Blood eosinophils levels in a Colombian cohort of biomass-and tobacco-related COPD patients.

Introduction: Chronic obstructive pulmonary disease (COPD) is a major cause of illness and death among adults. In 2019, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy incorporated blood eosinophils as a biomarker to identify patients at increased risk of exacerbations which, with the history of exacerbations during the previous year, allows identification of patients who would benefit from anti-inflammatory treatment to reduce the risk of future exacerbations. The aim of this study was to describe demographic and clinical characteristics, eosinophil counts, and exacerbations in a cohort of COPD patients stratified by clinical phenotypes (non-exacerbator, frequent exacerbator, asthma-COPD overlap) in a Colombian cohort at 2600 meters above sea level. Methods: A descriptive analysis of a historical cohort of patients with a confirmed diagnosis of moderate to severe COPD (FEV1/FVC < 0.7 and at least one risk factor for COPD) from two specialized centers with comprehensive disease management programs was performed from January 2015 to March 2019. Data were extracted from medical records 1 year before and after the index date. Results: 200 patients were included (GOLD B: 156, GOLD E: 44; 2023 GOLD classification); mean age was 77.9 (SD 7.9) years; 48% were women, and 52% had biomass exposure as a COPD risk factor. The mean FEV1/FVC was 53.4% (SD 9.8), with an FEV1 of 52.7% (20.7). No differences were observed between clinical phenotypes in terms of airflow limitation. The geometric mean of absolute blood eosinophils was 197.58 (SD 2.09) cells/µL (range 0 to 3,020). Mean blood eosinophil count was higher in patients with smoking history and frequent exacerbators. At least one moderate and one severe exacerbation occurred in the previous year in 44 and 8% of patients, respectively; during the follow-up year 152 exacerbations were registered, 122 (80%) moderate and 30 (20%) severe. The highest rate of exacerbations in the follow-up year occurred in the subgroup of patients with the frequent exacerbator phenotype and eosinophils ≥300 cells/µL. Discussion: In this cohort, the frequency of biomass exposure as a risk factor is considerable. High blood eosinophil count was related to smoking, and to the frequent exacerbator phenotype.

Use of complementary and alternative medicine by cancer patients in Colombia.

BACKGROUND: The use of complementary and alternative medicines (CAM) among cancer patients varies greatly. The available data suggest an increasing use of CAM over time and a higher prevalence in low- and middle-income countries. However, no reliable data are available from Latin America. Accordingly, we examined the prevalence of CAM use among cancer patients from six Colombian regions. METHODS: We conducted a survey on cancer patients attending comprehensive cancer centres in six capital cities from different regions. The survey was designed based on a literature review and information gathered through focus groups on CAM terminology in Colombia. Independent random samples of patients from two comprehensive cancer centres in every city were obtained. Patients 18 years and older with a histopathological diagnosis of cancer undergoing active treatment were eligible. The prevalence of CAM use is reported as a percentage with the corresponding confidence interval. CAM types are reported by region. The sociodemographic and clinical characteristics of CAM users and non-users were compared using Chi square and t tests. RESULTS: In total, 3117 patients were recruited. The average age 59.6 years old, and 62.8% were female. The prevalence of CAM use was 51.7%, and compared to non-users, CAM users were younger, more frequently women, affiliated with the health insurance plan for low-income populations and non-Catholic. We found no differences regarding the clinical stage or treatment modality, but CAM users reported more treatment-related side effects. The most frequent types of CAM were herbal products, specific foods and vitamins, and individually, soursop was the most frequently used product. Relevant variability between regions was observed regarding the prevalence and type of CAM used (range: 36.6% to 66.7%). The most frequent reason for using CAM was symptom management (30.5%), followed by curative purposes (19.5%). CONCLUSIONS: The prevalence of CAM use among cancer patients in Colombia is high in general, and variations between regions might be related to differences in cultural backgrounds and access to comprehensive cancer care. The most frequently used CAM products and practices have little scientific support, suggesting the need to enhance integrative oncology research in the country.

Adams-Oliver syndrome and associated complications: Report of a family in Colombia and review of the literature / Síndrome de Adams-Oliver y complicaciones asociadas: reporte de una familia en Colombia y revisión de la literatura

The Adams-Oliver syndrome is a rare congenital disorder characterized by aplasia cutis congenita of the scalp, terminal transverse limb defects, and congenital telangiectatic cutis marmorata. It can occur through different inheritance patterns: autosomal dominant, autosomal recessive, or de novo dominant mutations. Although the Adams-Oliver syndrome is a rare disease, it is essential to know its clinical characteristics and inheritance patterns, to establish a correct diagnosis and its possible complications during follow-up. In the present study, we describe the case of an adolescent with Adams-Oliver syndrome with an autosomal dominant inheritance pattern, pulmonary hypertension and plastic bronchitis, and several compromised family members.

