Efecto de la variabilidad glucémica intrahospitalaria en la mortalidad de los pacientes con diabetes / Effect of in-hospital glycemic variability on mortality in patients with diabetes

Introducción El objectivo fue evaluar la importancia de glucemia media (GM) y variabilidad glucémica (VG) durante la hospitalización sobre la mortalidad tras el alta.Material y métodosEstudio de cohortes retrospectivo longitudinal analítico. Se incluyeron pacientes dados de alta del Servicio de Medicina Interna con algún diagnóstico relacionado con la diabetes. El pronóstico evaluado fue la mortalidad. Se recogieron durante el ingreso variables clínicas, analíticas y relacionadas con el control glucémico hospitalario (GM, VG e hipoglucemias). La VG se midió con el coeficiente de variación (CV).Se calcularon las tasas de mortalidad por cada 1000 pacientes-año y se compararon con curvas de Kaplan-Meier. La determinación de los factores predictivos de mortalidad se realizó mediante regresión de Cox.ResultadosSe incluyeron 276 pacientes con edad media 77,6 (DE 10,2) años. La duración mediana del seguimiento extrahospitalario fue de 2,7 años.En análisis multivariante, una GM > 140 (HR=1,72; IC 95% 1,14-2,61; p=0,01) y un CV > 0,29 (HR=1,52; IC 95% 1,12-2,06; p=0,006), no así la presencia de hipoglucemias, se asociaron a incremento del riesgo de mortalidad de forma aditiva e independiente. Tener una GM > 140 simultáneamente con un CV > 0,29 incrementó las tasas de mortalidad (123 vs. 317 por 1.000 pacientes-año; p <0,001) y el riesgo ajustado de mortalidad (HR=2,70; IC 95% 1,71-4,27; p<0,001) respecto a tener una GM ≤ 140mg/dl.ConclusiónLa presencia simultánea de GM y VG elevadas constituye una potente herramienta de estratificación del riesgo de mortalidad tras el alta hospitalaria. (AU)

Introduction The aim of this study was to evaluate the impact of mean blood glucose (MBG) and glycaemic variability (GV) during hospitalisation on mortality after discharge.Material and methodsWe conducted a retrospective longitudinal analytical cohort study that included patients discharged form a department of internal medicine with a diabetes-related diagnosis The evaluated prognosis was mortality. During hospitalisation, the patients’ clinical, laboratory and glycaemic control-related variables were recorded (MBG, GV and hypoglycaemia). The GV was measured with the coefficient of variation (CV).We calculated the mortality rates for every 1000 patient-years and compared them with Kaplan-Meier curves. We determined the predictors of mortality by performing a Cox regression.ResultsThe study included 276 patients with a mean age of 77.6 (SD, 10.2) years. The median outpatient follow-up duration was 2.7 years.In the multivariate analysis, an MBG >140mg/dl (HR, 1.72; 95% CI 1.14–2.61; p=.01) and a CV >0.29 (HR, 1.52; 95% CI 1.12–2.06; p=.006) but not the presence of hypoglycaemia were additively and independently associated with an increased risk of mortality. An MBG >140mg/dl with a CV >0.29 increased the mortality rates (123 vs. 317 per 1000 patient-year; p <.001) and the adjusted mortality risk (HR, 2.70; 95% CI 1.71–4.27; p<.001) compared with having an MBG ≤140mg/dl.ConclusionThe simultaneous presence of a high MBG level and CV constitutes a powerful tool for stratifying mortality risk after hospital discharge. (AU)

Effect of in-hospital glycemic variability on mortality in patients with diabetes.

INTRODUCTION: The aim of this study was to evaluate the impact of mean blood glucose (MBG) and glycaemic variability (GV) during hospitalisation on mortality after discharge. MATERIAL AND METHODS: We conducted a retrospective longitudinal analytical cohort study that included patients discharged form a department of internal medicine with a diabetes-related diagnosis. The evaluated prognosis was mortality. During hospitalisation, the patients' clinical, laboratory and glycaemic control-related variables were recorded (MBG, GV and hypoglycaemia). The GV was measured with the coefficient of variation (CV). We calculated the mortality rates for every 1000 patient-years and compared them with Kaplan-Meier curves. We determined the predictors of mortality by performing a Cox regression. RESULTS: The study included 276 patients with a mean age of 77.6 (SD, 10.2) years. The median outpatient follow-up duration was 2.7 years. In the multivariate analysis, an MBG > 140 mg/dL (HR = 1.72; 95% CI 1.14-2.61; p = .01) and a CV > 0.29 (HR = 1.52; 95% CI 1.12-2.06; p = .006), but not the presence of hypoglycaemia, were additively and independently associated with an increased risk of mortality. An MG > 140 mg/dL with a CV > 0.29 increased the mortality rates (123 vs. 317 per 1000 patient-year; p < .001) and the adjusted mortality risk (HR = 2.70; 95% CI 1.71-4.27; p < .001) compared with having an MBG ≤ 140 mg/dL. CONCLUSION: The simultaneous presence of a high MBG level and CV constitutes a powerful tool for stratifying mortality risk after hospital discharge.

