34. Chiquete E, Ochoa-Guzmán A, García-Lamas L, Anaya-Gómez F, Gutiérrez-Manjarrez JI, Sánchez-Orozco LV, Godínez-Gutiérrez SA, Maldonado M, Román S, Panduro A. Hepatitis C virus infection and type 2 diabetes mellitus in Mexican patients. Rev Med Inst Mex Seguro Soc. 2012;50(5):481-6. [PMID: 23282259]
Introduction: Landscape of etiological profile and microbiological resistance of Spontaneous Bacterial Peritonitis (SBP) in Chronic Liver Disease (CLD) is continuously changing. Early antibiotic treatment of SBP is crucial but spread of Multidrug Resistant (MDR) organism makes its current management challenging. Our study provides fresh insight into its etiology and resistance profile to design better empiric regimen.
Objective: Study etiological profi le and resistance pattern of SBP in CLD Methods: This prospective observational study was conducted at Government Medical College, Srinagar from April 2018 to March 2019.
A Clinical Study: Tumour Necrosis Factor Alpha as a Clinical Marker in Malari...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Convalescent Plasma and COVID-19: Ancient Therapy Re-emergedasclepiuspdfs
Convalescent plasma has again re-emerged as a therapy during coronavirus disease (COVID-19) outbreaks currently use as a prophylactic or an interventional treatment in infected patients. Convalescent plasma has been used in the 20th century confronting different infectious diseases where there was no other therapy available. Conceivably, this convalescent plasma therapy tends to be proving a game-changing treatment in some COVID-19 patients and could support treatment, in addition to the current interventions before other developed therapies are available for the population.
Risk factors of chronic liver disease amongst patients receiving care in a Ga...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Introduction: Landscape of etiological profile and microbiological resistance of Spontaneous Bacterial Peritonitis (SBP) in Chronic Liver Disease (CLD) is continuously changing. Early antibiotic treatment of SBP is crucial but spread of Multidrug Resistant (MDR) organism makes its current management challenging. Our study provides fresh insight into its etiology and resistance profile to design better empiric regimen.
Objective: Study etiological profi le and resistance pattern of SBP in CLD Methods: This prospective observational study was conducted at Government Medical College, Srinagar from April 2018 to March 2019.
A Clinical Study: Tumour Necrosis Factor Alpha as a Clinical Marker in Malari...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Convalescent Plasma and COVID-19: Ancient Therapy Re-emergedasclepiuspdfs
Convalescent plasma has again re-emerged as a therapy during coronavirus disease (COVID-19) outbreaks currently use as a prophylactic or an interventional treatment in infected patients. Convalescent plasma has been used in the 20th century confronting different infectious diseases where there was no other therapy available. Conceivably, this convalescent plasma therapy tends to be proving a game-changing treatment in some COVID-19 patients and could support treatment, in addition to the current interventions before other developed therapies are available for the population.
Risk factors of chronic liver disease amongst patients receiving care in a Ga...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
frequency of hepatitis C virus infection in patients with type 2 diabetes mel...Dr Tarique Ahmed Maka
ABSTRACT
Objective: To determine the frequency of hepatitis C virus infection in patients with type 2 diabetes mellitus and to look for the common risk factors leading to this infection in diabetics. Study Design: Descriptive cross sectional study design. Place and Duration of Study: Department of Medicine, Combined Military Hospital (CMH) Kharian, from Jan 2015 to Jun 2015. Patients and Methods: This study was conducted in the department of Medicine, Combined Military Hospital Kharian. Through a descriptive cross sectional study design, a total of 140 patients with type 2 diabetes mellitus, admitted through casualty, OPD or private clinics were selected and tested for Hepatitis C virus infection. The common risk factors leading to such infection among positive cases were also scrutinized. Results: The mean age of patients was 48.82 ± 10.14 with 60.7% female gender predominating the overall sample of diabetics. Using 3rd generation ELISA method, hepatitis C virus was found in 45 (32.1%) of patients with 41-50 years of age group most commonly affected age group (34.7%) and female (57.8%) commonly affected gender. The distribution of risk factors leading to hepatitis C virus in diabetics are: 21 (46.7%) had history of surgery in the past, 13 (28.9%) had history of blood transfusion in the past, 7 (15.55%) had history of hemodialysis while only 4 (8.9%) had history of tattooing in the past. Conclusion: Hepatitis C virus infection is still a common problem in diabetic patients of our local population and we recommend further research work over its risk factors so that the guidelines for its control may be formulated. Keywords: Blood transfusion, Diabetes Mellitus, Haemodialysis, Hepatitis C virus infection, Risk Factors, Surgery, Tattooing.
Observational Study on 255 Mechanically Ventilated Covid Patients at the Beginning of the USA Pandemic
This article is a preprint and has not been peer-reviewed.
Twitter: @MattisVollan
3TC-DTG Dual Therapy and Its Implications in Hepatic Steatosis in People Livi...semualkaira
Hepatic disease is one of the major comorbidities
in people living with HIV. We intended to define the incidence of
NAFLD and to identify any factors which may be associated with
such a condition.
Serum Procalcitonin as a marker of infection in chronic kidney disease patien...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Mortalidad asociada al diagnóstico de síndrome de Guillain-Barré en adultos i...Erwin Chiquete, MD, PhD
Mortality associated with a diagnosis of Guillain-Barré syndrome in adults of Mexican health institutions
Introduction. Guillain-Barré syndrome (GBS) is a neurological emergency representing the main cause of flaccid paralysis
around the world, affecting all age groups. Little is known about the essential epidemiology of GBS in most Latin American
countries.
Aim. To determine the mortality associated with the diagnosis of GBS in hospital discharges during 2010 in hospitals of
the Ministry of Health, Mexico.
Patients and methods. We analyzed the database of hospital discharges of institutions pertaining to the Ministry of
Health. Study cases were identified by the code G61.0 of the International Classification of Diseases, 10th revision (ICD-10).
We excluded records of patients younger than 18 years and patients without complete demographic information.
Results. During the year 2010 there were 2,634,339 discharges from hospitals of the Ministry of Health. We identified a
total of 467 hospitalizations due to GBS in adults (median age: 41 years; 62.1% male) from 121 health institutions of the
32 Republic States. The highest frequency of GBS hospitalizations occurred during summer and fall. The median hospital
stay was 8 days. The hospital mortality rate was 10.5%. The probability of death was directly associated with age, without
a particular trend regarding gender, hospital care or state.
Conclusions. In 2010 GBS hospital mortality in this part of the Mexican health system was higher than that reported in
contemporary studies. A seasonal association was observed regarding the frequency of hospitalizations for GBS.
Key words. Climate. Epidemiology. Guillain-Barré syndrome. Mortality. Mexico.
