[Metformin for type-2 diabetes mellitus. Systematic review and meta-analysis]. / Metformina para la diabetes mellitus tipo 2. Revisión sistemática y metaanálisis.

OBJECTIVE: To evaluate the efficacy of metformin against placebo, diet, oral anti-diabetics, or insulin in type 2 diabetes mellitus. DESIGN: Systematic review. DATA SOURCES: MEDLINE (1966-2003), EMBASE (1974-2003), LILACS (1986-2003), Cochrane library (Issue 3, 2003). SELECTION OF STUDIES: 29 randomized clinical trials of metformin in monotherapy, with results on mortality, morbidity, and biochemistry. EXTRACTION OF DATA: RevMan 4 computer program. Two reviewers extracted the data and evaluated the quality. MAIN VARIABLES: any clinical event related to diabetes (mortality, coronary disease, stroke, arterial disease, and retinopathy). Secondary variables: weight and biochemistry. RESULTS: 29 clinical studies with 37 comparisons of metformin were analyzed (13 with sulphonylureas, 12 with placebo, 3 with diet, 3 with thiazolidinediones, 2 with alpha-glucosidase inhibitors, 2 with insulin, and 2 with meglitinides). Metformin was more beneficial than the sulphonylureas or insulin for any clinical event associated with diabetes (relative risk [RR]=0.78; 95% confidence interval [CI], 0.65-0.94) and than diet (RR=0.74; 95% CI, 0.60-0.90). Metformin decreased glycosylated hemoglobin A1 (weighted mean difference, -1.21%; 95% CI, -1.48 to -0.94), low density lipoprotein cholesterol (weighted mean difference, -0.24; 95% CI, -0.40 to -0.09), and weight (standardized mean difference, -0.11; 95% CI, -0.18 to -0.04). Metformin was more beneficial than the placebo, diet or the thiazolidinediones on glycosylated hemoglobin A1, and than the sulphonylureas or insulin on weight. CONCLUSIONS: In the long term metformin reduces the risks of clinical events associated with diabetes. There are no long term clinical trials which compare alpha-glucosidase inhibitors, meglitinides, and thiazolidinediones with metformin, in primary results. The different treatments compared with metformin did not obtain more benefit for the secondary results evaluated.

Metformina para la diabetes mellitus tipo 2. Revisión sistemática y metaanálisis / Metformin for type 2 diabetes mellitus. Systematic review and meta-analysis

Objetivo. Evaluar la eficacia de la metformina frente a placebo, dieta, antidiabéticos orales o insulina en la diabetes mellitus tipo 2. Diseño. Revisión sistemática. Fuentes de datos. MEDLINE (1966-2003), EMBASE (1974-2003), LILACS (1986- 2003), Cochrane library (Issue 3, 2003). Selección de estudios. Se seleccionaron 29 ensayos clínicos aleatorizados de metformina en monoterapia, con resultados sobre mortalidad, morbilidad y bioquímica. Extracción de datos. Programa informático RevMan 4. Dos revisores extrajeron los datos y evaluaron la calidad. Variables principales: cualquier acontecimiento clínico relacionado con la diabetes (mortalidad, coronariopatía, ictus, nefropatía, arteriopatía y retinopatía). Variables secundarias: peso y bioquímica. Resultados. Se analizaron 29 ensayos clínicos con 37 comparaciones de metformina (13 con sulfonilureas, 12 con placebo, 3 con dieta, 3 con tiazolidindionas, 2 con inhibidores de la alfa-glucosidasa, 2 con insulina y 2 con meglitinidas). La metformina mostró mayor beneficio que las sulfonilureas o la insulina para cualquier acontecimiento clínico relacionado con la diabetes (riesgo relativo = 0,78; intervalo de confianza [IC] del 95%, 0,65 a 0,94) y que la dieta (riesgo relativo = 0,74; IC del 95%, 0,60 a 0,90). La metformina disminuyó la hemoglobina A1 glucosilada (diferencia media ponderada: ­1,21%; IC del 95%, ­1,48 a ­0,94), colesterol unido a lipoproteínas de baja densidad (diferencia media ponderada: ­0,24; IC del 95%, ­0,40 a ­0,09) y peso (diferencia media estandarizada: ­0,11; IC del 95%, ­0,18 a ­0,04). La metformina presentó mayor beneficio que el placebo, la dieta o las tiazolidindionas en la hemoglobina A1 glucosilada, y que las sulfonilureas o la insulina en el peso. Conclusiones. A largo plazo la metformina disminuye el riesgo de acontecimientos clínicos relacionados con la diabetes. No existen ensayos clínicos a largo plazo que comparen con metformina los inhibidores de la alfa-glucosidasa, meglitinidas y tiazolidindionas, en resultados primarios. Las diferentes intervenciones comparadas con metformina no obtuvieron más beneficio para los resultados secundarios evaluados

