Time to develop chronic kidney disease in an Ecuadorian Type 2 Diabetes Mellitus cohort: Survival analysis in primary care.

Chronic Kidney Disease (CKD) represents a high burden to health systems. However, the survival time for CKD in a Type 2 Diabetes Mellitus (T2DM) population is unknown. AIMS: Determine the risk factors, survival time and the incidence rate of CKD in T2DM. METHODS: Retrospective clinical cohort study (follow up 10 years). 513 patients with T2DM were included. Numerical variables were compared using the mean difference. Chi squared and odds ratios were calculated for categorical variables. Survival analysis was done through life tables and Kaplan-Meier. RESULTS: The mean difference between the group that developed CKD and those who did not, was significant in: age, age at diagnosis of T2DM and years with T2DM. Risk factors for developing CKD were: the presence of hypertension, albuminuria, retinopathy, high triglycerides and high HbA1c. The incidence rate was 32.07 per 1000 person-years of follow-up and 207 (40.4%) of patients developed CKD during the study. The median for developing CKD was 20.52 years of disease with an increasing risk with time. CONCLUSIONS: Half of the patients with T2DM will develop CKD by the second decade of disease. Time, arterial hypertension, retinopathy, albuminuria and triglycerides are factors associated with CKD in patients with T2DM.

Contextualizing Evidence for Action on Diabetes in Low-Resource Settings-Project CEAD Part-II, Strengthening the Health System: A Mixed-Methods Study Protocol.

Diabetes is a major public health problem, increasingly affecting low- and middle-income countries. The project CEAD (Contextualizing Evidence for Action in Diabetes in low-resource settings) aims to evaluate the implementation of comprehensive diabetes care in two low-resource settings in Ecuador and to stimulate context-led health systems innovations to improve diabetes care and reduce inequity. The mixed-methods approach includes a 24-month retrospective study to assess the current level of implementation of comprehensive diabetes care and participants will be followed up prospectively for two years to assess changes in healthcare and clinical outcomes from the outset of the research. We will include individuals diagnosed with type-2 diabetes aged over 18 years, who are accessing diabetes care in health facilities in the study districts. Varied stakeholders (patients and family members, community members, healthcare workers and decision-makers) will interpret the underlying causes of the observed weaknesses and propose solutions to strengthen diabetes-related healthcare in focus group discussions (FG). A second set of FG will analyze perceived improvements in healthcare based on prospective cohort findings and consider the success/failure of any context-led innovations occurring throughout the research. Our study will demonstrate how evidence can be contextualized to stimulate local innovations and overcome weaknesses of diabetes-related healthcare in low resource settings.

Peripheral Artery Disease in Type 2 Diabetes Mellitus: Survival Analysis of an Ecuadorian Population in Primary Care.

BACKGROUND: Peripheral artery disease (PAD) is associated with cardiovascular risk in type 2 diabetes mellitus (DM). The ankle-brachial index (ABI) is used for diagnosis of PAD. OBJECTIVES: Establish the prevalence and incidence rate for PAD and determine the associated factors and survival time for the development of PAD. METHODS: Retrospective cross-sectional cohort study (follow up: 10 years) in 578 DM patients with at least 1 ABI measurement in a primary level of care diabetes clinic. Data was collected from clinical records. Sociodemographic and laboratory variables were analyzed determining its association (mean difference and bivariate logistic regression). Survival was calculated through life tables and Kaplan-Meier analysis. RESULTS: The prevalence of PAD was 13.98%. The incidence rate through the time of follow up was 23.38 per 1000 person-year (95% CI: 19.91-27.26). The group that developed PAD showed higher glycated hemoglobin levels (P = .025), more years of DM (P < .001) and lower glomerular filtration rate (GFR, P = .003). The median time for developing PAD was 26.97 years (95% CI: 26.89-27.05). The risk for PAD was higher in females (95% CI: 1.51-4.38), GFR <60 mL/min/m2 (95% CI: 1.05-2.22) and use of metformin plus insulin (95% CI: 1.10-2.35). CONCLUSION: Half of a DM patient's population in primary level of care will develop PAD in the third decade of disease. There are identifiable risk factors for PAD development in DM in the primary level of care such as low GFR, female sex, and use of metformin plus insulin.

Evaluating the effectiveness of a support programme for people with type 2 diabetes mellitus in primary care: an observational prospective study in Ecuador.

