Access to paediatric cardiac surgery in Colombia: a population-based study.

OBJECTIVES: Globally congenital heart disease mortality is declining, yet the proportion of infant deaths attributable to heart disease rises in Colombia and other middle-sociodemographic countries. We aimed to assess the accessibility of paediatric cardiac surgery (PCS) to children <18 years of age in 2016 in the South American country of Colombia. METHODS: In Bogotá, Colombia, a multi-national team used cross-sectional and retrospective cohort study designs to adapt and evaluate 4 health system indicators at the national level: first, the population with timely geographic access to an institution providing PCS; second, the number of paediatric cardiac surgeons; third, this specialized procedure volume and its national distribution; and fourth, the 30-day perioperative mortality rate after PCS in Colombia. RESULTS: Geospatial mapping approximates 64% (n = 9 894 356) of the under-18 Colombian population lives within 2-h drivetime of an institution providing PCS. Twenty-eight cardiovascular surgeons report performing PCS, 82% (n = 23) with formal training. In 2016, 1281 PCS procedures were registered, 90% of whom were performed in 6 of the country's 32 departments. National non-risk-adjusted all-cause 30-day perioperative mortality rate after PCS was 2.73% (n = 35). CONCLUSIONS: Colombia's paediatric population had variable access to cardiac surgery in 2016, largely dependent upon geography. While the country may have the capacity to provide timely, high-quality care to those who need it, our study enables future comparative analyses to measure the impact of health system interventions facilitating healthcare equity for the underserved populations across Colombia and the Latin American region.

Quality of life in children with infrequent congenital heart defects: cohort study with one-year of follow-up.

BACKGROUND: The evidence regarding patient related outcomes in children with infrequent congenital heart defects (I-CHD) is very limited. We sought to measure quality of life (QoL) in children with I-CHD, and secondarily, to describe QoL changes after one-year of follow-up, self-reported by children and through their caregivers' perspective. METHODS: We assembled a cohort of children diagnosed with an I-CHD in a cardiovascular referral center in Colombia, between August 2016 and September 2018. At baseline and at one-year follow-up, a clinical psychology assessment was performed to establish perception of QoL. The Pediatric Quality of Life Inventory (PedsQL) 4.0 scale was used in both general and cardiac modules for patients and for their caregivers. We used a Mann-Whitney U test to compare scores for general and cardiac modules between patients and caregivers, while a Wilcoxon test was used to compared patients' and caregivers' baseline and follow-up scores. Results are presented as median and interquartile range. RESULTS: To date, QoL evaluation at one-year follow-up has been achieved in 112/157 patients (71%). Self-reported scores in general and cardiac modules were higher than the QoL perceived through their caregivers, both at baseline and after one-year of follow-up. When compared, there was no statistically significant difference in general module scores at baseline between patients (median = 74.4, IQR = 64.1-80.4) and caregivers scores (median = 68.4, IQR = 59.6-83.7), p = 0.296. On the contrary, there was a statistical difference in baseline scores in the cardiac module between patients (median = 79.6, IQR = 69.7-87.4) and caregivers (median = 73.6, IQR = 62.6-84.3), p = 0.019. At one-year of follow-up, scores for the general module between patients (median = 72.8, IQR = 59.2-85.9) and caregivers (median = 69.9, IQR = 58.1-83.7) were not statistically different (p = 0.332). Finally, a significant difference was found for cardiac module scores between patient (median = 75.0, IQR = 67.1-87.1) and caregivers (median = 73.1, IQR = 59.5-83.8), p = 0.034. CONCLUSIONS: QoL in children with I-CHD can be compromised. However, children have a better perception of their QoL when compared with their caregivers' assessments. To provide high-quality care, besides a thorough clinical evaluation, QoL directly elicited by the child should be an essential aspect in the integral management of I-CHD.

Fortalecimiento de la capacidad institucional para la equidad en la investigación en salud: enseñanzas de América Latina y el Caribe

[EXTRACTO]. Actualmente se presta cada vez más atención a los determinantes políticos, económicos, ambientales y sociales de la salud. Esto ha generado una mayor demanda de investigación para la salud a nivel mundial que incluya a los países de ingresos bajos y medianos, con objeto de alcanzar los objetivos de desarrollo sostenible de las Naciones Unidas. Además del financiamiento, se necesitan suficientes recursos humanos e infraestructura para que estos países lleguen a ser asociados en un plano de igualdad con las instituciones de investigación internacionalmente reconocidas de los países de ingresos altos que establecen las agendas de investigación, y para garantizar que el programa de investigación mundial refleje sus necesidades. Las limitaciones en la capacidad de investigación y las grandes disparidades existentes entre los países de ingresos altos y los de ingresos bajos y medianos en cuanto a su capacidad de producir y usar la investigación para la salud han contribuido a producir una falta de evidencia que permita fundamentar la práctica clínica y orientar las políticas sanitarias regionales y mundiales. Esto ha perpetuado las desigualdades en la salud...

[EXTRACTO]. Existe atualmente um maior reconhecimento dos determinantes políticos, econômicos, ambientais e sociais da saúde. A consequência disso foi um aumento da demanda por pesquisa em saúde global, com participação dos países de baixa e média renda, para cumprir os objetivos de desenvolvimento sustentável das Nações Unidas. Além de financiamento, são necessários recursos humanos e infraestrutura suficientes para que esses países se tornem parceiros em igualdade de condições com instituições de pesquisa internacionalmente reconhecidas em países de alta renda que definem as agendas de pesquisa e cuidam para que o programa global de pesquisa em saúde reflita suas necessidades. A limitada capacidade de pesquisa e as grandes disparidades entre países de alta renda e países de baixa e média renda no tocante à capacidade de produzir e usar pesquisas para a saúde contribuíram para a falta de evidências para informar a prática e orientar as políticas de saúde regionais e globais, o que perpetuou as desigualdades em saúde...

