7 research outputs found
Aorto-oesophageal fistula after oesophageal stent placement in a patient with a Roux-en-Y gastric bypass
No full textHyperglycemia, hypoglycemia, and glycemic complexity are associated with worse outcomes after surgery
No full textPurpose: The purpose of this study was to determine if glycemic complexity, along with hypoglycemia and hyperglycemia, was associated with worse outcomes after cardiac surgery. Materials and methods: We conducted a retrospective analysis of 970 patients who had insulin infusions designed to keep blood glucose levels between 80 and 110 mg-dL. Glycemic complexity was calculated using jackknifed approximate entropy. Logistic regression was used to adjust for confounders. Results: A total of 495 patients (51percent) developed complications, and 32 patients (3.3percent) died. Along with older age, comorbidities, and complicated surgeries, any hypoglycemia (glucose 71 mg-dL) and the number of glucose values greater than 140 mg-dL were independent predictors of complications. Increased risk of mortality, after adjusting for other risk factors, was associated with older age, longer perfusion time, receiving intraoperative transfusions, and greater jackknifed approximate entropy of the glucose time series. Conclusion: We found that hypoglycemia (glucose 71 mg-dL) and hyperglycemia (glucose 140 mg-dL) were associated with increased risk of complications, whereas greater complexity of the glucose time series was associated with mortality. © 2014 Elsevier Inc.Amir J, 2011, CELL IMMUNOL, V272, P45, DOI 10.1016-j.cellimm.2011.09.008; Bagshaw SM, 2009, CRIT CARE, V13, DOI 10.1186-cc7921; Cochran WG, 1967, SAMPLING TECHNIQUES, P154; Cueni-Villoz N, 2011, CRIT CARE MED, V39, P2225, DOI 10.1097-CCM.0b013e31822572c9; D'Ancona G, 2011, EUR J CARDIO-THORAC, V40, P360, DOI 10.1016-j.ejcts.2010.11.065; Egi M, 2010, MAYO CLIN PROC, V85, P217, DOI 10.4065-mcp.2009.0394; Engoren M, 2009, J APPL PHYSIOL, V106, P766, DOI 10.1152-japplphysiol.90575.2008; Finfer S, 2009, NEW ENGL J MED, V360, P1283, DOI 10.1056-NEJMoa0810625; Finney SJ, 2003, JAMA-J AM MED ASSOC, V290, P2041, DOI 10.1001-jama.290.15.2041; Hermanides J, 2010, CRIT CARE MED, V38, P838, DOI 10.1097-CCM.0b013e3181cc4be9; Hermanides J, 2010, CRIT CARE MED, V38, P1430, DOI 10.1097-CCM.0b013e3181de562c; Hollingdal M, 2000, DIABETES, V49, P1334, DOI 10.2337-diabetes.49.8.1334; Kemeny SF, 2011, J BIOMECH, V44, P1927, DOI 10.1016-j.jbiomech.2011.04.026; Krinsley JS, 2004, MAYO CLIN PROC, V79, P992; Krinsley James Stephen, 2009, J Diabetes Sci Technol, V3, P1292; Lazar HL, 2009, ANN THORAC SURG, V87, P663, DOI 10.1016-j.athoracsur.2008.11.011; Li J, 2006, PHYS REV E, V73, DOI 10.1103-PhysRevE.73.052902; Mackenzie IMJ, 2011, INTENS CARE MED, V37, P435, DOI 10.1007-s00134-010-2103-2; Meyfroidt G, 2011, INTENS CARE MED, V37, P1151, DOI 10.1007-s00134-011-2159-7; Meyfroidt G, 2010, CRIT CARE MED, V38, P1021, DOI 10.1097-CCM.0b013e3181cf710e; Pappada SM, 2011, DIABETES TECHNOL THE, V13, P135, DOI 10.1089-dia.2010.0104; Pincus SM, 2008, J PSYCHIATR RES, V42, P337, DOI 10.1016-j.jpsychires.2007.01.001; Suh SW, 2007, GLIA, V55, P1280, DOI 10.1002-glia.20440; Van den Berghe G, 2006, NEW ENGL J MED, V354, P449, DOI 10.1056-NEJMoa052521; Van den Berghe G, 2001, NEW ENGL J MED, V345, P1359, DOI 10.1056-NEJMoa011300; Wang X, 2009, THESIS U VIRGINIA; Wessel N, 2000, PHYS REV E, V61, P733, DOI 10.1103-PhysRevE.61.7330
Dispersion of the HIV-1 Epidemic in Men Who Have Sex with Men in the Netherlands: A Combined Mathematical Model and Phylogenetic Analysis
No full textBACKGROUND: The HIV-1 subtype B epidemic amongst men who have sex with men (MSM) is resurgent in many countries despite the widespread use of effective combination antiretroviral therapy (cART). In this combined mathematical and phylogenetic study of observational data, we aimed to find out the extent to which the resurgent epidemic is the result of newly introduced strains or of growth of already circulating strains. METHODS AND FINDINGS: As of November 2011, the ATHENA observational HIV cohort of all patients in care in the Netherlands since 1996 included HIV-1 subtype B polymerase sequences from 5,852 patients. Patients who were diagnosed between 1981 and 1995 were included in the cohort if they were still alive in 1996. The ten most similar sequences to each ATHENA sequence were selected from the Los Alamos HIV Sequence Database, and a phylogenetic tree was created of a total of 8,320 sequences. Large transmission clusters that included ≥10 ATHENA sequences were selected, with a local support value ≥ 0.9 and median pairwise patristic distance below the fifth percentile of distances