Estimation of glucose rate of appearance in portal vein circulation using a phenomenological-based model.

The joint work of the stomach and the small intestine plays a fundamental role in human digestion. In the stomach, food is turned into a semi-fluid mixture that is slowly released into the small intestine, where most enzymatic reactions occur, and nutrients are absorbed as they become available. This whole process is closely related to glucose homeostasis, mainly because of the appearance of glucose in the portal system and the energetic expenditure of the process itself. The current phenomenological-based model describes such effects of the digestive process on blood glucose concentration. It considers enzymatic and mechanical transformations, energetic expenditure, and the impact of macro-nutrients, fiber, and water on overall digestion and glucose absorption. The model estimates the rate of glucose appearance in the portal vein and is intended to be further integrated into existing models for other human organs and used in model-based systems such as an artificial pancreas with automated insulin delivery.

Use of the Vitiligo Extent Score: a protocol for a scoping review.

INTRODUCTION: Vitiligo is a chronic skin condition with no cure. Clinical assessment and treatment evaluation relies heavily on clinometry tools and expert knowledge. The Vitiligo Extent Score has been proposed as one of the most reliable and easy-to-use clinometry tools for vitiligo. METHODS AND ANALYSIS: We proposed a scoping review to identify all the available evidence on the clinical research availability around the Vitiligo Extent Score. The following databases will be searched: MEDLINE (PubMed), Embase, Open Grey, Lens and Directory of Open Access Journals. In addition, the approach proposed in the Joanna Briggs Institute Reviewer's Manual will be followed. Finally, this review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. ETHICS AND DISSEMINATION: Ethics approval for this review is not required. We intend to publish the results in a specialised peer-reviewed journal and local, national and international conference presentations. It will also be incorporated as educational material in our institution's postgraduate programme in dermatology.

Insulinoma-related Endogenous Hypoglycaemia with a Negative Fasting Test: A Case Report and Literature Review.

We present the case of a patient with a history of symptomatic hypoglycaemic episodes and a negative 72-hour fasting test with histological confirmation of insulinoma. A literature review of hyperinsulinaemic hypoglycaemia with a negative fasting test was performed. LEARNING POINTS: The 72-hour fasting test is the gold standard for insulinoma diagnosis.Few cases of insulinoma with a negative fasting test have been reported.New strategies for insulinoma diagnosis are being investigated.

Accuracy of an Off-Label Transmitter and Data Manager Paired With an Intermittent Scanned Continuous Glucose Monitor in Adults With Type 1 Diabetes.

BACKGROUND: This work evaluates the accuracy and agreement between the FreeStyle Libre sensor (FSL) and an off-label converted real-time continuous glucose monitor (c-rtCGM) device consisting of the MiaoMiao transmitter and the xDrip+ application which can be coupled to the FSL. METHODS: Four weeks of glucose data were collected from 21 participants with type 1 diabetes using the c-rtCGM and FSL: two weeks with a single initial calibration (uncalibrated) and two weeks with a daily calibration (calibrated). Accuracy and agreement evaluation included mean absolute relative difference (MARD), the %20/20 rule, Bland-Altman plots, and the Consensus Error Grid analysis. RESULTS: Values reported by the c-rtCGM system compared with the FSL resulted in an overall MARD of 12.06% and 84.71% of the results falling within Consensus Error Grid Zone A when the device is calibrated. For uncalibrated devices, an overall MARD of 17.49% was obtained. Decreased accuracy was shown in the hypoglycemic range and for rates of change greater than 2 mg/dL/min. The between-device bias also incremented with increasing glucose values. CONCLUSION: Measurements recorded by the c-rtCGM were found to be accurate when compared with FSL data only when performing daily c-rtCGM device calibrations. High drops in accuracy and agreement between devices occurred when the c-rtCGM was not calibrated.

Short-Term Effectiveness and Reduction in Insulin Requirements in Patients With Type 2 Diabetes Treated With IdegLira in a Real-World Setting.