Attributed costs of health care-associated infections in a Colombian hospital, 2011- 2015 / Costos atribuidos a las infecciones asociadas con la atención en salud en un hospital de Colombia, 2011-2015

Introduction: The cost analysis of infections associated with health care represents a challenge for the health system in Colombia given their determinants. Objective: To determine the factors related to the increase and variability in the costs of hospital care for infections associated with health care in a fourth-level hospital in Bogotá from 2011 to 2015. Materials and methods: The costs of the care for 292 patients were analyzed including each of the activities carried out since the suspicion of the infectious disease until its resolution. These costs were standardized to the value of the Instituto de Seguros Sociales tariff manual adjusted by the annual consumer price index for health until 2014. The factors related to the increase in management costs were identified using a conditional logistic regression model. Results: A hospital stay of nine days or more prior to the infection was a factor associated with the increase of direct costs in the management of infections associated with health care (OR=2.06; 95% CI: 1.11-3.63). The median cost of the infections was COP $1.190.879. The antibiotic treatment represented 41% of the total value of the treatment, followed by laboratory tests with a cost equivalent to 13.5%. Conclusions: We found a relationship between the cost of the management of infections associated with health care and the hospital stay prior to their appearance. The pathological antecedents of the patients were not related to the increase in the cost.

Introducción. El análisis de los costos derivados de las infecciones asociadas con la atención en salud representa un desafío para el sistema de salud en Colombia dados sus factores determinantes. Objetivo. Determinar los factores relacionados con el aumento y la variabilidad de los costos de la atención hospitalaria por las infecciones asociadas con la atención en salud en un hospital de cuarto nivel de Bogotá, entre el 2011 y el 2015. Materiales y métodos. Se analizaron los costos de la atención de 292 pacientes, los cuales se estimaron para cada una de las actividades realizadas desde el momento de sospechar el cuadro infeccioso hasta su resolución. Dichos costos se estandarizaron según el valor del manual tarifario del Instituto de Seguros Sociales, ajustándolos por el índice de precios al consumidor para salud hasta el año 2014. Se determinaron los factores relacionados con el aumento del costo del manejo mediante un modelo logístico condicional. Resultados. La estancia hospitalaria de nueve días o más antes de la infección, se asoció con el aumento del costo directo del manejo de las infecciones relacionadas con la atención en salud (odds ratio, OR=2,06; IC95% 1,11-3,63). El costo medio del manejo de las infecciones fue de COP $1.190.879. Los antibióticos representaron el 41 % del valor total del tratamiento, seguidos de los exámenes de laboratorio, con un costo equivalente al 13,5 %. Conclusión. Se encontró una relación entre el costo del manejo de las infecciones asociadas con la atención en salud y la estancia hospitalaria previa a su aparición. Los antecedentes patológicos de los pacientes no se relacionaron con el aumento de los costos.

Costos atribuidos a las infecciones asociadas con la atención en salud en un hospital de Colombia, 2011-2015 / Attributed costs of health care-associated infections in a Colombian hospital, 2011- 2015

Resumen Introducción. El análisis de los costos derivados de las infecciones asociadas con la atención en salud representa un desafío para el sistema de salud en Colombia dados sus factores determinantes. Objetivo. Determinar los factores relacionados con el aumento y la variabilidad de los costos de la atención hospitalaria por las infecciones asociadas con la atención en salud en un hospital de cuarto nivel de Bogotá, entre el 2011 y el 2015. Materiales y métodos. Se analizaron los costos de la atención de 292 pacientes, los cuales se estimaron para cada una de las actividades realizadas desde el momento de sospechar el cuadro infeccioso hasta su resolución. Dichos costos se estandarizaron según el valor del manual tarifario del Instituto de Seguros Sociales, ajustándolos por el índice de precios al consumidor para salud hasta el año 2014. Se determinaron los factores relacionados con el aumento del costo del manejo mediante un modelo logístico condicional. Resultados. La estancia hospitalaria de nueve días o más antes de la infección, se asoció con el aumento del costo directo del manejo de las infecciones relacionadas con la atención en salud (odds ratio, OR=2,06; IC95% 1,11-3,63). El costo medio del manejo de las infecciones fue de COP $1.190.879. Los antibióticos representaron el 41 % del valor total del tratamiento, seguidos de los exámenes de laboratorio, con un costo equivalente al 13,5 %. Conclusión. Se encontró una relación entre el costo del manejo de las infecciones asociadas con la atención en salud y la estancia hospitalaria previa a su aparición. Los antecedentes patológicos de los pacientes no se relacionaron con el aumento de los costos.