in the whole tree. Time-varying reproduction numbers of the large MSM-majority clusters were estimated through mathematical modeling. We identified 106 large transmission clusters, including 3,061 (52%) ATHENA and 652 Los Alamos sequences. Half of the HIV sequences from MSM registered in the cohort in the Netherlands (2,128 of 4,288) were included in 91 large MSM-majority clusters. Strikingly, at least 54 (59%) of these 91 MSM-majority clusters were already circulating before 1996, when cART was introduced, and have persisted to the present. Overall, 1,226 (35%) of the 3,460 diagnoses among MSM since 1996 were found in these 54 long-standing clusters. The reproduction numbers of all large MSM-majority clusters were around the epidemic threshold value of one over the whole study period. A tendency towards higher numbers was visible in recent years, especially in the more recently introduced clusters. The mean age of MSM at diagnosis increased by 0.45 years/year within clusters, but new clusters appeared with lower mean age. Major strengths of this study are the high proportion of HIV-positive MSM with a sequence in this study and the combined application of phylogenetic and modeling approaches. Main limitations are the assumption that the sampled population is representative of the overall HIV-positive population and the assumption that the diagnosis interval distribution is similar between clusters. CONCLUSIONS: The resurgent HIV epidemic amongst MSM in the Netherlands is driven by several large, persistent, self-sustaining, and, in many cases, growing sub-epidemics shifting towards new generations of MSM. Many of the sub-epidemics have been present since the early epidemic, to which new sub-epidemics are being added
Место клопидогрела в современном лечении острого коронарного синдрома
No full textIn the article, a review is given of the facts that determined contemporary views of the role of clopidogrel in the treatment of acute coronary syndrome. The author described a history of the clinical studies of clopidogrel in acute coronary syndrome (ACS), analysed its role in the current approaches to the treatment of the disease during the widespread use of other platelet P2Y12 receptor antagonists (ticagrelor and prasugrel).The article discusses circumstances, when clopidogrel may have additional advantages, particularly the role of adherence to prolonged double antiplatelet therapy, as well as situations, when sever suppression of platelet function can be decreased (treatment de-escalation). According to a prospective randomized open-label PoPular Age study, clopidogrel combined with acetylsalicylic acid in patients with ACS without persistent ST segment elevations at the age of ≥70 years showed better adherence to treatment over the coming year as compared with clopidogrel combined with ticagrelor or prasugrel. As a result, these two approaches had comparable efficacy. Today, treatment de-escalation is a necessary measure to extend the double antiplatelet therapy in cases, when continued administration of prasugrel or ticagrelor appears unacceptable. There is insufficient evidence for the routine implementation of de-escalation in stented patients with ACS, although a small prospective, one-centre randomized open-label ToPIC study shows that this approach is safe.The author provides a review of the results of recently presented prospective studies on the choice of a platelet P2Y12 receptor antagonist for long-term treatment of acute coronary syndrome, taking into account the residual platelet reactivity and cytochrome p450 2c19 genetic polymorphisms. Among them are multicenter open randomized clinical TRoPICAL-ACS study, multicenter randomized open-label PoPular Genetics and TAILoR PCI studies. According to the study results, the long-term outcomes in stented patients with ACS with a good response to clopidogrel assessed by the residual functional activity of platelets or by studying cytochrome p450 2c19 genetic polymorphisms may not be worse than those during use of prasugrel or ticagrelor.В обзоре представлены факты, определившие современные представления о месте клопидогрела в лечении острого коронарного синдрома. Описывается история клинического изучения клопидогрела при остром коронарном синдроме (ОКС), анализируется его место при современных подходах к лечению заболевания при широком распространении других блокаторов P2Y12 рецептора тромбоцитов (тикагрелора и прасугрела).