Background: Type 2 diabetes mellitus (T2DM) is a chronic, highly prevalent disease with a significant impact on health. Appropriate treatment requires effective and timely escalation to achieve metabolic control. To evaluate the effectiveness and safety of IDegLira on adults with T2DM previously treated with oral antidiabetics and/or insulin in a real-life setting. Methods: An observational study in a real-world setting was conducted. Patients were selected from the outpatient clinic of two centers dedicated to specialized diabetes care. Main outcomes were HbA1c, body weight, insulin dose changes, hypoglycemia, and other adverse events. Results: 67 T2DM patients treated with IDegLira were monitored between 3 and 7 months. At the end of foll ow-up, the median change in HbA1c was -1.05% (CI95% -1.45, -0.65), and a decrease in insulin requirement was also observed (mean difference -10 TDD units (CI95% - 17 to -2.5). No treatment discontinuation was reported, hypoglycemia events were reported in 3 patients at the end of follow-up versus 8 patients at baseline. Conclusions: This real-life study shows the effectiveness in glycemic control of IDegLira use in T2DM patients who do not achieve goals with other therapies, with an adequate safety profile. The findings need to be confirmed with evaluation of therapeutic results in larger cohorts.

Efficacy and safety of carbohydrate counting versus other forms of dietary advice in patients with type 1 diabetes mellitus: a systematic review and meta-analysis of randomised clinical trials.

BACKGROUND AND AIMS: Diabetes mellitus (DM) is one of the most prevalent chronic noncommunicable diseases globally, and the only way to reduce its complications is good glycaemic control. Insulin remains the only approved treatment for type 1 DM (T1DM) and is used by many with type 2 DM (T2DM). Carbohydrate counting is considered the ideal way to calculate meal-related insulin doses as it allows greater flexibility in diet and could, in some people, reduce the burden of the disease. The primary objective of this systematic review was to assess carbohydrate counting efficacy in reducing glycated haemoglobin (HbA1c ) levels and safety by not increasing hypoglycaemia risk, inducing an increase in body weight or blood lipids, or reducing the quality of life of people with T1DM. METHODS: We included randomised controlled clinical trials with a parallel-group design comparing any carbohydrate counting forms with standard care or other forms of dietary advice or insulin dose calculation in people with T1DM with a follow up period of at least 3 months and with no restrictions in language, age or settings. As a primary outcome, we consider the change of HbA1c levels within at least 3 months. Secondary outcomes were hypoglycaemia events, body weight changes, blood lipids levels, and the total daily insulin dose. We also evaluated health-related quality-of-life changes and questionnaires on satisfaction with treatment of diabetes. RESULTS: Data from 11 studies with 899 patients were retrieved with a mean follow-up of 52 ± 35.5 weeks. Carbohydrate counting is not better in reducing HbA1c levels (SMD-0.24%, 95% CI -0.68 to 0.21) than all dietary advice forms. However, this finding was highly heterogeneous. We identified three studies that account for most of the heterogeneity using clustering algorithms. A second analysis excluding these studies shows a meaningful reduction in HbA1c levels (SMD-0.52%, 95% CI -0.82 to -0.23) with low heterogeneity. In the subgroup analysis, carbohydrate counting significantly reduces HbA1c levels compared with usual diabetes education. Carbohydrate counting does not relate to any substantial change in blood lipids, body weight, hypoglycaemia risk or daily insulin dose. Finally, we analysed the effect of trial duration on reduction in HbA1c levels and found no significant change related to time. CONCLUSIONS: Carbohydrate counting is an efficacious technique to safely reduce the levels of HbA1c in adults and children compared with standard diabetes education, and its effect does not appear to change with prolonged time. Standardisation in reporting important outcomes such as hypoglycaemia and quality of life are vital to produce comparable evidence in carbohydrate counting clinical trials. This systematic review was registered in PROSPERO under code: CRD42020218499.

Main glucose hepatic fluxes in healthy subjects predicted from a phenomenological-based model.