Rogelio Domínguez-Moreno, Paulina Tolosa-Tort, Anais Patiño-Tamez, Alejandra Quintero-Bauman,
Deisy K. Collado-Frías, María G. Miranda-Rodríguez, Obet J. Canela-Calderón, Pablo Hurtado-Valadez,
Raúl de Gante-Castro, Karoll M. Ortiz-Guillén, Bruno Estañol-Vidal, Horacio Sentíes-Madrid,
Guillermo García-Ramos, Carlos Cantú-Brito, José Luis Ruiz-Sandoval, Erwin Chiquete
Seroepidemiology of Toxoplasma gondii infection in drivers involved in road t...Erwin Chiquete, MD, PhD
Background: The prevalence of toxoplasmosis in the general population of Guadalajara, Mexico, is around 32%.
Toxoplasmosis can cause ocular lesions and slowing of reaction reflexes. Latent toxoplasmosis has been related
with traffic accidents. We aimed to assess the prevalence of anti-Toxoplasma gondii antibodies and visual
impairments related with traffic accidents in drivers from the metropolitan Guadalajara.
Methods: We prospectively evaluated the prevalence of IgG and IgM anti-T. gondii antibodies in 159 individuals
involved in traffic accidents, and in 164 control drivers never involved in accidents. Cases of toxoplasmosis
reactivation or acute infection were detected by PCR in a subset of 71 drivers studied for the presence of T. gondii
DNA in blood samples. Ophthalmologic examinations were performed in drivers with IgG anti-T. gondii antibodies
in search of ocular toxoplasmosis.
Results: Fifty-four (34%) traffic accident drivers and 59 (36%) controls were positive to IgG anti-T. gondii antibodies
(p = 0.70). Among the 113 seropositive participants, mean anti-T. gondii IgG antibodies titers were higher in traffic
accident drivers than in controls (237.9 ± 308.5 IU/ml vs. 122.9 ± 112.7 IU/ml, respectively; p = 0.01 by Student’s t
test, p = 0.037 by Mann–Whitney U test). In multivariate analyses, anti-T. gondii IgG antibody titers were consistently
associated with an increased risk of traffic accidents, whereas age showed an inverse association. The presence of
IgM-anti-T. gondii antibodies was found in three (1.9%) subjects among traffic accident drives, and in two (1.2%)
controls. Three (4.2%) samples were positive for the presence of T. gondii DNA, all among seropositive individuals.
No signs of ocular toxoplasmosis were found in the entire cohort. Moreover, no other ocular conditions were found
to be associated with the risk of traffic accidents in a multivariate analysis.
Conclusions: Anti-T. gondii antibody titers are associated with the risk of traffic accidents. We could not determine
any association of ocular toxoplasmosis with traffic accidents. Our results warrant further analyses in order to clarify
the link between toxoplasmosis and traffic accidents.
Tiempo de llegada hospitalaria y pronóstico funcional después deun infarto ce...Erwin Chiquete, MD, PhD
Introducción: La información sobre el tiempo de llegada hospitalaria después de un infartocerebral (IC) se ha originado en países con unidades especializadas en ictus. Existe poca infor-mación en naciones emergentes. Nos propusimos identificar los factores que influyen en eltiempo de llegada hospitalaria a 1, 3 y 6 h y su relación con el pronóstico funcional después delictus.Métodos: Se analizó la información de pacientes con IC incluidos en el estudio Primer RegistroMexicano de Isquemia Cerebral (PREMIER) que tuvieran tiempo definido desde el inicio de lossíntomas hasta la llegada hospitalaria. El desenlace funcional se evaluó mediante la escalamodificada de Rankin a los 30 días, 3, 6 y 12 meses.Resultados: De 1.096 pacientes con IC, 61 (6%) llegaron en < 1 h, 250 (23%) en < 3 h y 464 (42%)en < 6 h. Favorecieron la llegada temprana en < 1 h: el antecedente familiar de cardiopatíaisquémica y ser migra˜noso; en < 3 h: edad 40-69 a˜nos, antecedente familiar de hipertensión,antecedente personal de dislipidemia y cardiopatía isquémica, así como la atención en hospitalprivado; en < 6 h: antecedente familiar de hipertensión, ser migra˜noso, ictus previo, cardiopatíaisquémica y atención en hospital privado. La llegada hospitalaria tardía se asoció a ictus lacunary alcoholismo. Solo el 2,4% recibió trombólisis. Independientemente de la trombólisis, la llegadaen < 3 h se asoció a menor mortalidad a los 3 y 6 meses, además de menos complicacionesintrahospitalarias.
Comportamiento del barorreflejo en pacientes con síncope vasovagal durante el...Erwin Chiquete, MD, PhD
Caroline Malamud-Kessler, Bruno Estañol-Vidal, Óscar Infante-Vázquez, Miguel Campos-Sánchez,
Erwin Chiquete
Introducción. El síncope mediado neuralmente, también conocido como síncope vasovagal, se define como la pérdida
súbita y transitoria del estado de alerta como consecuencia de un descenso brusco y profundo de la presión arterial.
Objetivo. Conocer las diferencias de los parámetros hemodinámicos que median el barorreflejo durante el ortostatismo
activo en pacientes con diagnóstico clínico de síncope vasovagal y sujetos sanos.
Sujetos y métodos. Estudio transversal, observacional y comparativo. Se incluyeron 20 pacientes con diagnóstico de síncope
neuralmente mediado y 30 controles, a los que se les practicó la prueba de ortostatismo activo y se les registró por
finometría la presión arterial sistólica (PAS) y la frecuencia cardíaca (intervalo entre latidos) de manera continua (latido a
latido) y no invasiva.
Resultados. Los pacientes con síncope presentaron una PAS basal con una media significativamente mayor que la de los
sanos. Las magnitudes medidas desde la PAS basal demostraron una diferencia significativa, que era de menor valor en el
grupo de los controles. No se demostraron diferencias entre grupos en la caída de la PAS desde el primer pico, recuperación
de la PAS desde la sima o en las latencias medidas en la frecuencia cardíaca.