Рассматриваются обстоятельства, при которых клопидогрел может иметь дополнительные преимущества, в частности роль приверженности к длительной двойной антитромбоцитарной терапии, а также ситуации, при которых можно рассматривать уменьшение выраженности подавления функции тромбоцитов («деэскалацию» лечения). По данным проспективного рандомизированного открытого исследования PoPularAge, у больных с ОКС без стойких подъемов сегмента ST в возрасте ≥70 лет сочетание ацетилсалициловой кислоты с клопидогрелом характеризовалось лучшей приверженностью к лечению на протяжении ближайшего года по сравнению с ее сочетанием с тикагрелором или прасугрелом. В итоге эффективность этих двух подходов оказалась сопоставимой. «Деэскалация» лечения на сегодняшний день является вынужденной мерой, позволяющей продлить двойную антитромбоцитарную терапию в случаях, когда продолжение приема прасугрела или тикагрелора представляется неприемлемым. Данных за рутинное внедрение «деэскалации» у стентированных больных с ОКС на сегодняшний день недостаточно, хотя результаты небольшого проспективного одноцентового рандомизированного открытого исследования ToPIC указывают на безопасность такого подхода.Анализируются результаты недавно представленных проспективных исследований по выбору блокатора P2Y12 рецептора ромбоцитов для длительного лечения острого коронарного синдрома с учетом остаточной реактивности тромбоцитов и полиморфизмов гена цитохрома P450 2С19. Среди них многоцентровое открытое рандомизированное клиническое испытание TRoPICAL-ACS, многоцентровые рандомизированные открытые исследования PoPularGenetics и TAILoRPCI. Согласно их результатам, у стентированных больных с ОКС с хорошим ответом на клопидогрел, оцененным с помощью остаточной функциональной активности тромбоцитов или изучения полиморфизмов гена цитохрома P450 2С19, отдаленные результаты у могут быть не хуже, чем при применении прасугрела или тикагрелора
Evaluación del control glucémico perioperatorio en pacientes de 60 años y más con diabetes mellitus tipo 2 en un hospital de tercer nivel en Manizales, Colombia, estudio transversal
No full textTablas, gráficasObjetivo: Este estudio tuvo como objetivo evaluar el control glucémico perioperatorio de pacientes ancianos con diabetes, estimar la prevalencia del mal control y explorar asociaciones de éste con complicaciones hospitalarias. Métodos: Estudio transversal, con componente analítico, en pacientes de 60 años o más, con diabetes, ingresados en un hospital de tercer nivel en Colombia entre enero 2020 a febrero 2025. El mal control glucémico se determinó utilizando métricas de glucometría, incluidos valores promedio de glucosa fuera del rango objetivo, tiempo en rango derivado (TERd 100-180 mg/dL) 36%) e hipoglucemia (36%, el 65.4% tuvo un tiempo en rango 70%, el 38% presentó al menos un episodio de hipoglucemia. La mortalidad se presentó en el 6.4%, lesión renal aguda en el 47.7%, delirium 39% de los pacientes. Los factores que se asociaron a mal control glucémico fueron la edad, la nefropatía diabética y la insuficiencia cardiaca, características que delinean un perfil de alto riesgo en los pacientes. La variabilidad glucémica y un bajo tiempo en rango se asociaron a un mayor riesgo de mortalidad, infecciones, hipoglucemia, delirium y duración de la estancia hospitalaria. Conclusión: Se encontró asociación entre mal control glucémico y desenlaces como mortalidad, infección, mayor tiempo de estancia hospitalaria, delirium y lesión renal, de ahí que es importante un tratamiento individualizado, con estrategias de manejo óptimas para llegar a metas de control glucémico (utilizando métricas como el tiempo en rango y la variabilidad) y disminuir la probabilidad de estos desenlaces adversos, mejorando el pronóstico de los pacientesObjective: This study aimed to evaluate perioperative glycemic control in elderly patients with diabetes, estimate the prevalence of poor glycemic control, and explore its associations with in-hospital complications. Methods: Cross-sectional study with an analytical component, including patients aged 60 years or older with diabetes, admitted to a tertiary-level hospital in Colombia between January 2020 and February 2025. Poor glycemic control was determined using glucometry metrics, including mean glucose values outside the target range, derived time in range (dTIR 100–180 mg/dL) 36%), and hypoglycemia (36%; 65.4% had a time in range <70%; and 38% experienced at least one episode of hypoglycemia. Mortality occurred in 6.4% of patients, acute kidney injury in 47.7%, and delirium in 39%. Factors associated with poor glycemic control were age, diabetic nephropathy, and heart failure, characteristics that delineate a high-risk patient profile. Glycemic variability and low time in range were associated with a higher risk of mortality, infections, hypoglycemia, delirium, and longer hospital length of stay. Conclusion: An association was found