BACKGROUND: The liver has a unique role in blood glucose regulation in postprandial, postabsorptive, and fasting states. In the context of diabetes technology, current maximal models of glucose homeostasis lack a proper dynamical description of main glucose-related fluxes acting over and from the liver, providing a rather simplistic estimation of key quantities as endogenous glucose production and insulin and glucagon clearance. METHODS: Using a three-phase well-established phenomenological-based semi-physical modeling (PBSM) methodology, we built a detailed physiological model of hepatic glucose metabolism, including glucose utilization, endogenous glucose production through gluconeogenesis and glycogenolysis, and insulin and glucagon clearance. Mean absolute errors (MAE) were used to assess the goodness of fit of the proposed model against the data from three different in-vivo experiments -two oral glucose tolerance tests (OGTT) and a mixed meal challenge following overnight fasting-in healthy subjects. RESULTS: Needing little parameter calibration, the proposed model predicts experimental systemic glucose mean ± std 5.4 ± 5.2, 7.5 ± 6.8, and 7.5 ± 7.5 mg/dL, in all three experiments. Low MAEs were also obtained for insulin and glucagon at the hepatic vein. CONCLUSIONS: The quantitative concordance of our model to the experimental data exhibits a potential for its use in the physiological study of glucose liver metabolism. The model structure and parameter interpretability allow the union with other semi-physical models for a better understanding of whole-body glucose homeostasis and its use in developing diabetes technology tools.

Tiroiditis subaguda y tirotoxicosis posterior a vacuna contra SARS-CoV-2: reporte de 2 casos / Subacute thyroiditis and thyrotoxicosis after SARS-CoV-2 vaccine: report of 2 cases

La enfermedad por coronavirus SARS-CoV-2 que surgió en el año 2019 (COVID-19), ha obligado al rápido desarrollo de vacunas para prevenir su propagación e intentar controlar la pandemia. Dentro de las vacunas desarrolladas, las primeras en ser aprobadas con una tecnología nueva en el campo de la vacunación, fueron las vacunas basadas en ARNm (ácido ribonucleico mensajero), que lograron tasas de efectividad cercanas al 95 % para la prevención de la enfermedad COVID-19 grave. Los eventos adversos comunes son reacciones locales leves, pero ha habido varios informes de pacientes que desarrollaron tiroiditis subaguda y disfunción tiroidea después de recibir la vacuna contra SARS-CoV-2. Este artículo presenta dos casos de tiroiditis subaguda poco después de recibir la vacuna contra COVID-19

The SARS-CoV-2 coronavirus disease which emerged in 2019 (COVID-19), has forced the rapid development of vaccines to prevent the spread of infection and attempt to control the pandemic. Among the vaccines developed, one of the first to be approved with a new technology in the field of vaccination, was the mRNA (messenger ribonucleic acid) vaccine, with rates of effectiveness close to 95% for the prevention of severe COVID-19 disease. Common adverse events are mild local reactions, but there have been some reports of patients developing sub-acute thyroiditis and thyroid dysfunction after receiving the SARS-CoV-2 vaccine. This article presents two case reports of subacute thyroiditis shortly after receiving the COVID-19 vaccine

Therapeutic plasmapheresis for the treatment of thyrotoxicosis: A retrospective multi-center study.

BACKGROUND AND AIMS: Thyroid storm and severe thyrotoxicosis remain among the most frequent endocrine emergencies, and first-line hyperthyroidism treatment is not always an option. Since the first report in 1970, plasmapheresis is a second-line treatment for severe or otherwise untreatable thyrotoxicosis when rapid euthyroidism is desired. METHODS: We present a retrospective study of the experience in treating thyrotoxicosis with plasmapheresis between 2012 and 2020 in two specialized centers in Colombia. We register the demographic and clinical characteristic and compare the thyroid hormones and other biochemical measurements before and after treatment. RESULTS: Data from 19 patients was obtained, 58% female with a median age of 35 years (IQR 23.5), and most of them with Graves' disease. The most frequent indication for plasmapheresis was thyroid storm. A median of 4 (IQR 2) sessions lead to a significant reduction in FT4 (P .0001) and TT3 (P < .0003) with a nonsignificant decrease in beta-blocker (P .7353) dose, no change in hepatic enzymes, and no adverse events. After plasmapheresis, thyroidectomy was performed in 10 patients. CONCLUSIONS: Plasmapheresis is an effective and safe treatment option for reducing circulating thyroid hormones in severe thyrotoxicosis when other forms of treatment are contraindicated or in case of urgent thyroid and non-thyroid surgery. It is limited by its cost and the need for highly specialized resources.