Conclusiones. La PAS basal y la caída de la PAS medida desde la basal en posición supina fue mayor en los pacientes con
síncope mediado neuralmente que en los sujetos sanos. La magnitud de la elevación de la frecuencia cardíaca tuvo una
tendencia a ser mayor en el grupo de pacientes en comparación con el grupo control. Esto sugiere una hiperactividad
simpática en los pacientes con síncope
Delírium en adultos que reciben cuidados paliativos: revisión de laliteratura...Erwin Chiquete, MD, PhD
Delírium en adultos que reciben cuidados paliativos: revisión de laliteratura con un enfoque sistemáticoSofía Sánchez-Romána, Cristina Beltrán Zavalab, Argelia Lara Solaresby ErwinChiquetea,∗
El delírium en pacientes que reciben cuidados paliativos es frecuente y constituyeun importante reto de diagnóstico y tratamiento. Nuestro objetivo fue realizar en 2 fases unanálisis bibliométrico de la evidencia científica reciente (2007 a 2012) sobre diagnóstico y tra-tamiento del delírium en adultos en cuidados paliativos. En la fase 1 (estudios descriptivos yrevisiones narrativas) se identificaron 133 artículos relevantes: 73 trataron el tema del delíriumde forma secundaria y en 60 artículos como tema principal. Sin embargo, solo se identificaron4 estudios observacionales prospectivos en los que el delírium fue central. De 135 artículos iden-tificados en la fase 2 (ensayos clínicos o estudios descriptivos sobre tratamiento del delírium enpacientes paliativos), solo 3 fueron sobre prevención o tratamiento: 2 estudios retrospectivosy un ensayo clínico sobre prevención multicomponente en pacientes con cáncer. Gran parte dela literatura reciente corresponde a revisiones que hablan de estudios realizados hace másde una década en pacientes diferentes a los que reciben cuidados paliativos. En conclusión, laevidencia científica reciente sobre el delírium en cuidados paliativos es escasa y subóptima.Urgen estudios prospectivos que se enfoquen específicamente en esta población altamentevulnerable.
Central Adiposity and Mortality after First-Ever Acute Ischemic StrokeErwin Chiquete, MD, PhD
Erwin Chiquete a José L. Ruiz-Sandoval c Luis Murillo-Bonilla e
Carolina León-Jiménez g Bertha Ruiz-Madrigal d, f Erika Martínez-López d, f
Sonia Román d, f Arturo Panduro d, f Alma Ramos b Carlos Cantú-Brito
Background: The waist-to-height ratio (WHtR) may be a better
adiposity measure than the body mass index (BMI). We
evaluated the prognostic performance of WHtR in patients
with acute ischemic stroke (AIS). Methods: First, we compared
WHtR and BMI as adiposity measures in 712 healthy
adults by tetrapolar bioimpedance analysis. Thereafter,
baseline WHtR was analyzed as predictor of 12-month allcause
mortality in 821 Mexican mestizo adults with first-ever
AIS by a Cox proportional hazards model adjusted for baseline
predictors. Results: In healthy individuals, WHtR correlated
higher than BMI with total fat mass and showed a higher
accuracy in identifying a high percentage of body fat (p <
0.01). In AIS patients a U-shaped relationship was observed
between baseline WHtR and mortality (fatality rate 29.1%).
On multivariate analysis, baseline WHtR ≤ 0.300 or >0.800 independently
predicted 12-month all-cause mortality (h
José L. Ruiz-Sandoval, Guadalupe Ramírez-Guzmán,
Erwin Chiquete and Ángel Vargas-Sánchez
A 45-year-old garbage collector was referred to our department
with a history of tonic-clonic seizures and risky
sexual behavior (anilingus). A neurological examination was
normal. Contrast-enhanced cranial CT showed calcified lesions
and viable parasites compatible with a diagnosis of
massive non-encephalitic neurocysticercosis. Oral metallic
implants impeded performing brain MRI. Hepatitis and HIV
serologies were negative. The patient was discharged with
steroids and an anticonvulsant. Delayed cysticidal therapy
was planned; however, albendazole therapy was immediately
initiated in another hospital, which led to brain edema, uncontrolled
seizures, rostrocaudal deterioration and death.
Cestoda infections are rare in developed countries (1). In
contrast, neurocysticercosis is a leading cause of adult-onset
epilepsy in Latin America. Massive infections are classified
as encephalitic or non-encephalitic (2). In patients with the
encephalitic presentation, cysticidal drugs can cause extensive
parasite lysis and aggravate brain inflammation (2). In
patients with non-encephalitic massive neurocysticercosis,
cysticidal therapy is usually considered; (2) however, rapid
initiation of antiparasitic medications can launch an encephalitic
process.
Cost of care according to disease-modifying therapy in Mexicans with relapsin...Erwin Chiquete, MD, PhD
Miguel A. Macı´as-Islas • Isaac F. Soria-Cedillo • Merced Velazquez-Quintana •
Victor M. Rivera • Vero´nica I. Baca-Muro • Edith A. Lemus-Carmona • Erwin Chiquete
Limited data exist on the costs of care of
patients with multiple sclerosis (MS) in low- to middleincome
nations. The purpose of this study was to describe
the economic burden associated with care of Mexican
patients with relapsing-remitting MS in a representative
sample of the largest institution of the Mexican public
healthcare system. We analysed individual data of 492
patients (67 % women) with relapsing-remitting MS registered
from January 2009 to February 2011 at the Mexican
Social Security Institute. Direct costs were measured about
the use of diagnostic tests, disease-modifying therapies
(DMTs), symptoms control, medical consultations,
relapses, intensive care and rehabilitation. Four groups
were defined according to DMT alternatives: (1) interferon
beta (IFNb)-1a, 6 million units (MU); (2) IFNb-1a, 12MU;
(3) IFNb-1b, 8MU; and (4) glatiramer acetate. All patients
received DMTs for at least 1 year. The most frequently
used DMT was glatiramer acetate (45.5 %), followed by
IFNb-1a 12MU (22.6 %), IFNb-1b 8MU (20.7 %), and
IFNb-1a 6MU (11.2 %). The mean cost of a specialised
medical consultation was €74.90 (US $107.00). A single
relapse had a mean total cost of €2,505.97 (US $3,579.96).
No differences were found in annualised relapse rates and
costs of relapses according to DMT. However, a significant
difference was observed in total annual costs according to
treatment groups (glatiramer acetate being the most
expensive), mainly due to differences in unitary costs of
alternatives. From the public institutional perspective,
when equipotent DMTs are used in patients with comparable
characteristics, the costs of DMTs largely determine
the total expenses associated with care of patients with
relapsing-remitting MS in a middle-income country.
Blood pressure at hospital admission and outcome after primary intracerebral ...Erwin Chiquete, MD, PhD
Introduction: The importance of the admission blood pressure (BP) for intracerebral
hemorrhage (ICH) outcome is not completely clear. Our objective was to
analyze the clinical impact of BP at hospital arrival in patients with primary ICH.
Material and methods: We studied 316 patients (50% women, mean age:
64 years, 75% with hypertension history) with acute primary ICH. The first BP reading
at admission was evaluated for its association with neuroimaging findings
and outcome. A Cox proportional hazards model and Kaplan-Meier analyses
were constructed to evaluate factors associated with in-hospital mortality.
Results: Intraventricular irruption occurred in 52% of cases. A high frequency
of third ventricle extension was observed in patients with BP readings in the
upper quartiles of the distribution (systolic, diastolic, or mean arterial pressure).
Blood pressure readings did not correlate with hematoma volumes. In-hospital
case fatality rate was 46% (63% among those with ventricular irruption). Systolic
BP (SBP) > 190 mm Hg was independently associated with in-hospital mortality
in supratentorial (n = 285) ICH (hazard ratio: 1.19, 95% confidence interval:
1.02-1.38, for the highest vs. the lowest quartile) even after adjustment for
known strong predictors (age, ICH volume, Glasgow coma scale and ventricular
extension). Blood pressure was not significantly associated with ventricular
extension or outcome in patients with infratentorial ICH.
