External validation of a minimal-resource model to predict reduced estimated glomerular filtration rate in people with type 2 diabetes without diagnosis of chronic kidney disease in Mexico: a comparison between country-level and regional performance.

Background: Patients with type 2 diabetes are at an increased risk of chronic kidney disease (CKD) hence it is recommended that they receive annual CKD screening. The huge burden of diabetes in Mexico and limited screening resource mean that CKD screening is underperformed. Consequently, patients often have a late diagnosis of CKD. A regional minimal-resource model to support risk-tailored CKD screening in patients with type 2 diabetes has been developed and globally validated. However, population heath and care services between countries within a region are expected to differ. The aim of this study was to evaluate the performance of the model within Mexico and compare this with the performance demonstrated within the Americas in the global validation. Methods: We performed a retrospective observational study with data from primary care (Clinic Specialized in Diabetes Management in Mexico City), tertiary care (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán) and the Mexican national survey of health and nutrition (ENSANUT-MC 2016). We applied the minimal-resource model across the datasets and evaluated model performance metrics, with the primary interest in the sensitivity and increase in the positive predictive value (PPV) compared to a screen-everyone approach. Results: The model was evaluated on 2510 patients from Mexico (primary care: 1358, tertiary care: 735, ENSANUT-MC: 417). Across the Mexico data, the sensitivity was 0.730 (95% CI: 0.689 - 0.779) and the relative increase in PPV was 61.0% (95% CI: 52.1% - 70.8%). These were not statistically different to the regional performance metrics for the Americas (sensitivity: p=0.964; relative improvement: p=0.132), however considerable variability was observed across the data sources. Conclusion: The minimal-resource model performs consistently in a representative Mexican population sample compared with the Americas regional performance. In primary care settings where screening is underperformed and access to laboratory testing is limited, the model can act as a risk-tailored CKD screening solution, directing screening resources to patients who are at highest risk.

Impact of a multicomponent integrated care delivery program on diabetes care goals achievement: a primary care quality improvement initiative.

AIM: To evaluate the impact of multicomponent integrated care (MIC) delivery program in a primary care real-life setting on diabetes care goals. METHODS: Patients with T2D and usual primary care from the public health system in Mexico were invited to participate in a five-month ambulatory MIC quality initiative (DIAbetes Empowerment and Improvement of Care program, DIABEMPIC). RESULTS: 841 patients who finished the program and with complete data were analyzed. The patients had a mean decrease in hemoglobin A1c, systolic and diastolic pressure, and LDL-cholesterol of 2.4%, 9 mmHg, 3 mmHg, and 22.5 mg/dL, respectively (p < 0.001). The achievement of the optimal triple target goal increased from 1.8% to 26.7% (p < 0.001). In the adjusted analysis, the diabetes knowledge and global self-care behavior score post-intervention, as well as the increment of global self-care behavior score were associated with the optimal composite risk factor control achievement. CONCLUSION: The incorporation of diabetes therapeutic education interventions to improve self-care behaviors along with adequate treatment intensification in diabetes care are fundamental to attaining optimal risk factor control and attenuating disease burden.

Type 2 diabetes epidemic in Mexico. Burden of disease 1990-2021 analysis and implications for public policies.

BACKGROUND: Mexico faces a challenge due to the burden imposed by type 2 diabetes (T2D). OBJECTIVE: To analyze T2D epidemiology and burden in Mexico from 1990 to 2021, at the national and state levels. MATERIAL AND METHODS: Estimates from the Global Burden of Disease 2021 study were used to evaluate the prevalence, incidence, mortality, fatal and non-fatal burden. Metabolic, environmental and behavioral factors were considered. Comparative analyses were carried out by gender, age and state of the country. RESULTS: The prevalence of T2D increased by 25%. The incidence increased in those younger than 45 years, with a mortality decrease being found among women. The rate of disability-adjusted life years (DALY) showed an increase in all states, from 45.2% in Nuevo León to 237.6% in Tabasco. In 2021, T2D caused the loss of 3.1 million DALYs, which accounted for 6.6% of total burden in Mexico, out of which 64% was due to premature deaths. Diabetic neuropathy affected 47%, and there were 270,000 cases of visual impairment; 66.3% of the burden was attributed to obesity. CONCLUSIONS: Comprehensive policies are urgently needed in order to reduce the burden of T2D in Mexico, through standardized guidelines, evidence-based strategies and technological resources that improve medical care accessibility and efficiency.

