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Zhao Y, Lv X, Chen C, Li K, Wang Y, Liu J. The association between triglyceride-glucose index and hyperferritinemia in patients with type 2 diabetes mellitus. Hormones (Athens) 2023; 22:403-412. [PMID: 37233914 DOI: 10.1007/s42000-023-00453-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/12/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE To investigate the relationship between the triglyceride-glucose (TyG) index and serum ferritin (SF) levels in patients with type 2 diabetes mellitus (T2DM). METHODS A total of 881 T2DM patients were divided into T1(TyG index < 1.66), T2 (1.66 ≤ TyG index < 2.21), and T3 (TyG index ≥ 2.21) groups according to the tertiles of the TyG index. The differences in SF levels and the prevalence of hyperferritinemia (SF ≥ 300 ng/mL for male or SF ≥ 150 ng/mL for female) were compared. The independent correlations between the TyG index and SF, and between hyperferritinemia and TyG in T2DM patients were analyzed, respectively. RESULTS SF levels in male T2DM patients were higher in the T3 group (250.12 ng/mL) than in the T1 and T2 groups (180.45 and 196.56 ng/mL, both p < 0.01),while in female patients with T2DM,SF levels were higher in the T3 group (157.25 ng/mL) than in the T1 group (111.06 ng/mL, p < 0.05).The prevalence of hyperferritinemia in male T2DM patients was higher in the T3 group (31.3%) than those in the T1 and T2 groups (10.4% and 17.3%, both p < 0.05).The TyG index was positively correlated with SF levels in T2DM patients (R = 0.178, p < 0.001).TyG index was independently and positively correlated with SF levels after adjusting for confounders (β = 0.097, 95%CI [2.870,38.148], p = 0.023).The TyG index was positively independently correlated with hyperferritinemia in male T2DM patients (OR = 1.651, 95%CI [1.120,2.432], p = 0.011). CONCLUSIONS In parallel with increasing TyG index SF levels gradually increased. The TyG index was positively correlated with SF levels in patients with T2DM and was positively correlated with hyperferritinemia in male T2DM patients.
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Affiliation(s)
- Yangting Zhao
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Xiaoyu Lv
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Chongyang Chen
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Kai Li
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Yawen Wang
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Jingfang Liu
- The First Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China.
- Department of Endocrinology, the First Hospital of Lanzhou University, Donggang West Road, Lanzhou, Gansu, 730000, People's Republic of China.
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Glucose Homeostasis and Assessment of β-Cell Function by 3-hour Oral Glucose Tolerance (OGTT) in Patients with β-Thalassemia Major with Serum Ferritin below 1,000 ng/dL: Results from a Single ICET-A Centre. Mediterr J Hematol Infect Dis 2023; 15:e2023006. [PMID: 36660350 PMCID: PMC9833310 DOI: 10.4084/mjhid.2023.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023] Open
Abstract
Aims The primary aim of this study was to evaluate retrospectively the glucose homeostasis and surrogate indices of insulin sensitivity and resistance, during a 3-hour oral glucose tolerance test (OGTT), in β-thalassemia major patients (β-TM) with serum ferritin (SF) below 1,000 ng/mL. Patients and methods The retrospective cohort study evaluated the medical records of 24 β-TM patients from 2010 to 2022. At the year of study the mean age of patients was 31.0 ± 4.1 (20-37.11) years; 13 (54.1%) were females. The most commonly used iron chelator was deferoxamine (DFO: 75%), followed by deferiprone (DFP:12.5%) and deferasirox (DFX: 12.5%). Insulin sensitivity and resistance indices were derived from OGTT. A liver iron concentration (LIC) < 3 mg/g d.w. and a global heart T2* value > 20 ms were considered as conservative cut-off values for insignificant iron overload (IOL). Results The mean SF levels in the whole study cohort population at the age of evaluation was 549.6 ± 232.3 ng/mL. Based on the SF levels, two groups were identified: Group A (N = 14) < 500 ng/mL and Group B (N=10) 500-1,000 ng/mL. Normal glucose tolerance (NGT) during OGTT was observed in 4 patients of Group A (28.5 %) and in 5 patients of Group B (50%) (P: 0.29). The remaining 15/24 patients (62.5%) had glucose dysregulation (GD). The mean age at starting iron chelation therapy (ICT) and the mean SF peak in Group A versus Group B were significantly higher in group A. The GD was associated with significantly attenuated IGI (first phase of insulin response) and impaired oral disposition index (oDI). Hypogonadotropic hypogonadism (HH) was the most common associated endocrine complication in both groups of patients. Conclusions This study showed that efficient iron chelation monotherapy in patients with β-TM and SF < 1,000 ng/ml did not entirely prevent glucose metabolism disorders, abnormalities of insulin secretion and sensitivity, and development of acquired hypogonadism.