El síndrome de Adams-Oliver es un trastorno congénito raro, caracterizado por aplasia cutis congénita en el cuero cabelludo, defectos terminales transversales de las extremidades y piel marmorata telangiectásica congénita. Este puede presentarse debido a diferentes patrones de herencia de tipo autosómico dominante o autosómico recesivo, o por mutaciones dominantes de novo. Aunque el síndrome de Adams-Oliver es una enfermedad poco frecuente, es importante conocer sus características clínicas y patrones de herencia, para así establecer un correcto diagnóstico y sus posibles complicaciones durante el seguimiento. En el presente estudio, se describe el caso de una adolescente con síndrome de Adams-Oliver con patrón de herencia autosómica dominante, hipertensión pulmonar y bronquitis plástica. Había varios miembros de su familia con el mismo compromiso.

Consensus for the use of flash glucose monitoring in the Colombian adult population with type 1 and 2 diabetes mellitus / Consenso para el uso de monitoreo de glucosa flash en la población adulta colombiana con diabetes mellitus tipo 1 y 2

Abstract Introduction: in Colombia, the Clinical Practice Guidelines for the treatment of patients with type 1 (DM1) and type 2 (DM2) diabetes do not mention the use of flash glucose monitoring, as this system was not available. The objective of this study was to establish a set of recommendations for the use of intermittent flash monitoring in Colombia. Methods: the group of experts consisted of eight Colombian physicians from different cities within Colombia, with expertise in the management of patients with DM1 and DM2; a certified diabetes nurse educator; a patient with DM1; and a methodological expert. Using the Zoom Enterprise video conferencing application (Zoom Video Communications, San Jose, California), the group generated questions through the Metaplan method, then carried out a systematic literature search and evidence review. The recommendations were made according to the degree of evidence and strength of the recommendation, following the GRADE method. Results: clinical recommendations were made for: a) patients with DM1 and hypoglycemia; b) patients with DM1 and poor metabolic control; c) patients with insulin-treated DM2; d) pregestational diabetes; e) quality of life; and f) inpatient use. Conclusions: this consensus's clinical recommendations guide clinical decision making with regard to the use of intermittent flash monitoring in patients with diabetes in various clinical settings. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2239).

Resumen Introducción: en Colombia las Guías de Práctica Clínica para el manejo del paciente con diabetes tipo 1 (DM1) y tipo 2 (DM2) no mencionan el uso del monitoreo de glucosa flash dado que dicho sistema no estaba disponible. El objetivo del presente trabajo fue establecer un grupo de recomendaciones sobre el uso del monitoreo intermitente flash en Colombia. Métodos: el grupo de expertos estuvo conformado por ocho médicos colombianos expertos en el manejo de pacientes con DM1 y DM2 de diversas ciudades de Colombia, una enfermera licenciada educadora en diabetes, una paciente con diagnóstico de DM1 y un experto metodológico. A través de Zoom Enterprise versión de la aplicación de videoconferencia Zoom (Zoom Video Communications, San Jose, California) el grupo generó las preguntas con metodología Metaplan. Posteriormente, se realizó una búsqueda sistemática de la literatura y análisis de la evidencia. Las recomendaciones se generaron mediante grupo nominal según el grado de evidencia y la formaleza de la recomendación siguiendo la metodología GRADE. Resultados: se generaron recomendaciones clínicas enfocadas a: a) paciente con diagnóstico de DM1 e hipoglucemia; b) paciente con diagnóstico de DM1 y mal control metabólico, c) paciente con diagnóstico de DM tipo 2 tratado con insulina, d) diabetes pregestacional, e) calidad de vida y f) uso intrahospitalario. Conclusiones: las recomendaciones clínicas del presente consenso orientan la toma de decisiones clínicas con respecto al uso de monitoreo intermitente flash en el paciente con diagnóstico de diabetes en diferentes escenarios clínicos. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2239).

Etiology and the challenge of diagnostic testing of community-acquired pneumonia in children and adolescents.