ANTECEDENTES: México enfrenta un desafío por la carga que representa la diabetes tipo 2 (DT2). OBJETIVO: Analizar la epidemiología y la carga de DT2 en México de 1990 a 2021 en los ámbitos nacional y estatal. MATERIAL Y MÉTODOS: Se empleó el Global Burden of Disease 2021 para evaluar prevalencia, incidencia, mortalidad, carga letal y no letal. Se consideraron factores metabólicos, ambientales y de comportamiento. Se realizó análisis comparativo por sexo, edad y entidad federativa. RESULTADOS: Se incrementó la prevalencia de DT2 en 25 % y la incidencia en menores de 45 años; la mortalidad en mujeres disminuyó. La tasa de años de vida saludable (AVISA) perdidos se incrementó en todos los estados, entre 45.2 % en Nuevo León y 237.6 % en Tabasco. En 2021, la DT2 ocasionó 3.1 millones de AVISA perdidos, que representaron 6.6 % de la carga total en México, de la cual 64 % se atribuyó a muertes prematuras. La neuropatía diabética afectó a 47 % y las afecciones visuales a 270 000 personas; 66.3 % de la carga se atribuyó a obesidad. CONCLUSIONES: Urgen políticas integrales para reducir la carga de DT2 en México, mediante pautas estandarizadas, estrategias basadas en evidencia y recursos tecnológicos que mejoren la accesibilidad y eficiencia de la atención médica.

Adherence to antidiabetic treatment in primary health care in individuals with type 2 diabetes. A survey including socio-demographic, patient related and clinical factors.

BACKGROUND: Adherence to medications is a critical element in diabetes management. OBJECTIVE: To investigate patient-related factors associated with adherence to antidiabetic treatment in patients with type 2 diabetes in primary health-care units. METHODS: A cross-sectional study among patients receiving diabetes care in 18 primary care units in Mexico City was conducted. Data were collected from medical records and medical interviews. Adherence to antidiabetic therapy and patient-related factors associated with adherence were evaluated through a self-administered questionnaire. Socio-demographic, clinical, behavioral (self-care activities including a healthy diet, exercise or physical activity, self-monitoring of blood glucose testing, and foot care), and patients-adherence-related factors (health-care provider-patient communication; daily and social activities, and support network; alternative treatment beliefs; comorbidity, diabetes symptoms, and treatment; side effects and treatment access) were compared between the adherent and non-adherent group. RESULTS: Of 319 outpatients, 48.3% were adherent to their antidiabetic therapy. In the adjusted analysis, patient-related factors associated to adherence were exercise and physical activity self-care behavior (OR=1.26; 95%CI 1.09-1.46), treatment interference with daily activities (OR=0.27; 95%CI 0.14-0.52), not satisfied with resolution of questions by the physician (OR=0.42; 95%CI 0.19-0.94), independently to increased cardiovascular risk and insulin treatment. CONCLUSION: A low proportion of outpatients with T2D with regular primary care were adherent to diabetes treatment and this was associated with patient-related factors like answering patients' treatment-related questions by the physician. This information may be useful to identify patients at risk for low adherence, and to guide the design of quality-of-care strategies, like diabetes education programs to address suboptimal adherence in patients, and health-care professional communication skills training, particularly in primary care health systems.