Conclusions: A high BP on admission is associated with an increased risk of
intraventricular extension and early mortality in patients with supratentorial
ICH. However, a significant proportion of patients with high BP readings without
ventricular irruption still have an increased risk of death.
Serum Uric Acid and Outcome after Acute Ischemic Stroke: PREMIER StudyErwin Chiquete, MD, PhD
Background: Current evidence shows that uric acid is a potent
antioxidant whose serum concentration increases rapidly
after acute ischemic stroke (AIS). Nevertheless, the relationship
between serum uric acid (SUA) levels and AIS
outcome remains debatable. We aimed to describe the
prognostic significance of SUA in AIS. Methods: We studied
463 patients (52% men, mean age 68 years, 13% with glomerular
filtration rate <60 />2) at 30 days, or with
any outcome measure at 3, 6 or 12 months poststroke. After
adjustment for age, gender, stroke type and severity (NIHSS
<9),><24 h. Conclusions: A low SUA
concentration is modestly associated with a very good
short-term outcome. Our findings support the hypothesis
that SUA is more a marker of the magnitude of the cerebral
infarction than an independent predictor of stroke outcome.
Atherothrombotic Disease, Traditional Risk Factors, and 4-Year Mortality in a...Erwin Chiquete, MD, PhD
Erwin Chiquete, MD, PhD
Background: Atherothrombosis is becoming the leading cause of chronic morbidity in developing countries. This
epidemiological transition will represent an unbearable socioeconomic burden in the near future. We investigated
factors associated with 4-year all-cause mortality in a Latin American population at high risk.
Hypothesis: Largely modifiable risk factors as well as polyvascular disease are the main predictors of 4-year all-cause and
cardiovascular mortality in this Latin American cohort.
Methods: We analyzed 1816 Latin American stable outpatients (62.3% men, mean age 67 years) with symptomatic
atherothrombosis (87.1%) or with multiple risk factors only (12.9%), in the Reduction of Atherothrombosis for Continued
Health registry.
Results: Of patients with symptomatic atherothrombosis, 57.3% had coronary artery disease, 32% cerebrovascular disease,
and 11.7% peripheral artery disease at baseline (9.1% polyvascular). The main risk factors were hypertension (76%),
hypercholesterolemia (60%), and smoking (52.3%) in patients with established atherothrombosis; and hypertension
(89.7%), diabetes (80.8%), and hypercholesterolemia (73.9%) in those with risk factors only. Four-year all-cause mortality
steeply increased with none (6.8%), 1 (9.2%), 2 (15.5%), and 3 (29.2%) symptomatic arterial disease locations. In patients
with only 1 location, cardiovascular mortality was significantly higher with peripheral artery disease (11.3%) than with
cerebrovascular disease (6%) or coronary artery disease (5.1%). Significant baseline predictors of 4-year all-cause mortality
were congestive heart failure (hazard ratio [HR]: 3.81), body mass index<20 (HR: 2.32), hypertension (HR: 1.84), polyvascular
disease (HR: 1.69), and age ≥65 years (HR: 1.47), whereas statin use (HR: 0.49) and body mass index ≥30 (HR: 0.58) were
associated with a reduced risk.
Conclusions: Hypertension was the main modifiable risk factor for atherothrombosis and all-cause mortality in this Latin
José L. Ruiz-Sandoval, Erwin Chiquete,
Lucía E. Álvarez-Palazuelos, Miguel
A. Andrade-Ramos & Luis R. Rodríguez-
Rubio
Osmotic demyelination syndrome (ODS) is the
damage over the central nervous system caused by several
electrolytes, metabolic and toxic disorders. We aimed to
describe cases of unusual forms of ODS. In a 9-year period,
25 consecutive patients with ODS (15 men; mean age
42 years) were registered in our referral institution, among
them, four (16 %) with atypical neuroimaging findings
were abstracted for this communication. None of them
presented cardiorespiratory arrest, head trauma, seizures,
neuromyelitis optica spectrum or contact with toxic
chemicals. Case 1 was a 33-year-old alcoholic man without
hypertension or electrolyte imbalance, who presented a
classic central pontine myelinolysis (CPM) and a hemorrhage
within the pons. Case 2 was a 34-year-old alcoholic
man with hypoglycemia and hyponatremia who presented
CPM and diffuse bihemispheric extrapontine myelinolysis
(EPM) after correction of serum sodium. Case 3 was a
52-year-old woman with mild hypokalemia and hyponatremia
(inadequately corrected), who presented a peduncular
and cerebellar EPM. Case 4 was a 67-year-old
woman who had a suicidal attempt with antidepressants
and carbamazepine without impaired consciousness, who
complicated with mild hyponatremia associated with a
classical CPM and a spinal cord EPM. Case 2 died and the
rest remained with variable neurological impairments at
last follow-up visit. With modern neuroimaging, the
so-called atypical forms of ODS may not be as rare as
previously thought; however, they could have a more
adverse outcome than the classical ODS.
Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Na...Erwin Chiquete, MD, PhD
Introduction. Scarce information exists on intracerebral hemorrhage (ICH) in Latin America, and the existent is derived
from single-center registries with non-generalizable conclusions. The aim of this study is to describe the frequency, etiology,
management and outcome of ICH in Mexico.
Patients and methods. We studied consecutive patients with ICH pertaining to the National Multicenter Registry on Cerebrovascular
Disease (RENAMEVASC), conducted in 25 centers from 14 states of Mexico. The Intracerebral Hemorrhage Grading
Scale (ICH-GS) at admission was used to assess prognosis at 30 days follow-up.
Results. Of 2,000 patients with acute cerebrovascular disease registered in RENAMEVASC, 564 (28%) had primary ICH
(53% women; median age: 63 years; interquartile range: 50-75 years). Hypertension (70%), vascular malformations (7%)
and amyloid angiopathy (4%) were the main etiologies. In 10% of cases etiology could not be determined. Main ICH
locations were basal ganglia (50%), lobar (35%) and cerebellum (5%). Irruption into the ventricular system occurred in
43%. Median score of ICH-GS was 8 points: 49% had 5-7 points, 37% had 8-10 points and 15% had 11-13 points. The 30-day
case fatality rate was 30%, and 31% presented severe disability. The 30-day survival was 92% for patients with ICH-GS 5-7
points, whereas it decreased to 27% in patients with ICH-GS 11-13 points.
Conclusions. In Mexico, ICH represents about a third of the forms of acute cerebrovascular disease, and the majority of
patients present severe disability or death at 30 days of follow-up. Hypertension is the main cause; hence, control of this
important cardiovascular risk factor should reduce the health burden of ICH.
