant is a proven option of treatment for patients with type 1 diabetes mellitus and related end-stage renal disease, who are candidates for kidney transplantation. The results from the beginning of SPK transplant program in Comunidad Valenciana are presented. METHODS: Descriptive, retrospective, and single-center study of the pancreas transplant performed at the Hospital Universitari i Politècnic La Fe, from September 2002 to December 2015. Clinical variables from donors and recipients, peri-operative variables, patient survival, and pancreatic graft survival were collected. RESULTS: Eighty-one patients with type 1 diabetes mellitus (48 males and 33 females, mean age 37.4±5.7 years, mean BMI 24.1±3.4kg/m2, mean duration of diabetes 25.5±6.5 years) received SPK transplantation. The overall patient survival at one, 3, and 5 years were 91,3, 91,3 and 89,5%, respectively. However, patient survival in the periods 2002-2008 and 2009-2015 were 88.2 and 93.6% at one year, 88.2 and 93.7% at 3 years, and 85.3 and 93.7% at 5 years, respectively (P=1). The overall pancreatic graft survival at one, 3, and 5 years were 75.2, 69.1 and 63.2%, respectively. On the other hand, pancreatic graft survival in the periods 2002-2008 and 2009-2015 were 67.5 and 80.6% at one year, 64.7 and 71.8% at 3 years, and 58.8% and 65.3% at 5 years, respectively (P=.0109). Postransplant complications were: graft rejection 8.6%, venous graft thrombosis 7.4%, graft pancreatitis 4.9%. CONCLUSIONS: In 13-year's experience of SPK transplantation, patient and pancreatic graft survival and the rate of complications after pancreas transplantation were similar to those of other larger series. The medical-surgical team experience improves pancreatic graft survival without influencing patient survival.

Simultaneous Pancreas Kidney Transplantation Improves Cardiovascular Autonomic Neuropathy with Improved Valsalva Ratio as the Most Precocious Test.

BACKGROUND: Simultaneous pancreas-kidney (SPK) transplantation is a proven option of treatment for patients with type 1 diabetes mellitus (T1DM) and related end-stage renal disease. There is discrepancy between the results of different studies about the impact of prolonged normalization of glucose metabolism achieved by SPK on the course of diabetic complications including severe forms of diabetic neuropathy. The objective of the study was to evaluate the prevalence of cardiovascular autonomic neuropathy (CAN) in patients undergoing SPK transplantation and its evolution 10 years after transplantation. METHODS: Prospective study of 81 patients transplanted in a single center from year 2002 to 2015. Autonomic function was assessed using cardiovascular autonomic reflex tests (CARTs). CARTs were made before SPK transplantation and during the follow-up. Evolution of tests after SPK transplantation was evaluated by contrasting hypotheses (paired tests). Multiple testing was adjusted with the Benjamini-Hochberg procedure with a false discovery rate of 10%. RESULTS: 48 males and 33 females, mean age 37.4 ± 5.7 years, mean BMI 24.0 ± 3.4 kg/m2, and mean duration of diabetes 25.5 ± 6.5 years, received SPK transplantation. Ten years after SPK transplantation, 56 patients re tained the pancreatic graft (42 of them with normofunctioning pancreas and 14 with low doses of insulin therapy). These 42 patients were selected for the autonomic study. Before transplant procedure, all CART results were abnormal. After SPK transplantation, paired test analysis showed an improvement of systolic blood pressure (SBP) response to orthostasis at the 5th year after SPK (p = 0.03), as well as improvement of the Valsalva ratio at the 3rd (p < 0.001) and 5th (p = 0.001) year after SPK. After correcting for the false discovery rate, all the variables of autonomic study reached significance at different time points. CONCLUSIONS: Prevalence of CAN in patients who are candidates for SPK transplantation is high and is generally advanced. SPK transplantation improves CAN with improved Valsalva ratio as the most precocious test.

Autoimmune Diabetes Recurrence After Pancreas Transplantation: Diagnosis, Management, and Literature Review.