BACKGROUND: Pneumonia is the leading cause of mortality in pediatric population. The etiology of pneumonia in this population is variable and changes according to age and disease severity and where the study is conducted. Our aim was to determine the etiology of community-acquired pneumonia (CAP) in children aged 1 month to 17 years admitted to 13 Colombian hospitals. METHODS: Prospective cohort study. Hospitalized children with radiologically confirmed CAP and ≤ 15 days of symptoms were included and followed together with a control group. Induced sputum (IS) was submitted for stains and cultures for pyogenic bacteria and Mycobacterium tuberculosis, and multiplex PCR (mPCR) for bacteria and viruses; urinary antigens for pneumococcus and Legionella pneumophila; nasopharyngeal swabs for viruses, and paired serology for atypical bacteria and viruses. Additional cultures were taken at the discretion of primary care pediatricians. RESULTS: Among 525 children with CAP, 71.6% had non-severe pneumonia; 24.8% severe and 3.6% very severe pneumonia, and no fatal cases. At least one microorganism was identified in 84% of children and 61% were of mixed etiology; 72% had at least one respiratory virus, 28% pyogenic bacteria and 21% atypical bacteria. Respiratory syncytial virus, Parainfluenza, Rhinovirus, Influenza, Mycoplasma pneumoniae, Adenovirus and Streptococcus pneumoniae were the most common etiologies of CAP. Respiratory syncytial virus was more frequent in children under 2 years and in severe pneumonia. Tuberculosis was diagnosed in 2.3% of children. IS was the most useful specimen to identify the etiology (33.6%), and blood cultures were positive in 3.6%. The concordance between all available diagnostic tests was low. A high percentage of healthy children were colonized by S. pneumoniae and Haemophilus influenzae, or were infected by Parainfluenza, Rhinovirus, Influenza and Adenovirus. CONCLUSIONS: Respiratory viruses are the most frequent etiology of CAP in children and adolescents, in particular in those under 5 years. This study shows the challenges in making an etiologic diagnosis of CAP in pediatric population because of the poor concordance between tests and the high percentage of multiple microorganisms in healthy children. IS is useful for CAP diagnosis in pediatric population.

Sistema endocannabinoide y cannabidiol en el manejo del dolor en perros: revisión narrativa

Introducción: la marihuana (Cannabis sativa L.) es una planta originaria de Asia cada vez más reconocida por su valor terapéutico en la medicina humana y veterinaria. Contiene una gran cantidad de componentes entre los que destacan los fitocannabinoides, de los cuales los más representativos son el delta-9-tetrahidrocannabinol (THC) y Cannabidiol (CBD) que se acoplan respectivamente a los receptores CB1 y CB2 en el sistema endocannabinoide que es un sistema neurotransmisor entre células que regula varios procesos en los vertebrados como memoria, dolor, inflamación, apetito y procesos inmunológicos entre otros. Objetivo: realizar una síntesis narrativa del sistema endocannabinoide y cannabidiol en el manejo del dolor en perros, a partir de la búsqueda de publicaciones en bases de datos electrónica PubMed, NCBI, SciELO, Science Direct, Dialnet, Google y Google Académico. Resultados: el CBD es el principal cannabinoide utilizado en la terapia del manejo del dolor en perros por sus propiedades analgésicas y carencia de efectos psicoactivos. Conclusión: se evidencia la necesidad de realizar más investigaciones con ensayos clínicos controlados sobre el uso terapéutico del cannabidiol, que tengan validez interna y externa, con poblaciones más significativas en la especie de interés.

SUMMARY Introduction: marijuana (CannabissativaL.) is a plant native to Asia that is increasingly recognized for its therapeutic value in human and veterinary medicine. It contains a large number of components among which the phytocannabinoids stand out, of which the most representative are delta-9-tetrahydrocannabinol (THC) and Cannabidiol (CBD) that are coupled respectively to the CB1 and CB2 receptors in the endocannabinoid system, which is a neurotransmitter system between cells that regulates various processes in vertebrates such as memory, pain, inflammation, appetite and immune processes among others. Aim: to carry out a narrative synthesis of the endocannabinoid and cannabidiol system in the management of pain in dogs, from the search of publications in electronic databases PubMed, NCBI, SciELO, Science Direct, Dialnet, Google and Google Scholar. Results: CBD is the main cannabinoid used in pain management therapy in dogs due to its analgesic proper-ties and lack of psychoactive effects. Conclusion: there is evidence of the need for more research with controlled clinical trials on the therapeutic use of cannabidiol, which have internal and external validity, with more significant populations in the species of interest.

Introdução: a maconha (Cannabis sativa L.) é uma planta nativa da Ásia que é cada vez mais reconhecida por seu valor terapêutico na medicina humana e veterinária. Ele contém muitos componentes entre os quais se destacam os fitocanabinóides, dos quais os mais representativos são delta-9-tetrahidrocanabinol (THC) e Canabidiol (CBD) que estão acoplados respectivamente aos receptores CB1 e CB2 no sistema endocanabinóide, que é um sistema neurotransmissor entre as células que regula vários processos nos vertebrados, como memória, dor, inflamação, apetite e processos imunológicos, entre outros. Objetivo: realizar uma síntese narrativa do sistema endocanabinoide e canabidiol no manejo da dor em cães, a partir da busca de publicações nas bases de dados eletrônicas PubMed, NCBI, SciELO, Science Direct, Dialnet, Google e Google Scholar. Resultados: O CBD é o principal canabinoide utilizado na terapia de controle da dor em cães devido às suas propriedades analgésicas e ausência de efeitos psicoativos. Conclusão: há evidências da necessidade de mais pesquisas com ensaios clínicos controlados sobre o uso terapêutico do canabidiol, que tenham validade interna e externa, com populações mais significativas nas espécies de interesse.