An Expandable Prosthesis with Dual Cage-and-Plate Function in a Single Device...Erwin Chiquete, MD, PhD
Juan J. Ramı´rez, Erwin Chiquete, Juan J. Ramı´rez, Jr., Ernesto Go´mez-Limo´n, and Juan M. Ramı´rez
An expandable vertebral body prosthesis with dual cage-and-plate function in a single
device (JR prosthesis) was designed to test the hypothesis that this modular system can
provide the biomechanical requirements for immediate and durable spine stabilization
after corpectomy. Cadaver assays were performed with a stainless steal device to test fixation
and adequacy to the human spine anatomy. Then, 14 patients with vertebral tumors
(eight metastatic) underwent corpectomy and vertebral body replacement with a titaniummade
JR prosthesis. All patients had neurological deficit, severe pain and spine instability
prior to surgery. Mean pain score before surgery on a visual analog scale decreased from
7.6e3.0 points after operation ( p 5 0.002). All patients achieved at least one grade of
improvement in the Frankel score ( p 5 0.003), excepting the three patients with Frankel
grade A before surgery. Two patients with renal cell carcinoma died during the following
4 days after surgery. The remaining patients attained a painless and stable spine immediately,
which was maintained for long periods (mean follow-up: 25.4 months). No significant
infections or implant failures were registered. A nonfatal case of inferior vena cava
surgical injury was observed (repaired during surgery without further complications). In
conclusion, the JR prosthesis stabilizes the spine immediately after surgery and for the
rest of the patients’ life. To our knowledge, this is the first report on the clinical experience
of any expandable vertebral body prosthesis with dual cage-and-plate function in
a single device.
Expression profile of BRCA1 and BRCA2 genes in premenopausal Mexican women wi...Erwin Chiquete, MD, PhD
Gloria Loredo-Pozos, Erwin Chiquete,
Antonio Oceguera-Villanueva, Arturo Panduro,
Fernando Siller-Lo´pez, Martha E. Ramos-Márquez
Low BRCA1 gene expression is associated with
increased invasiveness and influences the response of
breast carcinoma (BC) to chemotherapeutics. However,
expression of BRCA1 and BRCA2 genes has not been
completely characterized in premenopausal BC. We analyzed
the clinical and immunohistochemical correlates of
BRCA1 and BRCA2 expression in young BC women. We
studied 62 women (mean age 38.8 years) who developed
BC before the age of 45 years. BRCA1 and BRCA2 mRNA
expression was assessed by reverse transcriptase-polymerase
chain reaction (RT-PCR) and that of HER-2 and
p53 proteins by immunohistochemistry. Body mass index
(BMI) C27 (52%) and a declared family history of BC
(26%) were the main risk factors. Ductal infiltrative adenocarcinoma
was found in 86% of the cases (tumor size
[5 cm in 48%). Disease stages I–IV occurred in 2, 40, 55,
and 3%, respectively (73% implicating lymph nodes).
Women aged B35 years (24%) had more family history of
cervical cancer, stage III/IV disease, HER-2 positivity, and
lower BRCA1 expression than older women (P-.05).
BRCA1 and BRCA2 expression correlated in healthy, but
not in tumor tissues (TT). Neither BRCA1 nor BRCA2
expression was associated with tumor histology, differentiation,
nodal metastasis or p53 and HER-2 expression.
After multivariate analysis, only disease stage explained
BRCA1 mRNA levels in the lowest quartile. Premenopausal
BC has aggressive clinical and molecular
characteristics. Low BRCA1 mRNA expression is associated
mainly with younger ages and advanced clinical stage
of premenopausal BC. BRCA2 expression is not associated
with disease severity in young BC women.
En conclusión, la neurotoxicidad por exposición
crónica a PDCB es rara y ha sido poco descrita
en la bibliografía. Las propiedades lipofílicas de
este compuesto producen desmielinización central,
y dan lugar a leucoencefalopatía difusa,
supra e infratentorial. Las manifestaciones más
frecuentemente descritas son agudas, y son de
interés particular, en nuestro paciente, las manifestaciones
cognitivas de tipo demenciales en
un seguimiento a largo plazo. Las recomendaciones
domésticas deben dirigirse a evitar el
contacto por parte de los menores de edad con
este compuesto, así como a su eventual sustitución
por productos menos tóxicos.
Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Na...Erwin Chiquete, MD, PhD
José L. Ruiz-Sandoval, Erwin Chiquete, Alejandra Gárate-Carrillo, Ana Ochoa-Guzmán, Antonio Arauz,
Carolina León-Jiménez, Karina Carrillo-Loza, Luis M. Murillo-Bonilla, Jorge Villarreal-Careaga,
Fernando Barinagarrementería, Carlos Cantú-Brito, and the RENAMEVASC investigators
Introduction. Scarce information exists on intracerebral hemorrhage (ICH) in Latin America, and the existent is derived
from single-center registries with non-generalizable conclusions. The aim of this study is to describe the frequency, etiology,
management and outcome of ICH in Mexico.
Patients and methods. We studied consecutive patients with ICH pertaining to the National Multicenter Registry on Cerebrovascular
Disease (RENAMEVASC), conducted in 25 centers from 14 states of Mexico. The Intracerebral Hemorrhage Grading
Scale (ICH-GS) at admission was used to assess prognosis at 30 days follow-up.
Results. Of 2,000 patients with acute cerebrovascular disease registered in RENAMEVASC, 564 (28%) had primary ICH
(53% women; median age: 63 years; interquartile range: 50-75 years). Hypertension (70%), vascular malformations (7%)
and amyloid angiopathy (4%) were the main etiologies. In 10% of cases etiology could not be determined. Main ICH
locations were basal ganglia (50%), lobar (35%) and cerebellum (5%). Irruption into the ventricular system occurred in
43%. Median score of ICH-GS was 8 points: 49% had 5-7 points, 37% had 8-10 points and 15% had 11-13 points. The 30-day
case fatality rate was 30%, and 31% presented severe disability. The 30-day survival was 92% for patients with ICH-GS 5-7
points, whereas it decreased to 27% in patients with ICH-GS 11-13 points.
Conclusions. In Mexico, ICH represents about a third of the forms of acute cerebrovascular disease, and the majority of
patients present severe disability or death at 30 days of follow-up. Hypertension is the main cause; hence, control of this important cardiovascular risk factor should reduce the health burden of ICH.
Hemorragia intracerebral espontánea en México: resultados del Registro Hospit...Erwin Chiquete, MD, PhD
José L. Ruiz-Sandoval, Erwin Chiquete, Alejandra Gárate-Carrillo, Ana Ochoa-Guzmán, Antonio Arauz,
Carolina León-Jiménez, Karina Carrillo-Loza, Luis M. Murillo-Bonilla, Jorge Villarreal-Careaga,
Fernando Barinagarrementería, Carlos Cantú-Brito, investigadores RENAMEVASC
Introducción. Existe poca información respecto a la hemorragia intracerebral (HIC) en América Latina, y la existente ha
sido derivada de registros hospitalarios de un solo centro con conclusiones no generalizables. El objetivo de este estudio
es describir la frecuencia, etiología, manejo y desenlace clínico de la HIC en México.
