Diabetic myonecrosis in a patient with hepatic cirrhosis: a case report and review of the literature

Introduction: Diabetic myonecrosis was first reported by Angervall and Stener in 1965. In its classical clinical expression, it affects type 1 diabetes mellitus patients with long-standing poor metabolic control and advanced chronic microvascular complications. A sudden-onset of severe pain in the region of the involved muscle, usually the quadriceps, is the typical clinical manifestation. Magnetic resonance imaging (MRI) confirms the clinical diagnosis; in some cases of diagnostic uncertainty, a muscle biopsy may be required. Case Presentation: We present the case of a 38 year-old Hispanic male from Mexico, with alcohol-induced hepatic cirrhosis (Child-Pugh C/MELD 45) and type 2 diabetes mellitus admitted to the emergency room due to hepatic encephalopathy with intense pain and an increase in volume of the left thigh. MRI showed edema and inflammatory changes of the quadriceps muscle with a hyperintense signal on T2-weighted images; in addition, there was a subacute hematoma. Conclusion: To the best of our knowledge, this is the first case of diabetic myonecrosis associated with and complicated by advanced hepatic cirrhosis reported in the literature

Aptitud de los alumnos de pregrado de la carrera de Medicina ante dos modelos de evaluación: El caso de Endocrinología.

Antecedentes: La Facultad de Medicina de la UANL inició en agosto del 2006 un nuevo plan de estudios y un modelo educativo basado en el aprendizaje y en la participación más intensa del alumno. Esta modificación en la estrategia de formar a los futuros médicos requiere ser evaluada científicamente con el propósito de medir si los cambios esperados con la implementación del plan de estudios y del modelo educativo, están ocurriendo. Objetivo: Comparar la aptitud de los alumnos del curso de pregrado de endocrinología ante dos métodos de evaluación. Método: Comparación de dos exámenes como proceso de evaluación ante dos planteamientos académicos: el actual (basado en la aplicación del conocimiento, casos clínicos) y el próximo anterior (basado en la memorización de conocimientos). Se contrastó la aptitud de los alumnos del nuevo plan de estudios (n = 74) vs. los alumnos del plan anterior (n = 137), ante el mismo examen. Resultados: Los alumnos del nuevo plan de estudios tuvieron una aptitud casi idéntica al ser evaluados con el examen actual y con el aplicado en ciclos anteriores (73.4 + 7.8 vs. 72.9 + 10.7, respectivamente) p = 0.2553. El porcentaje de aprobación fue de un 71 vs. 67%. Al comparar la aptitud de los alumnos del plan actual y el anterior ante un mismo examen, la aptitud fue muy favorable en el grupo de alumnos del nuevo plan de estudios (74.7 ± 10.7 vs. 56.0 ± 9.3), p< 0.0001. Conclusiones: La combinación de un modelo educativo centrado en el aprendizaje, en una acentuada participación del alumno en la clase, en una forma de evaluación que incentiva el estudiar la clase diaria y en la aplicación de exámenes dirigidos a evaluar la aplicación del conocimiento como en la vida real de un médico, son los aspectos que debemos fortalecer en el proceso de formación de nuestros futuros médicos

Ovarian and Adrenal Androgens and Their Link to High Human Chorionic Gonadotropin Levels: A Prospective Controlled Study

Background. Although the association between human chorionic gonadotropin (hCG) and hyperandrogenism was identified more than 40 years ago, relevant questions remain unanswered. Design and Methods. We conducted a prospective, longitudinal, and controlled study in 23 women with a diagnosis of a complete hydatidiform mole (HM). Results. All participants completed the study. Before HM evacuation mean hCG was markedly higher in the cases than in the control group (P≤0.001). Free testosterone (T) and dehydroepiandrosterone sulfate (DHEA-S) were found to be higher in the cases (2.78 ± 1.24 pg/mL and 231.50 ± 127.20 μ/dL) when compared to the control group (1.50 ± 0.75 pg/mL and 133.59 ± 60.69 μ/dL) (P=0.0001 and 0.001), respectively. There was a strong correlation between hCG and free T/total T/DHEA-S concentrations (r=0.78; P≤0.001, r=0.74;  P≤0.001, and r=0.71;  P≤0.001), respectively. In the cases group 48 hours after HM evacuation, hCG levels were found to be significantly lower when compared to initial levels (P=0.001) and free T and DHEA-S declined significantly (P=0.0002 and 0.009). Conclusion. Before uterus evacuation, hCG, free T, and DHEA-S levels were significantly higher when compared with controls finding a strong correlation between hCG and free T/DHEA-S levels. Forty-eight hours after HM treatment hCG levels declined and the difference was lost. A novel finding of our study is that in cases, besides free T, DHEA-S was also found to be significantly higher and both the ovaries and adrenal glands appear to be the sites of this androgen overproduction

