ABSTRACT
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Abstract Recent studies have reported the occurrence of thrombotic phenomena or coagulopathy in patients with COVID-19. There are divergent positions regarding the prevention, diagnosis, and treatment of these phenomena, and current clinical practice is based solely on deductions by extension from retrospective studies, case series, observational studies, and international guidelines developed prior to the pandemic. In this context, the aim was to generate a group of recommendations on the prevention, diagnosis and management of thrombotic complications associated with COVID-19. Methods: A rapid guidance was carried out applying the GRADE Evidence to Decision (EtD) frameworks and an iterative participation system, with statistical and qualitative analysis. Results: 31 clinical recommendations were generated focused on: a) Coagulation tests in symptomatic adults with suspected infection or confirmed SARS CoV-2 infection; b) Thromboprophylaxis in adults diagnosed with COVID-19 (Risk scales, thromboprophylaxis for outpatient, in-hospital management, and duration of thromboprophylaxis after discharge from hospitalization), c) Diagnosis and treatment of thrombotic complications, and d) Management of people with previous indication of anticoagulant agents. Conclusions: Recommendations of this consensus guide clinical decision-making regarding the prevention, diagnosis, and treatment of thrombotic phenomena in patients with COVID-19, and represent an agreement that will help decrease the dispersion in clinical practices according to the challenge imposed by the pandemic.
Subject(s)
Humans , Male , Female , Adult , SARS-CoV-2 , COVID-19 , Embolism and Thrombosis , Consensus , AnticoagulantsABSTRACT
Resumen En la actualidad los profesionales de la salud son el recurso más valioso con el que cuenta cada país para combatir la enfermedad COVID-19. Las tasas de contagio intrahospitalario son altas y ligadas al acto de atención sanitaria. Las medidas de protección por parte de los empleadores son fundamentales para el cuidado de los que cuidan. La situación de pánico generada por el temor a contraer o transmitir la enfermedad, siendo primeros respondedores en la línea de combate ante la pandemia, ha sido amplificada por varios factores. Cuestiones como presión psicológica, carga laboral, mediatización, aspectos judiciales, desprotección, falta de descanso, nuevos roles, discriminación y agresiones son algunas de las situaciones a las que se los profesionales se deben enfrentar.(Acta Med Colomb 2020; 45. DOI:https://doi.org/10.36104/amc.2020.1975).
Abstract Today, healthcare professionals are a country's most valuable resource for combating COVID-19. Hospital contagion rates are high and linked to the practice of health care. Employers' protective measures are essential in caring for the caregivers. The panic resulting from a fear of contracting or transmitting the disease, with first responders being at the front line of the battle against the pandemic, has been amplified by various factors. Issues such as psychological pressure, workload, media coverage, legal aspects, lack of protection, lack of rest, new roles, discrimination and assaults are some of the situations faced by these professionals.(Acta Med Colomb 2020; 45. DOI:https://doi.org/10.36104/amc.2020.1975).
Subject(s)
COVID-19 , Health Personnel , Aggression , Pandemics , Social DiscriminationABSTRACT
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The exponential increase in the request for laboratory tests of 25-Hydroxyvitamin D or [25 (OH) D has ignited the alarms and generated a strong call for attention, since it may reflect deficiencies in the standardization of clinical practice and in the use non-systematic scientific evidence for decision-making in real life, which allows to analyze the indications of the test, its frequency, interpretation and even to assess the impact for health systems, especially when contrasted with the minimum or almost. No effects of the strategy of screening or supplying indiscriminately to the general population, without considering a comprehensive clinical assessment of risks and needs of people. From a purely public health impact point of view, the consequence of massive and unspecified requests is affecting most of the health systems and institutions at the global level. The primary studies that determined average population intake values have been widely used in the formulation of recommendations in Clinical Practice Guidelines, but unfortunately misinterpreted as cut points to diagnose disease and allow the exaggerated prescription of nutritional substitution. The coefficient of variation in routine tests to measure blood levels of 25 (OH) D is high (28%), decreasing the overall accuracy of the test and simultaneously, increasing both the falsely high and falsely low values. The most recent scientific evidence analyzes and seriously questions the usefulness and the real effect of the massive and indiscriminate practice of prescribing vitamin D without an exhaustive risk analysis. The available evidence is insufficient to recommend a general substitution of vitamin D to prevent fractures, falls, changes in bone mineral density, incidence of cardiovascular diseases, cerebrovascular disease, neoplasms and also to modify the growth curve of mothers' children. They received vitamin D as a substitute during pregnancy. The recommendations presented in the document are based on the critical analysis of current evidence and the principles of good clinical practice and invite to consider a rational use of 25 (OH) D tests in the context of a clinical practice focused on people and a comprehensive assessment of needs and risks. The principles of good practice suggest that clinicians may be able to justify that the results of the 25 (OH) D test strongly influence and define clinical practice and modify the outcomes that interest people and impact their health and wellness. Currently there is no clarity on how to interpret the results, and the relationship between symptoms and 25 (OH) D levels, which may not be consistent with the high prevalence of vitamin D deficiency reported. For this reason, it is suggested to review the rationale of the request for tests for systematic monitoring of levels of 25 (OH) D or in all cases where substitution is performed. Consider the use of 25 (OH) D tests within the comprehensive evaluation of people with suspicion or confirmation of the following conditions: rickets, osteomalacia, osteoporosis, hyper or hypoparathyroidism, malabsorption syndromes, sarcopenia, metabolic bone disease.