Pacientes y métodos. Se estudiaron pacientes consecutivos con HIC incluidos en el Registro Nacional Mexicano de Enfermedad
Vascular Cerebral (RENAMEVASC), conducido en 25 centros de 14 estados de la República Mexicana. Se usó la
Intracerebral Hemorrhage Grading Scale (ICH-GS) para estimar el pronóstico a 30 días.
Resultados. De 2.000 pacientes con ictus agudo en el RENAMEVASC, 564 (28%) presentaron HIC espontánea (53% mujeres;
edad media: 63 años; rango intercuartílico: 50-75 años). La hipertensión arterial (70%), las malformaciones vasculares
(7%) y la angiopatía amiloidea (4%) fueron las causas más frecuentes. No se determinó la etiología en el 10% de
los casos. Las localizaciones más frecuentes fueron ganglionar (50%), lobar (35%) y cerebelosa (5%). La irrupción hacia
el sistema ventricular ocurrió en el 43%. La mediana en la escala ICH-GS al ingreso hospitalario fue de 8 puntos: el 49%
presentó 5-7 puntos; el 37%, 8-10 puntos, y el 15%, 11-13 puntos. La tasa de mortalidad a 30 días fue del 30%, y el 31%
mostró discapacidad grave. La sobrevida a 30 días fue del 92% en pacientes con 5-7 puntos en la escala ICH-GS, mientras
que se redujo al 27% en aquellos con 11-13 puntos.
Conclusiones. En México, la HIC representa casi un tercio de las formas de enfermedad vascular cerebral aguda, y la mayoría de los pacientes que la padecen presentan discapacidad funcional grave o muerte a 30 días. La hipertensión es la principal causa, por lo que el control de este importante factor de riesgo debería reducir la carga sanitaria de la HIC.
Presión arterial sistólica y pronóstico funcional en pacientes con enfermedad...Erwin Chiquete, MD, PhD
Manuel Baños-González, Carlos Cantú-Brito, Erwin Chiquete, Antonio Arauz, José Luís Ruiz-Sandoval, Jorge Villarreal-Careaga, Fernando Barinagarrementeria, José Juan Lozano y los investigadores RENAMEVASC
Objetivo: Analizar la asociación de la presión arterial sistólica (PAS) al ingreso hospitalario
y la evolución clínica a 30 días en pacientes con enfermedad vascular cerebral (EVC) aguda.
Métodos: El REgistro NAcional Mexicano de Enfermedad VAScular Cerebral (RENAMEVASC) es un registro
hospitalario multicéntrico realizado de noviembre de 2002 a octubre de 2004. Se registraron
2000 pacientes con distintos síndromes clínicos de EVC aguda confirmados por neuroimagen. La
estratificación de la evolución clínica se realizó mediante la escala de Rankin modificada.
Resultados: Se analizaron 1721 pacientes con registro de la PAS: 78 (4.5%) con isquemia cerebral
transitoria, 894 (51.9%) con infarto cerebral, 534 (30.9%) con hemorragia intracerebral,
165 (9.6%) con hemorragia subaracnoidea y 50 (2.9%) con trombosis venosa cerebral. De los
1036 (60.2%) pacientes con el antecedente de hipertensión, sólo 32.4% tenía un tratamiento
regular. La tasa de mortalidad a 30 días presentó un patrón en J con respecto a la PAS, de
tal manera que el riesgo de muerte fue máximo en <100><100>65 años (RR: 2.16, IC 95%: 1.74 - 2.67).
Conclusión: Tanto la hipotensión como la hipertensión arterial significativa al ingreso hospitalario
se asocian a un pronóstico adverso en la EVC aguda. No obstante, un buen pronóstico
funcional se puede lograr en un amplio rango de cifras de PAS.
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
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comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
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How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
Hepatitis C virus infection and type 2 diabetes mellitus in Mexican patients.
1. APORTACIONES ORIGINALES
1
Erwin Chiquete, 1Ana Ochoa-Guzmán, 1Leopoldo García-Lamas,
2
Francisco Anaya-Gómez, 3Juan I. Gutiérrez-Manjarrez,
4
Laura V. Sánchez-Orozco, 1Sergio A. Godínez-Gutiérrez,
5
Montserrat Maldonado, 5Sonia Román, 5Arturo Panduro
1
Division of Internal Medicine,
2
Critical Care Unit
3
Department of Gastroenterology
4
Department of Molecular Biology and Genomics,
Centro Universitario de Ciencias de la Salud,
Universidad de Guadalajara, Jalisco, México
5
Department of Molecular Biology in Medicine
Authors 1, 2, 3 and 5, Hospital Civil de Guadalajara
“Fray Antonio Alcalde”, Jalisco, México
Resumen
Hepatitis C virus
infection
and type 2 diabetes mellitus
in Mexican patients
Correspondence: Erwin Chiquete
Phone number: (33) 3613 4016. Fax: 52 (33) 3614 1121
E-mail: erwinchiquete@runbox.com.mx
Summary
Objetivo: probar que la diabetes mellitus tipo 2 (DM2) es frecuente en mexicanos con infección por virus de la hepatitis C (VHC).
Objective: to measure the frequency of type 2 diabetes mellitus (T2DM) in patients with confirmed HCV infection.
Métodos: 125 adultos positivos a anticuerpos antiVHC (62.4 %
mujeres), con pruebas confirmatorias para viremia mediante
RT-PCR (63.2 % positivos al ARN del VHC).
Methods: we studied 125 adults reactive to anti-HCV antibodies
(62.4 % women, mean age 46.8 years) who received confirmatory RT-PCR testing for viremia (63.2 % HCV-RNA-positive).
Resultados: 22 pacientes presentaron DM2 (17.6 %, IC 95 % =
11.8-25.3); la diabetes fue más frecuente en pacientes con
viremia detectable que en negativos (23.3 adversus 9.6 %,
p = 0.04), y entre aquellos con enfermedad hepática avanzada
que en compensados (28.9 adversus 11.3 %, p = 0.01). Catorce
pacientes (17.7 %) recibieron interferón y seis (42.8 %) experimentaron respuesta virológica sostenida; ninguno de los últimos presentaron DM2; dos de los ocho (25 %) no respondedores
tuvieron diabetes. Los pacientes con DM2 eran más añosos que
aquellos sin diabetes (57.7 adversus 44.5 años, p < 0.001).
Después del análisis multivariado ajustado por confusores relevantes, solo la edad se asoció significativamente con DM2.
