Impacto de un programa educativo para mejorar el control de la glucemia en pacientes hospitalizados en servicios de medicina interna / Impact of an educational program to improve glycemic control in patients hospitalized in Internal Medicine departments

Fundamento: Es preciso implementar programas que incentiven la adherenciaa las guías de práctica clínica. Las recomendaciones actualesaconsejan mantener la glucemia inferior a 180 mg/dL en pacientes ingresadosen áreas de hospitalización convencional. Métodos: Llevamos acabo un estudio preintervención, un programa educativo y un estudio postintervención.El programa educativo se dirigió a médicos y personal deenfermería de los servicios de urgencias y medicina interna, y estuvo basadoen ocho recomendaciones publicadas por la Asociación Americanade Diabetes. La aplicabilidad del programa fue evaluada mediante uncuestionario dirigido a los médicos. Se evaluaron variables de proceso ydesenlace en cada periodo de estudio, tras incluir un total de 92 pacientescon diabetes tipo 2 o hiperglucemia >180 mg/dL detectada en urgencias,con 3 o más días de ingreso hospitalario y que no presentaban indicaciónde uso de insulina intravenosa. Resultados: El cuestionario, respondidopor 33 médicos (48%), mostró la total conformidad de éstos con seguirel programa propuesto. El programa educativo tuvo como consecuenciauna reducción en el uso de antidiabéticos orales (44 frente a 9%; p=0,000) y una disminución en el uso de insulina administrada según escalamóvil (50 frente a 7%; p= 0,000) y en la mediana de glucemia observadaen el día previo al alta (185 frente a 153 mg/dL; p= 0,005). El usode insulina en régimen basal-bolo se incrementó de forma signifi cativa enel periodo postintervención (17 frente a 85%; p= 0,000). Los episodiosde hipoglucemia (glucemia <60 mg/dL) fueron similares en los dos periodos(0,30 frente a 0,70%; p= 0,54). Conclusión: El programa educativoconsiguió mejoras signifi cativas en las variables de proceso y de desenlacerelacionadas con el control glucémico(AU)

Background: It is necessary to implement programs to increase adherenceto guidelines. According to current recommendations serum glucoseshould be maintained below 180 mg/dL (8.9 mmol/L) in patients admittedto general wards. Methods: We carried out a preintervention study, aneducative program and a postintervention study. The educative programwas addressed to physicians and nurses in the emergency and the internalmedicine departments. The program was based on 8 recommendationspublished by the American Diabetes Association for hospitalized patients.Program feasibility was evaluated by means of a questionnaire addressedto physicians. We analyzed process and outcome variables in 46 consecutivepatients admitted to each study period with type-2 diabetes or hyperglycemiagreater than 180 mg/dL (9.9 mmol/L), a length of stay of 3 ormore days and no indication for intravenous insulin treatment. Results:The questionnaire survey answered by 33 physicians (48%) showed totalagreement with the proposed program. The program was followed by significant reductions in the use of oral hypoglycemic agents (44% vs 9%, p=0.000), in the use of sliding scale insulin (50% vs 7%, p= 0.000), and inthe median glycemic values (185 mg/dL [10.2 mmol/L] vs 153 mg/dL [7.6 mmol/L], p= 0.005) observed in the day previous to hospital discharge.Basal-bolus insulin administration increased signifi cantly in thepostintervention period (17% vs 85%, p= 0.000). Hypoglycemia (glycemia<60 mg/dL [3.3 mmol/L]) episodes were similar between the twoperiods (0.30% vs 0.70%, p= 0.54). Conclusion: Our educational programwas followed by improvements in process and outcome variablesrelated with glycemic control in hospitalized patients(AU)

Riesgos del tratamiento estrogénico en trastornos de identidad sexual: a propósito de un caso / Risks of estrogen treatment in gender identity disorders: apropos of a case

Los riesgos potenciales del tratamiento estrogénico se deben tener en cuenta al tratar a los pacientes transexuales de varón a mujer con estos fármacos. Presentamos el caso de una paciente transexual de varón a mujer que estaba siendo tratada con etinilestradiol y sufrió un episodio de trombosis venosa profunda en el miembro inferior tras inmovilización por un esguince. Dicha paciente fue sometida posteriormente a un estudio de trombofilia y se detectó que era portadora heterocigota del factor V Leiden, por lo que se contraindicó el tratamiento con estrógenos de por vida. Debemos valorar, en los pacientes con mayor riesgo de trombosis venosa profunda, la realización de un estudio de trombofilia previo al tratamiento, así como la necesidad de profilaxis tromboembólica en caso de coexistir un reto trombótico (AU)

The potential risks of estrogen treatment when the male-to-female (M-to-F) transsexual patients are treated with estrogens should not be forgotten. We report the case of a M-to-F transsexual patient undergoing treatment with ethinyl estradiol who developed deep vein thrombosis of the lower extremity after a period of immobility because of a sprain. Thrombophilia study revealed that she was a heterozygous carrier of factor V Leiden. Estrogens were therefore contraindicated. We recommend screening for thrombophilic defects in patients at high risk for deep vein thrombosis before starting estrogen therapy. In addition, these patients require thromboembolic prophylaxis if there are concomitant triggering factors (AU)

Weekly paclitaxel for advanced non-small cell lung cancer patients not suitable for platinum-based therapy.

