Control glucémico intensivo y sobretratamiento en pacientes mayores de 60 años con diabetes mellitus / Intensive glycemic control and overtreatment in diabetic patients older than 60 years

Resumen ANTECEDENTES: existe incremento de la prevalência de diabetes mellitus 2 y del envejecimiento. Así, los riesgos asociados con control glucémico intensivo en esta población vulnerable se incrementan. Por ello, debe considerarse la posibilidad de un sobretratamiento en estos pacientes. OBJETIVO: determinar la prevalencia de control glucémico intensivo y sobretratamiento en pacientes con diabetes mellitus tipo 2 mayores de 60 años. MATERIAL Y MÉTODO: estudio retrospectivo, transversal, observacional y analítico. De 2013 a 2015 se evaluaron pacientes mayores de 60 años de edad con diabetes mellitus tipo 2, hemoglobina glucosilada (HbAlc) <7% y administración de hipoglucemiantes. Los pacientes se clasificaron en control glucémico intensivo (HbAlc 6.6-7%) y sobretratamiento (HbAlc <6.5%). Los porcentajes de ambos grupos y sus complicaciones cardiovasculares y no cardiovasculares asociadas se compararon utilizando una prueba Z. RESULTADOS: se incluyeron 13,229 pacientes con diabetes mellitus tipo 2 mayores de 60 años; en 2013, fueron 4,381, 16% (n=701) en control glucémico intensivo y 6% (n=256) en sobretratamiento; en 2014 fueron 4,383, 16% (n=697) en control glucémico intensivo y 6% (n=252) en sobretratamiento; en 2015 fueron 4,465, 16% (n=708) en control glucémico intensivo y 6% (n=260) con sobretratamiento. El control glucémico intensivo causó 5, 3 y 1% de complicaciones durante 2013, 2014 y 2015, respectivamente. En el grupo con sobretratamiento el porcentaje de complicaciones fue de 4% en 2013 y de 6% en 2015. Se obtuvo un valor Z de -2.90 (p<0.05), mostrando mayor número en sobretratamiento. CONCLUSIONES: de la población estudiada, 16% estaba en control glucémico intensivo y 6% en sobretratamiento, con incremento significativo de complicaciones en el grupo con sobretratamiento, la hipoglucemia fue la más frecuente.

Abstract BACKGROUND: Due to increasing prevalence of type 2 diabetes mellitus (T2DM) and the overall aging of the population, the number of elderly patients with T2DM is continuously growing. Given the risks associated with intensive glycemic control of those patients, the possibility of overtreatment must be considered. OBJECTIVE: To determine the prevalence of intensive glycemic control and overtreatment in individuals >60 years with T2DM. MATERIAL AND METHOD: An observational, cross-sectional, retrospective and analytical study was done from 2013 to 2015. Individuals >60 years old with T2DM, glycated hemoglobin (HbA1c) <7%, and use of hypoglycemic agents were included. Patients were divided into two groups: intensive glycemic control (HbA1c 6.6-7%) and overtreatment (HbA1c <6.5%). Cardiovascular and non-cardiovascular complications associated with treatment were compared by Z-test. RESULTS: There were included 13,229 patients older than 60 years with T2DM; 4,381 in 2013, 16% (n=701) was classified as intensive glycemic control and 6% (n=256) as overtreatment; 4,383 in 2014, 16% (n=697) as intensive glycemic control and 6% (n=252) as over-treatment; 4,465 in 2015, 16% (n=708) as intensive glycemic control and 6% (n=260) as overtreatment. By this period, adverse outcomes were reported in 5%, 3% and 1% during 2013, 2014 and 2015, respectively; referring to intensive glycemic control group. Likewise, adverse outcomes were reported in 4% and 6% during 2013 and 2015, respectively; referring to overtreatment group. A value of Z-test -2.90 (p<0.05) was obtained, which was increased in overtreatment group. CONCLUSIONS: All data collected during the study highlights a significant increase of cardiovascular and non-cardiovascular adverse outcomes in patients with strict glycemic management, being hypoglycemia the most frequent; 16% are in intensive glycemic control and 6% in overtreatment.