Volviéndonos mejores: necesidad de acción inmediata ante el reto de la obesidad. Una postura de profesionales de la salud / Becoming better: the need for immediate action to address obesity. A position statement from health professionals

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Abstract: In recent decades, the growing obesity epidemic in Mexico has become one of the most important public health challenges faced by the country. With support from the World Obesity Federation, we formed a working group in 2021 to identify and summarize priority actions that Mexico can take to face this epidemic. More than 1 000 health professionals joined the development and discussion process. Recommendations from previously published, high-level documents and guidelines were taken into account. In commemoration of World Obesity Day 2022, this statement is presented as input for health care professionals to develop actions to address obesity. The statement includes 10 recommendations that include population-level and individual-level actions. It emphasizes the importance of social participation, comprehensive interventions with a person- centered perspective, planetary sustainability, on improving education and communication campaigns, as well as fostering a built environment that promotes active living, and shielding prevention and control efforts from conflicts of interest. The statement calls for obesity to be treated seriously, based on scientific evidence, in a timely and comprehensive manner, employing a life-course and ethical approach that does not perpetuate weight stigma in society.

The imperious need for telemedicine for the care of diabetes during the COVID-19 pandemic. A comprehensive approach study.

INTRODUCTION: Patients with diabetes experience difficulties to maintain glycemic control during the confinement due to the COVID-19 pandemic, with the risk of developing diabetes chronic complications and severe COVID-19. OBJECTIVE: The purpose of this study was to evaluate the conversion of an outpatient diabetes primary care center from a face-to-face care modality to a telemedicine care service by telephone. METHODS: Medical consultations were made by telephone during the initial phase of confinement (April to June 2020), to then continue the follow-up of patients admitted to a multicomponent diabetes care program. RESULTS: A total of 1,118 consultations were made by telephone and follow-up was subsequently continued in 192 patients with type 2 diabetes. Different professionals from different health areas participated, including medical care, diabetes education, nutrition, psychology and podiatry. CONCLUSIONS: Multicomponent diabetes care was successfully transformed from a face-to-face care modality to a telemedicine service. Many primary care patients may be candidates for telemedicine. A redesign of the care model that incorporates telemedicine should be considered to mitigate chronic diseases burden of morbidity and mortality imposed by COVID-19 pandemic, but also for the post-COVID-19 era.

INTRODUCCIÓN: Los pacientes con diabetes experimentan dificultades para mantener el control glucémico durante el confinamiento por la pandemia de COVID-19, con el riesgo de presentar complicaciones crónicas de la diabetes y COVID-19 grave. OBJETIVO: El propósito de este estudio fue evaluar la conversión de un centro de atención primaria presencial de diabetes a un servicio de telemedicina por llamada telefónica. MÉTODOS: Se realizaron consultas médicas por llamada telefónica durante la etapa inicial del confinamiento (abril a junio de 2020), para continuar el seguimiento de pacientes ingresados a un programa de atención multicomponente en diabetes. RESULTADOS: Se realizaron 1118 consultas por llamada telefónica para continuar el seguimiento de 192 pacientes con diabetes tipo 2. Participaron diferentes profesionales de distintas áreas de la salud: atención médica, educación en diabetes, nutrición, psicología y podología. CONCLUSIONES: La atención multicomponente en diabetes se transformó con éxito de un esquema de atención presencial a un servicio de telemedicina. Numerosos pacientes de atención primaria pueden ser candidatos a telemedicina. Se debe considerar un rediseño del modelo de atención que incorpore la telemedicina para mitigar la carga de morbimortalidad en enfermedades crónicas impuesta por la pandemia de COVID-19, pero también para la era pos-COVID-19.

La imperiosa necesidad de telemedicina en la atención de diabetes durante la pandemia de COVID-19. Un estudio de abordaje integral / The imperious need for telemedicine for the care of diabetes during the COVID-19 pandemic. A comprehensive approach study