Abstract Introduction: The cost analysis of infections associated with health care represents a challenge for the health system in Colombia given their determinants. Objective: To determine the factors related to the increase and variability in the costs of hospital care for infections associated with health care in a fourth-level hospital in Bogotá from 2011 to 2015. Materials and methods: The costs of the care for 292 patients were analyzed including each of the activities carried out since the suspicion of the infectious disease until its resolution. These costs were standardized to the value of the Instituto de Seguros Sociales tariff manual adjusted by the annual consumer price index for health until 2014. The factors related to the increase in management costs were identified using a conditional logistic regression model. Results: A hospital stay of nine days or more prior to the infection was a factor associated with the increase of direct costs in the management of infections associated with health care (OR=2.06; 95% CI: 1.11-3.63). The median cost of the infections was COP $1.190.879. The antibiotic treatment represented 41% of the total value of the treatment, followed by laboratory tests with a cost equivalent to 13.5%. Conclusions: We found a relationship between the cost of the management of infections associated with health care and the hospital stay prior to their appearance. The pathological antecedents of the patients were not related to the increase in the cost.

Endoscopic subcutaneous component separation as an adjunct to abdominal wall reconstruction.

BACKGROUND: Proper defect closure during abdominal wall reconstruction (AWR) is a key to improving cosmetic and functional results, and reducing morbidity. We have completed the initial prospective evaluation of a technique we previously described and published: endoscopic subcutaneous anterior component separation (ACS) as an adjunct to mainly laparoscopic AWR. We now present the long-term clinical and imaging follow-up results. STUDY DESIGN: Data were prospectively collected over a 3-year period (2012-2015) on patients who underwent AWR with endoscopic ACS. Inclusion criteria included the following: defects of 6-15 cm that are longer than wider; no skin dystrophy; no loss of domain; no active infection; no previous multiple, complex repairs; no previous multiple mesh repairs; and no high probability of severe adhesions. All patients were followed up clinically at 3, 6, and 12 months postoperatively and then annually. All patients underwent CT scanning of the abdominal wall (sagittal, axial, coronal, and 3D reconstruction) at 3 months and 1 year postoperatively and then annually. RESULTS: Twenty consecutive patients underwent adjunctive endoscopic ACS: 17 laparoscopic AWRs, 2 open repairs, and 1 hybrid repair. Up to 38 months (mean 21 months) of follow-up, there were no ventral hernia recurrences or de novo hernias at the ACS site. One patient experienced partial primary closure failure. Morbidity consisted in one case each of hematoma, seroma, and transient neuralgia. Cosmetic results and patient satisfaction were excellent. CONCLUSION: We confirmed that endoscopic subcutaneous ACS is a safe, effective, reliable, reproducible technique that facilitates primary closure of defects during AWR in selected patients.

Perioperative Aspirin for Prevention of Venous Thromboembolism: The PeriOperative ISchemia Evaluation-2 Trial and a Pooled Analysis of the Randomized Trials.

BACKGROUND: The PeriOperative ISchemia Evaluation-2 (POISE-2) trial compared aspirin with placebo after noncardiac surgery. METHODS: The authors randomly assigned 10,010 patients undergoing noncardiac surgery to receive 200 mg aspirin or placebo 2 to 4 h before surgery and then 100 mg aspirin daily or placebo daily for up to 30 days after surgery. Herein, the authors report the effect of aspirin on venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, as well as an updated pooled analysis of randomized trials of antiplatelet therapy for VTE prevention in noncardiac surgery patients. RESULTS: Six thousand five hundred forty-eight patients (65.4%) received anticoagulant prophylaxis. VTE occurred in 53 patients (1.1%) allocated to aspirin and in 60 patients (1.2%) allocated to placebo (hazard ratio, 0.89; 95% CI, 0.61 to 1.28). Major or life-threatening bleeding occurred in 312 patients (6.3%) allocated to aspirin and in 256 patients (5.1%) allocated to placebo (hazard ratio, 1.22; 95% CI, 1.04 to 1.44). Concomitant use of anticoagulant prophylaxis did not modify the effect of aspirin on VTE or bleeding. Pooled analysis of the POISE-2 and Pulmonary Embolism Prevention trials demonstrated that symptomatic VTE occurred in 173 (1.3%) of 13,724 patients allocated to aspirin and in 246 (1.8%) of 13,730 patients allocated to placebo (odds ratio, 0.71; 95% CI, 0.56 to 0.89; heterogeneity P = 0.27; I = 17%); the impact of aspirin was very similar in those who did and did not receive pharmacologic prophylaxis. Pooled estimates for symptomatic VTE were similar to the pooled estimates for any deep vein thrombosis and pulmonary embolism from the POISE-2 trial, Pulmonary Embolism Prevention trial, and the Antiplatelet Trialists' Collaboration meta-analysis. CONCLUSIONS: Aspirin in the POISE-2 trial did not reduce VTE, but two thirds of patients received anticoagulant prophylaxis, there were few VTE events, and results were consistent with a wide range of aspirin effects. A pooled analysis of the randomized trials demonstrates evidence for the efficacy of aspirin for VTE prevention in hospitalized surgical patients.

Differences by Altitude in the Frequency of Congenital Heart Defects in Colombia.