BACKGROUND Pancreas transplantation can be a viable treatment option for patients with type 1 diabetes mellitus (T1DM), especially for those who are candidates for kidney transplantation. T1DM may rarely recur after pancreas transplantation, causing the loss of pancreatic graft. The aim of this study was to describe the prevalence of T1DM recurrence after pancreas transplantation in our series. MATERIAL AND METHODS Eighty-one patients transplanted from 2002 to 2015 were included. Autoantibody testing (GADA and IA-2) was performed before pancreas transplantation and during the follow-up. RESULTS The series includes 48 males and 33 females, mean age 37.4±5.7 years and mean duration of diabetes 25.5±6.5 years. Patients received simultaneous pancreas kidney (SPK) transplantation. After SPK transplantation, 56 patients retained pancreatic graft, 8 patients died, and 17 patients lost their pancreatic graft. T1DM recurrence occurred in 2 of the 81 transplanted patients, yielding a prevalence of 2.5%, with an average time of appearance of 3.3 years after transplant. Pancreatic enzymes were normal in the 2 patients, ruling out pancreatic rejection. T1DM recurrence was confirmed histologically, showing selective lymphoid infiltration of the pancreatic islets. CONCLUSIONS T1DM recurrence after pancreas transplantation is infrequent; however, it is one of the causes of pancreatic graft loss that should always be ruled out. Negative autoimmunity prior to transplantation does not ensure that T1DM does not recur.

Driving Type 2 Diabetes Risk Scores into Clinical Practice: Performance Analysis in Hospital Settings.

Electronic health records and computational modelling have paved the way for the development of Type 2 Diabetes risk scores to identify subjects at high risk. Unfortunately, few risk scores have been externally validated, and their performance can be compromised when routine clinical data is used. The aim of this study was to assess the performance of well-established risk scores for Type 2 Diabetes using routinely collected clinical data and to quantify their impact on the decision making process of endocrinologists. We tested six risk models that have been validated in external cohorts, as opposed to model development, on electronic health records collected from 2008-2015 from a population of 10,730 subjects. Unavailable or missing data in electronic health records was imputed using an existing validated Bayesian Network. Risk scores were assessed on the basis of statistical performance to differentiate between subjects who developed diabetes and those who did not. Eight endocrinologists provided clinical recommendations based on the risk score output. Due to inaccuracies and discrepancies regarding the exact date of Type 2 Diabetes onset, 76 subjects from the initial population were eligible for the study. Risk scores were useful for identifying subjects who developed diabetes (Framingham risk score yielded a c-statistic of 85%), however, our findings suggest that electronic health records are not prepared to massively use this type of risk scores. Use of a Bayesian Network was key for completion of the risk estimation and did not affect the risk score calculation (p > 0.05). Risk score estimation did not have a significant effect on the clinical recommendation except for starting pharmacological treatment (p = 0.004) and dietary counselling (p = 0.039). Despite their potential use, electronic health records should be carefully analyzed before the massive use of Type 2 Diabetes risk scores for the identification of high-risk subjects, and subsequent targeting of preventive actions.

Integration of Distributed Services and Hybrid Models Based on Process Choreography to Predict and Detect Type 2 Diabetes.

Life expectancy is increasing and, so, the years that patients have to live with chronic diseases and co-morbidities. Type 2 diabetes is one of the most prevalent chronic diseases, specifically linked to being overweight and ages over sixty. Recent studies have demonstrated the effectiveness of new strategies to delay and even prevent the onset of type 2 diabetes by a combination of active and healthy lifestyle on cohorts of mid to high risk subjects. Prospective research has been driven on large groups of the population to build risk scores that aim to obtain a rule for the classification of patients according to the odds for developing the disease. Currently, there are more than two hundred models and risk scores for doing this, but a few have been properly evaluated in external groups and integrated into a clinical application for decision support. In this paper, we present a novel system architecture based on service choreography and hybrid modeling, which enables a distributed integration of clinical databases, statistical and mathematical engines and web interfaces to be deployed in a clinical setting. The system was assessed during an eight-week continuous period with eight endocrinologists of a hospital who evaluated up to 8080 patients with seven different type 2 diabetes risk models implemented in two mathematical engines. Throughput was assessed as a matter of technical key performance indicators, confirming the reliability and efficiency of the proposed architecture to integrate hybrid artificial intelligence tools into daily clinical routine to identify high risk subjects.

Insuficiencia suprarrenal inducida por acetato de megestrol: a propósito de 2 casos / Adrenal insufficiency induced by megestrol acetate: Report of two cases

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Hipertiroidismo inducido por yodo tópico / Hyperthyroidism induced by topical iodine

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