Resumen Introducción: Los pacientes con diabetes experimentan dificultades para mantener el control glucémico durante el confinamiento por la pandemia de COVID-19, con el riesgo de presentar complicaciones crónicas de la diabetes y COVID-19 grave. Objetivo: El propósito de este estudio fue evaluar la conversión de un centro de atención primaria presencial de diabetes a un servicio de telemedicina por llamada telefónica. Métodos: Se realizaron consultas médicas por llamada telefónica durante la etapa inicial del confinamiento (abril a junio de 2020), para continuar el seguimiento de pacientes ingresados a un programa de atención multicomponente en diabetes. Resultados: Se realizaron 1118 consultas por llamada telefónica para continuar el seguimiento de 192 pacientes con diabetes tipo 2. Participaron diferentes profesionales de distintas áreas de la salud: atención médica, educación en diabetes, nutrición, psicología y podología. Conclusiones: La atención multicomponente en diabetes se transformó con éxito de un esquema de atención presencial a un servicio de telemedicina. Numerosos pacientes de atención primaria pueden ser candidatos a telemedicina. Se debe considerar un rediseño del modelo de atención que incorpore la telemedicina para mitigar la carga de morbimortalidad en enfermedades crónicas impuesta por la pandemia de COVID-19, pero también para la era pos-COVID-19.

Abstract Introduction: Patients with diabetes experience difficulties to maintain glycemic control during the confinement due to the COVID-19 pandemic, with the risk of developing diabetes chronic complications and severe COVID-19. Objective: The purpose of this study was to evaluate the conversion of an outpatient diabetes primary care center from a face-to-face care modality to a telemedicine care service by telephone. Methods: Medical consultations were made by telephone during the initial phase of confinement (April to June 2020), to then continue the follow-up of patients admitted to a multicomponent diabetes care program. Results: A total of 1,118 consultations were made by telephone and follow-up was subsequently continued in 192 patients with type 2 diabetes. Different professionals from different health areas participated, including medical care, diabetes education, nutrition, psychology and podiatry. Conclusions: Multicomponent diabetes care was successfully transformed from a face-to-face care modality to a telemedicine service. Many primary care patients may be candidates for telemedicine. A redesign of the care model that incorporates telemedicine should be considered to mitigate chronic diseases burden of morbidity and mortality imposed by COVID-19 pandemic, but also for the post-COVID-19 era.

Influence of social determinants, diabetes knowledge, health behaviors, and glycemic control in type 2 diabetes: an analysis from real-world evidence.

BACKGROUND: Although important achievements have been done in type 2 diabetes mellitus (T2D) treatment and glycemic control, new strategies may take advantage of non-pharmacological approaches and of other potential determinants of health (e.g., socioeconomic status, education, diabetes knowledge, physical activity, and self-care behavior). However, the relationships between these factors are not totally clear and have not been studied in the context of large urban settings. This study aimed to explore the relationship between these determinants of glycemic control (GC) in a low-income urban population from Mexico City, focused in exploring potential the mediation of self-care behaviors in the association between diabetes knowledge and GC. METHODS: A multicenter cross-sectional study was conducted in patients with type 2 diabetes (T2D) from 28 primary care outpatient centers located in Mexico City. Using multivariable-adjusted models, we determined the associations between diabetes knowledge, self-care behaviors, and GC. The mediation analyses to determine the pathways on glycemic control were done using linear regression models, where the significance of indirect effects was calculated with bootstrapping. RESULTS: The population (N = 513) had a mean age of 53.8 years (standard deviation: 11.3 yrs.), and 65.9% were women. Both socioeconomic status and level of education were directly associated with diabetes knowledge. Using multivariable-adjusted linear models, we found that diabetes knowledge was associated with GC (ß: -0.102, 95% Confidence Interval [95% CI] -0.189, - 0.014). Diabetes knowledge was also independently associated with self-care behavior (for physical activity: ß: 0.181, 95% CI 0.088, 0.273), and self-care behavior was associated with GC (for physical activity: ß: -0.112, 95% CI -0.194, - 0.029). The association between diabetes knowledge and GC was not observed after adjustment for self-care behaviors, especially physical activity (ß: -0.084, 95% CI -0.182, 0.014, p-value: 0.062). Finally, the mediation models showed that the effect of diabetes knowledge on GC was 17% independently mediated by physical activity (p-value: 0.049). CONCLUSIONS: Socioeconomic and educational gradients influence diabetes knowledge among primary care patients with type 2 diabetes. Self-care activities, particularly physical activity, mediated the effect of diabetes knowledge on GC. Our results indicate that diabetes knowledge should be reinforced in low-income T2D patients, with an emphasis on the benefits physical activity has on improving GC.