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Shah F, Huey K, Deshpande S, Turner M, Chitnis M, Schiller E, Yucel A, Moro Bueno L, Oliva EN. Relationship between Serum Ferritin and Outcomes in β-Thalassemia: A Systematic Literature Review. J Clin Med 2022; 11:4448. [PMID: 35956067 PMCID: PMC9369259 DOI: 10.3390/jcm11154448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/10/2022] Open
Abstract
Among the difficulties of living with β-thalassemia, patients frequently require blood transfusions and experience iron overload. As serum ferritin (SF) provides an indication of potential iron overload, we conducted a systematic literature review (SLR) to assess whether SF levels are associated with clinical and economic burden and patient-reported outcomes (PROs). The SLR was conducted on 23 April 2020 and followed by analysis of the literature. Dual-screening was performed at the title, abstract, and full-text levels using predefined inclusion and exclusion criteria. Ten studies identified by the SLR were eligible for inclusion in the analysis. Seven studies were conducted in Europe, and most were prospective or retrospective in design. The patient populations had a median age of 20.7-42.6 years, with a percentage of men of 38-80%. Sparse data were found on the correlation between SF levels and mortality, and hepatic, skeletal, and cardiac complications; however, in general, higher SF levels were associated with worsened outcomes. The bulk of the evidence reported on the significant association between higher SF levels and endocrine dysfunction in its many presentations, including a 14-fold increase in the risk of diabetes for patients with persistently elevated SF levels. No studies reporting data on PROs or economic burden were identified by the SLR. SF levels provide another option for prognostic assessment to predict a range of clinical outcomes in patients with β-thalassemia.
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Affiliation(s)
- Farrukh Shah
- Department of Haematology, Whittington Health NHS Foundation Trust, London N19 5NF, UK
| | - Krystal Huey
- Bristol Myers Squibb, Princeton, NJ 08648, USA; (K.H.); (A.Y.); (L.M.B.)
| | | | - Monica Turner
- Evidera, Waltham, MA 02451, USA; (M.T.); (M.C.); (E.S.)
| | | | - Emma Schiller
- Evidera, Waltham, MA 02451, USA; (M.T.); (M.C.); (E.S.)
| | - Aylin Yucel
- Bristol Myers Squibb, Princeton, NJ 08648, USA; (K.H.); (A.Y.); (L.M.B.)
| | - Luciana Moro Bueno
- Bristol Myers Squibb, Princeton, NJ 08648, USA; (K.H.); (A.Y.); (L.M.B.)
| | - Esther Natalie Oliva
- Hematology Unit, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, 89124 Reggio Calabria, Italy;
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Mayneris-Perxachs J, Mousa A, Naderpoor N, Fernández-Real JM, de Courten B. Plasma Phospholipids with Long-Chain Polyunsaturated Fatty Acids and Dihydroceramides at the Crossroads of Iron Stores and Insulin Resistance. Mol Nutr Food Res 2020; 64:e1901055. [PMID: 31945260 DOI: 10.1002/mnfr.201901055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/18/2019] [Indexed: 11/07/2022]
Abstract
SCOPE Iron plays an important role in the pathogenesis of insulin resistance (IR) and type 2 diabetes. Recent studies suggest a role of specific lipids in the induction of IR, but the potential relationships between iron and lipid metabolites in relation to IR have not been explored. Therefore, the aim of the study is to evaluate the association among iron, IR, and the lipidome. METHODS AND RESULTS The plasma lipidome, IR, parameters of iron metabolism, and several cytokines and adipokines in 65 overweight/obese participants are measured. Measurements of IR correlate positively with ferritin, a measure of iron storage (r = 0.35, p = 0.005), and negatively with adiponectin (r = -0.30, p = 0.02). The serum ferritin/adiponectin ratio has a stronger association with IR (r = 0.41, p < 0.001). From multivariate analyses adjusted for age, sex, and BMI, several phospholipids containing long chain polyunsaturated fatty acids (PUFA) with 20-22 carbons (phosphatidylcholines, phosphatidylethanolamines, phosphatidylinositols, and a phosphatidylserine), are positively associated with ferritin and the ferritin/adiponectin ratio. Two dihydroceramides (Cer(18:0/22:0), Cer(18:0/24:0)) and several diglycerides and triglycerides, mainly comprised of C14:0, C16:0, C18:0, C18:1, and C18:2, also have positive correlations with ferritin and the ferritin/adiponectin ratio. CONCLUSIONS The positive associations between these lipid species and ferritin or the ferritin/adiponectin ratio suggest a potential crosstalk between iron and lipid metabolism in obesity and IR.