More evidence is needed that links the diagnosis of different congenital heart diseases (CHD) identified after birth, with intermediate altitudes above sea level in geographically and ethnically diverse populations. Our aim was to estimate relative frequencies of CHD diagnosis by altitude and gender in the pediatric population of 12 cities in Colombia. This was a cross-sectional study based on the information collected between 2008 and 2013 in Colombia, during annual congenital heart disease (CHD) case detection campaigns in the post-natal period. All children underwent physical examination, pulse-oximetry, and echocardiography. The odds ratio (OR) was used as the summary statistic to assess associations with altitude in the relative frequency of CHD diagnosis. Data from 5900 children who attended the campaigns were evaluated (54.3 % male), out of which 3309 (56.1 %) were diagnosed with CHD. There were statistically significant differences in the relative distribution of the different CHD by city altitude and gender (p < 0.0001). When compared with sea level, altitudes between 1285 and 3000 m above sea level were associated with increased Patent Ductus Arteriosus (PDA) (ORmh 1.68, 95 % CI 1.34-2.09; p < 0.0001) and left ventricular outflow tract obstruction (LVOTO) diagnoses (ORmh 2.06, 95 % CI 1.63-2.61; p < 0.0001), while the opposite was true for right ventricular outflow tract (RVOTO) diagnosis (OR 0.60; 95 % CI 0.49-0.74, p < 0.0001). These associations were not modified by gender differences. In a geographically and ethnically diverse population, altitudes between 1285 and 3000 m above sea level carried an independent and clinically important excess diagnostic risk of PDA and of LVOTO, when compared to all other CHD.

Combination inhaled steroid and long-acting beta2-agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease.

BACKGROUND: The long-acting bronchodilator tiotropium and single-inhaler combination therapy of inhaled corticosteroids and long-acting beta2-agonists (ICS/LABA) are commonly used for maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). Combining these treatments, which have different mechanisms of action, may be more effective than administering the individual components. OBJECTIVES: To assess relative effects of the following treatments on markers of exacerbations, symptoms, quality of life and lung function in patients with COPD.• Tiotropium plus LABA/ICS versus tiotropium.• Tiotropium plus LABA/ICS versus LABA/ICS. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register of Trials (April 2015), ClinicalTrials.gov (www.ClinicalTrials.gov), the World Health Organization (WHO) trials portal and reference lists of relevant articles. SELECTION CRITERIA: We included parallel, randomised controlled trials (RCTs) lasting three months or longer conducted to compare ICS and LABA combination therapy in addition to inhaled tiotropium versus tiotropium alone or combination therapy alone. DATA COLLECTION AND ANALYSIS: We independently assessed trials for inclusion, then extracted data on trial quality and outcome results. We contacted study authors to ask for additional information. We collected trial information on adverse effects. MAIN RESULTS: Tiotropium plus LABA/ICS versus tiotropiumWe included six studies (1902 participants) with low risk of bias that compared tiotropium in addition to inhaled corticosteroid and long-acting beta2-agonist combination therapy versus tiotropium alone. Investigators found no statistically significant differences in mortality between treatments (odds ratio (OR) 1.80, 95% confidence interval (CI) 0.55 to 5.91; two studies; 961 participants), a reduction in all-cause hospitalisations with the use of combined therapy (tiotropium + LABA/ICS) (OR 0.61, 95% CI 0.40 to 0.92; two studies; 961 participants; number needed to treat for an additional beneficial outcome (NNTB) 19.7, 95% CI 10.75 to 123.41). The effect on exacerbations was heterogeneous among trials and was not meta-analysed. Health-related quality of life measured by St. George's Respiratory Questionnaire (SGRQ) showed a statistically significant improvement in total scores with use of tiotropium + LABA/ICS compared with tiotropium alone (mean difference (MD) -3.46, 95% CI -5.05 to -1.87; four studies; 1446 participants). Lung function was significantly different in the combined therapy (tiotropium + LABA/ICS) group, although average benefit with this therapy was small. None of the included studies included exercise tolerance as an outcome.A pooled estimate of these studies did not show a statistically significant difference in adverse events (OR 1.16, 95% CI 0.92 to 1.47; four studies; 1363 participants), serious adverse events (OR 0.86, 95% CI 0.57 to 1.30; four studies; 1758 participants) and pneumonia (Peto OR 1.62, 95% CI 0.54 to 4.82; four studies; 1758 participants). Tiotropium plus LABA/ICS versus LABA/ICSOne of the six studies (60 participants) also compared combined therapy (tiotropium + LABA/ICS) versus LABA/ICS therapy alone. This study was affected by lack of power; therefore results did not allow us to draw conclusions for this comparison. AUTHORS' CONCLUSIONS: In this update, we found new moderate-quality evidence that combined tiotropium + LABA/ICS therapy compared with tiotropium plus placebo decreases hospital admission. Low-quality evidence suggests an improvement in disease-specific quality of life with combined therapy. However, evidence is insufficient to support the benefit of tiotropium + LABA/ICS for mortality and exacerbations (moderate- and low-quality evidence, respectively). Of note, not all participants enrolled in the included studies would be candidates for triple therapy according to current international guidance.Compared with the use of tiotropium plus placebo, tiotropium + LABA/ICS-based therapy does not increase undesirable effects such as adverse events or serious non-fatal adverse events.

Factors associated with Allergic Rhinitis in Colombian subpopulations aged 1 to 17 and 18 to 59.

BACKGROUND: Several studies have shown variations in the prevalence of allergic rhinitis (AR) around the world, and different potential predisposing factors. More studies are needed on risk factors, specifically in developing countries. This study explored the association of several factors and AR among urban residents in six cities of Colombia. METHODOLOGY: A cross-sectional study and a nested case-control study were carried out between 2009 and 2010 involving two Colombian subpopulations: children/adolescents and adults. Cases were affirmative respondents to "In the past 12 months, have you (or your child) had a problem with sneezing or a running or blocked nose, when you (or your child) did not have a cold or the flu?" "Controls" were subjects who never had been diagnosed with asthma, AR or atopic eczema by a physician, and whom did not report any symptoms in the past twelve months. Weighted logistic regression was used to assess the association of different factors with case/control status. RESULTS: Factors associated with AR in children/adolescents were family history of AR, acetaminophen consumption and high socioeconomic status. Among adults, family history of asthma, AR and atopic eczema, and cetaminophen consumption were associated with AR. Consumption of cereals among children/adolescents and eating eggs among adults showed protective associations. CONCLUSIONS: Our findings suggest the presence of previously unknown cultural, environmental and family factors associated with the presence of AR in Colombia.