Role of social and other determinants of health in the effect of a multicomponent integrated care strategy on type 2 diabetes mellitus.

BACKGROUND: Although important advances in treatment strategies have been developed in type 2 diabetes mellitus (T2DM), large gaps exist in achieving glycemic control and preventing complications, particularly in low-and middle-income countries, which suggests a potential effect of social determinants of health (SDH, i.e., education level and socioeconomic status). However, few studies have determined the role of SDH and other determinants of health (ODH, i.e., diabetes knowledge and self-care scores) in achieving T2DM goals during effective multidisciplinary interventions. We aimed to examine a multicomponent integrated care (MIC) program on diabetes care goals and determine the effect of SDH and ODH on T2DM patients. METHODS: A before-and-after design (a pretest, a 5-month intervention, and a follow-up) was used in a T2DM population from Mexico City. The SDH included education level and socioeconomic status; the ODH included diabetes knowledge, self-care scores, and deltas (i.e., differences between baseline and follow-up scores). The triple-target goal (glycated hemoglobin, blood pressure, and LDL-cholesterol) was established as a measurement of T2DM goals. RESULTS: The DIABEMPIC (DIABetes EMPowerment and Improvement of Care) intervention (n = 498) reduced the glycated hemoglobin levels (mean reduction 2.65%, standard deviation [SD]: 2.02%) and cardiometabolic parameters; it also improved health-related quality of life. From 1.81% at baseline, 25.9% of participants (p-value< 0.001) achieved the triple-target goal. We found a significant association between education level (p-value = 0.010), diabetes knowledge at baseline (p-value = 0.004), and self-care scores at baseline (p-value = 0.033) in the delta (change between baseline and follow-up assessments) of HbA1c levels. Improvements (increase) in diabetes knowledge (p-value = 0.006) and self-care scores (p-value = 0.002) were also associated with greater reductions in HbA1c. CONCLUSIONS: MIC strategies in urban primary care settings contribute to control of T2DM. SDH, such as education level, and ODH (diabetes knowledge and self-care scores at baseline) play a key role in improving glycemic control in these settings.

Developing thyroid disorders is associated with poor prognosis factors in patient with stable chronic heart failure.

We sought to assess the developing of thyroid disorders in forty eight patients with chronic stable heart failure and without thyroid abnormalities during six months follow-up. Thyroid function disorders were observed in 27.1% of the subjects: sick euthyroid syndrome (12.5%), subclinical hypothyroidism (10.4%) and overt hypothyroidism (6.2%). Subjects with higher thyroid stimulating hormone (TSH) levels at the end of the study had more hospitalizations. The developing of altered thyroid profile was related to lower hemoglobin levels, smaller phase angle with bioelectrical impedance method and more fatigue perception by the patients. This abnormal thyroid function behavior on stable chronic heart failure and was observed as part of the disease progress and was associated to worse prognosis factors as lower phase angle and anemia.

Reversible changes of electrocardiographic abnormalities after parathyroidectomy in patients with primary hyperparathyroidism.

BACKGROUND: Several studies have reported that primary hyperparathyroidism is a risk factor of higher cardiovascular mortality, mainly because hyperparathyroidism is related to arterial hypertension, arrhythmias, structural heart abnormalities and activation of the renin-angiotensin- aldosterone system. However, very few studies have shown the electrocardiographic changes that occur after parathyroidectomy. That was the aim of this study. METHODS: We studied 57 consecutive patients with primary hyperparathyroidism surgically treated. Electrocardiogram, serum electrolytes, parathyroid hormone, creatinine and albumin measures were obtained before and after surgery and were compared. RESULTS: The most common basal electrocardiographic abnormalities were left ventricular hypertrophy (LVH, 24.6%), conduction disturbances (16.3%), and short QT and QTc intervals. After surgery, a QTc interval lengthening and a tendency of T wave shortening were observed, as well as an inverse association between QTc interval and serum levels of magnesium and corrected calcium. There were no differences in LVH and conduction disturbances after surgery. CONCLUSIONS: Primary hyperparathyroidism is an important factor in the development of electrocardiographic abnormalities in this population, some of which are not corrected after parathyroidectomy. Further studies are required to demonstrate what factors are associated with persistence of electrocardiographic disturbances after surgery.