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Affiliation(s)
- Jordi Mayneris-Perxachs
- Department of Endocrinology, Diabetes and Nutrition, Hospital of Girona "Dr Josep Trueta" , University of Girona and CIBERobn Pathophysiology of Obesity and Nutrition, Instituto de Salud Carlos III, Madrid, Spain
| | - Aya Mousa
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Negar Naderpoor
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - José-Manuel Fernández-Real
- Department of Endocrinology, Diabetes and Nutrition, Hospital of Girona "Dr Josep Trueta" , University of Girona and CIBERobn Pathophysiology of Obesity and Nutrition, Instituto de Salud Carlos III, Madrid, Spain
| | - Barbora de Courten
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Adamska A, Łebkowska A, Krentowska A, Adamski M, Kowalska I. The Association Between Serum Ferritin Concentration and Visceral Adiposity Estimated by Whole-Body DXA Scan in Women With Polycystic Ovary Syndrome. Front Endocrinol (Lausanne) 2019; 10:873. [PMID: 31969861 PMCID: PMC6960176 DOI: 10.3389/fendo.2019.00873] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 11/28/2019] [Indexed: 12/23/2022] Open
Abstract
Objective: Women with polycystic ovary syndrome (PCOS) are characterized by insulin resistance and higher prevalence of obesity. Serum ferritin is increased in obesity and is associated with insulin resistance. The aim of the present study was to evaluate the relationships between serum ferritin concentration with insulin resistance and body composition estimated by dual-energy X-ray absorptiometry (DXA) in PCOS women in comparison to the control group. Patients and Methods: One hundred four women were enrolled to the study-65 women with PCOS and 39 women matched for age and BMI as a control group. Serum ferritin concentration and oral glucose tolerance test (OGTT) were performed. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. DXA was performed to estimate fat, fat-free mass, and visceral adipose tissue (VAT). Results: Women with PCOS have higher serum concentration of ferritin (p = 0.002), insulin at baseline (p = 0.03), at 60 min of OGTT (p = 0.01), at 120 min of OGTT (p = 0.004), HOMA-IR (p = 0.03), and VAT (p = 0.0001) in comparison to the control group. We observed a relationship of serum ferritin with insulin concentration at baseline (r = 0.25, p = 0.04) and at 120 min of OGTT (r = 0.31, p = 0.01) and with HOMA-IR (r = 0.30, p = 0.01) in the PCOS group. We noticed an association between serum ferritin concentration and VAT (r = 0.42, p = 0.001), trunk fat mass (r = 0.25, p = 0.04), and android fat mass (r = 0.25, p = 0.04) in the PCOS group. Multiple regression analysis revealed that ferritin (p = 0.02, β = 0.17), insulin at baseline (p = 0.001, β = 0.30), glucose at the 120 min of OGTT (p = 0.007, β = 0.26), and triglycerides (p = 0.001, β = 0.33) were independent predictors of VAT amount in PCOS women. Conclusions: Elevated serum ferritin concentration is connected with insulin resistance as well as with DXA-estimated VAT, android, and trunk fat mass in PCOS women, and could be a marker of metabolic dysfunction.