Medical decisions concerning the end of life for cancer patients in three Colombian hospitals - a survey study.

BACKGROUND: Cancer patients' end-of-life care may involve complex decision-making processes. Colombia has legislation regarding provision of and access to palliative care and is the only Latin American country with regulation regarding euthanasia. We describe medical end-of-life decision-making practices among cancer patients in three Colombian hospitals. METHODS: Cancer patients who were at the end-of-life and attended in participating hospitals were identified. When these patients deceased, their attending physician was invited to participate. Attending physicians of 261 cancer patients (out of 348 identified) accepted the invitation and answered a questionnaire regarding end-of-life decisions: a.) decisions regarding the withdrawal or withholding of potentially life-prolonging medical treatments, b.) intensifying measures to alleviate pain or other symptoms with hastening of death as a potential side effect, and c.) the administration, supply or prescription of drugs with an explicit intention to hasten death. For each question addressing the first two decision types, we asked if the decision was fully or partially made with the intention or consideration that it may hasten the patient's death. RESULTS: Decisions to withdraw potentially life-prolonging treatment were made for 112 (43%) patients, 16 of them (14%) with an intention to hasten death. For 198 patients (76%) there had been some decision to not initiate potentially life-prolonging treatment. Twenty-three percent of patients received palliative sedation, 97% of all patients received opioids. Six patients (2%) explicitly requested to actively hasten their death, for two of them their wish was fulfilled. In another six patients, medications were used with the explicit intention to hasten death without their explicit request. In 44% (n = 114) of all cases, physicians did not know if their patient had any advance care directives, 26% (n = 38) of physicians had spoken to the patient regarding the possibility of certain treatment decisions to hasten death where this applied. CONCLUSIONS: Decisions concerning the end of life were common for patients with cancer in three Colombian hospitals, including euthanasia and palliative sedation. Physicians and patients often fail to communicate about advance care directives and potentially life-shortening effects of treatment decisions. Specific end-of-life procedures, patients' wishes, and availability of palliative care should be further investigated.

Decision making in the end-of-life care of patients who are terminally ill with cancer - a qualitative descriptive study with a phenomenological approach from the experience of healthcare workers.

BACKGROUND: In Colombia, recent legislation regarding end-of-life decisions includes palliative sedation, advance directives and euthanasia. We analysed which aspects influence health professionals´ decisions regarding end-of-life medical decisions and care for cancer patients. METHODS: Qualitative descriptive-exploratory study based on phenomenology using semi-structured interviews. We interviewed 28 oncologists, palliative care specialists, general practitioners and nurses from three major Colombian institutions, all involved in end-of-life care of cancer patients: Hospital Universitario San Ignacio and Instituto Nacional de Cancerología in Bogotá and Hospital Universitario San José in Popayan. RESULTS: When making decisions regarding end-of-life care, professionals consider: 1. Patient's clinical condition, cultural and social context, in particular treating indigenous patients requires special skills. 2. Professional skills and expertise: training in palliative care and experience in discussing end-of-life options and fear of legal consequences. Physicians indicate that many patients deny their imminent death which hampers shared decision-making and conversations. They mention frequent ambiguity regarding who initiates conversations regarding end-of-life decisions with patients and who finally takes decisions. Patients rarely initiate such conversations and the professionals normally do not ask patients directly for their preferences. Fear of confrontation with family members and lawsuits leads healthcare workers to carry out interventions such as initiating artificial feeding techniques and cardiopulmonary resuscitation, even in the absence of expected benefits. The opinions regarding the acceptability of palliative sedation, euthanasia and use of medications to accelerate death without the patients´ explicit request vary greatly. 3. Conditions of the insurance system: limitations exist in the offer of oncology and palliative care services for important proportions of the Colombian population. Colombians have access to opioid medications, barriers to their application are largely in delivery by the health system, the requirement of trained personnel for intravenous administration and ambulatory and home care plans which in Colombia are rare. CONCLUSIONS: To improve end-of-life decision making, Colombian healthcare workers and patients need to openly discuss wishes, needs and care options and prepare caregivers. Promotion of palliative care education and development of palliative care centres and home care plans is necessary to facilitate access to end-of-life care. Patients and caregivers' perspectives are needed to complement physicians' perceptions and practices.