Results: twenty-two patients had T2DM (17.6 %, 95 % confidence interval: 11.8-25.3 %; mean National prevalence: 14.4 %),
more frequent among patients with detectable viremia than in
negative cases (23.3 % vs. 9.6 %, respectively; p = 0.04), and
among those with advanced liver disease, than in compensated
patients (28.9 % vs. 11.3 %, respectively; p = 0.01). Fourteen
(17.7 %) patients received interferon-based treatment and 6
(42.8 %) had sustained virology response. None of the 6 responders had T2DM, but 2 of the 8 (25 %) non-responders had
diabetes. T2DM patients were older than those without diabetes
(57.7 vs. 44.5 years, p < 0.001), and after multivariate analysis,
only age was significantly associated with diagnosis of T2DM.
Conclusiones: la DM2 fue altamente prevalente entre pacientes con infección por el VHC. La edad fue el factor determinante en la ocurrencia de diabetes en este grupo no pareado.
Conclusions: T2DM was highly prevalent among patients with
chronic HCV infection. Age was the most important determining
factor.
Palabras clave
diabetes mellitus tipo 2
hepatitis C
hígado
Diabetes mellitus (DM) and chronic liver disease are highly
prevalent in Mexico, they represented the first and fourth
cause of general mortality in 2008, respectively.1 The relationship between several liver diseases and abnormalities
of glucose metabolism has been recognized since antiquity
and classical medical textbooks.2,3 Modern medicine has
also demonstrated the magnitude of this association, with
salient clinical implications in diagnosis, treatment and
prognosis. 4-6
Rev Med Inst Mex Seguro Soc 2012; 50 (5): 481-486
Key words
diabetes mellitus, type 2
hepatitis C
liver
Near 40 % of patients with the hepatitis C virus (HCV)
infection have extrahepatic manifestations of the disease.7 A
considerable body of clinical and experimental evidence has
consistently indicated a link between HCV infection and
type 2 DM (T2DM).8-21 It appears that this relationship goes
beyond the mere liver injury as was first hypothesized.8 Since
chronic HCV infection implies a state of systemic inflammation that leads to peripheral, rather than hepatic, insulin resistance.20 Moreover, HCV can infect the pancreatic β-cell and
481
2. Chiquete E et al. Type 2 diabetes mellitus in Mexican patients with chronic hepatitis C virus infection
potentially impair its endocrine function.21 According to the
most recent data, prevalence of diabetes mellitus in Mexican
adults is 14.4 %.22 Frequency of confirmed cases living with
HCV infection in Mexico is estimated to be < 1 %.23,24
Surprisingly, data on the association of HCV infection with
T2DM in Mexico are scarce. 5,6 We aimed to test the
hypothesis that HCV infection is associated with a high
prevalence of T2DM in Mexican adults.
Methods
A retrospective study was performed on a research database
of 125 consecutive patients aged > 20 years, all reactive to
anti-HCV antibodies, who were referred for molecular testing
and confirmation of HCV infection, to the Department of
Molecular Biology at the Hospital Civil de Guadalajara “Fray
Antonio Alcalde”. The internal Committee of Ethics of our
hospital approved the study. Informed consent was required
to be included in our research database.
Ambulatory patients were referred from blood bank and
infectology, gastroenterology, general internal medicine,
pediatrics and hematology departments. We considered for
Figure 1
482
this study only adult patients reactive to a screening test for
anti-HCV antibodies in at least two occasions, with or without
clinical manifestations of liver decompensation. A standardized structured questionnaire was used to collect data from
the patient regarding demography, relevant antecedents and
risk factors. Overt liver decompensation was considered to
occur in a patient if jaundice, ascitis or collateral superficial
veins were present. The antecedent diagnosis or previous
hospitalization for liver decompensation (i.e., upper gastrointestinal bleeding, hepatic encephalopathy, and other complications) was also considered as liver decompensation.25
Diagnosis of diabetes was registered by history taking and
fasting blood glucose ≥ 126 mg/dL in at least two occasions.21
Cases with type 1 diabetes mellitus were not included in the
present analysis.
A 9 mL blood sample was obtained in 3 test tubes (3 mL
each) from a peripheral vein for serologic and molecular assays.
An automated third generation microparticle enzyme immunoassay (MEIA, IMx HCV Version 3.0 Abbott Diagnostics, Chicago, IL, USA) was used to assess the presence of anti-HCV
antibodies in sera samples stored at –70 ºC.25 Immunoassay
signal strength of the sample to cut-off rate (S/CO) ratio > 1
was considered as reactive test, according to directions of the
Type 2 diabetes mellitus among different subgroups of patients, as compared with the Mexican prevalence.
The shadow background emphasizes the difference between subgroups of viremic patients and the reference standard, as well as the putative protective effect of the interferon-based therapy
Rev Med Inst Mex Seguro Soc 2012; 50 (5): 481-486
3. Chiquete E et al. Type 2 diabetes mellitus in Mexican patients with chronic hepatitis C virus infection
manufacturer. A home-made qualitative nested reverse-transcription polymerase chain reaction (RT-PCR) was used to
detect HCV RNA in all sera samples, first stored at –70 ºC.
Total RNA was extracted from each serum without pooling,
using QIAamp Viral RNA Mini Kit (QIAGEN, Chatsworth,
CA) as indicated the manufacturer. Then, RT was carried out
to obtain complementary DNA (cDNA) using M-MLV RT kit
(MMLV, GIBCO/BRL). PCR amplification of cDNA and later a
nested-PCR were performed with two pairs of primers that
hybridize in a segment of the 5’ non-coding region of the HCV
genome, as is described elsewhere.25-27 Nested RT-PCR was
performed per duplicate in all samples and the reaction products were analyzed in gel electrophoresis.
Statistical analysis
Demographic data are reported as simple frequencies. The
95 % confidence interval for relevant frequencies was calculated with the adjusted Wald method. Age and S/CO ratios
are presented and analyzed as medians with minimum and
maximum, as these variables followed a non-normal distribution. Chi-square or Fisher exact test was used for nominal
variables in univariate analyses, as indicated. Student t test
was used to compare continuous, normally distributed variables. Mann-Whitney U test was performed when an ordinal
or scale non-parametric variable was distributed between two
groups. To find independent predictors for the presence of
diabetes mellitus, multivariate analyses were performed by
forward stepwise logistic regression. Adjusted odds ratios
(OR) with 95 % confidence intervals (CI) are provided. The
fitness of the model was evaluated by using the HosmerLemeshow goodness-of-fit test, which was considered as reliable if p was > 0.2. Statistical comparisons or interactions
with p < 0.05 were regarded as significant. All p values reported are two-sided. SPSS v. 17.0 (Chicago, Ill; USA) statistical
package was used for all the analyses.
Results
We studied 125 patients reactive to anti-HCV antibodies in at
least two occasions: 78 (62.4 %) women and 47 (37.6 %) men.
