Juan Manuel Toro

Strict glycaemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomised clinical trial

IntroductionCritically ill patients can develop hyperglycaemia even if they do not have diabetes. Intensive insulin therapy decreases morbidity and mortality rates in patients in a surgical intensive care unit (ICU) and decreases morbidity in patients in a medical ICU. The effect of this therapy on patients in a mixed medical/surgical ICU is unknown. Our goal was to assess whether the effect of intensive insulin therapy, compared with standard therapy, decreases morbidity and mortality in patients hospitalised in a mixed ICU.MethodsThis is a prospective, randomised, non-blinded, single-centre clinical trial in a medical/surgical ICU. Patients were randomly assigned to receive either intensive insulin therapy to maintain glucose levels between 80 and 110 mg/dl (4.4 to 6.1 mmol/l) or standard insulin therapy to maintain glucose levels between 180 and 200 mg/dl (10 and 11.1 mmol/l). The primary end point was mortality at 28 days.ResultsOver a period of 30 months, 504 patients were enrolled. The 28-day mortality rate was 32.4% (81 of 250) in the standard insulin therapy group and 36.6% (93 of 254) in the intensive insulin therapy group (Relative Risk [RR]: 1.1; 95% confidence interval [CI]: 0.85 to 1.42). The ICU mortality in the standard insulin therapy group was 31.2% (78 of 250) and 33.1% (84 of 254) in the intensive insulin therapy group (RR: 1.06; 95%CI: 0.82 to 1.36). There was no statistically significant reduction in the rate of ICU-acquired infections: 33.2% in the standard insulin therapy group compared with 27.17% in the intensive insulin therapy group (RR: 0.82; 95%CI: 0.63 to 1.07). The rate of hypoglycaemia (≤ 40 mg/dl) was 1.7% in the standard insulin therapy group and 8.5% in the intensive insulin therapy group (RR: 5.04; 95% CI: 1.20 to 21.12).ConclusionsIIT used to maintain glucose levels within normal limits did not reduce morbidity or mortality of patients admitted to a mixed medical/surgical ICU. Furthermore, this therapy increased the risk of hypoglycaemia.Trial Registrationclinicaltrials.gov Identifiers: 4374-04-13031; 094-2 in 000966421

Guía de práctica clínica para la prevención, detección temprana, diagnóstico, tratamiento y seguimiento de las dislipidemias: tratamiento farmacológico con estatinas

Objective To evaluate the impact of statin therapy on the incidence and recurrence of cardiovascular and cerebrovascular events (primary and secondary prevention), the levels of lipid fractions and the incidence of side effects (cancer and diabetes mellitus) in people with hypercholesterolemia.

Asociación entre títulos de anticuerpos anticardiolipinas y eventos trombóticos

Resumen Introduccion la trombosis es la manifestacion principal del sindrome antifosfolipido (SAF); los marcadores serologicos de esta entidad son los anticuerpos anticardiolipinas (aCL), la anti-s2 glicoproteina 1 y el anticoagulante lupico. Aun se discute si los titulos de aCL o la presencia de un “segundo hit” son factores de riesgo para trombosis. Objetivo evaluar la asociacion entre fenomenos tromboticos vasculares con la presencia y los titulos de aCL; ademas del papel de otros factores protromboticos. Material y metodo estudio descriptivo transversal. Se revisaron historias clinicas de pacientes con sospecha clinica de SAF y con al menos una medicion de titulos de aCL, se evaluo la presencia o no de eventos tromboticos y de comorbilidades (segundo hit). Resultados historias clinicas de 49 pacientes, 33 con un total de 36 eventos tromboticos de los cuales 23 ocurrieron en lechos venosos y 13 en lechos arteriales. Aunque la mayoria de los pacientes con titulos de aCL > 20 GLP o MLP se encontraban en el grupo de trombosis, no se encontro asociacion significativa entre la presencia de trombosis y los titulos de aCL; como tampoco entre trombosis y la existencia de otras comorbilidades. Conclusiones los hallazgos encontrados permiten sugerir la mayor frecuencia de eventos tromboticos en pacientes con titulos de aCL

Cost-effectiveness analysis of ticagrelor compared to clopidogrel for the treatment of patients with acute coronary syndrome in Colombia

INTRODUCTION Acute coronary syndrome is one of the most frequent medical emergencies in developing countries. OBJECTIVE To determine, from the perspective of the Colombian health system, the cost-effectiveness of ticagrelor compared to clopidogrel for the treatment of patients with acute coronary syndrome. MATERIALS AND METHODS We conducted a cost-effectiveness analysis from the perspective of the Colombian health system comparing ticagrelor and clopidogrel for the treatment of patients with acute coronary syndrome. To estimate the expected costs and outcomes, a Markov model was constructed in which patients could remain stable without experiencing new cardiovascular events, suffer from a new event, or die. For the baseline case, a 10-year time horizon and a discount ratio of 3% for costs and benefits were adopted. The transition probabilities were extracted from the PLATO (Platelet Inhibition and Patient Outcomes) clinical trial. Vital statistics were drawn from the Departmento Administrativo Nacional de Estadística (DANE) and additional information from Colombian patients included in the Access registry. To identify and measure resource use, a standard case was built by consulting guidelines and protocols. Unit costs were obtained from Colombian rate lists. A probabilistic sensitivity analysis was conducted in which costs were represented by a triangular distribution, and the effectiveness through a beta distribution. RESULTS In the base case, the additional cost per quality-adjusted life-year gained with ticagrelor was COP

CARDIOLOGÍA DEL ADULTO – ARTÍCULO ORIGINALGuía de práctica clínica para la prevención, detección temprana, diagnóstico, tratamiento y seguimiento de las dislipidemias: tratamiento farmacológico con estatinasClinical practice guidelines for prevention, early detection, diagnose, treatment and follow-up of dyslipidemias: farmacological treatment with statins

28,411,503. The results were sensitive to changes in the time horizon and the unit cost of clopidogrel. For a willingness-to-pay equivalent to three times the Colombian per capita gross domestic product, the probability of ticagrelor being cost-effective was 75%. CONCLUSIONS Ticagrelor is a cost-effective strategy for the treatment of patients with acute coronary syndrome in Colombia.

Hipercolesterolemia familiar: Artículo de revisión

Objective To evaluate the impact of statin therapy on the incidence and recurrence of cardiovascular and cerebrovascular events (primary and secondary prevention), the levels of lipid fractions and the incidence of side effects (cancer and diabetes mellitus) in people with hypercholesterolemia.