Platinum-based combinations are efficacious in the treatment of advanced non-small cell lung cancer (NSCLC) but their toxicity makes them unsuitable for elderly and for patients with co-morbidities. We assessed the efficacy and toxicity of low-dose of paclitaxel in patients who were elderly or who had contraindications against cisplatin therapy. Seventy-one patients (median age 68; range 42-82 years) with unresectable NSCLC were treated with weekly paclitaxel (80 mg/m2) infusion (1 h) for several cycles without intervening rest periods. Thirty-seven patients had PS 1 and 34 had PS 2 status. A total of 614 courses were administered (median 9, range 2-20). There were no episodes of grade 4 toxicities and only 1 patient had grade 3 thrombopenia. Grade 3 anemia or neutropenia were not observed and severe non-hematological toxicity was uncommon: grade 1-2 fatigue in 52%; grade 1-2 motor neuropathy in 42% and grade 3 in 5.5%; grade 1-2 sensory neuropathy in 46.3% of patients. Twenty-seven of the 67 evaluable patients (40.3%) had an objective response, whereas 26 patients (38.8%) had stable disease. The median overall survival for the entire group was 8.4 months (95% CI = 5.6 to 11.2) and the 1-year and 2-year survival was 37.4% and 12.1%, respectively. The median time-to-progression was 5.4 months (95% CI = 3.3 to 7.4). Our data show that low-dose weekly paclitaxel is active and well tolerated in this group of patients with NSCLC and poor prognosis and, as such, is useful for patients in whom platinum-based combinations are not suitable.

Cardiopatía isquémica en la gestación diabética / Ischemic cardiomyopathy in diabetic patients during pregnancy

Las manifestaciones cardiovasculares de la arteriosclerosis son la causa más frecuente de la morbimortalidad en los pacientes diabéticos. No existen evidencias de que el embarazo constituya por sí mismo un riesgo independiente para la cardiopatía isquémica; en la gestante diabética el factor de riesgo más asociado es la hipertensión arterial. Es de destacar que la cardiopatía isquémica en la gestante diabética suele presentarse en forma de infarto de miocardio, generalmente en el tercer trimestre y preferentemente en multigrávidas, con una media de 33 años de edad. En caso de larga evolución de la diabetes es necesario un estudio cardiológico pregestacional. Cuando la cardiopatía isquémica es conocida y se desea el embarazo, sería necesario cirugía revascularizadora previa. Durante la gestación, el tratamiento de la cardiopatía isquémica no difiere del habitual, a excepción de la precaución con el uso de determinados fármacos por su posible acción teratógena, debiendo extremar la vigilancia durante el segundo y tercer trimestre, parto y postparto por la mayor inestabilidad hemodinámica que conllevan. Podemos admitir que la gestación diabética asociada a cardiopatía isquémica representa una situación de riesgo elevado y que si bien no es contraindicación absoluta para la gestación sí es una circunstancia para evaluar el riesgo detallada e individualmente (AU)

Complicaciones metabólicas agudas en la gestante diabética / Acute metabolic complications in diabetic patients during pregnancy

La complicación aguda más frecuente de la diabetes (10 por ciento con episodios repetidos) es la hipoglucemia, que consiste en un descenso de los niveles plasmáticos de glucosa (glucemia plasmática < 45-50 mg/dl), responsable de la presentación de una serie de síntomas que desaparecen si se normaliza la glucemia. Esta complicación es mucho más frecuente en la gestante con diabetes tipo 1, en relación con el tratamiento intensivo insulínico y alteración de la contrarregulación. El esquema actual del tratamiento en las gestantes con diabetes tipo 1 durante el embarazo supone iniciar un control estricto de la glucemia antes de la concepción y durante la gestación; esto implica que tengamos que recurrir a regímenes de insulinoterapia intensiva que pueden provocar episodios más frecuentes e intensos de hipoglucemia. La clínica de la hipoglucemia es profusa, con síntomas relativamente inespecíficos, que pueden remedar diversos cuadros clínicos; pero, de una manera general, podemos distinguir dos grandes grupos: síntomas secundarios a descarga adrenérgica y a neuroglucopenia. En caso de hipoglucemia, hay varias opciones terapéuticas dependiendo de la gravedad del episodio. Por otra parte, las descompensaciones hiperglucémicas cetósicas y, especialmente, la cetoacidosis diabética (CAD), constituyen urgencias metabólicas que pueden provocar la muerte del feto y la madre. La CAD se trata de una complicación metabólica grave que se asocia con morbilidad y mortalidad materna y fetal muy elevadas. Es una complicación típica de la diabetes tipo 1, aunque también puede aparecer en gestantes con diabetes tipo 2 o con diabetes gestacional, ante situaciones de estrés o infecciones. En los últimos años se ha reducido de forma espectacular esta complicación, gracias al estricto control de la diabetes durante el embarazo (AU)