Objective. To evaluate the efficacy of metformin against placebo, diet, oral anti-diabetics, or insulin in type 2 diabetes mellitus. Design. Systematic review. Data sources. MEDLINE (1966-2003), EMBASE (1974-2003), LILACS (1986-2003), Cochrane library (Issue 3, 2003). Selection of studies. 29 randomized clinical trials of metformin in monotherapy, with results on mortality, morbility, and biochemistry. Extraction of data. RevMan 4 computer program. Two reviewers extracted the data and evaluated the quality. Main variables: any clinical event related to diabetes (mortality, coronary disease, stroke, arterial disease, and retinopathy). Secondary variables: weight and biochemistry. Results. 29 clinical studies with 37 comparisons of metformin were analyzed (13 with sulphonylureas, 12 with placebo, 3 with diet, 3 with thiazolidinediones, 2 with alpha-glucosidase inhibitors, 2 with insulin, and 2 with meglitinides). Metformin was more beneficial than the sulphonylureas or insulin for any clinical event associated with diabetes (relative risk [RR]=0.78; 95% confidence interval [CI], 0.65-0.94) and than diet (RR=0.74; 95% CI, 0.60-0,90). Metformin decreased glycosylated hemoglobin A1 (weighted mean difference, ­1.21%; 95% CI, ­1.48 to ­0.94), low density lipoprotein cholesterol (weighted mean difference, ­0.24; 95% CI, ­0.40 to ­0.09), and weight (standardized mean difference, ­0.11; 95% CI, ­0.18 to ­0.04). Metformin was more beneficial than the placebo, diet or the thiazolidinediones on glycosylated hemoglobin A1, and than the sulphonylureas or insulin on weight. Conclusions. In the long term metformin reduces the risks of clinical events associated with diabetes. There are no long term clinical trials which compare alpha-glucosidase inhibitors, meglitinides, and thiazolidinediones with metformin, in primary results. The different treatments compared with metformin did not obtain more benefit for the secondary results evaluated

Los nuevos precios de referencia: una oportunidad en la gestión eficiente del medicamento / The new reference prices: an opportunity for efficient management of medication

No disponible

Glucocorticoids for croup.