between poor glycemic control and outcomes such as mortality, infection, longer hospital length of stay, delirium, and acute kidney injury. Therefore, individualized treatment with optimal management strategies aimed at achieving glycemic control targets, using metrics such as time in range and variability, is important to reduce the likelihood of these adverse outcomes and improve patient prognosis.Información general del proyecto -- Resumen -- Palabras clave -- Descriptores del proyecto -- Marco teórico -- Objetivos -- Metodología -- Aspectos éticos -- Resultados -- Descripción de las características hospitalarias -- Características de control glucémico intrahospitalario -- Desenlaces hospitalarios -- Factores asociados a mal control glucémico -- Mal control glucémico y desenlaces adversos -- Discusión -- Ventajas y limitaciones -- Conclusiones -- Recomendaciones -- Bibliografía -- AnexosEspecializaciónTomando como base la cohorte de la población de 60 años y más, y diabética del Hospital de Caldas, Manizales – Colombia, que fue llevada a intervenciones quirúrgicas durante la hospitalización, se realizó la evaluación de los pacientes incluidos en la base de datos hasta febrero del 2025. Se obtuvo la información de los datos almacenados en la historia clínica de los pacientes en el sistema Dinámica Gerencial del Hospital y la información se recolectó y almacenó a través de los computadores y en área dispuesta por el propio hospital, datos que se ingresaron en una base de datos donde estaban registradas las variables que se midieron para cumplir los objetivos. Posteriormente se determinó el grado de control glucémico de los pacientes, y se dividieron en dos grupos según su buen o mal control glucémico, y se compararon las diferencias en las características de los pacientes y los desenlaces post operatorios.
Para la estimación del tamaño de la muestra se asumió un diseño transversal con el objetivo de estimar la proporción de pacientes con control glucémico adecuado durante la hospitalización postoperatoria. Se consideró una proporción esperada del 30%, basada en datos propios reportados previamente en pacientes hospitalizados con diabetes(13), con un nivel de confianza del 95% (Z = 1.96) y un margen de error absoluto de ±5 puntos porcentuales. Aplicando la fórmula clásica para proporciones en estudios descriptivos n=Z^2⋅p⋅(1-p)/d^2, se obtuvo un tamaño mínimo requerido de 312 pacientes.
La caracterización de la población se llevó a cabo mediante estadística descriptiva. Las variables cualitativas se presentaron como frecuencias absolutas y porcentajes. Para las variables continuas, se reportaron medidas de tendencia central y dispersión (media con desviación estándar [DE] o mediana con rango intercuartílico [RIC]). En variables con distribuciones asimétricas o presencia de valores atípicos significativos, se reportaron además estimadores robustos, como la media recortada al 10% y la desviación estándar winsorizada, para ofrecer una descripción más fidedigna de la tendencia central y la dispersión. La prevalencia de mal control metabólico se calculó como una proporción puntual. Se hizo el cálculo del tiempo en rango derivado utilizando mediciones de glucometría registradas durante la hospitalización. Las asociaciones bivariadas se evaluaron según la naturaleza de las variables. Para las categóricas, se empleó la prueba de χ² de Pearson o la prueba exacta de Fisher, y la magnitud de la asociación se cuantificó con el Odds Ratio (OR) y su IC al 95%.Especialista Medicina Interna - GeriatríaDiabete
Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study
No full textBackground Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications.Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged >= 18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients' preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARR(adj)). This study is registered with ClinicalTrials. gov, number NCT01865513.Findings Between June 16, 2014, and April 29, 2015, data from 22 803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7.6%] of 21 694); ORadj 1.86, 95% CI 1.53-2.26; ARR(adj) -4.4%, 95% CI -5.5 to -3.2). Only 2.3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1.31, 95% CI 1.15-1.49; ARR(adj) -2.6%, 95% CI -3.9 to -1.4) and the administration of reversal agents (1.23, 1.07-1.41; -1.9%, -3.2 to -0.7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1.03, 95% CI 0.85-1 center dot 25; ARR(adj) -0.3%, 95% CI -2.4 to 1.5) nor extubation at a train-of-four ratio of 0.9 or more (1.03, 0.82-1.31; -0.4%, -3.5 to 2.2) was associated with better pulmonary outcomes.Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications
