Dr. Manuel García de los Ríos Álvarez: Maestros de la Medicina Interna Chilena / Manuel A. García de los Ríos, MD, MACP, Master of Internal Medicine (Chile)

En 2007, en ocasión del XXIX Congreso Chileno de Medicina Interna, se entregó el título de "Maestro de la Medicina Interna" al Dr. Manuel García de los Ríos Alvarez, M.A.C.P. El Dr. García de los Ríos es Profesor de Medicina en la Universidad de Chile, Miembro de Número de la Academia Chilena de Medicina y "Master" del American College of Physicians, entre otras distinciones nacionales e internacionales en Medicina Interna y Diabetología. Ha sido un colaborador permanente de la Revista Médica de Chile, como revisor externo y Miembro del Comité Editorial Asesor.

Control of type 2 diabetes mellitus among general practitioners in private practice in nine countries of Latin America.

OBJECTIVES: To better understand how diabetes care and control are being administered by general practitioners/nonspecialists in private practice in nine countries of Latin America, and to identify the most significant patient- and physician-related barriers to care. METHODS: A multicenter, cross-sectional, epidemiological survey was conducted in nine countries in Latin America: Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, Mexico, Peru, and Venezuela. General practitioners in private practice were asked to provide care and control data for patients 18 to 75 years of age with type 2 diabetes mellitus (T2DM), including demographics, medical and medication history, laboratory exams, and information on the challenges of patient management. RESULTS: Of the 3 592 patient questionnaires returned by 377 physicians, 60% of the patients had a family history of diabetes, 58% followed a poor diet, 71% were sedentary, and 79% were obese or overweight. Poor glycemic control (fasting blood glucose >or= 110 mg/dL) was observed in 78% of patients. The number of patients with HbA1c < 7.0% was 43.2%. Glycemic control decreased significantly with increased duration of T2DM. Comorbid conditions associated with T2DM were observed in 86% of patients; insulin use and comorbid conditions, especially those associated with microvascular complications, increased significantly disease duration. Ensuring compliance with recommended diet and exercise plans was the most-cited patient management challenge. CONCLUSIONS: Blood glucose levels are undercontrolled in T2DM patients in the private health care system in Latin America, particularly among those who have had the disease the longest (>15 years). Considering the differences between private and public health care in Latin America, especially regarding the quality of care and access to medication, further studies are called for in the public setting. Overall, a more efficient and intensive program of T2DM control is required, including effective patient education programs, adjusted to the realities of Latin America.

Control of type 2 diabetes mellitus among general practitioners in private practice in nine countries of Latin America

OBJECTIVES: To better understand how diabetes care and control are being administered by general practitioners/nonspecialists in private practice in nine countries of Latin America, and to identify the most significant patient- and physician-related barriers to care. METHODS: A multicenter, cross-sectional, epidemiological survey was conducted in nine countries in Latin America: Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, Mexico, Peru, and Venezuela. General practitioners in private practice were asked to provide care and control data for patients 18 to 75 years of age with type 2 diabetes mellitus (T2DM), including demographics, medical and medication history, laboratory exams, and information on the challenges of patient management. RESULTS: Of the 3 592 patient questionnaires returned by 377 physicians, 60 percent of the patients had a family history of diabetes, 58 percent followed a poor diet, 71 percent were sedentary, and 79 percent were obese or overweight. Poor glycemic control (fasting blood glucose > 110 mg/dL) was observed in 78 percent of patients. The number of patients with HbA1c < 7.0 percent was 43.2 percent. Glycemic control decreased significantly with increased duration of T2DM. Comorbid conditions associated with T2DM were observed in 86 percent of patients; insulin use and comorbid conditions, especially those associated with microvascular complications, increased significantly disease duration. Ensuring compliance with recommended diet and exercise plans was the most-cited patient management challenge. CONCLUSIONS: Blood glucose levels are undercontrolled in T2DM patients in the private health care system in Latin America, particularly among those who have had the disease the longest (>15 years). Considering the differences between private and public health care in Latin America, especially regarding the quality of care and access to medication, further studies are called for in the public...