Effect of in-hospital glycemic variability on mortality in patients with diabetes. / Efecto de la variabilidad glucémica intrahospitalaria en la mortalidad de los pacientes con diabetes.

INTRODUCTION: The aim of this study was to evaluate the impact of mean blood glucose (MBG) and glycaemic variability (GV) during hospitalisation on mortality after discharge. MATERIAL AND METHODS: We conducted a retrospective longitudinal analytical cohort study that included patients discharged form a department of internal medicine with a diabetes-related diagnosis The evaluated prognosis was mortality. During hospitalisation, the patients' clinical, laboratory and glycaemic control-related variables were recorded (MBG, GV and hypoglycaemia). The GV was measured with the coefficient of variation (CV). We calculated the mortality rates for every 1000 patient-years and compared them with Kaplan-Meier curves. We determined the predictors of mortality by performing a Cox regression. RESULTS: The study included 276 patients with a mean age of 77.6 (SD, 10.2) years. The median outpatient follow-up duration was 2.7 years. In the multivariate analysis, an MBG >140mg/dl (HR, 1.72; 95% CI 1.14-2.61; p=.01) and a CV >0.29 (HR, 1.52; 95% CI 1.12-2.06; p=.006) but not the presence of hypoglycaemia were additively and independently associated with an increased risk of mortality. An MBG >140mg/dl with a CV >0.29 increased the mortality rates (123 vs. 317 per 1000 patient-year; p <.001) and the adjusted mortality risk (HR, 2.70; 95% CI 1.71-4.27; p<.001) compared with having an MBG ≤140mg/dl. CONCLUSION: The simultaneous presence of a high MBG level and CV constitutes a powerful tool for stratifying mortality risk after hospital discharge.

Leishmaniasis visceral, nuestra experiencia en 30 años / Visceral leishmaniasis, our experience in 30 years

Objetivos. El kala azar o leishmaniasis viscera (LV) es una de las enfermedades más olvidadas del mundo. En los países en desarrollo, 350 millones de personas están en riesgo de contraer LV, habiendo 2 millones de casos nuevos al año, En España, a partir de 1982, se hizo enfermedad de declaración obligatoria, notificándose unos 90 casos/año. A partir de 1995 pasó a ser enfermedad de declaración obligatoria en zonas endémicas, considerándose Aragón una de ellas. Pacientes y métodos. Estudio descriptivo retrospectivo de 14 casos de LV confirmados en edad pediátrica (0 a 14 años) ingresados en la Unidad de Infecciosos del Hospital Infantil Miguel Servet, de Zaragoza, entre enero de 1980 a diciembre de 2010. Resultados. Fueron ingresados 16 niños con el diagnóstico de LV. El estudio se lleva a cabo con datos de 14 pacientes. La edad media de presentación fue 3 años (rango 9 meses-12 años, mediana 19 meses). El 64% de los pacientes procedían del medio rural. Al ingreso presentaban una media de 3.700 leucocitos, con neurtropenia en el 71% de los pacientes. Existían trombopenia (<150.000 plaquetas/mm3) en un 77% de los casos. Presentaban anemia el 100% de los pacientes con una media de hemoglobina de 7,7 mg/dl. Un 64 % de los niños debutaron con pancitopenia. La VSG se elevó por encima de 20 mm/h en el 100% de los casos. En todos los pacientes se realizó aspirado de médula ósea, visualizándose el parásito en todas las muestras, confirmando el diagnóstico de LV. Todos los casos fueron tratados con meglumina antimoniato, excepto el último registrado en 2010 que recibió anfotericina B liposomal, todos con buena respuesta clínica (...) (AU)