A randomized, crossover comparison of standard-dose versus low-dose lenograstim in the prophylaxis of post-chemotherapy neutropenia.

The aim of this trial was to compare the severity of neutropenia, the frequency of hospital admission for fever or infection, and the use of antibiotics among patients treated with a standard dose of lenograstim (263 microg/day of Euprotin) and others treated with half of this dose (131.5 microg/day) and the cost-effectiveness of each of the two doses. In this single-center study, 44 patients with solid tumors, who were all receiving standard-dose chemotherapy regimens following previous neutropenia or were at high risk of neutropenia, were randomized to receive lenograstim at a dose of 263 microg or 131.5 microg daily in the first cycle and then crossed over to the alternate dose for the following cycle. Crossover to the alternate dose was repeated for patients who received more than two cycles. Lenograstim was administered from day +5 to day +14. The absolute neutrophil count (ANC) was assessed on days +5, +8, +12 and +15 of each cycle. Statistical analysis was performed using a general lineal model for repeated samples. In all, 120 cycles were administered, with a median of 3 cycles (range 1-6). Only 4 patients received only 1 cycle. No statistically significant difference (P=0.324) in ANC was observed between standard-dose (mean 5.3, 10.7, 8.3, 11.4 x 10(9)/l) and low-dose (5.0, 8.6, 5.4, 7.5 x 10(9)/l) treatment at days +5, +8, +12 and + 15. Neutropenia grade III-IV was more common in patients receiving the low than in those receiving the standard dose of lenograstim (20% vs 12%, respectively), but the difference did not reach statistical significance (P=0.1). The incidence of fever and frequency of hospital admission were not affected by the dose of lenograstim: 3 patients presented with fever with the standard dose (all of those were admitted to hospital) and 2 patients with the low dose (1 was admitted). ANC in both groups (standard and low doses) was independent of chemotherapy line (first versus second or more). Lenograstim at a dose of 131.5 microg/day is as effective as the standard dose in limiting the severity of neutropenia and in preventing episodes of fever and hospital admissions after chemotherapy for solid tumors. The lower dose of lenograstim is cost-effective in neutropenia prophylaxis. Starting its administration on day +5 reduces costs while maintaining efficacy.

Airway responsiveness to acetaldehyde in patients with asthma: relationship to methacholine responsiveness and peak expiratory flow variation.

BACKGROUND: Although airway hyperresponsiveness to inhaled acetaldehyde has been documented in Japanese patients with asthma, the response to this bronchoconstrictor agent has never been studied in Caucasians. OBJECTIVES: The objectives of the study were to determine differences in airway responsiveness to acetaldehyde between asthmatic and healthy subjects, and to examine the relationship between acetaldehyde responsiveness and the variability of peak expiratory flow (PEF). METHODS: The response to methacholine and acetaldehyde challenges was measured in 81 non-smoking adults (61 asthmatics and 20 normal controls). Subjects recorded PEF morning and evening for 14 days. The response to both bronchoconstrictor agents was measured by the PC20 (provocative concentration required to produce a 20% fall in FEV1). PEF variation was expressed as amplitude percentage mean, and as low percentage best (lowest PEF expressed as a percentage of the best PEF recorded). RESULTS: The two types of challenge yielded a similarly high level of sensitivity (100% for methacholine and 92% for acetaldehyde) and specificity (90 and 100%, respectively) to distinguish between asthma and controls. Asthmatic subjects were on average 265-fold less sensitive to acetaldehyde than to methacholine. PC20 acetaldehyde correlated weakly but significantly with both indices of PEF variation (amplitude percentage mean: rho = - 0.36, P = 0. 004; low percentage best: rho = 0.42, P = 0.001). CONCLUSIONS: These results indicate that airway hyperresponsiveness to acetaldehyde is a sensitive and specific indicator for separating asthmatic and normal subjects. Airway responsiveness to methacholine or acetaldehyde and PEF variation are not reflecting the same pathophysiological process in the airways.