HIPOALBUMINEMIA Y ASCITIS

SESION HIPOALBUMINEMIA
ROTACION PATOLOGIA CLINICA ENERO 2014
PRESENTADO POR : DR. HAUSTON FERNANDO BECERRA
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SESION ASCITIS
ROTACION PATOLOGIA CLINICA ENERO 2014
PRESENTADO POR : DR. HAUSTON FERNANDO BECERRA
MODULO MEDICINA INTERNA

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Two More Levels to Check for Diabetes Risk?

Fructosamine and glycated albumin levels could help predict risk of diabetes and microvascular complications, particularly when glycated hemoglobin (HbA1c) levels aren't reliable, researchers found.

Having levels above the 95th percentile of each measurement was associated with an increased risk of diabetes, and both tests were predictive of retinopathy and kidney disease,Elizabeth Selvin, PhD, of Johns Hopkins, and colleagues reported online in the Lancet Diabetes & Endocrinology.

In statistical analyses, however, HbA1c maintained the best predictive tool for development of diabetes, they noted.

HbA1c is the standard for monitoring glucose control and for diagnosing diabetes, but it may not be as accurate in all settings, such as anemia, recent transfusion, pregnancy, and kidney disease.

Fructosamine and glycated albumin could serve as alternative markers of short-term glycemic control (about 2 to 4 weeks) or could add complementary prognostic information to HbA1c, the researchers said.

The fructosamine assay is available in the U.S., but has limited use because of a lack of data on long-term outcomes. The glycated albumin panel is used in Japan, but isn't common in the U.S.

To assess the performance of fructosamine and glycated albumin for identifying people at risk of diabetes or other complications, Selvin and colleagues measured levels in blood samples from 11,348 patients without diabetes and 958 patients with the disease who participated in the Atherosclerosis Risk in Communities (ARIC) study.

They found that baseline fructosamine and glycated albumin levels were strongly associated with risk of diabetes, even after adjustment in multivariate analyses. For instance, fructosamine values above 95th percentile (above 264 mcmol/L) were significantly associated with diabetes (HR 2.61, 95% CI), as were glycated albumin values above the 95th (greater than 15.2%) percentile (HR 3.27).

Both measures were also significantly associated with increased risks of retinopathy and chronic kidney disease, they reported.

However, associations between HbA1c and incident diabetes were stronger than those for fructosamine or glycated albumin, Selvin and colleagues noted. And in C-statistic analyses, HbA1c outperformed both fructosamine and glycated albumin for prediction of incident diabetes (0.759 versus 0.706 and 0.703, respectively).

Still, they concluded that their findings "suggest that fructosamine and glycated albumin can be used to predict diabetes, chronic kidney disease, and retinopathy in the community, [can] add complementary information to HbA1c, and ... might be particularly useful in settings where HbA1c testing or interpretation is problematic."

Robert Cohen, MD, of the University of Cincinnati, and William Herman, MD, of the University of Michigan in Ann Arbor, wrote in an accompanying editorial that all three tests seem to work well, but it "remains to be seen how well they perform in individuals, especially for the diagnosis of diabetes."

"Although all three measures might work well for most patients, it will not always be obvious for whom these indirect measures of average glycemia do not work," they wrote.

In the meantime, they said, clinicians should "use multiple sources of information to asses glycemia and maintain a high index of suspicion when an indirect measure does not seem correct."

Tomado de: MedPage Today

Kristina Fiore

Selvin E, et al "Fructosamine and glycated albumin for risk stratification and prediction of incident diabetes and microvascular complications" Lancet Diabetes & Endocrinol 2014; DOI: 10.1016/S2213-8587(13)70199-2.

Intensive lifestyle interventions benefit patients with type 2 diabetes

Lifestyle interventions can have a number of positive effects in the management of type 2 diabetes.

It has been well documented in two landmark clinical trials on the prevention of diabetes that dietary changes and regular physical activity will prevent or delay the development of diabetes in high-risk individuals.

Landmark clinical trials

The Diabetes Prevention Project (DPP), a randomized controlled trial in patients with prediabetes, showed that 7% weight loss, achieved by a lifestyle modification program, reduced the 4-year cumulative incidence of diabetes by 58% vs. a placebo group that made no formal lifestyle changes. The program incorporated individual and group counseling sessions that encouraged a low-fat diet and at least 150 minutes of exercise (brisk walking) per week.

The Finnish Diabetes Prevention Study extended the DPP by looking at the reduction in the incidence of diabetes in high-risk, middle-aged (mean age, 55 years) adults at as much as 5 years post-intervention. The intervention included personal counseling sessions aimed at moderate (5%) weight loss achieved by a low-fat, high-fiber diet and moderate exercise for about 30 minutes per day. The average weight loss at 5 years was only 4.6 lb, but resulted in a lower incidence of diabetes in this population (23%) vs. placebo (11%).

Modest reductions in weight using a combination of dietary modifications and exercise resulted in significant reductions in the incidence of diabetes in high-risk individuals.

Look AHEAD

A more recent analysis of the Action for Health in Diabetes (Look AHEAD) study by Gregg and colleagues examined the association of a long-term intensive weight-loss intervention with the frequency of remission of type 2 diabetes. This was a randomized controlled trial involving more than 4,500 participants followed for 4 years. All participants had type 2 diabetes and a BMI of at least 25 at the beginning of the study. They were randomly assigned to intensive lifestyle intervention or a standard lifestyle intervention.

The intensive intervention involved weekly counseling for the first 6 months, then three sessions per month for 6 months, followed by two sessions per month for remainder of study. The primary aim of the intensive group was a reduction in total caloric intake to 1,200 kcal/day to 1,800 kcal/day, along with 175 minutes/week of exercise.

