Mesa 3: Efectos cardiovasculares de fármacos antidiabéticos / Table 3: Cardiovascular effects of anti-diabetic drugs

Los eventos cardiovasculares representan la mayor complicación de la diabetes. La evidencia sugiere que la metformina mejora los resultados cardiovasculares en pacientes con diabetes, especialmente en el United Kingdom Prospective Diabetes Study (UKPDS) y otros estudios posteriores, por distintos mecanismos. Hay pocos estudios de seguridad cardiovascular para sulfonilureas aunque no tendrían un perfil seguro a este nivel. La gliclazida parece ser la de mejor performance de las drogas de este grupo. Algo similar ocurre con las meglitinidas, para las cuales los datos indican que no aumentarían el riesgo pero tampoco mejorarían la incidencia de eventos cardiovasculares. Las tiazolidinedionas son las drogas más cuestionadas, aunque los estudios y metaanálisis son contradictorios no habría dudas que aumentan el riesgo de insuficiencia cardíaca. Los inhibidores de la DPPIV mostraron resultados neutros a excepción de saxagliptina que aumentaría el riesgo de internación por insuficiencia cardíaca. Existen datos convincentes que los inhibidores de los receptores SGLT-2 a nivel renal y los análogos del GLP-1 intestinal tienen efectos positivos a nivel cardiovascular, con algunas diferencias entre los integrantes de esta familia. En cuanto a las insulinas, los estudios sugieren que tanto los análogos lentos como rápidos tendrían un mejor perfil cardiovascular, ligado principalmente a la menor incidencia de hipoglucemias severas, que insulina NPH y regular respectivamente.

Cardiovascular events represent the greatest complication of diabetes. Evidence suggests that metformin improves CV outcomes in patients with diabetes, especially in the United Kingdom Prospective Diabetes Study (UKPDS) and other subsequent studies, by different mechanisms. There are few cardiovascular safety studies for sulfonylureas although they would not have a safe profile at this level. Gliclazide appears to be the best performing drug in this group. Something similar occurs with meglitinides for which the data indicates that they would not increase the risk but neither would they improve the incidence of cardiovascular events. Thiazolidinediones are the most questioned drugs, although the studies and meta-analyzes are contradictory, there would be no doubt that they increase the risk of heart failure. DPPIV inhibitors showed neutral results except for saxagliptin, which would increase the risk of hospitalization for heart failure. There is convincing data that SGLT-2 receptor inhibitors at the renal level and intestinal GLP-1 analogues have positive effects at the cardiovascular level with some differences between the members of these families. Regarding insulins, studies suggest that both slow and fast analogues would have a better cardiovascular profile, mainly linked to the lower incidence of severe hypoglycemia, than NPH and regular insulin, respectively

Mesa 2: Diabetes Mellitus Tipo 1 y actividad física / Table 2: Diabetes Mellitus Type 1 and physical activity

En personas con diabetes tipo 1 (DM1) el ejercicio físico realizado en forma regular brindaría protección cardiovascular y tendría propiedades inmunomoduladoras pero la compleja interacción entre los efectos del ejercicio sobre el metabolismo glucídico y la terapia con insulina exógena supone un verdadero desafío. El ejercicio aeróbico por la contracción muscular disminuye la glucemia, conduce a un estado de hiperinsulinemia relativa y genera hipoglucemia al inicio o después del mismo mientras que el ejercicio anaeróbico se asocia a hiperglucemia por aumento de catecolaminas e incremento de lactato que favorece la neoglucogénesis hepática. El deterioro de la respuesta de hormonas contrarreguladoras existente en la DM1 amplifica la variabilidad glucémica y dificulta el control metabólico. Existen guías y recomendaciones que buscan brindar un marco de seguridad para la prescripción de actividad física considerando la multiplicidad de disciplinas deportivas, la edad del paciente y la evaluación de las complicaciones crónicas de la diabetes antes del inicio de la misma. Entre las estrategias terapéuticas se encuentran la modulación con hidratos de carbono, la adecuación pre y pos ejercicio de la insulinoterapia y el control intensivo de glucemia y cetonas. Los nuevos infusores de insulina y monitoreo glucémico ofrecen la posibilidad del fraccionamiento y/o suspensión de dosis convirtiéndose en el gold standard entre los deportistas de alto rendimiento. A futuro modelos integrados con calculadoras de ejercicio inteligentes, capacidad predictiva y de "aprendizaje individualizado" (páncreas artificial) posibilitarán mantener la euglucemia y optimizar los beneficios del ejercicio como parte del tratamiento

Bases fisiopatológicas de las modificaciones endocrino metabólicas post-cirugía bariátrica en diabetes tipo 2 / Pathophysiological basis of endocrine metabolic modifications after bariatric surgery in type 2 diabetes