BACKGROUND: Since the initial version of this systematic review in 1997, a number of randomised trials examining the benefit of glucocorticoids have been published, reflecting a continued interest in the use of glucocorticoids to treat patients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas of uncertainty for future research. OBJECTIVES: To determine the effect of glucocorticoids for children with croup. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to April 2003) and Excerpta Medica/EMBASE (January 1974 to August 2003). We also contacted authors of identified croup trials published in the last ten years to inquire about additional published or unpublished trials. SELECTION CRITERIA: Randomised controlled trials that examine children with croup and objectively measure the effectiveness of glucocorticoid treatment. DATA COLLECTION AND ANALYSIS: Based on review of the title and abstract (when available), two researchers identified studies for potential relevance. The complete text was retrieved and using a priori inclusion criteria, the studies were independently reviewed for relevance by two reviewers. Two observers independently assessed quality. Differences with respect to inclusion status and quality assessment were resolved by consensus. Data were extracted using a structured form by one reviewer and checked for accuracy by a second reviewer. Standard statistical analyses were performed. MAIN RESULTS: Thirty-one studies were deemed relevant for inclusion (N = 3736). Glucocorticoid treatment was associated with an improvement in the Westley score at six hours with a weighted mean difference of -1.2 (95% confidence interval -1.6 to -0.8) and at 12 hours -1.9 (-2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in patients treated with glucocorticoids (relative risk 0.50; 0.36 to 0.70). Length of time spent in accident and emergency or hospital (weighted mean difference 12 hours, five to 19 hours) was significantly decreased for patients treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 1 to 20). No other decreases in additional treatments were found in the primary analysis. Publication bias does not impact results importantly. No between-trial significant differences were found between populations with mild and moderate croup. Oral dexamethasone may be superior to intramuscular dexamethasone. REVIEWER'S CONCLUSIONS: Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased in inpatients. Dexamethasone is also effective in mild croup populations. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence to improve outcomes.

[An analysis of the diagnoses and prescription for chronic patients at a health center]. / Análisis de diagnósticos y prescripción de crónicos en un centro de salud.

OBJECTIVE: To find out if there are differences between inhabitants ages 14-64 with prescription charge (group A), pensioners ages 14-64 without prescription charge (group B), and pensioners aged over 64 without prescription charge (group C), related with chronic morbidity, associated treatment and costs data. DESIGN: A crossover descriptive study (1995). SETTING: Urban primary health care centre. PATIENTS AND OTHER PARTICIPANTS: Participants are inhabitants 14 and over assigned to this health centre (12,605), included in a data bank register, patients are participants with at least a chronic diagnostic (7,007). MEASUREMENTS AND MAIN RESULTS: Participants data were transferred to a practice computer system. Three groups (above) were established according to age band and prescription charge status: group A (73.6% participants), B (8.4%), and C (18%). CONCLUSIONS: Inhabitants ages 14-64 without prescription charge were a differentiated group related with number of chronic diagnoses, number of items to chronic treatment prescribed, and annual average chronically drug costs. So they are intended for use in the future in allocation of budgets to primary health care centres.

[Drug-to-drug interactions and pharmaceutical advice]. / Interacciones medicamento-medicamento y asesoramiento farmacéutico.

OBJECTIVE: To describe suspects of drug interactions in primary health care. DESIGN: Descriptive and transversal study during 1 month. SETTING: Urban health center, primary care, Madrid (Spain). PATIENTS AND OTHER PARTICIPANTS: Patients were treated simultaneously with more than 1 drug (145), 2 general practitioners (GP) and 1 pharmacist. INTERVENTIONS: GP registered in a sheet-form data from diagnostic and pharmacological treatments. The pharmacist checked the sheet-forms to detect drug interactions, and later assessed to the GP about it. The proposals were classified in 3 ways: no change in treatment; to modify or stop the current treatment, and to monitor plasmatic level or clinical parameters. MEASUREMENTS AND MAIN RESULTS: 333 drug interactions were detected in 145 patients. The 67.5% of interactions produced by 7 groups of drugs: theophylines, diuretics, antacids, benzodiacepines, betablockers, NSAID's and ACE's. GP accepted 74% of pharmacist's proposals (recommendations). CONCLUSIONS: Seven types of drugs were involved in the main interactions in primary care. The drug interactions increased as more drugs takes a patient in an accelerated trend. Older than 55 were the most affected. GP accepted 3/4 of the recommended pharmacist proposals.

[Something more about adverse reactions to medications]. / Algo más sobre reacciones adversas a medicamentos.