The effect of left ventricular dysfunction on right ventricle ejection fraction during exercise in heart failure patients: Implications in functional capacity and blood pressure response.

BACKGROUND: The aim of this study was to assess the effect of left ventricular dysfunction on right ventricular ejection fraction during exercise in heart failure patients and its implications in functional capacity and blood pressure response. METHODS: In a cross-sectional study 65 patients with heart failure were included. Left and right ventricular ejection fractions were evaluated by radio-isotopic ventriculography. All subjects underwent an exercise treadmill test (Bruce modified protocol). Systolic and diastolic blood pressures were also recorded. RESULTS: From the total population, 38 (58.46%) showed a significant increase (> or = 5%) in left ventricular ejection fraction (LVEF) and 27 (41.5%) showed a significant decrease in LVEF (> or = 5%) after the stress test. Patients with a significant reduction in LVEF during stress had lower exercise tolerance (4.1 +/- 2.5 vs. 6.1 +/- 2.5 METs, p = 0.009) compared to those who showed an increase in LVEF. Diastolic blood pressure was higher at rest among those who had a reduced LVEF during stress (83 +/- 12.2 vs. 72.6 +/- 12.2 mm Hg, p = 0.035) and during exercise (95 +/- 31.3 vs. 76.9 +/- 31.3 mm Hg, p = 0.057), as well as mean arterial pressure in the same group (97.1 +/- 11.6 mm Hg, p = 0.05). In addition, this group decrease of -8.8 +/- 51.6% in the right ventricular ejection fraction after exercise compared to an increase of 27.3 +/- +/- 49.1% (p = 0.007) among the patients with an increase in LVEF. CONCLUSIONS: Biventricular systolic dysfunction during exercise is associated with higher rest and stress blood pressure and worse functional capacity.

Changes in the arrhythmic profile of patients treated for heart failure are associated with modifications in their myocardial perfusion conditions.

BACKGROUND: Heart failure (HF) patients can benefit from a proper RS. We had observed that they show an increase in the number of arrhythmias during the first year of pharmacological treatment. METHODS: We carried out a prospective observational study in which patients in an HF Clinic were included when they had follow-up Holter monitoring. Patients also had a baseline myocardial perfusion scan (Tc99 sestaMIBI/dypiridamole) and a control scan. RESULTS: We included 90 patients with follow-up Holter and 35 with scintigraphy, for analysis. Fifty-six (62.2%) were men and the average age was 60.8 +/- 14.6 years. Follow-up periods were divided by six-month intervals up to 18 months or more, an increase in premature ventricular contractions (PVCs) occurred in the six-month to one-year period (1915.4 +/- +/- 4686.9 vs. 2959 +/- 6248.1, p = 0.09). In the one-year to 18-month control, PVCs went from 781.6 +/- 1082.4 to 146.9 +/- 184.1, p = 0.05. The increase in PVCs correlated with a reduction in scintigraphy-detected ischemic territories, 5.64 +/- 5.9 vs. 3.18 +/- 3 (p = 0.1) and a gain in those showing a reverse redistribution pattern (0.18 +/- 0.6 vs. 2.09 +/- 4.01, p = 0.1). Necrotic territories and time domain heart rate variability did not show significant changes. CONCLUSIONS: PVCs increase during the first year of HF treatment, and then they tend to diminish and stabilize. These changes seem to correlate with changes in the perfusion state of the patient. While ischemic territories decrease, reverse redistribution increases, showing that endothelial dysfunction could have a relevant role in arrhythmia generation, possibly because of membrane instability of recovered hibernating myocardium.