Perspectivas de pacientes y profesionales en torno al uso de medicinas alternativas y complementarias para el cuidado del cáncer: un estudio exploratorio / Perception of Alternative and Complementary Medicine for Cancer Care among Patients and Health Professionals: An Exploratory Study

Introducción: el uso de medicinas alternativas y complementarias (MAC) por pacientes oncológicos es una práctica extendida, generalmente por fuera del tratamiento principal. La falta de entendimiento entre percepciones de pacientes y profesionales puede derivar en problemas de comunicación con repercusión negativa en el cuidado. Objetivo: indagar por coincidencias y divergencias en la percepción de pacientes y profesionales frente al uso de MAC en el paciente oncológico. Métodos: estudio exploratorio con análisis interpretativo fenomenológico mediante grupos focales, usando dominios prestablecidos. Se realizó codificación manual independiente y, posteriormente, se agruparon los códigos para su interpretación. El agrupamiento fue triangulado con el equipo de investigación para generar categorías definitivas. Resultados: surgieron dos categorías: conceptualización y vivencia frente a MAC. Cada categoría incluye subcategorías similares (p. ej., denominaciones, uso de MAC) y diferenciales (p. ej. valoración, fundamentación), entre los dos grupos. La conceptualización reconoce cómo los participantes caracterizan la MAC y la vivencia identifica la forma y vías como se relacionan con la MAC. Conclusiones: pacientes y profesionales comparten inquietudes frente al uso de MAC, pero existen diferencias en lenguaje y expectativas frente a su uso. Para los pacientes el consejo médico es relevante pero no definitivo y la evidencia científica solo es relevante para los profesionales.

Barreras de acceso en la atención de las enfermedades pulmonares intersticiales en Colombia / Barriers to access for interstitial lung diseases care in Colombia

Resumen Existe una creciente cantidad de información referente al manejo de las enfermedades pulmonares intersticiales en el mundo, sin embargo, las barreras en el acceso a los sistemas de salud afectan la adherencia a los estándares de tratamiento de estos pacientes. Este artículo busca explorar las perspectivas de los médicos neumólogos sobre las barreras en el diagnóstico y tratamiento de los pacientes con enfermedades pulmonares intersticiales en Colombia. Para este fin, realizamos un estudio cualitativo cuya aproximación metodológica fue la fenomenología. Se conformaron grupos focales con médicos neumólogos para explorar las barreras en el acceso a los servicios de salud. Los datos se analizaron usando un análisis temático inductivo. Los participantes manifestaron la existencia de barreras derivadas de la falta de capacitación en atención primaria, de la ausencia de integralidad en los servicios y de la escasez de grupos de discusión multidisciplinaria. La inequidad en la atención se encuentra relacionada con problemas estructurales del sistema de seguridad social colombiano. Como conclusiones identificamos que las características del sistema de salud establecen la mayoría de las barreras para la atención de los pacientes. Una mayor sensibilización al personal médico podría evitar retrasos en el acceso a la atención especializada.

Abstract There is a growing amount of information regarding the management of interstitial lung diseases in the world. However, barriers in access to health systems affect adherence to treatment standards for these patients. This article aims to explore the perspectives of pulmonologists about the barriers in the diagnosis and treatment of patients with interstitial lung diseases in Colombia. For this purpose, we conducted a qualitative study whose methodological approach was phenomenological. Focus groups were formed with pulmonologists to explore the barriers in access to health services. The data were analyzed using an inductive thematic analysis. The participants expressed the existence of barriers derived from the lack of training in primary care, the lack of integrated services and the scarcity of multidisciplinary discussion groups. Inequality of care is related to structural problems of the Colombian social security system. We concluded that the characteristics of the health system establish most of the barriers to patient care. Greater awareness among medical professionals could avoid delays in access to specialized care.

La gestión de recursos humanos y la construcción de subjetividades en las nuevas condiciones de la economía / Human Resources Management and the Construction of Subjectivities in the New Economy Conditions

Resumen Este documento analiza la Teoría del capital humano y sus consecuencias en la gestión humana, donde cobran relevancia los planteamientos de Foucault y sus análisis de las formas de gobernar a sujetos y poblaciones, que interesan al estudio de las organizaciones. La presente revisión surge de la preocupación por discursos convertidos en mandatos en el mundo empresarial que plantean retos y objetivos a las empresas y las áreas de gestión humana, sin que se visibilicen los aportes críticos surgidos en el ámbito académico que establecen los riesgos de seguir trabajando desde miradas reduccionistas y pragmáticas, donde los sujetos son asumidos como absolutos responsables de sus éxitos, en un ámbito donde pareciera innecesaria la construcción de sentidos de comunidad.