ABSTRACT
RESUMEN Se presenta la segunda parte de las recomendaciones latinoamericanas para el manejo de la Hipertensión Arterial (HTA) en adultos. En una primera fase se han descripto los aspectos más relevantes de la epidemiología, aspectos fisiopatológicos, cómo hacer diagnóstico, pautas terapéuticas, urgencias y emergencias hipertensivas, poblaciones especiales, hipertensión refractaria y la aplicación de las guías en la vida real. En esta segunda parte, se emiten recomendaciones respondiendo a preguntas específicas para prevención primaria, secundaria, terciaria y cuaternaria. En general pocas recomendaciones al respecto del manejo de la hipertensión arterial surgen desde la clínica médica/ medicina interna, a pesar de dos situaciones: la mayoría de los pacientes con hipertensión arterial son evaluados y manejados por los clínicos, y la clínica médica es la especialidad que permite la mirada holística e integrada de los problemas de salud del adulto, permitiendo agregar el enfoque biográfico al biológico, comprender e interpretar no solo el problema de salud sino sus causas y consecuencias (que muchas veces suelen corresponder a diferentes parénquimas, lo cual en el modelo fragmentado haría transitar al paciente por distintas especialidades). El bajo porcentaje de pacientes hipertensos controlados obliga a todos los profesionales involucrados en el manejo de los mismos a optimizar recursos y detectar problemas que se asocien a un control deficitario como la sub utilización del tratamiento farmacológico, baja tasa de pacientes tratados con estrategia combinada (la mayoría de los pacientes actualmente recibe monoterapia), falta de prescripción adecuada de los cambios en el estilo de vida, baja adherencia terapéutica e inercia clínica. En la presente publicación se presentan recomendaciones efectuadas por especialistas en clínica médica / medicina interna para el manejo de la hipertensión arterial en adultos, respondiendo preguntas de prevención primaria, secundaria, terciaria, y cuaternaria.
ABSTRACT The second part of the Latin American recommendations for the management of Arterial Hypertension (HTA) in adults is presented. In a first phase, the most relevant aspects of epidemiology, physiopathological aspects, how to diagnose, therapeutic guidelines, hypertension emergencies, special populations, refractory hypertension and the application of guides in real life have been described. In this second part, recommendations are issued answering specific questions for primary, secondary, tertiary and quaternary prevention. In general, few recommendations regarding the management of arterial hypertension arise from the medical clinic / internal medicine, despite two situations: the majority of patients with hypertension are evaluated and managed by the clinicians, and the medical clinic is the specialty that allows the holistic and integrated look of the health problems in adults, allowing to add the biographical approach to the biological, to understand and interpret not only the health problem but its causes and consequences (which often correspond to different parenchyma, which in the fragmented model would make the patient move through different specialties). The low percentage of controlled hypertensive patients forces all the professionals involved in the management of them to optimize resources and detect problems that are associated with a deficit control such as the under utilization of pharmacological treatment, low rate of patients treated with combined strategy (the most patients currently receive monotherapy), lack of adequate prescription of changes in lifestyle, low therapeutic adherence and clinical inertia. This publication presents recommendations made by specialists in medical clinic/internal medicine for the management of hypertension in adults, answering primary, secondary, tertiary and quaternary prevention questions.