Evaluación económica de la denervación simpática renal: simplicidad, todavía no / Economic evaluation of renal sympathetic denervation: Simplicity, not yet

Al sector salud colombiano se le asignan recursos finitos y es preciso escoger entre muchos posibles usos competitivos. En esta situación de recursos limitados (pero igual que en cualquier otro país), los recursos no alcanzan para ofertar a todos los usuarios del sector, todo el armamentario humano y tecnológico conocido; el considerarlo es una imposibilidad lógica, filosófica, y matemática. La complejidad a la que se ve abocado el sector es, entonces, balancear tres situaciones de manera simultánea, claramente en conflicto: a) disponer, casi de inmediato, de muchas intervenciones que mejoran y/o prolongan la vida; b) proveer acceso al sistema a la mayor cantidad posible de ciudadanos y c) mantener los costos de operación del sistema dentro de límites manejables. ¿Cuál es entonces la mejor forma de asignar los recursos existentes en el sector, con base en evidencias, para lograr el máximo beneficio de la población? Esta pregunta es el área de estudio y de aplicación de las evaluaciones económicas de la salud, y poder cumplir con su función social de soportar decisiones muchas veces difíciles y controversiales. Para estos análisis, los investigadores tienen un armamentario disponible. La herramienta de uso más común es el análisis de costo-efectividad, en el que se comparan los efectos clínicos de diferentes intervenciones (en medidas de morbilidad o mortalidad) contra sus costos monetarios. Aunque más compleja, otra herramienta derivada de la previa es el análisis de costo-utilidad (más amplio que el anterior e indicado cuando las intervenciones afectan tanto la calidad como la duración de la vida), donde una medida de tiempo, usualmente un año de vida, se cualifica por la calidad (o discapacidad) experimentadas con las diferentes intervenciones, y se deriva simultáneamente de los principales efectos clínicos observados.

Factores de riesgo cardiovascular y de enfermedades crónicas en población caficultora / Risk factors for cardiovascular and chronic diseases in a coffee-growing population

Objetivos: Estimar la prevalencia de los factores de riesgo cardiovascular y de enfermedades crónicas en población caficultora colombiana. Métodos: Estudio transversal, entre febrero y noviembre de 2007. Muestreo multietápico y por conglomerados, 55 veredas de 13 municipios, 2 516 encuestas. Cuestionarios recomendados por OPS, mediciones antropométricas y bioquímicas. Análisis descriptivos univariados y bivariados, IC95%, pruebas de significan-cia, comparación con estudios previos. Resultados: La prevalencia de fumadores actuales fue 21,1 % (IC95%: 19,2-23,3), sedentarismo 31,2 % (IC95%: 27,8-32,6), personas que consumen al día menos de 5 porciones entre frutas y verduras 86,3 % (IC95%: 84,4-87,9), consumo eleva-do de alcohol 2,2 % (IC95%: 1,6-3,2), hipertensión arterial 26,2 % (IC95%: 23,9-28,6), diabetes 4,6 % (IC95%: 3,6-5,8), hiperlipidemia 62,1 % (IC95%: 59,5-64,7), sobrepeso y obesidad 42,9 % (IC95%: 40,4-45,5). El 85 % tenían al menos 2 o más factores de riesgo simultáneamente. Sedentarismo, diabetes, hiperlipidemia y sobrepeso/obesidad fue mayor en mujeres (p<0,001). Consumo de alcohol y taba-quismo fue mayor en hombres (p<0,001). Edad, estado civil, educación, ingresos y sistema de salud estuvieron relacionados con los factores de riesgo estudiados. Conclusiones: Se aportan nuevos conocimientos a la escasa información disponi-ble en poblaciones rurales latinoamericanas. En comparación con el segundo es-tudio nacional de factores de riesgo de enfermedades crónicas (ENFREC II) no se encontraron avances importantes en disminución de la prevalencia de factores de riesgo. Se requieren estudios adicionales para profundizar en los determinantes sociales y de los sistemas de salud, que expliquen los hallazgos de este estudio.

Objectives: Estimating the prevalence of cardiovascular and chronic disease risk factors in a Colombian coffee-growing population. Methods: This cross-sectional study was carried out from February to November 2007. Multistage conglomerate sampling of 55 rural areas in 13 municipalities led to 516 people being surveyed. The questionnaires used were recommended by PAHO (anthropometric and biochemical measurements). The resulting data was subjected to univariate and bivariate descriptive analysis using 95 % CI, significan-ce tests and comparison with previous studies. Results: There was 21.1 % (19.2-23.3 95 %CI) current smoker prevalence, 31.2 % sedentarism (27.8-32.6 95 % CI), 86.3 % people consumed less than 5 portions of fruit and vegetables per day (84.4-87.9 95 % CI), 2.2 % had high alcohol con-sumption level (1.6-3.2 95 %CI), 26.2 % suffered from hypertension (23.9-28.6 95 % CI), 4.6 % diabetes (3.6-5.8 95 % CI), 62.1 % hyperlipidaemia (59.5-64.7 95 % CI) and 42.9 % (40.4-45.5 95 % CI) were overweight or obese. 85 % had at least 2 or more risk factors simultaneously. Sedentarism, diabetes, hyperlipidaemia and being overweight /obese was greater in females (p<0.001). Alcohol consumption and smoking were greater in males (p<0.001). Age, civil state, education, income and health system were related to the risk factors being studied. Conclusions: The study provided fresh knowledge concerning the lack of available information regarding rural Latin-American populations. Compared to the second Colombian study of chronic disease risk factors (ENFREC II), no important ad-vances were found regarding a reduction of the prevalence of risk factors. Further studies are required for going deeper into social determinants and health systems explaining this study's findings.