After inclusion, all patients received at least two qualitative
RT-PCR assays for confirmation of HCV viremia, and those
suitable for antiviral treatment received a quantitative assessment for viral load and genotyping. Mean age was 46.8 years
(range 21 to 82 years). There was only one patient with HBV
infection, confirmed by PCR testing, who had a negative
RT-PCR test for HCV. Of the 125 patients studied, 46 (36.8 %)
were false-positive cases (with low, although positive signal
in anti-HCV serology), with a repeatedly negative RT-PCR
for HCV-RNA. On the other hand, 79 (63.2 %) patients had
confirmed HCV infection by RT-PCR testing, and of them,
Rev Med Inst Mex Seguro Soc 2012; 50 (5): 481-486
14 (17.7 %, all with HCV 1a/1b genotypes) received interferonbased treatment, with 6 (42.8 %) patients who had cleared
the virus by the time they were re-assayed for HCV viremia.
As a result, 73 (58.4 %) of the 125 patients had a positive test
for HCV viremia in our laboratory, which includes 8 nonresponders to interferon-based therapy. Mean age of the
confirmed cases was higher than that of the HCV-negative
cases (49.2 vs. 42.6 years, respectively; p = 0.02). Age was
not significantly different between patients who received
interferon therapy and non-treated patients (48.2 vs. 49.4
years; respectively; p = 0.74).
In all, the frequency of T2DM was 17.6 % (95 % confidence
interval: 11.8–25.3 %; n = 22), which was significantly more
prevalent among patients with HCV viremia, than in patients
with no detectable HCV RNA in serum (23.3 % vs. 9.6 %,
respectively; p = 0.04). None (0 %) of the 6 responders (either
with early or sustained viral response) to interferon-based
therapy had T2DM, as compared with 2 (25 %) among the 8
non-responders). Patients with T2DM were significantly older than patients without diabetes (57.7 vs. 44.5 years, respectively; p < 0.001). Nevertheless, T2DM appeared to be more
prevalent in HCV-infected patients than the National Mexican
reference of 14.4 % (figure 1), especially for the age groups 50 to
59 and 60 to 69 years (table I). After multivariate analysis, controlled for viral status, among other variables, only age was
significantly associated with T2DM (table II). Advanced liver
disease (i.e., liver decompensation) was observed in 45 patients,
who were significantly older than patients without
decompensated liver disease (51.4 vs. 44.2 years, respectively;
p = 0.002). T2DM was significantly more prevalent among patients with advanced liver disease, than in compensated patients (28.9 % vs. 11.3 %, respectively; p = 0.013).
Discussion
In the present study, patients who had HCV viremia, either
because they had not received or did not respond to interferon-based therapy, had a high frequency of T2DM. Our
study was underpowered to detect a significant difference
on T2DM frequency between responders and non-responders to interferon-based treatment; however, it has been
previously noted that the risk of T2DM lowers after clearing
the virus.19,28 This represented an issue deserving in-depth
study in Mexico and Latin America. Chronic HCV infection
enables a state of inflammation, post-insulin receptor (i.e.,
type D) insulin resistance and impaired β-cell function.20,21,29,30
These factors together, impaired insulin secretion and action,
represent the condition sine qua non T2DM occurs. But the
reason that most HCV-infected patients (usually > 70 %)
actually will not develop diabetes, is a very interesting and
yet unresolved issue that may be more related to host factors than to viral characteristics.4 It represents a potential
483
4. Chiquete E et al. Type 2 diabetes mellitus in Mexican patients with chronic hepatitis C virus infection
Table I
Prevalence of type 2 diabetes mellitus across age groups, as compared with the Mexican standard
reference (Ensanut 2006) 22
Patients with
confirmed
past or present
viremia (n = 79)
%
Age decades
National Mexican
prevalence
%
20-29
3.3
0
0
0
0
30-39
8.5
6.3
0
0
0
40-49
16.5
3.0
4.0
4.2
4.5
50-59
31.1
32.4
40.0
47.6
44.4
60-69
32.75
46.7
50.0
50.0
55.6
70-97
26.1
20.0
25.0
25.0
25.0
area of research in molecular biology and genomics applied
to medicine.
The present report provides relevant clinical information
and hypotheses with potential issues to pursue. This study,
although exploratory in its nature, is different from most
publications about this issue in that only patients reactive
to anti-HCV antibodies were analyzed, and comparators (i.e.,
controls) of the frequency of T2DM were non-viral patients
within the same seropositive population, and still, an association was found between HCV infection and T2DM. In
most previous epidemiological studies, although large, do
not distinguish between seropositive patients to anti-HCV
antibodies and true infected persons with detectable viremia
by RT-PCR, and in some reports controls are healthy individuals negative to anti-HCV antibodies.8-21 It is difficult to
assess the pathophysiological relationship between HCV
infection and altered glucose metabolism when it is not clear
how many seropositive patients to anti-HCV antibodies are
in fact infected with HCV, if no confirmatory tests are
Table II
performed by molecular assays. The rate of false-positives
can be high in certain populations.24,25 This factor may
account, at least in part, for the wide variation on the frequency of T2DM in HCV-infected individuals across studies.
Interestingly, in the present report the frequency of T2DM
among HCV-infected patients is quite similar (≈ 22 %) to that
reported in previous Mexican studies addressing a similar
topic.5,6 However, in our report patients with diabetes were
older than those without this condition, which may confound
the magnitude of the association. This particular issue will
only be clarified with a sufficiently powered, large-scale
community-based study. Nonetheless, as compared with the
national reference, frequency of T2DM seems to be
consistently higher in the subgroups of patients with either
past or current HCV viremia. Furthermore, as it has been
described for the US population. 11 The older patients
presented in this paper had the highest difference in diabetes frequency, when compared with the population reference
within the same age group.
Multivariate analysis on factors associated with type 2 diabetes mellitus: a binary logistic regression
model.*
Variable
Age, each decade from 20 years
Constant
Patients with
current viremia
(n = 73)
%
Interferon-näive
patients with
current viremia
(n = 65)
%
All patients
reactive to antiHCV
antibodies (n = 125)
%
Regression coefficient
Standard error
Odds ratio
(95 % confidence interval)
p
0.86
0.24
2.36 (1.47-3.79)
< 0.001
–5.60
4.328
—
< 0.001
*Adjusted for gender, HCV viremia, liver decompensation, alcohol consumption, smoking habit and educational level. Hosmer-Lemeshow test for
goodness of fit in final step of the regression model: χ2 = 4.37, 1 df, p = 0.22
484
Rev Med Inst Mex Seguro Soc 2012; 50 (5): 481-486
5. Chiquete E et al. Type 2 diabetes mellitus in Mexican patients with chronic hepatitis C virus infection
Although clearly underpowered to detect small, but
clinically meaningful differences, this study represented the
largest focusing exclusively on patients reactive to anti-HCV
antibodies in Mexico.5,6 Nonetheless, important limitations
should be emphasized. The design of this study could not
account for several variables known to be associated with
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