OBJECTIVE: To describe adverse drug effects (ADE) and their frequency in primary care patients. DESIGN: Descriptive and longitudinal study during 1 year (1990). SETTING: Urban Health Center. Primary Care. Madrid (Spain). PATIENTS AND OTHER PARTICIPANTS: 15,483 persons, nine general practitioner and one pharmacist. INTERVENTIONS: Doctors were invited to register any adverse drug effects they had notice in their patients. Doctors registered information and gave notice to the pharmacist about medicines, dosage and period of administration, clinical manifestations, and improving or not if drug was withdrawal. MEASUREMENTS AND MAIN RESULTS: 326 adverse drugs effects were notified, 30.9 ADE per thousand attended patients. 117 principles actives were involved, and 415 clinical manifestations were registered. The more affected patients were women (2/1). The age groups with higher ADE relative frequencies were children under one year and older people. CONCLUSIONS: The absolute frequency of medicines involved in ADE are different to relative frequencies when ADE per thousand prescription units are used. Some of the ADE notified were not referred before in the bibliography, so primary care is a good place to research on pharmacosurveillance.

[Hyperglycemia in toxic oil syndrome]. / Hiperglucemia en el síndrome del aceite tóxico.

OBJECTIVE: To know the prevalence of hyperglycemia in patients with Spanish toxic oil syndrome (TOS). To analyze clinical, biochemical, and pathological associated factors. To compare them with a control group. DESIGN: Case and controls study. SETTING: Primary Health Care. XI Sanitary district in Madrid. PATIENTS AND OTHER PARTICIPANTS: 734 cases with toxic oil syndrome. 1474 control subjects. MEASUREMENTS AND MAIN RESULTS: Prevalence of impaired glucose tolerance was 2.95% in TOS and 0.07% in control subjects (p < 0.001; OR, 7.55; IC, 291-19.57). Diabetes No insulin treated was 7.78% in TOS and 3.26% in controls (p < 0.001; OR 250; IC 1.62-3.87). Diabetes insulin treated was 1.99% in TOS and 0.47% in controls (p < 0.01; OR, 4.98; IC, 1.80-13.78). Prevalence of diabetes mellitus in TOS was 9.77 and 3.67% (p < 0.001; OR, 2.85; IC, 1.90-4.25) in controls. The pancreatic lesions found in the necropsies were vasculitis type TOS (4 cases) and endothelial vascular lesions (1 case). CONCLUSIONS: The prevalence of hyperglycemia in TOS reached 13%, where as in the control subjects, it was 3.8% (p < 0.001). The pancreatic lesions detected in deceased TOS patients did not coincide with those commonly described in diabetes mellitus.

[Computerized record system for the analysis of diagnosis of chronic diseases and their treatment in primary health care]. / Sistema informatizado de registro para el análisis de diagnósticos crónicos y sus tratamientos en atención primaria.

OBJECTIVE: To present the design and setting up of a computerised data base for primary care. DESIGN: A descriptive crossover study. The recording lasted a year. SETTING: Gómez Acebo Health Centre in Madrid. Primary Care. PATIENTS AND OTHER PARTICIPANTS: The whole of the health centre catchment population, comprising 14,407 people, as well as 20 doctors and nurses. INTERVENTIONS: The consultations of ten doctors and ten nurses at the health centre were computerised. The computer programme, language-designed for inter-related data bases, linked four data bases (users, chronic illnesses, medicines, and the diagnosis and treatment record-sheet). The population under study comprised 14,407 people over one year, 1993. MEASUREMENTS AND MAIN RESULTS: The users file held the data of 14,407 people. 7,867 of these contained 23,993 chronic diagnoses with 12,405 treatments. The commonest diagnosis groups were: cardiovascular, psychiatry, endocrinology and articulations. The therapeutic groups with most prescriptions were C (cardiovascular), A (digestive and metabolic), N (nervous system) and R (respiratory). Daily expenditure in medicines was 634,207 pesetas. CONCLUSIONS: The main contribution of this computerised data base is to be able to analyse the associations between pathologies and their associated treatments, along with the pharmacological cost per primary care transaction, interactions and adverse side-effects.