Diabetes mellitus y COVID-19: fisiopatología y propuesta de tratamiento para el control glucémico en el tiempo de la pandemia / Diabetes mellitus and COVID-19: pathophysiology and treatment proposal for glycemic control at the time of the pandemic

RESUMEN El coronavirus 2 del síndrome respiratorio agudo grave es el tercer betacoronavirus desde el año 2003 capaz de ocasionar una infección del tracto respiratorio inferior, llevando, en casos críticos, al síndrome de dificultad respiratoria aguda y la muerte. La edad avanzada, la hipertensión arterial y la diabetes mellitus son, entre otros, tres factores determinantes en los peores desenlaces clínicos. Múltiples mecanismos pueden explicar la mayor susceptibilidad de las personas diabéticas a las infecciones respiratorias. La hiperglucemia crónica altera tanto a la inmunidad humoral como al celular. Esta enfermedad predispone a la sobreexpresión de la proteína de la membrana celular que sirve como receptora del virus y a una respuesta inflamatoria exacerbada, aumentando el riesgo de una descompensación y de la aparición de crisis hiperglicémicas. Ante la ausencia de un tratamiento efectivo o de una vacuna, todos los esfuerzos deben hacerse para procurar un buen control metabólico de los pacientes con diabetes mellitus con y sin COVID-19. Por lo anterior, se plantean en este artículo de reflexión, diferentes propuestas para el tratamiento de la diabetes mellitus en la unidad de cuidados intensivos, sin descartar la forma ambulatoria, en donde la telemedicina y otras tecnologías permitirán acortar la distancia y mantener las medidas de aislamiento preventivo.

SUMMARY Severe acute respiratory syndrome coronavirus 2 is the third beta-coronavirus since 2003 capable of causing lower respiratory tract infection, leading to severe cases of acute respiratory distress syndrome and death. Advanced age, high blood pressure and diabetes mellitus are three predictors of worse clinical outcomes. Multiple mechanisms could explain the greater susceptibility of diabetic people to respiratory infections. Chronic hyperglycemia alters both humoral and cellular immunity. This disease predisposes to virus receptor overexpression and an exaggerated inflammatory response, increasing the risk of decompensation and hyperglycemic crises. In the absence of an effective vaccine or treatment for the virus, this vicious circle should be stopped with an emphasis on controlling glucose. This paper presents different proposals for the treatment of diabetes mellitus both on an outpatient basis where telemedicine and other technologies will make it possible to continue adequate ambulatory care to maintain preventive isolation measures up to care in the intensive care unit.

A phenomenological-based semi-physical model of the kidneys and its role in glucose metabolism.

The kidneys play an important role in glucose homeostasis in three ways: Via endogenous glucose production from non-carbohydrate precursors (e.g. glutamine, lactate, alanine, glycerol) during both postprandial and post-absorptive states; via glucose filtration and reabsorption by the glomerulus and proximal tubule, respectively; and via glucose utilization and the elimination of its excess in the urine when glucose levels exceed 180mg/dl. The renal release of glucose into the circulation occurs mainly in the renal cortex and results from the glucose phosphorylating capacity of those renal cells, meaning that, cells in the renal cortex can form glucose-6-phosphate. Considering glucose filtration and reabsorption, the kidneys filtrate and reabsorb all circulating glucose, rendering the urine virtually glucose-free in a healthy person. Finally, the kidneys take up glucose from the circulation for energetic self-supply. Besides their role in glucose metabolism, the kidneys are the major site of insulin clearance from the systemic circulation, removing approximately 50% of peripheral insulin. In this regard, insulin clearance by kidneys occurs by degradation in the proximal tubule after being filtered in the glomerulus. All the aforementioned mechanisms affect the glucose concentration levels in the blood, preventing the parametrization of a mathematical model for patients with diabetes mellitus, in the implementation of an artificial pancreas. Aiming for a complete physiological model of the glucose homeostasis, a physiological submodel of the kidneys is presented in a way not described in the literature so far. This submodel is a phenomenological-based semi-physical model with a basic structure rooted in the conservation law and for which the parameters are interpretable. The model's results coincide well with the available clinical data reported for kidney functions associated with glucose and insulin.