Objectives. Kala azar o viscera leishmaniasis (LV) is one of the most neglected disease in the world. In developing countries, 350 million people are at risk of having LV and 2 million cases are reported every year. In Spain, since 1982 LV has become a compulsory notifiable disease with around 90 cases reported every year. In 1995, it was declared notifiable disease in endemic areas and one of them was Aragón. Patients and Methods. Retrospective study of 14 VL cases. All of them in patients between 0-14 years old admitted into the Infectious Diseases Unit at Children´s Hospital Miguel Servet in Zaragoza between January 1980 to December 2010. Results. A total of 16 children were admitted with the diagnosis of I. V. The study was carried out with data of 14 of these patients. The mean age at diagnosis was 3 years (range 9 months-12 years, median 19 months). The 64% of them came from rural areas. At admission, they had 3700 leukocyte average with neutropenia in 71% of those cases. All of them (100%9 were anemic with a 7.7 mg/ld hemoglobin/dl range but only nearly 77% has thrombocytopenia (<150,000 platelets/mm3). The 64% of the children debuted with pancytopenia. ESR rose were more than 20 mm/h in all cases (...) (AU)

Hemorragia fetomaterna masiva: A propósito de dos casos y revisión / Massive fetomaternal hemorrhage: A report of two cases

La hemorragia fetomaterna masiva es una patología poco frecuente pero de elevada morbimortalidad debido a la expoliación sanguínea que puede cursar con una clínica inapreciable. En la mayoría de los casos la causa es desconocida, existiendo diversos factores e intervenciones sobre el feto que pueden favorecerla. Describimos dos casos de transfusión fetomaterna masiva que plantean una serie de comentarios en relación diversos aspectos de estas afecciones, especialmente el interés del test de Kleihauer para el diagnóstico precoz, que puede ser vital para el feto o recién nacido. El primer caso era especialmente grave, debido a una transfusión aguda que causó un shock hemodinámica grave, naciendo en estado de muerte aparente. El segundo presentaba una mejor adaptación postnatal, lo que hace suponer que la hemorragia fuera prolongada, dando lugar a un mejor reajuste hemodinámico fetal. En ambos la evolución ha sido favorable, sin objetivarse hasta el momento secuelas en su seguimiento posterior (AU)

Massive fetomaternal haemorrhage although an infrequent pathology is associated with high morbimortality, because imperceptible clinical manifestations can follow an important blood loss. Its cause remains unknown in most cases, existing several factors or interventions on the foetus that can promote it. We describe tow cases of massive fetomaternal transfusion. We review a series of aspect related to these conditions. Kleihauer test is of special interest for its early diagnosis, which can be vital for the foetus or newborn. The first case was especially severe, caused by an acute transfusion which produced a serious hemodynamic shock, being the newborn born apparently dead. The second one showed better postnatal adaptation, for which it is supposed a prolonged bleeding leading to a better foetal hemodynamic readjustment. Favourable outcome has been observed in both cases, without showing sequelae in subsequent follow-up (AU)

Perioperative and short-term advantages of mini-open approach for lumbar spinal fusion.

It has been widely reported a vascular and neurologic damage of the lumbar muscles produced in the classic posterior approach for lumbar spinal fusions. The purpose of this study is to demonstrate a better clinical and functional outcome in the postoperative and short term in patients undergoing minimal invasive surgery ("mini-open") for this lumbar spinal arthrodesis. We designed a prospective study with a 30 individuals cohort randomized in two groups, depending on the approach performed to get a instrumented lumbar circumferential arthrodesis: "classic posterior" (CL group) or "mini-open" approach (MO group). Several clinical and functional parameters were assessed, including blood loss, postoperative pain, analgesic requirements and daily life activities during hospital stay and at the 3-month follow-up. Patients of the "mini-open approach" group had a significant lower blood loss and hospital stay during admission. They also had significant lower analgesic requirements and faster recovery of daily life activities (specially moderate efforts) when compared to the patients of the "classic posterior approach" group. No significant differences were found between two groups in surgery timing, X-rays exposure or sciatic postoperative pain. This study, inline with previous investigations, reinforces the concept of minimizing the muscular lumbar damage with a mini-open approach for a faster and better recovery of patients' disability in the short term. Further investigations are necessary to confirm these findings in the long term, and to verify the achievement of a stable lumbar spinal fusion.

[Epidemiological analysis of the improving areas for blood pressure control at Primary Care practice]. / Análisis de las áreas de mejora del control de la hipertensión arterial en Atención Primaria.

BACKGROUND AND OBJECTIVES: Most hypertensive patients do not have their blood pressure (BP) under control. This study aims to evaluate Primary Care physicians' management of hypertension by analyzing the four main areas proposed by experts to improve BP control. MATERIAL AND METHODS: From February to May 2003 a questionnaire was completed by 195 Primary Care physicians from 33 Primary Care centers of Madrid, Spain. Four aspects of clinical practice were examined: a) knowledge of hypertension guidelines and objectives; b) diagnosis and follow-up of patients; c) hypertension treatment, and d) drug compliance. RESULTS: Guidelines were followed by 90.6% of the physicians. Twenty six percent of the physicians perceived that guideline objectives are too strict and only 32% identified systolic BP as the component that provides more risk. Only 14% used automatic devices to measure BP while 89% still use the mercury sphygmomanometer. Diuretics were included among the 3 most used antihypertensive drugs by 94% of the physicians, ACEI by 91%, beta blockers by 62% and combinations only by 24%. Eighty eight percent believed that more than 40% of their patients have their BP under control and 53% felt that less than 20% of their patients were non-compliant with antihypertensive treatment. CONCLUSIONS: Hypertension management among Primary Care physicians showed some deficiencies in the 4 analyzed areas. Thus, perception of excessively rigorous guideline objectives, underrating of systolic BP, underuse of automatic devices and drug associations, and the overestimation of BP control and therapeutic compliance are specific areas that should be modified to improve BP control.

Estudio comparativo del tratamiento de la luxación recidivante de hombro mediante las técnicas de Bankart y Boytchev / Comparative study of the treatment of recurrent shoulder dislocation with the Bankart and Boytchev procedures

Objetivos. Comparar retrospectivamente los resultados de las técnicas de Bankart y Boytchev para el tratamiento abierto de la luxación recidivante anterior de hombro. Material y método. Se intervinieron 75 pacientes con luxación recidivante anterior de hombro, 41 mediante la técnica de Bankart utilizando suturas ancladas (grupo A), y 34 mediante la técnica de Boytchev (grupo B).Resultados. Hubo un número significativamente mayor de pacientes con estabilidad normal en el grupo A (p < 0,05), y un número significativamente mayor de pacientes en el grupo B con aprensión cuando se realizó una posición forzada (p < 0,05). El número de pacientes sin limitaciones funcionales fue significativamente mayor en el grupo A (p < 0,05), y el de pacientes con una limitación leve significativamente mayor en el B (p < 0,05). No existieron diferencias significativas en cuanto a la flexión y la rotación interna postoperatorias. Hubo más pacientes con una limitación de la rotación externa en el grupo A, siendo esta diferencia estadísticamente significativa (p < 0,01). La limitación media de la rotación externa fue mayor en el grupo A (6,4o) que en el grupo B (1,9o), siendo esta diferencia estadísticamente significativa (p < 0,01). El resultado global según la escala de Rowe fue mejor en el grupo A, aunque la diferencia no fue estadísticamente significativa. Conclusiones. La técnica de Bankart proporciona una estabilidad y una función más satisfactorias que la de Boytchev, aunque produce una mayor limitación de la rotación externa. (AU)

Comparison of two different posterior approachs for hemiarthroplasty of the hip.

A prospective study was undertaken on 183 patients who had suffered a femoral neck fracture between 1998 and 1999. The aim was to compare the complication rates for the classical posterior approach and the modified posterior approach. The modified posterior approach used was the one described by Williams et al., which preserved the pyriformis, the labrum and the capsule. Group 1 included 95 patients, who were operated on by the posterior approach. Group 2 included 88 patients, who were operated on by the modified posterior approach. The dislocation rate for the posterior approach was 7.4% (7 cases), and 1.1% (1 case) for the modified posterior approach. This difference was statistically significant (p < 0.05). There were no significant differences in the incidences of other intraoperative and postoperative complications. We concluded that the modified posterior approach significantly increases the stability of a hemiarthroplasty in relation to the classical posterior approach.

Changes in the morphology of hip fractures within a 10-year period.

The objective of this study was to find out whether the morphology of various types of hip fractures and the mean ages of the patients had changed in a recent 10-year period. All patients aged 65 years or more with acute hip fracture admitted to Miguel Servet University Hospital in 1989-1990 (n = 457) and in 1999-2000 (n = 518) were studied. The results showed a significant increase in the incidence of displaced cervical fractures (P < 0.001) and a decrease in the incidence of nondisplaced cervical fractures (P < 0.001) in women. The incidence of different types of trochanteric fractures did not vary. No change was observed in the mean age of patients with cervical fractures, but the mean age of women with A12 trochanteric fractures was significantly higher in 1999-2000 than in 1989-1990 (P < 0.05).

Laparoscopic cholecystectomy in the third trimester of pregnancy.