Cuando la diabetes mellitus tipo 2 (DM2) se asocia a obesidad mórbida, frecuentemente la eficacia a largo plazo de las intervenciones terapéuticas no logran los objetivos ni disminuyen el riesgo cardiovascular o las complicaciones crónicas. Datos emergentes postulan a la cirugía bariátrica como tratamiento efectivo para la obesidad y sus comorbilidades. El objetivo del presente trabajo es investigar sobre esta nueva alternativa terapéutica de la DM2 analizando desde la fisiopatología hasta los predictores de suceso y fracaso en los resultados post-quirúrgicos. La reorganización intestinal post-quirúrgica produciría modificaciones hormonales en los ácidos biliares, sensado de nutrientes, microbioma intestinal, incretinas y anti-incretinas, asignándose un rol clave como responsable de los efectos normoglucemiantes. No obstante, la fisiología y los mecanismos moleculares subyacentes aún no se comprenden totalmente. Numerosos ensayos clínicos aleatorios a corto/mediano plazo demuestran que la cirugía metabólica logra un excelente control glucémico y reduce factores de riesgo cardiovascular. Aunque se necesitan estudios adicionales para demostrar beneficios a largo plazo, existe suficiente evidencia que apoya su inclusión entre las intervenciones contra la DM2. Una mejor comprensión de esta constelación de factores que intervienen en la homeostasis glucémica abre el camino hacia potenciales dianas terapéuticas, incluyendo drogas específicas, técnicas menos invasivas, optimización de los resultados quirúrgicos y fundamentalmente promover una mayor individualización de la terapia en la DM2

Incidence of Mechanical Complications of Central Venous Catheterization Using Landmark Technique: Do Not Try More Than 3 Times.

PURPOSE: Central venous catheterization is a standard procedure in intensive care therapy. In developing countries, this intervention is frequently performed by physicians in training and without the availability of ultrasound guidance. Purpose of this study was to determine the incidence and potential risk factors for mechanical complications during central venous catheterization in an intensive care setting performed by a mixed group of practitioners without the use of adjunct ultrasound. METHODS: Prospective observational cohort study in a university teaching hospital. Three hundred critically ill patients requiring their first central venous catheter insertion were enrolled. All patients were observed for 24 hours for mechanical complications (pneumothorax, hemothorax, arterial puncture, incorrect tip position, cardiac dysrhythmia, and/or subcutaneous hematoma). Potential associations with mechanical complications were adjusted using multivariable analysis. Main outcome was the cumulative incidence of mechanical complications. RESULTS: The incidence of mechanical complications was 17% (n = 51). After covariate adjustment, the number of punctures was significantly related to mechanical complications. Compared with 1 puncture, 3 or more attempts were significantly associated with mechanical complications (odds ratio 3.62 [95% confidence interval 1.34-9.8]; P = .011). Experience of the operator was not associated with mechanical complications. CONCLUSIONS: The incidence of mechanical complications is affected by the number of punctures performed. After adjustment, the risk increases substantially with more than 3 attempts. Limiting the number of attempts, appropriate supervision and the use of ultrasound guidance when available are recommended for the further reduction in mechanical complications of central venous catheterization.

ELISA seroprevalence of Trypanosoma cruzi in a cohort of heart disease patients.

INTRODUCTION: Chagas disease is the most important parasitic disease in El Salvador and Latin America. The disease has two phases: acute and chronic, with an intermediate unspecified phase. The chronic phase develops in 30% of infected persons and its most common manifestation is cardiac disease. This study aimed to obtain reference data for the prevalence of T. cruzi seropositivity in a cohort of cardiac patients. METHODOLOGY: A cross-sectional study involving consecutive heart disease patients consulting at the National Hospital Rosales was conducted over a six-month period. Congenital heart disease patients were excluded. A survey, file review, and ELISA serological test were conducted for each subject. RESULTS: Out of 455 subjects, 76 were seropositive for T. cruzi, giving a seropositivity prevalence of 16.7%. The average age of the patients was 58.09 years and the female:male ratio was 2.79:1. No significant difference was found between T. cruzi seropositive and seronegative patients in terms of age and gender. No association between T. cruzi serological status and either area of residence or seeing vectors in the house was found. However, living in the Salvadoran western region during childhood was significantly associated with seropositivity (p = 0.003). Other factors associated with T. cruzi seropositivity included: clinical diagnosis of cardiac Chagas disease; electrocardiographic (ECG) findings of a permanent pacemaker, all atrioventricular (AV) blocks and right bundle branch block; and grade III-IV radiological cardiomegaly. CONCLUSIONS: T. cruzi seropositivity prevalence was found to be 16.7% among heart disease patients in a public reference hospital.

The ethics of a genetic screening study for antisocial personality disorder with Mesoamericans: case study in the ethics of mental health research.

This article contains an analysis of a research ethics committee's (REC) concerns about a study protocol involving genetic screening for antisocial personality disorder. The study was proposed by US university researchers and to be conducted with Mesoamerican populations in the United States and in their countries of origin. The analysis explains why the study was not considered ethical by the REC, pointing to issues with the choice of study population, informed consent, confidentiality, and posttrial obligations. Some recommendations are provided for ways in which the study could have been redesigned.