Enfermedad hepática grasa no alcohólica en personas no obesas: revisión narrativa de la literatura / Nonalcoholic fatty liver disease in non-obese individuals: narrative review of the literature

La enfermedad hepática grasa no alcohólica (EHGNA) es una condición altamente prevalente y usualmente relacionada con el sobrepeso y la obesidad, pero afecta al 10% de la población no obesa en el mundo, con tendencia al aumento. Mecanismos diferentes a los tradicionalmente relacionados con el exceso de grasa corporal, como algunos polimorfismos genéticos y la exposición a ciertos factores ambientales, se han asociado con el desarrollo de esta entidad. Comparados con individuos sanos, las personas con EHGNA tienen con mayor frecuencia desarreglos metabólicos, como resistencia a la insulina y síndrome metabólico. El curso de la enfermedad hepática pareciera ser más benigno en los individuos no obesos en comparación con las personas obesas, pero el riesgo de desarrollar enfermedades como la diabetes mellitus pareciera ser mayor. En Latinoamérica se ha reportado una de las prevalencias más altas de EHGNA, sin embargo, el fenómeno en personas no obesas se ha estudiado principalmente en Asia y los datos en poblaciones latinas son prácticamente inexistentes. El propósito con esta revisión narrativa es sintetizar la información disponible acerca de la EHGNA en personas no obesas, haciendo énfasis en la población latina.

Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent disease and usually related to overweight and obesity, but it affects 10% of the non-obese population in the world and the rates are increasing. Different mechanisms from those traditionally related to excess body fat, such as some genetic polymorphisms and exposure to certain environmental factors, have been associated with the development of this condition. Compared with healthy individuals, people with NAFLD have more frequent metabolic disorders such as insulin resistance and metabolic syndrome. The course of the liver disease appears to be more benign in non-obese individuals compared to obese people, but the risk of developing diseases such as diabetes mellitus appears to be higher. In Latin America, one of the highest prevalences of NAFLD has been reported, however, this condition in non-obese people has been studied mainly in Asia and data on Latin American populations are practically nonexistent. The purpose of this narrative review is to synthesize the information available about NAFLD in non-obese individuals, with an emphasis on the Latin American population.

Phenomenological-Based model of human stomach and its role in glucose metabolism.

The stomach is a segment of the gastrointestinal (GI) tract which receives food from the esophagus, mixes it, breaks it down, and then passes it on to the small intestine in smaller portions. In the stomach, the main secretory functions and digestion process begin. However, the most critical and important function of the stomach in digestive physiology is perhaps gastric motility. In this way, the functions of the stomach are mainly three: (i) the storage of large quantities of food to be further processed in the duodenum, and lower intestinal tract, (ii) the mixing of this food with gastric secretions to form a semi-fluid mixture, and (iii) to slow down the emptying of that semi-fluid mixture into the small intestine at a rate suitable for proper digestion and absorption. Regarding the motor activity, the stomach must consume glucose to generate the power necessary to carry out the digestion process. Although glucose consumption in the stomach is relatively low, it can affect the glucose concentration in the bloodstream. In order to know the variations in the glucose levels in the bloodstream during the stomach digestion, a Phenomenological Based Semi-physical Model (PBSM) of the role of the stomach in the glucose homeostasis is developed. The simulation of the stomach model is able to mimic physiological results without risking the life of the patient, in order to test the impact of diverse medicines and foods on glucose homeostasis. The model may then be integrated to existing models of glucose homeostasis to improve the simulation scenario with respect to the glucose appearance from a mixed meal. Our model allows the change of the macronutrient composition and rheological properties of the meal as well as the digestion particularities of every subject. In this way, the integrated model will be fitted to real patient physiology providing a better model to use in, for example, automated insulin delivery systems like the artificial pancreas (AP).

Characteristics of hyperglycemic crises in an adult population in a teaching hospital in Colombia.

BACKGROUND: Hyperglycemic crisis are the most serious forms of acute decompensation of diabetes mellitus and require urgent medical attention. The epidemiological data of these conditions in Latin America are scarce and in Colombia unknown, that is why we decided to describe the clinical characteristics and factors associated with the mortality of adults who presented with hyperglycemic crises in a teaching hospital in Colombia. MATERIALS AND METHODS: Retrospective cohort study of all episodes of hyperglycemic crisis treated in Pablo Tobón Uribe Hospital in a three-year period. RESULTS: The records of 2233 hospitalization episodes related to diabetes mellitus were review, the prevalence of hyperglycemic crises was 2%, half of the events were diabetic ketoacidosis and 57% of the events occurred in people with type 2 diabetes mellitus, 32% of the events were precipitated by an infection and 27% by and inadequate therapy. The average hospital length of stay was 14 ± 3 days and the mortality rate 2.27%. CONCLUSIONS: In a teaching hospital in Latin America hyperglycemic crises are common, with diabetic ketoacidosis being the most frequent, and in a significant number of cases may be preventable. The hospital length of stay in our population is longer than reported in the literature.