Prevalence of asthma and other allergic conditions in Colombia 2009-2010: a cross-sectional study.

BACKGROUND: While it is suggested that the prevalence of asthma in developed countries may have stabilized, this is not clear in currently developing countries. Current available information for both adults and children simultaneously on the burden and impact of allergic conditions in Colombia and in many Latin American countries is limited. The objectives of this study were to estimate the prevalence for asthma, allergic rhinitis (AR), atopic eczema (AE), and atopy in six colombian cities; to quantify costs to the patient and her/his family; and to determine levels of Immunoglobulin E (IgE) in asthmatic and healthy subjects. METHODS: We conducted a cross-sectional, population-based study in six cities during the academic year 2009-2010. We used a school-based design for subjects between 5-17 years old. We carried out a community-based strategy for subjects between 1-4 years old and adults between 18-59 years old. Serum samples for total and antigen-specific (IgE) levels were collected using a population-based, nested, case-control design. RESULTS: We obtained information on 5978 subjects. The largest sample of subjects was collected in Bogotá (2392). The current prevalence of asthma symptoms was 12% (95% CI, 10.5-13.7), with 43% (95% CI, 36.3-49.2) reporting having required an emergency department visit or hospitalization in the past 12 months. Physician diagnosed asthma was 7% (95% CI, 6.1-8.0). The current prevalence of AR symptoms was 32% (95% CI, 29.5-33.9), and of AE symptoms was 14% (95% CI, 12.5-15.3). We collected blood samples from 855 subjects; 60.2% of asthmatics and 40.6% of controls could be classified as atopic. CONCLUSIONS: In Colombia, symptom prevalence for asthma, AR and AE, as well as levels of atopy, are substantial. Specifically for asthma, symptom severity and absence from work or study due to symptoms are important. These primary care sensitive conditions remain an unmet public health burden in developing countries such as Colombia.

Risk factors associated with postoperative seizures in patients undergoing cardiac surgery who received tranexamic acid: a case-control study.

Antifibrinolytic agents are used during cardiac surgery to minimize bleeding and reduce exposure to blood products. Several reports suggest that tranexamic acid (TA) can induce seizure activity in the postoperative period. To examine factors associated with postoperative seizures in patients undergoing cardiac surgery who received TA. University-affiliated hospital. Case-control study. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) between January 2008 and December 2009 were identified. During this time, all patients undergoing heart surgery with CPB received TA. Cases were defined as patients who developed seizures that required initiation of anticonvulsive therapy within 48 h of surgery. Exclusion criteria included subjects with preexisting epilepsy and patients in whom the convulsive episode was secondary to a new ischemic lesion on brain imaging. Controls who did not develop seizures were randomly selected from the initial cohort. From an initial cohort of 903 patients, we identified 32 patients with postoperative seizures. Four patients were excluded. Twenty-eight cases and 112 controls were analyzed. Cases were more likely to have a history of renal impairment and higher preoperative creatinine values compared with controls (1.39 ± 1.1 vs. 0.98 ± 0.02 mg/dL, P = 0.02). Significant differences in the intensive care unit, postoperative and total lengths of stay were observed. An association between high preoperative creatinine value and postoperative seizure was identified. TA may be associated with the development of postoperative seizures in patients with renal dysfunction. Doses of TA should be reduced or even avoided in this population.

[Risk factors for cardiovascular and chronic diseases in a coffee-growing population]. / Factores de riesgo cardiovascular y de enfermedades crónicas en población caficultora.

OBJECTIVES: Estimating the prevalence of cardiovascular and chronic disease risk factors in a Colombian coffee-growing population. METHODS: This cross-sectional study was carried out from February to November 2007. Multistage conglomerate sampling of 55 rural areas in 13 municipalities led to 516 people being surveyed. The questionnaires used were recommended by PAHO (anthropometric and biochemical measurements). The resulting data was subjected to univariate and bivariate descriptive analysis using 95 % CI, significance tests and comparison with previous studies. RESULTS: There was 21.1 % (19.2-23.3 95 %CI) current smoker prevalence, 31.2 % sedentarism (27.8-32.6 95 % CI), 86.3 % people consumed less than 5 portions of fruit and vegetables per day (84.4-87.9 95 % CI), 2.2 % had high alcohol consumption level (1.6-3.2 95 %CI), 26.2 % suffered from hypertension (23.9-28.6 95 % CI), 4.6 % diabetes (3.6-5.8 95 % CI), 62.1 % hyperlipidaemia (59.5-64.7 95 % CI) and 42.9 % (40.4-45.5 95 % CI) were overweight or obese. 85 % had at least 2 or more risk factors simultaneously. Sedentarism, diabetes, hyperlipidaemia and being overweight /obese was greater in females (p<0.001). Alcohol consumption and smoking were greater in males (p<0.001). Age, civil state, education, income and health system were related to the risk factors being studied. CONCLUSIONS: The study provided fresh knowledge concerning the lack of available information regarding rural Latin-American populations. Compared to the second Colombian study of chronic disease risk factors (ENFREC II), no important advances were found regarding a reduction of the prevalence of risk factors. Further studies are required for going deeper into social determinants and health systems explaining this study's findings.