Alopecia androgenética en varones jóvenes: un indicador clínico temprano de resistencia a la insulina

Estudios epidemiológicos han asociado a la alopecia androgenética (AGA) con enfermedad cardiovascular severa a una edad temprana. Diabetes mellitus y otras enfermedades relacionadas a la resistencia a la insulina tienen mayor prevalencia en hombres con alopecia, según un estudio poblacional finlandés. La asociación entre AGA en hombres y resistencia a insulina también se ha evaluado en los últimos años; sin embargo, deficiencias metodológicas serias en estos estudios tornan confusas las implicaciones clínicas de sus resultados. Para estudiar la asociación entre la AGA y la resistencia a la insulina realizamos un estudio de casos y controles en varones jóvenes, pareados para edad y peso. Para participar en este estudio se eligieron a ochenta casos y sus controles respectivos, varones, con edades entre 18 y 35 años, con AGA en estadio clínico igual o superior a III, según la clasificación de Hamilton-Norwood. Se encontró una interrelación estadísticamente significativa entre la obesidad y la alopecia para la insulina, el índice de HOMA, los lípidos y la testosterona libre cuando se analizó por ANOVA para tendencias a través de los grupos, cuando éstos se estratificaron de acuerdo a la presencia de alopecia y obesidad. La identificación de AGA en varones jóvenes obliga a tener una sospecha de un riesgo mayor de resistencia a la insulina y, por ende, más tarde, a sus consecuencias en la vida para el desarrollo de enfermedades como la hipertensión arterial, la diabetes mellitus y las dislipidemias. En conclusión, nuestro estudio da soporte para recomendar la evaluación de resistencia a la insulina y sus hallazgos clínicos, o la enfermedad cardiovascular relacionada en todos los varones jóvenes con AGA moderada o severa, según la clasificación de Hamilton-Norwood. Epidemiological studies have associated androgenetic alopecia (AGA) with severe cardiovascular disease at an early age. In a Finnish population study, diabetes mellitus and other diseases related to insulin resistance were more prevalent in men with alopecia. However, serious methodological flaws in these studies make for confusing clinical implications of their results. To study the association between AGA and insulin resistance, we conducted a case-control study in young men, matched for age and weight. Eighty cases were selected and their respective controls, male, aged between 18 and 35, with AGA clinical stage III or greater according to the Hamilton-Norwood classification. We found a significant relationship between obesity and alopecia for insulin, HOMA index, lipid, and free testosterone when analyzed by ANOVA for trend across groups, when these were stratified according to the presence of alopecia and obesity. In conclusion, the identification of AGA in young men should force a suspicion of an increased risk of insulin resistance and, consequently, the subsequent development later in life of diseases such as hypertension, diabetes mellitus and dyslipidemia

Carotid Intima-Media Thickness in Patients with Subclinical Hypothyroidism: A Prospective Controlled Study

Purpose: The association between subclinical hypothyroidism (SCH) and cardiovascular risk, particularly with a TSH &lt;10 µIU/ml, remains controversial. The objective of our study was to assess the association between SCH and cardiovascular risk through carotid intima-media thickness, and alternatively, to evaluate its change after treatment with levothyroxine. Methods: A total of 54 individuals were included in the study: 18 with SCH; 18 with overt hypothyroidism (OH); and 18 healthy controls (HC). The carotid intima-media thickness was measured in each group. In SCH, follow-up was performed at three and six months after the start of levothyroxine treatment. Results: The mean age of the total population at baseline was 35.8 years. The median TSH in SCH was 6.15 µIU/ml. The carotid intima-media thickness (mean and standard deviation) was greater in SCH in comparison to the HC group: right common carotid artery (RCCA), 0.486 ± 0.106 mm and 0.413 ± 0.075 mm in SCH and HC, respectively, p=0.01 and left common carotid artery (LCCA), 0.511 ± 0.144 mm and 0.427 mm ± 0.090 in SCH and HC, respectively, p=0.03). In patients with SCH, there was a decrease in the carotid intima-media thickness after treatment with levothyroxine (RCCA and LCCA, p &lt;0.05 at three and six months). Conclusions: There was an association between increased carotid intima-media thickness in patients with SCH in comparison with HC, even with a TSH &lt;10 µIU/ml. The increase was reversed with levothyroxine therapy. The association of this increased thickness with important cardiovascular outcomes remains uncertain and should be evaluated in future studies