Hiperparatiroidismo primario / Primary hyperparathyroidism

Resumen: el hiperparatiroidismo primario es uno de los trastornos endocrinos más frecuentes, caracterizado por la producción no controlada de la paratohormona. Esta condición clínica puede ser completamente asintomática o mostrarse con manifestaciones que ponen en peligro la vida de quien la padece. La gran variedad en las formas de presentación y algunos errores frecuentes en la interpretación de los resultados de las pruebas disponibles para su diagnóstico hacen de esta alteración un reto para el médico. Un hiperparatiroidismo no diagnosticado, y en consecuencia no tratado, puede tener consecuencias nefastas para los pacientes como deterioro en la función renal, que puede llevar a requerir una terapia de reemplazo renal, osteoporosis, que se puede acompañar de fracturas por fragilidad y cambios neurocognitivos que pueden socavar la calidad de vida de las personas. Por lo anterior, es fundamental conocer y comprender este trastorno, así como reconocer e interpretar adecuadamente las ayudas diagnósticas para poder proponer un plan de tratamiento adecuado que, afortunadamente en la mayoría de los casos, lleva a la curación del trastorno. (AU)

Abstract: Primary hyperparathyroidism is one of the most frequent endocrine disorders characterized by uncontrolled production of parathyroid hormone. This clinical condition could be a completely asymptomatic disorder or one with manifestations that threaten the patient life. The great variety in clinical manifestations and misinterpretation of the diagnostic test make the primary hyperparathyroidism a real challenge for physicians. An undiagnosed and in consequence an untreated primary hyperparathyroidism could carry detrimental consequences for patients including impaired of renal function, which may lead to renal replacement therapy, osteoporosis, which may be accompanied with fragility fractures, and neurocognitive changes, that can disturb the quality of life of the individual. For this reason, it is fundamental to know and understand hyperparathyroidism, as well as properly recognize and interpret the diagnostic tools to be capable to propose an adequate treatment plan that fortunately in most cases leads to the cure of this disorder. (AU)

Experiencia clínica con infecciones causadas por Klebsiella pneumoniae productora de carbapenemasa, en una institución de enseñanza universitaria en Medellín, Colombia / Clinical experience with infections caused by carbapenemase-producing Klebsiella pneumoniae in a tertiary care teaching institution in Medellin, Colombia

Antecedentes: Las infecciones por Klebsiella pneumoniae productora de carbapenemasa (KPC) son un problema de salud pública mundial. Desde 2008 nuestra institución experimenta casos endémicos de infecciones por KPC posteriores a un brote cuyo caso índice fue un paciente de Israel admitido para trasplante hepático. Objetivo: Describir características clínicas y mortalidad en pacientes hospitalizados con infecciones nosocomiales por KPC. Métodos: Estudio observacional retrospectivo, descriptivo. Resultados: Un total de 52 pacientes fueron incluidos, la edad media fue 45,7 ± 27 años, 65,4% fueron hombres. Uso de inmunosupresores, cirugía gastrointestinal, hepatopatía crónica y trasplante de órgano sólido fueron las comorbilidades importantes. El 100% recibió antibióticos antes de la infección por KPC. Las principales infecciones fueron bacteriemia (30,7%), infección intraabdominal (23,1%) y neumonía (17,3%). El tratamiento fue dirigido por antibiograma en 50,7%. Tigeciclina fue administrada en el 51,9% y colistina en el 32,7%, ambas en terapia combinada con otros antibióticos. En el 15,4% se utilizó tigeciclina más colistina. La duración del tratamiento fue 15,7 ± 7,5 días. El 51,9% desarrolló bacteriemia y falla renal aguda y el 76,9% requirió atención en UCI. La mortalidad fue 48,1% y fue significativamente mayor en pacientes con bacteriemia vs. sin bacteriemia (74,1 vs. 20%; p = 0,01). No hubo diferencias significativas en mortalidad cuando se comparó uso de tigeciclina vs. colistina (45 vs. 52%; p = 0,609). Conclusión: La inmunosupresión, cirugía gastrointestinal, tratamiento previo con antibióticos y estancia en UCI son factores importantes para la infección por KPC. La mortalidad es alta a pesar de la terapia dirigida, especialmente en pacientes con bacteriemia.