Causes for an Incomplete Donation Process at a Tertiary Care Hospital.

INTRODUCTION: This study aims to identify the causes for the incomplete donation process at a tertiary care hospital. MATERIALS AND METHODS: A descriptive, retrospective study was performed; all potential donors reported to the Transplant Service within the period of 2005 to 2014 were included. Descriptive statistics were used across frequencies and proportions for categorical variables, central tendency, and dispersion for continuous variables. RESULTS: The total number of deaths reported at the University Hospital (HU) was 8472, of which 815 (n = 815) were reported to COETRA ("Consejo Estatal de Trasplantes"). Among organ or tissue donors, the main known cause of death was head trauma (HT) in 26% (72). Cardiac arrest (CA) as cause of death provided the largest number of donations (141, 57%); of these, 102 (41%) were male and 39 (16%) were female. In comparison, brain death (BD) provided 104 (43%); of these, 65 (27%) were male, and 39 (16%) were female. The age interval was with a higher donation rate was 45 to 49 y (BD 18, CA 22). Donation request was not performed in 359 patients because of medical contraindication 60% (215), rapid deterioration 18% (64), and incomplete donation process 8% (27). Of 452 organ requests, 207 were not accomplished, because of body integrity 28% (57), family disagreement 20% (42), and no acceptance of BE 13% (26). CONCLUSIONS: Opportunity areas: (1) Ensure the notification of all deaths to Transplant Department for identification of potential donors; (2) Reduce rapid deterioration and raise number of completed donation protocols; (3) Increase the donation rate.

Estrategias nutricionales ante el estreñimiento y la deshidratación en las personas mayores / Nutritional strategies towards constipation and dehydration in older people

El estreñimiento puede ser definido por defecación infrecuente y esfuerzo defecatorio excesivo. Las causas más habituales son la deshidratación, la dieta pobre en fibra, el consumo de determinados fármacos y las enfermedades debilitantes, circunstancias especialmente frecuentes en la edad geriátrica. El estreñimiento en anciano puede asociarse a complicaciones derivadas de la impactación fecal y otras derivadas del excesivo esfuerzo para conseguir la defecación. Para que se produzca deshidratación, virtualmente en todos los casos, debe existir una alteración en la percepción de la sed o en la capacidad de ingerir agua. Cuando el déficit de agua supera al de sodio el paciente desarrolla un síndrome clínico de hipernatremia/hiperosmolaridad que siempre está asociada a un aumento de la osmolaridad plasmática efectiva y, por tanto, con una disminución del volumen intracelular. Las causas desencadenantes en el anciano son la infección, el uso excesivo de diuréticos, el ictus, tratamiento con corticoides, situación de postoperatorio, la suspensión de un tratamiento antidiabético o la diabetes insípida. El tratamiento de rehidratación debe realizarse preferiblemente por vía oral y de forma lenta para evitar el daño neurológico. La corrección debe incluir agua y electrolitos (sales de sodio y potasio) y obliga a un cálculo preciso del aporte, sobre todo cuando está alterado el estado de conciencia y precisamos de tratamiento intravenoso, para evitar la sobrehidratación y las alteraciones electrolíticas. El tratamiento del estreñimiento incluye, además de la rehidratación, la educación del paciente en un patrón horario, postural y de ejercicio físico para reforzar la prensa abdominal. Un cambio en los hábitos alimentarios para aumentar el contenido en fibra alimentaria en la dieta aumenta el tamaño del bolo fecal, mejora la consistencia de las heces y disminuye las molestias abdominales. Así mismo, el uso de prebióticos, complementado con fibra fermentable, logra aumentar la masa fecal. Los alimentos de uso común ricos en fibra son el salvado de trigo, legumbres, harinas integrales, frutas y verduras. Las recomendaciones sobre el consumo de fibra son de 10 a 13 g/1.000 kcal siendo el 70-75% de fibra insoluble y un 25-30% de fibra soluble. El uso juicioso de fármacos con efecto laxante tiene un papel en el tratamiento del estreñimiento cuando éste no responde a las medidas higiénico-dietéticas. Existen cuatro grupos farmacológicos de uso habitual: laxantes con efecto osmótico, estimulantes del peristaltismo, emolientes y aumentadores del bolo fecal con distintas indicaciones. En el paciente de edad avanzada, podemos iniciar el tratamiento con lactulosa o lactitiol o recurrir directamente a fármacos estimulantes como bisacodilo, picosulfato sódico o senósidos. Los azúcares osmóticos serán los laxantes recomendados para el uso crónico. Debemos usar con precaución los laxantes estimuladores del peristaltismo, ya que la secreción de agua y electrolitos a la luz intestinal es responsable de episodios de hipotensión ortostática que pueden ocasionar caídas en el paciente anciano (AU)