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Affiliation(s)
- Agnieszka Adamska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Białystok, Białystok, Poland
- *Correspondence: Agnieszka Adamska
| | - Agnieszka Łebkowska
- Department of Internal Medicine and Metabolic Diseases, Medical University of Białystok, Białystok, Poland
| | - Anna Krentowska
- Department of Internal Medicine and Metabolic Diseases, Medical University of Białystok, Białystok, Poland
| | - Marcin Adamski
- Faculty of Computer Science, Bialystok University of Technology, Białystok, Poland
| | - Irina Kowalska
- Department of Internal Medicine and Metabolic Diseases, Medical University of Białystok, Białystok, Poland
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Toro-Huamanchumo CJ, Urrunaga-Pastor D, Guarnizo-Poma M, Lazaro-Alcantara H, Paico-Palacios S, Pantoja-Torres B, Ranilla-Seguin VDC, Benites-Zapata VA. Triglycerides and glucose index as an insulin resistance marker in a sample of healthy adults. Diabetes Metab Syndr 2019; 13:272-277. [PMID: 30641711 DOI: 10.1016/j.dsx.2018.09.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/11/2018] [Indexed: 12/12/2022]
Abstract
AIM To assess the association between elevated triglycerides/glucose index (TGI) and insulin resistance (IR) or hyperinsulinemia after oral glucose tolerance test (OGTT) in a sample of healthy adults. METHODS We conducted an analytical cross-sectional study in euthyroid non-diabetic adults, who attended the outpatient service of a private clinic in Lima-Peru during the 2012-2016 period. Participants were categorized in two groups according to the presence or absence of elevated TGI, IR or hyperinsulinemia after OGTT. A TGI value ≥ 8.65 was considered as elevated. We defined IR as a Homeostasis Model Assessment (HOMA-IR) value ≥ 2.28 and hyperinsulinemia after OGTT as a serum insulin value ≥ 80μU/mL after 120 min of 75-g glucose intake. We elaborated crude and adjusted Poisson regression models to assess the association between elevated TGI and IR or hyperinsulinemia after OGTT. The reported association measure was the prevalence ratio (PR) with their respective 95% confidence intervals (95%CI). RESULTS We analyzed 118 individuals, the average age was 37.5 ± 11.3 years, 21 (17.8%) were males and the median BMI was 22.7 ± 1.6 kg/m2. The prevalence of elevated TGI was 25.4% (n=30) while the prevalence of IR and hyperinsulinemia after OGTT was 24.6% (n=29) and 17.0% (n=20) respectively. In the adjusted model, elevated TGI was associated with both IR (aPR=6.36; 95%CI: 3.41-11.86) and hyperinsulinemia after OGTT (aPR=4.19; 95%CI: 1.81-9.70). CONCLUSIONS We found that elevated TGI was associated with both IR markers in a sample of euthyroid adults without T2DM and with a normal BMI. The simplicity of the TGI calculation makes it the first-choice alternative when the hyperinsulinemic-euglycemic clamp or HOMA-IR are not available.
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Affiliation(s)
- Carlos J Toro-Huamanchumo
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru.
| | - Diego Urrunaga-Pastor
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru.
| | | | | | | | | | | | - Vicente A Benites-Zapata
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru.
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Pantoja-Torres B, Toro-Huamanchumo CJ, Urrunaga-Pastor D, Guarnizo-Poma M, Lazaro-Alcantara H, Paico-Palacios S, Del Carmen Ranilla-Seguin V, Benites-Zapata VA. High triglycerides to HDL-cholesterol ratio is associated with insulin resistance in normal-weight healthy adults. Diabetes Metab Syndr 2019; 13:382-388. [PMID: 30641729 DOI: 10.1016/j.dsx.2018.10.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/09/2018] [Indexed: 12/11/2022]
Abstract
AIM To evaluate the association between high triglyceride/HDL-cholesterol (TG/HDL-C) ratio and insulin resistance (IR) or hyperinsulinemia after oral glucose tolerance test (OGTT) in normal-weight healthy adults. METHODS We carried out an analytical cross-sectional study in euthyroid non-diabetic adults, who attended the outpatient service of a private clinic in Lima-Peru from 2012 to 2016. Participants were divided in two groups according to the presence or absence of high TG/HDL-C ratio, IR or hyperinsulinemia after OGTT. TG/HDL-C ratio values ≥ 3 were considered as high. IR was defined as a Homeostasis Model Assessment (HOMA-IR) value ≥ 2.28 and hyperinsulinemia after OGTT as a serum insulin value ≥ 80μU/mL after 120 min of 75-g glucose intake. We elaborated crude and adjusted Poisson generalized linear models to evaluate the association between high TG/HDL-C ratio and IR or hyperinsulinemia after OGTT and reported the prevalence ratio (PR) with their respective 95% confidence intervals (95%CI). RESULTS We analyzed the data of 118 individuals. Prevalence of high TG/HDL-C ratio was 17.8% (n = 21) while the prevalence of IR and hyperinsulinemia after OGTT was 24.6% (n = 29) and 17.0% (n = 20), respectively. TG/HDL-C-ratio values were positively correlated with HOMA-IR (r = 0.498; p < 0.01) and serum insulin after OGTT (r = 0.326; p < 0.001). In the adjusted model, high TG/HDL-C ratio was associated with both IR (aPR = 3.16; 95%CI: 1.80-5.77) and hyperinsulinemia after OGTT (aPR = 2.36; 95%CI: 1.20-4.63). CONCLUSIONS High TG/HDL-C ratio was associated with both IR markers used in our study, appearing to be a clinically useful tool to assess IR in euthyroid normal-weight adults without type 2 diabetes mellitus.