[Venous thromboembolism prophylaxis in Colombian surgical and medical patients: results for Colombia of the ENDORSE study]. / Profilaxis de la tromboembolia venosa en pacientes colombianos de tratamiento médico o quirúrgico: resultados para Colombia del estudio ENDORSE.

INTRODUCTION: More information is needed on the risk of venous thromboembolism in the hospital setting, and on patterns of use of thromboprophylaxis, as advocated in consensus guidelines. ENDORSE was an international study aimed at evaluating hospital venous thromboembolism prevention practices in medical and surgical patients. OBJECTIVES: The risk of venous thromboembolism was evaluated along with the use of thromboprophylaxis in hospitalized medical and surgical subjects; these data were compared with the international sample from the ENDORSE study. MATERIALS AND METHODS: Participating institutions in Colombia were selected arbitrarily. The medical charts for medical and surgical patients were evaluated randomly. The 2004 American College of Chest Physician guidelines were used to evaluate risk of venous thromboembolism and adherence to recommended thromboprophylaxis regimens. RESULTS: The study included 761 subjects (218 surgical, 543 medical) located in five acute care hospitals; 49% of these subjects were considered at risk of venous thromboembolism (40% medical, 72% surgical), compared with 52% in the international sample. Prophylaxis use was higher in medical patients at risk (63.7%, n=137) than in surgical patients (48.4%, n=76; p=0.01). Compared with the international sample, the use of prophylaxis in Colombia was greater in medical patients (63.7% vs. 39.5%, p=0.003), but lower in surgical patients (48.4% vs. 58.5%, p=0.02). CONCLUSIONS: Participating Colombian centers treat patients at risk of venous thromboembolism similarly to other participant countries, but appropriate prophylaxis was prescribed more frequently to medical patients. Greater efforts are needed, both in Colombia and around the world, to improve rates of appropriate venous thromboembolism prophylaxis in at-risk subjects.

Asthma in adults.

INTRODUCTION: About 10% of adults have suffered an attack of asthma, and up to 5% of these have severe disease that responds poorly to treatment. Patients with severe disease have an increased risk of death, but patients with mild-to-moderate disease are also at risk of exacerbations. Most guidelines about the management of asthma follow stepwise protocols. This review does not endorse or follow any particular protocol, but presents the evidence about specific interventions. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for chronic asthma? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 54 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: adding anti-IgE treatment; beta(2) agonists (adding long-acting inhaled beta(2) agonists when asthma is poorly controlled by inhaled corticosteroids, or short-acting inhaled beta(2) agonists as needed for symptom relief); inhaled corticosteroids (low dose and increasing dose); leukotriene antagonists (with or without inhaled corticosteroids); and theophylline (when poorly controlled by inhaled corticosteroids).

Profilaxis de la tromboembolia venosa en pacientes colombianos de tratamiento médico o quirúrgico: resultados para Colombia del estudio ENDORSEA / Venous thromboembolism prophylaxis in Colombian surgical and medical patients: Results for Colombia of the ENDORSE study

Introducción. La profilaxis en pacientes de tratamiento médico o quirúrgico con riesgo de tromboembolia venosa, requiere ser evaluada para obtener suficiente información que contribuya a mejorar estas prácticas, para que sean efectivas y eficaces, y ayudar con las medidas necesarias de prevención hospitalaria de la tromboembolia venosa. Objetivo. Evaluar el riesgo de tromboembolia venosa y de los hábitos de profilaxis en pacientes de tratamiento médico o quirúrgico hospitalizados en Colombia y compararlos con los de los centros internacionales participantes en el estudio ENDORSE. Materiales y métodos. Las instituciones fueron escogidas al azar. Se evaluaron todas las historias clínicas de pacientes de tratamiento médico o quirúrgico. Se utilizaron las guías del 2004 del American College of Chest Physicians para evaluar el riesgo de tromboembolia venosa y lo apropiado de la profilaxis. Resultados. Se evaluaron 761 pacientes: 218 de tratamiento quirúrgico y 543 de tratamiento médico, de cinco centros hospitalarios de Colombia. De esta población, 49 % se encontraba en riesgo de tromboembolia venosa (40 % de los de tratamiento médico y 72% de los de tratamiento quirúrgico), en comparación con 52 % de la muestra internacional. La profilaxis fue significativamente mayor en los pacientes de tratamiento médico en riesgo (63,7 %, n=137), que en los de tratamiento quirúrgico (48,4 %, n=76, P=0,01). En comparación con la muestra internacional, la profilaxis en los de tratamiento médico fue significativamente superior (63,7 % Vs. 39,5 %, P=0,003), a diferencia de los de tratamiento quirúrgico (48,4 % Vs. 58,5 %, P=0,02). Conclusiones. Los resultados muestran que en los centros hospitalarios de Colombia se trataron pacientes con riesgo de tromboembolia venosa en forma similar al resto de los países participantes en el estudio ENDORSE, y que se hizo más profilaxis apropiada en pacientes de tratamiento médico. Sin embargo, se requiere mejorar la utilización de profilaxis en pacientes hospitalizados.