Abstract The present document analyzes the theory of human capital and its consequences in the human management, where Foucault's approaches are relevant and his analysis of forms of governing resulting in new studies of organizations. The inspiration for this article came from the concern that the elevated discussions of chain of command in the business world would incorrectly identify the challenges and objectives for the businesses and for the areas of human management, without considering the suggestions from the academic world that establishes the risks of working only from the pragmatic point of view. From this point, the subjects are assumed as absolute responsibilities of their successes, where in the business world it appears unnecessary to create a sense of community.

Guía colombiana de práctica clínica para el tratamiento de la diabetes mellitus tipo 2: falla al tratamiento inicial / Colombian Clinical Practice Guideline for Treatment of Type 2 Diabetes Mellitus: First Line Treatment Failure

Introducción: Existen diferentes opciones de manejo para pacientes con diabetes mellitus tipo 2 (DMT2) que ya iniciaron tratamiento farmacológico con metformina y no han alcanzado metas de control glucémico. Resulta prioritario definir pautas para escoger la mejor opción en estos pacientes, así como en aquellos que no han tenido un control óptimo con la combinación de dos medicamentos. Objetivo: Definir cuál es antidiabético de elección, entre sulfonilureas, tiazolidinedionas, inhibidores de DPP-4, agonista del receptor de GLP-1 o insulina basal, como segunda y tercera líneas de manejo en pacientes con DMT2. Métodos: Se elaboró la guía de práctica clínica, siguiendo los lineamientos de la guía metodológica del Ministerio de Salud y Protección Social colombiano. Se revisó la evidencia disponible de forma sistemática y se formularon las recomendaciones utilizando la metodología GRADE. Conclusiones: En pacientes con DMT2 y falla terapéutica al manejo con metformina como monoterapia (HbA1C > 7 %) se recomienda como primera opción adicionar un inhibidor DPP-4, como segunda opción adicionar inhibidor SGLT2 o sulfonilureas con bajo riesgo de hipoglucemia y como tercera opción agregar insulina basal a los pacientes que con la combinación de dos fármacos fallen en alcanzar su meta de HbA1C. Si la falla terapéutica se asocia con un IMC persistentemente ≥ 30, se sugiere la adición de un agonista de GLP-1 por el potencial beneficio sobre la reducción de peso.

Introduction: There are different options to treat type 2 diabetes (DMT2) patients who began treatment with metformin and have not reached therapeutic golds. It is imperative to define rules to choose the best option, in these patients, as in those who have not achieved an optimal control under combined therapy. Aim: To define the best option between sulfonylureas, thiazolidinediones, DPP4 inhibitors, GLP-1 agonist or basal insulin, as second or third line treatment, in patients with DMT2 who have not reached therapeutic golds with metformin or combined therapy. Methods: A clinical practice guide has been developed following the broad outline of the methodological guide from the Colombian Ministry of Health and Social Welfare, with the aim of systematically gathering scientific evidence and formulating recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. Conclusions: In patients with DMT2 who did not reach their therapeutic goal with metformin as a monotherapy (Hb1Ac <7%), addition of a second oral antidiabetic medication is recommended. it is recommended as a first step to add a DPP-4 inhibitor. It is suggested to add a SGLT2 inhibitor or a sulfonylurea having low risk of hypoglycemia as acceptable options. It is suggested to add basal insulin as a third antidiabetic medication if the combination of two pharmacological treatments does not enable the patient to reach and maintain the HbA1c goal. It is suggested to add a GLP-1 agonist if therapeutic failure appears in patients who remain obese (BMI ≥30 kg/m²), considering its potential to reduce weight.

Validez diagnóstica de los volúmenes pulmonares por pletismografía para el diagnóstico clínico y el seguimiento de la fibrosis pulmonar idiopática / Diagnostic validity of lung volumes by plethysmography for clinical diagnosis and follow-up of idiopathic pulmonary fibrosis