Constipation can be defined as infrequent defecation and straining at stool. The most common causes are dehydration, low-fiber diet, use of certain drugs and debilitating disease, particularly common conditions in geriatric patients. Constipation in the elderly may be associated with fecal impaction and other complications deriving from excessive straining to pass stools. Dehydration occurs, in virtually all cases, with an alteration in the perception of thirst or water intake capacity. When the water deficit exceeds that of sodium, the patient develops clinical signs and symptoms of hypernatremia/hyperosmolality, always associated with an increase in effective plasma osmolality and consequent decrease in intracellular volume. Precipitating causes in the elderly are infection, excessive use of diuretics, stroke, treatment with corticosteroids, postoperative status, suspension of antidiabetic drugs or diabetes insipidus. Rehydration should preferably be oral and done slowly to prevent neurological damage. Treatment should include water and electrolytes (sodium and potassium salts) and requires accurate calculation of input to prevent overload and electrolyte imbalance, especially in the case of altered consciousness with the patient needing intravenous therapy. In addition to rehydration, the treatment of constipation includes educating the patient about bowel training to establish a regular pattern, posture and physical exercise to strengthen the muscles in the abdominal wall. A change in eating habits to increase dietary fiber content increases the size of the feces, improves stool consistency and reduces abdominal discomfort. Likewise, the use of prebiotics, supplemented with fermentable fiber, helps increase fecal mass. Commonly-used foods rich in fiber are wheat bran, beans, whole flour, fruit and vegetables. Recommended fiber intake is 10 to 13 g/1,000 kcal with 70-75% insoluble fiber and 25-30% soluble fiber. Judicious use of laxative drugs does have a role in the treatment of constipation if patients do not respond to the toileting / dietary measures. There are four commonly used drug classes: osmotic laxatives, peristalsis stimulants, emollients and fecal enhancers, with different indications. In the older patient, we can begin treatment with lactulose or lactitiol or go directly to stimulant drugs such as bisacodyl, cassia extracts or sodium picosulfate. Sugar osmotic laxatives are recommended for long-term use. Stimulating peristalsis laxatives have to be used with caution since secretion of water and electrolytes into the intestinal lumen can be responsible for orthostatic hypotension, causing falls in the elderly (AU)

[Pheochromocytoma: more than a decade of experience. Review of the literature]. / Feocromocitoma: más de una década de experiencia. Revisión de la literatura.