Venous thromboembolism prophylaxis in Colombian surgical and medical patients: Results for Colombia of the ENDORSE study Introduction. More information is needed on the risk of venous thromboembolism in the hospital setting, and on patterns of use of thromboprophylaxis, as advocated in consensus guidelines. ENDORSE was an international study aimed at evaluating hospital venous thromboembolism prevention practices in medical and surgical patientes. Objectives. The risk of venous thromboembolism was evaluated along with the use of thromboprophylaxis in hospitalized medical and surgical subjects; these data were compared with the international sample from the ENDORSE study. Materials and methods. Participating institutions in Colombia were selected arbitrarily. The medical charts for medical and surgical patients were evaluated randomly. The 2004 American College of Chest Physician guidelines were used to evaluate risk of venous thromboembolism and adherence to recommended thromboprophylaxis regimens. Results. The study included 761 subjects (218 surgical, 543 medical) located in five acute care hospitals; 49% of these subjects were considered at risk of venous thromboembolism (40% medical, 72% surgical), compared with 52% in the international sample. Prophylaxis use was higher in medical patients at risk (63.7%, n=137) than in surgical patients (48.4%, n=76; p=0.01). Compared with the international sample, the use of prophylaxis in Colombia was greater in medical patients (63.7% vs. 39.5%, p=0.003), but lower in surgical patients (48.4% vs. 58.5%, p=0.02). Conclusions. Participating Colombian centers treat patients at risk of venous thromboembolism similarly to other participant countries, but appropriate prophylaxis was prescribed more frequently to medical patients. Greater efforts are needed, both in Colombia and around the world, to improve rates of appropriate venous thromboembolism prophylaxis in at-risk subjects.

Comparación de la función pulmonar de pacientes con diabetes mellitus tipo 2 sometidos a tratamiento de insulina inyectada versus tratamiento con hipoglucemiantes orales / Comparison of the pulmonary function of patients with type 2 diabetes mellitus treated with insulin injections versus that of patients treated with oral hypoglucemic agents

Introducción: la potencial asociación entre el tipo de tratamiento de la diabetes mellitus tipo 2 (DM2) y alteración de la función pulmonar es algo poco estudiado hasta ahora. Objetivos: comparar la función pulmonar de pacientes con DM2 que reciben tratamiento con insulina inyectable versus hipoglicemiantes orceles (HO). Determinar si niveles de marcadores de inflamación en pacientes con tratamiento basado en insulina son diferentes a los de los tratados con HO. Métodos: estudio observacional analítico de corte transversal a partir de una muestra de conveniencia de 369 pacientes con diagnóstico de DM2, y tratamiento con insulina o HO. Se realizaron espirometrías, y se obtuvieron valores residuales promedios para VEF1, CVF y relación VEF1/CVF. Mediante regresión lineal múltiple, se ajustó por diferencias en determinantes conocidos de la función pulmonar, así como por control de la diabetes y tiempo desde el diagnóstico. Adicionalmente, se midieron niveles de marcadores inflamatorios sanguíneos para cada grupo de tratamiento. Resultados: 63 pacientes (17%) recibían tratamiento con insulina y 306 (83%) con HO. La diferencia en residuales favoreció a los tratados con HO. Para VEF1, CVF y VEF1/CVF la diferencia fue 57.6 mL (IC95% 32.45-82.74; P 0.0047), 45.6 mL (IC95% 20.84-70.39; P 0.0231) y 0.017, (IC95% 0.01- 0.02, P<0.0001), respectivamente. No hubo cambios estadísticamente significativos en marcadores de inflamación. Conclusiones: los pacientes en tratamiento con HO presentaron mejor función pulmonar que los tratados con insulina. Este hallazgo de diferencias en función pulmonar pudiera tener implicación clínica en el manejo de los pacientes diabéticos, pero debe confirmarse en estudios prospectivos (Acta Med Colom; 2010: 35: 113-118).

Introduction: the potential association between the type of treatment of type 2 diabetes mellitus (DM2) and impaired lung function is something rarely studied so far. Objectives: to compare the lung function of patients with DM2 who are treated with injectable insulin versus HO. To determine whether levels of inflammatory markers in patients with insulin-based treatment are different from those treated with HO. Methods: an observational, analytical, cross-sectional study from a convenience sample of 369 patients diagnosed with DM2 and treated with insulin or HO. Spirometry was performed, and residual values were averaged for FEV1, FVC and FEV1/FVC ratios. Multiple linear regression results were adjusted by differences in known determinants of lung function, as well as control of diabetes and time since diagnosis. Additionally, we measured blood levels of inflammatory markers for each treatment group. Results: 63 patients (17%) were treated with insulin and 306 (83%) with OH. The difference in residual favored those treated with HO. For FEV1, FVC and FEV1/FVC the difference was 57.6 mL (95% CI 32.45 to 82.74, P 0.0047), 45.6 mL (95% CI 20.84 to 70.39, P 0.0231) and 0.017 (95% CI 0.01 to 0.02, P <0.0001), respectively. There were no statistically significant changes in inflammation markers. Conclusions: patients treated with HO showed better lung function than those treated with insulin. This finding of differences in lung function may have clinical implications in the management of diabetic patients, but needs to be confirmed in prospective studies (Acta Med Colom; 2010: 35: 113-118).