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Affiliation(s)
| | - Carlos J Toro-Huamanchumo
- Universidad San Ignacio de Loyola, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru.
| | - Diego Urrunaga-Pastor
- Universidad San Ignacio de Loyola, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru.
| | | | | | | | | | - Vicente A Benites-Zapata
- Universidad San Ignacio de Loyola, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru.
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Urrunaga-Pastor D, Guarnizo-Poma M, Moncada-Mapelli E, Aguirre LG, Lazaro-Alcantara H, Paico-Palacios S, Pantoja-Torres B, Benites-Zapata VA. High free triiodothyronine and free-triiodothyronine-to-free-thyroxine ratio levels are associated with metabolic syndrome in a euthyroid population. Diabetes Metab Syndr 2018; 12:155-161. [PMID: 29254889 DOI: 10.1016/j.dsx.2017.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/12/2017] [Indexed: 12/24/2022]
Abstract
AIMS To determine the association between free triiodothyronine (FT3), free thyroxine (FT4) and free-triiodothyronine-to-free-thyroxine ratio (FT3/FT4) levels and Metabolic Syndrome (MetS). MATERIALS AND METHODS We carried out an analytical cross-sectional study in euthyroid adults of both sexes, who attended the outpatient service of a private clinic in Lima-Peru during the 2014-2016 period. Participants were divided into tertiles (low, intermediate and high) according to their FT3, FT4, and FT3/FT4 ratio values. MetS was defined when three or more metabolic criteria were met by the participants. ROC curves were constructed, and Youden's Index were used to identify the optimal cut-points of each thyroid marker. We elaborated crude/adjusted Poisson regression models to evaluate the association between the thyroid markers and the presence of MetS. The reported association measure was the prevalence ratio (PR) with their respective 95% confidence intervals (95% CI). RESULTS We analyzed 245 participants, the average age was 38.5 ± 10.3 years, 29.8% were males, and the prevalence of MetS was 31%. In the adjusted Poisson regression models, the prevalence of MetS was higher among the high FT3 tertile compared to the low tertile (aPR = 2.01; 95% CI: 1.22-3.34). The prevalence of MetS was higher among the intermediate FT3/FT4 ratio tertile and the high FT3/FT4 ratio tertile compared to the low tertile, (aPR = 1.78; 95% CI: 1.02-3.10) and (aPR = 2.80; 95% CI: 1.67-4.72); respectively. The highest areas under the curve (AUC) were found for FT3 and FT3/FT4 ratio with areas of 0.654 (95% CI: 0.58-0.73) and 0.649 (95% CI: 0.57-0.72); respectively. CONCLUSION Elevated levels of FT3 and FT3/FT4 ratio were associated with MetS in a euthyroid population.
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Affiliation(s)
- Diego Urrunaga-Pastor
- Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Universidad de San Martín de Porres, Lima, Peru.
| | | | - Enrique Moncada-Mapelli
- Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Universidad de San Martín de Porres, Lima, Peru.
| | - Luis G Aguirre
- Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Universidad de San Martín de Porres, Lima, Peru.
| | | | | | | | - Vicente A Benites-Zapata
- Centro de Investigación en Epidemiología Clínica y Medicina Basada en Evidencias, Instituto de Investigación, Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru.
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