INTRODUCCIÓN: La fibrosis pulmonar idiopática es definida como una forma de neumonía intersticial crónica, progresiva, de causa desconocida, limitada a los pulmones, la cual se presenta principalmente en adultos mayores de 65 años. El diagnóstico de la enfermedad incluye la presencia de un patrón radiológico compatible con neumonía intersticial o hallazgos histopatológicos compatibles con neumonía intersticial usual y la exclusión de: enfermedades ocupacionales, toxicidad por drogas o enfermedades del colágeno que puedan producir enfermedad intersticial. La determinación de los volúmenes pulmonares por pletismografía permite identificar la presencia de trastornos restrictivos y la gravedad de estos en los estados patológicos del pulmón. OBJETIVO: Determinar la validez de la medición de los volúmenes pulmonares por pletismografía como apoyo del proceso diagnóstico de la fibrosis pulmonar idiopática y como medida del seguimiento de la progresión de la enfermedad. MÉTODOS: Dos estudios fueron incluidos, estos evaluaban pacientes con fibrosis pulmonar idiopática en los que se realizaron volúmenes pulmonares por pletismografía y se correlacionaron los datos de CPT con la tasa de sobrevida, la progresión de la enfermedad y las exacerbaciones. Se encontró que la media de sobrevida de estos pacientes es de 36 meses proximadamente y se asocia a bajos niveles de capacidad vital forzada y capacidad pulmonar total entre otros. Adicionalmente que pacientes con una reducción combinada de CPT y CV por debajo de los valores predichos presentan un deterioro restrictivo de la función pulmonar y un reducción de la sobrevida. CONCLUSIONES: La medición de los volúmenes pulmonares es un método complementario a la espirometría para determinar las capacidades y volúmenes pulmonares que ayudan a definir la gravedad de las alteraciones obstructivas, restrictivas o ambas, que está comprometiendo al paciente. La evidencia existente no soporta su efectividad en la confirmación diagnóstica de la fibrosis pulmonar idiopática, para la cual existen otras pruebas de mayor utilidad diagnóstica y tampoco soporta su como método de seguimiento de la progresión de la enfermedad.(AU)

Leucemia/linfoma T del adulto en pacientes infectados con HTLV-1: reporte de dos casos de Colombia / Adult T-cell leukemia/lymphoma in HTLV-1 infected patients: report of two cases in Colombia

La leucemia/linfoma de células T del adulto ( Adult T-Cell Leukemia/Lymphoma , ATLL) es una neoplasia maligna de los linfocitos T CD4 maduros, que resulta de la infección con el virus T-linfotrópico humano de tipo 1 (HTLV-1), con varias manifestaciones sistémicas y cutáneas. Se presentan dos casos de leucemia/linfoma de células T del adulto en pacientes del suroccidente de Colombia, cuyos diagnósticos fueron confirmados por histología, inmunohistoquímica, citometría de flujo y pruebas ELISA y Western blot. También, se discute acerca del virus y cómo hacer el diagnóstico en países como el nuestro.

Adult T-cell leukemia/lymphoma (ATLL) is a malignant neoplasia of mature CD4+ T lymphocytes,resulting from infection with human T-lymphotropic virus type 1 (HTLV-1), with several systemic and cutaneous manifestations. We present two cases of adult T-cell leukemia/lymphoma, in patients from the Colombian Southwestern region, whose diagnoses were confirmed by histology, immunohistochemistry, flow cytometry, ELISA and Western blot tests. We also discuss about the virus and how to make this diagnosis in countries like Colombia.

Episodio de hipotonía-hiporreactividad posvacunación con DtPa / Hypotonic-hyporesponsive episode following acellular pertussis vaccination

La introducción de la vacunación sistemática contra la tos ferina determinó un descenso drástico en la incidencia de esta patología, aunque todavía representa un problema de salud pública, incluso en los países con alta cobertura de vacunación. Sin embargo, además de la disminución de los casos por la proflaxis activa, se ha observado la emergencia de efectos adversos neurológicos graves, como los denominados "episodios de hipotonía-hiporreactividad" (HHE), caracterizados por una pérdida súbita del tono muscular asociada a escasa respuesta a los estímulos y palidez cutánea o cianosis. Los HHE son un fenómeno infrecuente después de la administración de la vacuna con un componente antitosferínico, pero es fundamental que el personal sanitario sepa reconocerlos, sobre todo en las siguientes 48 horas de la vacunación. Aunque en ocasiones es difícil establecer una relación causal entre la administración de la vacuna y un efecto adverso, debe comunicarse cualquier evento sospechoso.

The introduction of routine vaccination against whooping cough caused a drastic decline in the incidence of this disease, but remains today a public health problem even in countries with high vaccination coverage. However, with this decrease in cases, there were an emergence of neurological severe adverse events such as the "hypotonic-hyporesponsive episodes" (HHE), characterized by sudden loss of muscle tone associated with poor response to stimuli and skin pallor or cyanosis. The HHE is a rare phenomenon after administration of pertussis vaccine, but it is essential for health workers recognition of such reactions, especially in the 48 hours following vaccination. Although sometimes can become diffcult to attribute a causal relationship between vaccine administration and an adverse effect, any suspicious events should be reported.

[Adult T-cell leukemia/lymphoma in HTLV-1 infected patients: report of two cases in Colombia]. / Leucemia/linfoma T del adulto en pacientes infectados con HTLV-1: reporte de dos casos de Colombia.