Background: Carbapenemase-producing Klebsiella pneumoniae (KPC) infections are a worldwide public health problem. Since 2008, our institution has experienced endemic cases of KPC infection after an outbreak whose index case was a patient from Israel admitted for liver transplantation. Objective: To describe the clinical characteristics and mortality of inpatients with nosocomial KPC infections. Methods: Retrospective, descriptive observational study. Results: A total of 52 patients were included, with an average age of 45.7 ± 27 years; 65.4% were men. Use of immunosuppressants, gastrointestinal surgery, chronic liver disease and solid organ transplantation were significant comorbidities. All the patients had received antibiotics before the KPC infection. The primary infections were bacteraemia (30.7%), intra-abdominal infections (23.1%) and pneumonia (17.3%). Treatment was directed by antibiogram in 50.7% of cases. Tigecycline was administered in 51.9% of cases and colistin in 32.7%, both in combination therapy with other antibiotics. Colistin plus tigecycline was used in 15.4% of cases. The treatment duration was 15.7 ± 7.5 days, with 51.9% of patients developing bacteraemia and acute renal failure and 76.9% requiring ICU care. Mortality was 48.1% and was significantly higher in the patients with bacteraemia compared with those without (74.1 vs. 20%, respectively, p = 0.01). There were no significant differences in mortality between tigecycline and colistin use (45 vs. 52%, respectively, p = 0.609). Conclusion: Immunosuppression, gastrointestinal surgery, previous treatment with antibiotics and ICU stay are important factors for infection with KPC. Mortality is high despite targeted therapy, particularly in patients with bacteraemia.

Adrenal venous sampling in a patient with adrenal Cushing syndrome.

The primary bilateral macronodular adrenal hyperplasia or the independent adrenocorticotropic hormone bilateral nodular adrenal hyperplasia is a rare cause hypercortisolism, its diagnosis is challenging and there is no clear way to decide the best therapeutic approach. Adrenal venous sampling is commonly used to distinguish the source of hormonal production in patients with primary hyperaldosteronism. It could be a useful tool in this context because it might provide information to guide the treatment. We report the case of a patient with ACTH independent Cushing syndrome in whom the use of adrenal venous sampling with some modifications radically modified the treatment and allowed the diagnosis of a macronodular adrenal hyperplasia.

La hiperplasia macro nodular bilateral o hiperplasia adrenal nodular bilateral independiente de la hormona adrenocorticotrópica es una de las causas menos frecuentes de hipercortisolismo, su diagnóstico supone un reto y no se tiene claridad de cuál es la mejor aproximación terapéutica. El muestreo venoso adrenal que frecuentemente se utiliza para hacer la distinción del sitio de producción hormonal en el hiperaldosteronismo primario podría ser una herramienta útil en este contexto ya que podría brindar información que pudiera guiar el tratamiento. Presentamos el caso de una paciente con síndrome de Cushing ACTH independiente en quien el uso del muestreo venoso adrenal con algunas modificaciones cambio de manera radical el tratamiento y permitió confirmar una hiperplasia adrenal macro nodular.

Adrenal venous sampling in a patient with adrenal Cushing syndrome / Uso del muestreo venoso adrenal en un paciente con un síndrome de Cushing adrenal

The primary bilateral macronodular adrenal hyperplasia or the independent adrenocorticotropic hormone bilateral nodular adrenal hyperplasia is a rare cause hypercortisolism, its diagnosis is challenging and there is no clear way to decide the best therapeutic approach. Adrenal venous sampling is commonly used to distinguish the source of hormonal production in patients with primary hyperaldosteronism. It could be a useful tool in this context because it might provide information to guide the treatment. We report the case of a patient with ACTH independent Cushing syndrome in whom the use of adrenal venous sampling with some modifications radically modified the treatment and allowed the diagnosis of a macronodular adrenal hyperplasia.