OBJETIVOS: Comprender mejor cómo los médicos generales/no especialistas del sector privado atienden y controlan la diabetes en nueve países de América Latina e identificar los principales problemas relacionados con el paciente y el médico, que obstaculizan la atención. MÉTODOS:Se realizó un estudio epidemiológico, multicéntrico, transversal, en nueve países de América Latina: Argentina, Brasil, Chile, Costa Rica, Ecuador, Guatemala, México, Perú y Venezuela. Se pidió a los médicos generales del sector privado la información sobre la atención y el control de sus pacientes de 18 a 75 años de edad con diabetes mellitus tipo 2 (DMT2), así como los datos demográficos, la historia clínica y de medicación, las pruebas de laboratorio e información sobre los retos relacionados con la atención del paciente. RESULTADOS: De los 3 592 cuestionarios de pacientes entregados por 377 médicos, 60 por ciento de los pacientes tenían antecedentes familiares de diabetes, 58 por ciento seguían una dieta inadecuada, 71 por ciento eran sedentarios y 79 por ciento presentaban obesidad o sobrepeso. Se observó un inadecuado control glucémico (glucemia en ayunas > 110 mg/dL) en 78 por ciento de los pacientes. La proporción de pacientes con HbA1c < 7,0 por ciento fue de 43,2 por ciento. El control glucémico se redujo significativamente al aumentar la duración de la DMT2. En 86 por ciento de los pacientes se encontraron enfermedades concurrentes asociadas con la DMT2; el uso de insulina y las enfermedades concurrentes -especialmente las asociadas con complicaciones microvasculares- incrementaron significativamente la duración de la diabetes. En cuanto al tratamiento de los pacientes, el reto más frecuentemente citado fue garantizar la adhesión a la dieta y al plan de ejercicios recomendados. CONCLUSIONES: Los niveles de glucemia no están suficientemente controlados en los pacientes con DMT2 que se atienden en el sistema privado de salud de América Latina, particularmente...

Nueva clasificación y criterios diagnósticos de la diabetes mellitus / New classification and diagnostic criteria for diabetes mellitus

The new Classification and Diagnostic Criteria for Diabetes Mellitus (DM), prepared by a group of experts from the American Diabetes Association is presented and analyzed. On an etiopathogenic basis, it designates Insulin Dependent and Non Insulin Dependent as Type 1 and Type 2 respectively. It specifies DM having specific known causes. It maintains Gestational Diabetes and Glucose Intolerance and adds the Impaired Fasting Glucose Condition. It recommends fasting plasma glucose for search and diagnosis, and lowers the level to ,126 mg/dl instead of ,140 mg/dl, due to its association with chronical complications of DM. It mantains the diagnostic criteria of random and post charge glycemia ,200 mg/dl. It does not alter the glucose intolerance figure (140-200 mg/dl in OGTT) and introduces fasting abnormality ,110 and <126 mg/dl. It encourages the search with fasting glucose every 3 years in individuals aged over 45, and at more frequent intervals in younger individuals with high risk factors. Analysis of the report allows to conclude that, although the classification does not introduce any significant change in daily clinical use, its pathogenic orientation makes future innovations possible. The preferential use of fasting glucose ,126 mg/dl for diagnosis of DM has theoretical basis and practical advantages. Identification of individuals with impaired fasting glucose allows to detect, in a simple manner, a high risk group in which to start preventive measures. However, there is a percentage of cases which are not diagnosed by fasting glycemia, but are diagnosed by OGTT, therefore the latter should not be discarded

Consumo de glucosa in vivo inducido por insulina en individuos sanos / In vivo glucose consumption induced by insulin in normal controls

El desarrollo del clamp glicémico ha significado un importante avance en el estudio de la sensibilidad insulínica in vivo. En el presente trabajo se determinó el consumo de glucosa inducido por insulina por medio del clamp euglicémico hiperinsulinémico en 8 sujetos sanos: edad 45 ñ 7 años e índice de masa corporal (IMC) 25 ñ 6 kg/m*. Se realizaron correlaciones por análisis de regresión lineal simple, determinándose su significancia estadística por "t" de student. Los individuos presentaron una glicemia basal de 95 ñ 10 mg/dl con una concentración de insulina sérica de 9 ñ 3 uU/ml. La glicemia de la última media hora del clamp fue de 94 ñ 10 mg/dl y las insulinemias 73 ñ 12 uU/ml. Los coeficientes de variación de la glicemia e igual período del clamp estuvieron en el rango de 3 a 11%. El metabolismo de la glucosa inducido por la insulina (M), fue de 6,67 ñ 3,13 mg/kg/min y la eficiencia en la utilización de glucosa (MCR) 7,23 ñ 3,54 ml/kg/min. Por otro lado, el índice de sensibilidad a la insulina (M/Ins x 100) tuvo un valor de 9,52 ñ 5,23 (mg/kg/min). (uU/ml) x 100. Los estudios de correlación mostraron una asociación lineal entre M y MCR (r = 0,978; p < 0,0002) entre M y M/Ins x 100 (r = 0,965; p < 0,0002) y entre MCR y M/Ins x 100 (r = 0,945; p < 0,0002). Nuestros resultados confirman que el clamp euglicémico hiperinsulínico es una técnica reproducible y aplicable a la investigación clínica