OBJECTIVES: We present 18 patients with pheochromocytoma in the past 12 years. MATERIAL AND METHODS: It is a retrospective observational study evaluating the clinical, biochemical and pathological most important. RESULTS: The mean age was 53.5 years with male predominance and monitoring of five years, being the most frequent incidental findings (29%). Four patients had a familial syndrome hereditary. The tumors were equally distributed with a bilateral case. For the clinical study was made and plasma catecholamines and metanephrines in urine for 24h and subjected to control blood pressure before surgery and beta blockers. Until the introduction of laparoscopic surgery in our department in 2003, the treatment of choice was open surgery. Transabdominal subcostal access was more frequent (47%) and average duration of 207 min. No patients showed metachronous tumors and two patients developed distant metastases to death in short time. CONCLUSIONS: Pheochromocytoma in a threatening disease by cardiovascular disease, which needs to perform an analytical and functional. Surgical treatment, by open or laparoscopic surgery, depending on the characteristics of the tumor and the patient, is satisfactory and comparable results.

Feocromocitoma: más de una década de experiencia. Revisión de la literatura / Pheochromocytoma: More than a decade of experience. Review of the literature

Objetivos: Presentamos 18 pacientes diagnosticados de feocromocitoma en los últimos 12 años. Material y métodos: Es un estudio retrospectivo observacional valorando los aspectos clínicos, analíticos y patológicos más importantes. Resultados: La edad media fue de 53,5 años con predominio masculino y un seguimiento de 5 años; siendo la consulta más frecuente el hallazgo incidental (29%). Cuatro pacientes padecían un síndrome familiar hereditario. Los tumores se distribuyeron por igual con un caso bilateral. Para el estudio clínico se solicitaron catecolaminas y metanefrinas plasmáticas y en orina de 24h, siendo sometidos a control de la tensión arterial antes de la cirugía con alfabloqueantes y betabloqueantes. Hasta la introducción de la cirugía laparoscópica en nuestro servicio en el 2003, el tratamiento de elección era la cirugía abierta. El acceso transabdominal subcostal fue el más utilizado (47%) y la duración media de 207min.Ninguno presentó tumores metacrónicos y dos pacientes desarrollaron metástasis a distancia con fallecimiento en corto espacio de tiempo. Conclusiones: El feocromocitoma en una enfermedad amenazante por su morbilidad cardiovascular, que precisa realizar un estudio analítico y funcional. El tratamiento quirúrgico, por vía abierta o laparoscópica, dependiendo de las características del tumor y del paciente, tiene resultados satisfactorios y comparables (AU)

Objectives: We present 18 patients with pheochromocytoma in the past 12 years. Material and methods: It is a retrospective observational study evaluating the clinical, biochemical and pathological most important. Results: The mean age was 53.5 years with male predominance and monitoring of five years, being the most frequent incidental findings (29%). Four patients had a familial syndrome hereditary. The tumors were equally distributed with a bilateral case. For the clinical study was made and plasma catecholamines and metanephrines in urine for 24h and subjected to control blood pressure before surgery and beta blockers. Until the introduction of laparoscopic surgery in our department in 2003, the treatment of choice was open surgery. Transabdominal subcostal access was more frequent (47%) and average duration of 207min.No patients showed metachronous tumors and two patients developed distant metastases to death in short time. Conclusions: Pheochromocytoma in a threatening disease by cardiovascular disease, which needs to perform an analytical and functional. Surgical treatment, by open or laparoscopic surgery, depending on the characteristics of the tumor and the patient, is satisfactory and comparable results (AU)

Severe hypocalcemia secondary to hypomagnesaemia, successfully treated by self-administered subcutaneous magnesium.

We report the case of a patient with recurrent severe hypocalcemia, secondary to hypomagnesaemia, and prerenal renal failure, due to ileostomy losses after a colectomy, who needed several admissions to the hospital through more than one year. Finally, he was successfully treated by self-administered subcutaneous magnesium: he reached and maintained normal levels of serum calcium, magnesium and PTH, no more hospital admission were needed and he resumed a normal life.

Mitochondrial and microsatellite DNA markers reveal a Balkan origin for the highly invasive horse-chestnut leaf miner Cameraria ohridella (Lepidoptera, Gracillariidae).