La hiperplasia macro nodular bilateral o hiperplasia adrenal nodular bilateral independiente de la hormona adrenocorticotrópica es una de las causas menos frecuentes de hipercortisolismo, su diagnóstico supone un reto y no se tiene claridad de cuál es la mejor aproximación terapéutica. El muestreo venoso adrenal que frecuentemente se utiliza para hacer la distinción del sitio de producción hormonal en el hiperaldosteronismo primario podría ser una herramienta útil en este contexto ya que podría brindar información que pudiera guiar el tratamiento. Presentamos el caso de una paciente con síndrome de Cushing ACTH independiente en quien el uso del muestreo venoso adrenal con algunas modificaciones cambio de manera radical el tratamiento y permitió confirmar una hiperplasia adrenal macro nodular.

Características clínicas, factores de riesgo y perfil de susceptibilidad de las infecciones por micobacterias documentadas por cultivo, en un hospital universitario de alta complejidad en Medellín (Colombia) / Clinical features, risk factors and susceptibility profile of mycobacterial infections documented by culture in a university hospital of high complexity in Medellin (Colombia)

Introduction: Tuberculosis (TB) remains an entity of high prevalence and mortality worldwide. The rising drug resistance is a public health problem. Besides, non-tuberculosis mycobacterial (NTM) infections are described with increasing frequency in areas of high prevalence of TB. Objectives: To determine epidemiological, clinical and microbiological characteristics of mycobacterial infections documented by culture. Materials and Methods: An observational, descriptive study in hospitalized patients. Results: M. tuberculosis complex was identified in 90,9% of 187 patients; 9,1% had NTM, 64% were male and the mean age was 40 years (range 1-88 years). The main co-morbidities were HIV / AIDS (23.5%), use of corticosteroids (13.3%) and chronic kidney disease (9.6%). Clinical forms were pulmonary (56.6%), extra-pulmonary (23.9%) and disseminated (19.2 The most common extra-pulmonary compromise was nodal (7.4%) and gastrointestinal (7%). 10.6% of M. tuberculosis were multi-drugresistant (MDR) and 2.12% had extended drug resistance (XDR). Mycobacterium avium andM. abscessus were the most frequent NTM. Overall mortality was 10%. Conclusions: In our study immune suppression is the main risk factor for extrapulmonary and disseminated disease. Resistance, MDR and XDR is higher in inpatients with TB. MNT infections are not uncommon in our country.

Introducción: Tuberculosis (TBC) es aún una entidad de alta prevalencia y mortalidad en el mundo. La resistencia ascendente a fármacos es un problema de salud pública. Además se describen con mayor frecuencia infecciones por micobacterias no tuberculosas (MNT) en áreas de alta prevalencia de TBC. Objetivos: Determinar características epidemiológicas, clínicas y microbiológicas de las infecciones por micobacterias documentadas por cultivo. Materiales y Métodos: Estudio observacional, descriptivo, en pacientes hospitalizados. Resultados: De 187 pacientes, en 90,9% se identificó complejo M. tuberculosis y en 9,1% MNT; 64% fueron hombres. Edad promedio 40 años (rango 1-88 años). Las principales co-morbilidades fueron infección por VIH/SIDA (23,5%), uso de corticoesteroides (13,3%) y enfermedad renal crónica (9,6%). Las formas clínicas fueron pulmonares (56,6%), extra-pulmonares (23,9%) y diseminadas (19,2%). El compromiso extra-pulmonar más frecuente fue ganglionar (7,4%) y gastrointestinal (7%). En M. tuberculosis 10,6% fueron multidrogoresistentes (MDR) y 2,12% con resistencia extendida (XDR). Mycobacterium avium y M. abscessus fueron las MNT más frecuentes. La mortalidad general fue 10%. Conclusiones: Inmuno-supresión es el principal factor de riesgo para enfermedad extrapulmonar y/o diseminada y la resistencia a fármacos en pacientes hospitalizados con TBC es llamativa, con mayor incidencia de MDR y XDR. Las infecciones por MNT no son infrecuentes en nuestro medio.