Laparoscopic cholecystectomy has become the method of choice for symptomatic cholelithiasis. Laparoscopic cholecystectomy during pregnancy is also becoming more accepted, as illustrated by several recent publications on this subject. In the third trimester, however, laparoscopic cholecystectomy has been less commonly attempted, with only a few case reports. We present a series of four patients who underwent laparoscopic cholecystectomy during the third trimester of pregnancy without complication. We describe a safe and effective technique for this procedure, and review the literature on this topic.

The increase in spinal bone density that occurs in response to fluoride therapy for osteoporosis is not maintained after the therapy is discontinued.

In 44 osteoporotic subjects who had been treated with fluoride for 37 +/- 16 months, the fluoride was discontinued because they had shown fluoride-dependent increases in trabecular spinal bone densities from low initial levels (below the fracture threshold) to values that were equivalent to normal peak bone densities in the spines of young adults. During the subsequent period, after discontinuation of the fluoride therapy (i.e. 19 +/- 9 months), spinal bone density decreased in 73% of the subjects (i.e. 32 of 44, p < 0.03), at a rate that was comparable to the rate of the previous gain that had occurred during the treatment with fluoride (i.e. -3.23 +/- 2.39 mg/cm3 per month, compared with + 3.91 +/- 1.96 mg/cm3 per month in this, subgroup of patients, p < 0.001). Although 9 of the 44 subjects showed continuing increases in spinal bone density after discontinuation of the fluoride therapy, spinal bone density decreased in the entire group of 44 at an average rate of -1.02 +/- 4.72 mg/cm3 per month (p < 0.001, compared with the rate of the previous gain during the treatment with fluoride; i.e. +3.83 +/- 1.82 mg/cm3 per month). Surprisingly, our data showed that the rate of decrease in spinal bone density during the post-fluoride period was not affected by concurrent (undesigned) treatment with calcium, calcium plus estrogen, or calcium plus calcitriol. The cessation of fluoride therapy was also associated with a decrease in serum alkaline phosphatase activity (i.e. a decrease from the elevated levels that were observed during the period of fluoride therapy, back to the original, pre-treatment levels; p < 0.001), and that the rate of spinal bone loss after cessation of fluoride could be correlated with the prior rate of increase in serum alkaline phosphatase activity that had occurred during the treatment with fluoride (n = 44, r = 0.312, p = 0.039). Together, the observations from this retrospective analysis of data obtained from our clinical subjects suggest that fluoride-treated osteoporotic subjects who have exhibited increases in trabecular spinal bone density are at risk for bone loss after discontinuation of the fluoride therapy.

Parathyroid hormone-related protein: primary osteolytic factor produced by breast tumor cells in vitro?

Tumor cells in bone metastases are thought to induce bone resorption primarily by releasing paracrine factors. Parathyroid hormone related protein (PTHrp) has been proposed to mediate osteolytic activity of many tumors. PTHrp is produced by 40% to 60% of breast tumors and is elevated in the serum of up to 50% of patients with breast cancer metastases to bone. Most biologic processes in humans are heterogeneous in nature, so the purpose of this study was to investigate the hypothesis that paracrine factors other than PTHrp could mediate bone resorption by breast tumor cells. Serum-free conditioned medium (CM) was collected from five human breast tumor cell lines and tested for bone resorption-stimulating activity (BRSA) in mouse calvaria organ cultures. CM from all tumor cells studied produced significant bone resorption, comparable to that produced by 10 nM PTH. Small amounts of immunoreactive PTHrp (1.4-12.5 pM) were produced by all breast tumor cell lines. When tested in vitro, equivalent amounts of human PTHrp [1-36] did not produce significant bone resorption. Indomethacin (1 microM) significantly blocked BRSA by CM from all cell lines but did not decrease BRSA by PTHrp. In contrast PTHrp antibody (130 micrograms/ml) completely blocked BRSA by 1 nM PTHrp but did not modify BRSA by CM of breast tumor cells. The results of this study support the hypothesis that breast cancer cells release paracrine factors in vitro that stimulate bone resorption by a mechanism that is partially dependent on prostaglandin synthesis and at least in part different from that of PTHrp.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing survival in advanced gastric cancer.

Even though the incidence of gastric carcinoma is decreasing, the prognosis remains poor. A review of 88 patients with advanced gastric cancer was evaluated by univariate and multivariate analysis to determine prognostic factors. Univariate analysis showed that both "curative" resection (P = 0.006) and adjuvant chemotherapy (P = 0.02) were important therapy variables. These factors were not independent when evaluated by multivariate analysis. However, when they were combined and re-evaluated by multivariate analysis, the combination of "curative" surgery and adjuvant chemotherapy significantly improved survival in advanced gastric cancer (P = 0.04).