BACKGROUND: The success of primary health care relies on the integration of empowered practitioners with cooperative patients regardless of socioeconomic status. Using resources efficiently would help to improve healthcare promotion and reduce complications of chronic non-communicable diseases (NCDs). The importance of network support programmes relies on the fact that they allow to accurately deliver medical care by shaping a sense of community and purpose among the patients. AIM: To evaluate the effectiveness of a network support programme for patients with type 2 diabetes mellitus (T2DM). DESIGN & SETTING: A centre-based observational prospective study took place in a primary care setting in Ecuador. METHOD: The impact of the diabetes care programme was assessed by comparing initial and final metabolic characteristics and outcomes of 593 patients with T2DM, followed-up from April 2007 to December 2017, using paired sample t-test. Electrocardiograms (ECGs), ankle-brachial indexes (ABIs), ocular fundus, and monofilament neuropathy tests were assessed with the McNemar test to evaluate complications at the beginning and end of the study. RESULTS: Glycated haemoglobin (HbA1c), lipid profile, and systolic blood pressure (SBP) showed statistically significant decreases between the initial measurement (IMs) and final measurements (FMs). In the FM, significantly lower HbA1c, diastolic blood pressure (DBP), and atherogenic index were found. Despite the length of time since diagnosis, during the follow-up time, long-term micro- and macro-vascular complications, such as ocular fundus, serum creatinine, and ABI, remained unchanged throughout the period of active participation in this healthcare programme. CONCLUSION: This study demonstrates the feasibility of reducing plasma glucose, plasma lipids, and long-term complications in patients with T2DM by implementing a network support programme, which involves the medical team and patients themselves in an environment with limited resources.

Contextualizing Evidence for Action on Diabetes in Low-Resource Settings-Project CEAD Part I: A Mixed-Methods Study Protocol.

Challenges remain for policy adoption and implementation to tackle the unprecedented and relentless increase in obesity, diabetes and other non-communicable diseases (NCDs), especially in low- and middle-income countries. The aim of this mixed-methods study is to analyse the contextual relevance and applicability to low-resource settings of a sample of evidence-based healthy public policies, using local knowledge, perceptions and pertinent epidemiological data. Firstly, we will identify and prioritise policies that have the potential to reduce the burden of diabetes in low-resource settings with a scoping review and modified Delphi method. In parallel, we will undertake two cross-sectional population surveys on diabetes risk and morbidity in two low-resource settings in Ecuador. Patients, community members, health workers and policy makers will analyse the contextual relevance and applicability of the policy actions and discuss their potential for the reduction in inequities in diabetes risk and morbidity in their population. This study tackles one of the greatest challenges in global health today: how to drive the implementation of population-wide preventative measures to fight NCDs in low resource settings. The findings will demonstrate how local knowledge, perceptions and pertinent epidemiological data can be used to analyse the contextual relevance and applicability of potential policy actions.

Which Factors may reduce the Health-Related Quality of Life of Ecuadorian Patients with Diabetes?

OBJECTIVE: To quantify the health-related quality of life (HRQoL) of patients with type 2 diabetes mellitus (DM) in Ecuador and to determine its association, or lack thereof, with demographic and clinical variables, particularly with the comorbidities and complications of DM. METHODS: This was an analytical cross-sectional study with 325 patients attending regular care at a primary health care center in Quito, Ecuador. HRQoL was measured using the EuroQol 5-dimension 3-level (EQ-5D-3L) questionnaire. The patients were screened for diabetic nephropathy, retinopathy, and peripheral artery disease (PAD). Clinical files were reviewed to obtain data regarding gender, age, time since diagnosis, type of treatment, glycemic control, and history (if any) of hypertension and/or dyslipidemia. Associations were verified using the Mann-Whitney U or Kruskal-Wallis test, and the confounding effects of the variables "age" and "gender" were controlled for using logistic regression analysis. RESULTS: The mean HRQoL for the population was 0.844 (±0.215) on the EQ-5D-3L index (EQ-Index) and 80.6 (±18.8) on the EQ visual analogue scale (EQ-VAS). The prevalence of DM complications was 1.8% for nephropathy, 14.8% for retinopathy, and 14.5% for PAD. Of the participating patients, 66.8% presented hypertension and 91.4%, dyslipidemia. Significant associations were found between lower scores on the EQ-Index and age (≥65 years) (0.84 vs. 0.87; p = 0.016), time since diagnosis (≥10 years) (0.81 vs. 0.87; p = 0.005), presence of hypertension (0.83 vs. 0.88; p = 0.017), and, after controlling for age and gender, presence of nephropathy. For the EQ-VAS, only time since diagnosis (≥10 years) was associated with a lower score (77.99 vs. 82.97; p = 0.043). CONCLUSION: Older age, longer disease duration, hypertension, and nephropathy are associated with having a lower HRQoL, in patients with type 2 DM in Quito, Ecuador.

Edema pulmonar de grandes alturas / Pulmonary edema of gradnes heights

Estudia tres caso clínicos con diagnóstico de Edema Agudo de Pulmón de Altura, en pacientes residentes en la ciudad andina de Quito, a una altitud de 2860m, con antecedentes de haber descendido a nivel del mar y de haber retornado a su ciudad de residencia, (ninguno tenía antecednetes de patología cardíaca previa), luego de lo cual, al poco tiempo, presentan un cuadro de Edema Agudo de Pulmón, los tres pacientes acudieron para tratamiento clínico oportuno y evolucionaron sin complicaciones hasta su recuperación completa. Se discute sobre la probable etiopatogenia y fisiopatogenia y se concluye con algunas recomendaciones profilácticas de esta patología.