The standard group received three counseling sessions per year focusing on diet, exercise and social support. The results showed that the intensive intervention group lost significantly more weight and had greater fitness increases. The intensive group also was more likely to achieve remission of their diabetes vs. the control group (7.3% vs. 2%, respectively). It should be noted that more patients achieved partial remission than complete remission. This lends some support to more intensive lifestyle interventions than what is commonly done for many patients with type 2 diabetes. 

Tomado de: Endocrine Today, December 2013 .    James R. Taylor, PharmD, CDE

Inflammatory markers associated with IBD colon cancer risk

As C-reactive protein levels and erythrocyte sedimentation rates go up in patients with inflammatory bowel disease, the risk of colorectal cancer goes up, too, a finding that suggests a role for both as markers of colon cancer risk, Boston investigators reported in a prospective study published online Jan. 6 in Clinical Gastroenterology and Hepatology.

The team divided 3,145 IBD patients into quartiles based on median C-reactive protein (CRP) levels, and 4,008 others into quartiles based on median erythrocyte sedimentation rates (ESR), then followed them for a median of 6 years.

On multivariate analysis, there was a significant increase in the risk of colorectal cancer (CRC) across quartiles of CRP elevation (P fortrend = .017). Higher median ESR was also independently associated with higher risk of CRC across quartiles (P for trend = .007) (Clin. Gastroenterol. Hepatol. 2014 Jan. 6 [doi: 10.1016/j.cgh.2013.12.030]).

"This association adds another clinical variable to help stratify patients into risk categories. There is an important need to identify high-risk subgroups that may benefit from continued intensive surveillance strategies while allowing for less frequent colonoscopies in patients at low risk of CRC. We believe that our findings ... suggest that an individual patient’s severity of inflammation may be helpful in further personalizing surveillance recommendations," and might even help monitor other outcomes, including treatment response, said the authors, led by Dr. Ashwin Ananthakrishnan, a gastroenterologist at Massachusetts General Hospital, Boston.

After adjustment for age, sex, race, IBD type, and other factors, the patients in the highest CRP quartile had more than double the risk of colorectal cancer compared with those in the lowest quartile (OR 2.72, 95% CI 0.95-7.76). The strength of association was similar in men and women, and in Crohn’s disease and ulcerative colitis.

Similarly, patients in the highest ESR quartile had double the risk compared with those in the lowest (OR 2.06, 95% CI 1.14-3.74). The correlation was strongest in ulcerative colitis patients and men.

The median CRP values in each of the quartiles were 0.8, 2.7, 7.5, and 32.8 mg/L. In the ESR group, the median quartile values were 7, 14, 25, and 50 mm/hr.

Overall, 33 patients in the CRP cohort and 102 patients in the ESR cohort developed colorectal cancer at a median age of 55 years. The median number of CRP measurements was three, and median number of ESR measurements six. More than half the subjects were women, most were white, and ulcerative colitis was slightly more common than was Crohn’s disease.

Adjusting for number of colonoscopies, intensity of health care utilization, use of corticosteroids, and other factors did not change results for either the CRP or ESR cohorts.

The National Institutes of Health funded the work. The investigators have no disclosures.

Tomado de Internalmedicinenews.com

By: M. ALEXANDER OTTO, 

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New Early Detection Test for Prostate Cancer

More than 1 million men will undergo a prostate biopsy this year, but only about one-fifth of those biopsies will result in a cancer diagnosis.

The reason is that the traditional prostate cancer screening test – a blood test to measure prostate specific antigen, or PSA – does not give doctors a complete picture.

Now, the University of Michigan Health System has begun offering a new urine test called Mi-Prostate Score to improve on PSA screening for prostate cancer. The test incorporates three specific markers that could indicate cancer and studies have shown that the combination is far more accurate than PSA alone.

“Many more men have elevated PSA than actually have cancer but it can be difficult to determine this without biopsy. We need new tools to help patients and doctors make better decisions about what to do if serum PSA is elevated. Mi-Prostate Score helps with this,” says Scott Tomlins, M.D., Ph.D., assistant professor of pathology and urology at the University of Michigan.

Researchers validated the new test on nearly 2,000 urine samples. Mi-Prostate Score, or MiPS, was significantly more accurate than PSA alone for predicting cancer as well as predicting aggressive prostate cancer that is likely to grow and spread quickly.

Mi-Prostate Score developed from a discovery in the lab of Arul Chinnaiyan, M.D., Ph.D., in 2005 of a genetic anomaly that occurs in about half of all prostate cancers, an instance of two genes changing places and fusing together.

This gene fusion, T2:ERG, is believed to cause prostate cancer. Studies in prostate tissues show that the gene fusion almost always indicates cancer.

The new urine test looks for the T2:ERG fusion as well as another marker, PCA3. This is combined with serum PSA measure to produce a risk assessment for prostate cancer. The test also predicts risk for having an aggressive tumor, helping doctors and patients make decisions about whether to wait and monitor test levels or pursue immediate biopsy.

“This combination test is not designed to say definitively at diagnosis whether a man has aggressive prostate cancer, but it can provide a more accurate estimate of the likelihood of having cancer and the likelihood of that cancer being aggressive,” Tomlins says.

The test is available to anyone but requires a request from a doctor.

Prostate cancer statistics: 238,590 Americans will be diagnosed with prostate cancer this year and 29,720 will die from the disease, according to the American Cancer Society

University of Michigan Health System. "New early detection test for prostate cancer." ScienceDaily, 25 Sep. 2013. Web. 16 Jan. 2014