Biological invasions usually start with a small number of founder individuals. These founders are likely to represent a small fraction of the total genetic diversity found in the source population. Our study set out to trace genetically the geographical origin of the horse-chestnut leafminer, Cameraria ohridella, an invasive microlepidopteran whose area of origin is still unkown. Since its discovery in Macedonia 25 years ago, this insect has experienced an explosive westward range expansion, progressively colonizing all of Central and Western Europe. We used cytochrome oxidase I sequences (DNA barcode fragment) and a set of six polymorphic microsatellites to assess the genetic variability of C. ohridella populations, and to test the hypothesis that C. ohridella derives from the southern Balkans (Albania, Macedonia and Greece). Analysis of mtDNA of 486 individuals from 88 localities allowed us to identify 25 geographically structured haplotypes. In addition, 480 individuals from 16 populations from Europe and the southern Balkans were genotyped for 6 polymorphic microsatellite loci. High haplotype diversity and low measures of nucleotide diversities including a significantly negative Tajima's D indicate that C. ohridella has experienced rapid population expansion during its dispersal across Europe. Both mtDNA and microsatellites show a reduction in genetic diversity of C. ohridella populations sampled from artificial habitats (e.g. planted trees in public parks, gardens, along roads in urban or sub-urban areas) across Europe compared with C. ohridella sampled in natural stands of horse-chestnuts in the southern Balkans. These findings suggest that European populations of C. ohridella may indeed derive from the southern Balkans.

Severe hypocalcemia secondary to hypomagnesaemia, successfully treated by self-administered subcutaneous magnesium / Hipocalcemia severa, secundaria a hipomagnesemia, tratada con éxito mediante auto-administración subcutánea de magnesio

We report the case of a patient with recurrent severe hypocalcemia, secondary to hypomagnesaemia, and prerenal renal failure, due to ileostomy losses after a colectomy, who needed several admissions to the hospital through more than one year. Finally, he was successfully treated by self-administered subcutaneous magnesium: he reached and maintained normal levels of serum calcium, magnesium and PTH, no more hospital admission were needed and he resumed a normal life (AU)

Se trata de un paciente con hipocalcemia severa recurrente, secundaria a hipomagensemia, y fracaso renal agudo prerrenal secundario a perdidas digestivas a través de una ileostomía, tras una colectomía. Por este motivo necesitó varios ingresos hospitalarios a lo largo de más de un año. Finalmente fue tratado con éxito mediante autoadministración subcutánea de magnesio. Con este tratamiento mantuvo niveles normales de calcio, magnesio y PTH, no requirió más ingresos hospitalarios y recuperó una vida normal (AU)

Hipercalcemia secundaria a carcinoma paratiroideo / Hypercalcemia secondary to paratyrhoid carcinoma

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[Motility of the colon: electric and manometric description of the mass movement]. / Motilidad del colon: descripción eléctrica y manométrica del movimiento de masa.

"Mass movement" was described at the beginning of the century by radiologists, who occasionally observed during exploration a sudden transport of barium from one section of the colon to another. In this paper we focused our attention on the electromechanical factors that accompany evacuation through a colostomy, since we thought that these would be the myoelectrical and pressure translation of the "mass phenomenon" described by radiologists. We used an electromyographic recording probe to which a conventional microtransducer probe was affixed by suction. Using this method we made 24-hour recordings in 8 patients with sigmoid colostomy. We observed five large evacuations. When the electrical and pressure phenomena that occurred a few minutes before evacuation were analyzed, two clearly differentiated phases were apparent. The first, which we called the "previous phenomenon", consisted of a succession of contractions and spike potentials over a mean period of 5.6 min. (sigma = 2.22), after which a "large contraction" appeared, with a mean pressure value of 127 mmHg (sigma = 38.77) and a mean electrical value of 10.6 mv. The mean duration of this phenomenon was 24.93 sec (sigma = 6.19) and it was recorded almost synchronically in the three recording points studied. Undoubtedly, these electrical-pressure phenomena resulted from mass transport since in all 5 cases a large discharge through the colostomy was seen.