Adult T-cell leukemia/lymphoma (ATLL) is a malignant neoplasia of mature CD4+ T lymphocytes,resulting from infection with human T-lymphotropic virus type 1 (HTLV-1), with several systemic and cutaneous manifestations. We present two cases of adult T-cell leukemia/lymphoma, in patients from the Colombian Southwestern region, whose diagnoses were confirmed by histology, immunohistochemistry, flow cytometry, ELISA and Western blot tests. We also discuss about the virus and how to make this diagnosis in countries like Colombia.

Etiología de las neumonías adquiridas en comunidad en la población infantil / Etiology in community acquired pneumonia in children population

Respiratory infections of lower respiratory tract remain a major cause of mortality in young children worldwide, particularly in developing countries. The Community Acquired Pneumonia (CAP), the infectious etiology pneumonia acquired by a previously healthy individual outside a hospital. In 2012, WHO stated that S. pneumoniae and H. influenzae type b (Hib) are the first and second most common cause of bacterial pneumonia in children, respectively, whereas Respiratory Syncytial Virus is the most frequent cause of viral pneumonia. The assessment and treatment of a child with a respiratory infection of lower airways becomes a challenge as not only the clinical manifestations of infection by viruses, bacteria or atypical bacteria may overlap, but also coinfections occur frequently. The etiological agents of pneumonia in children can be divided into three groups: common bacteria(S. pneumoniae, H. influenzae, S. aureus, M. catarrhalis, S. pyogenes, B. pertussis, M. tuberculosis, among others),respiratory viruses (RSV, Influenza A and B, Parainfluenza 1, 2 and 3, Adenovirus, Rhinovirus, Coronavirus, Metapneumovirus, Bocavirus, Enterovirus, Varicella Zoster, among others) and atypical pathogens (M. pneumoniae, C. pneumoniae, C. trachomatis, L. pneumophila, C. burnetii, among others). The etiological diagnosis of CAP in pediatric patients is supported by laboratory tests that generate direct or indirect evidence of the causal germ. The search for the causing agent becomes a challenge, primarily due to the limitation in obtaining appropriate samples and the difficulty to identify the etiological agent and differentiate between colonization and infection. With the available methods, a specific germ is expected to be detected from 16 to 85 percent of the cases, making it difficult to determine the true incidence of these infections. In addition, the variety of diagnostic techniques used in clinical trials and interpretation of the results in the absence...

Las infecciones respiratorias de vías aéreas inferiores siguen siendo una de las principales causas de mortalidad en niños pequeños alrededor del mundo, particularmente en países en desarrollo. La Neumonía Adquirida en la Comunidad (NAC), es la neumonía de etiología infecciosa que adquiere un individuo previamente sano, fuera de un hospital. En el 2012, la OMS, establece que S. pneumoniae y H. influenzae tipo b (Hib) son la primera y segunda causa más común de etiología bacteriana en niños, respectivamente; mientras que el Virus Sincitial Respiratorio es la causa más frecuente de neumonía viral. La evaluación y el manejo de un niño con una infección respiratoria de vías aéreas inferiores, se convierte un reto ya que no sólo las manifestaciones clínicas de las infecciones por virus, bacterias o bacterias atípicas pueden solaparse, sino que también ocurren frecuentemente coinfecciones. Los agentes etiológicos de las neumonías en niños se pueden dividir en 3 grupos: bacterias comunes (S. pneumoniae, H. influenza, S. aureus, M. catarrhalis, S. pyogenes, B. pertussis, M. tuberculosis, entre otros), virus respiratorios (VSR, Influenza A y B, Parainfluenza 1, 2 y 3, Adenovirus, Rhinovirus, Coronavirus, Metapneumovirus, Bocavirus,Enterovirus, Varicela, entre otros) y gérmenes atípicos (M. pneumoniae, C. pneumoniae, C. trachomatis, L. pneumophila, Coxiella burnetii, entre otros). El diagnóstico etiológico de NAC en el paciente pediátrico se apoya en pruebas de laboratorio que generan una evidencia directa o indirecta del germen causal. La búsqueda del agente causal se convierte en un reto debido principalmente a la limitación para obtener muestras adecuadas y a la dificultad de identificar el agente etiológico y diferenciar entre colonización e infección. Con los métodos disponibles se estima que se puede detectar un germen específico entre el 16 al 85 por ciento de los casos; lo cual dificulta la determinación de la incidencia real de estas infecciones...

[Isonymy analysis in a sample of parents of cystic fibrosis patients from Antioquia, Colombia]. / Análisis de isonimia en una muestra de padres de pacientes antioqueños con fibrosis quística.

INTRODUCTION: Cystic fibrosis (CTFR) is one of the most common autosomal recessive disorders in European descendants. Geographic distribution of CFTR gene mutations vary worldwide. OBJECTIVE: The degree of isonimy was evaluated in a sample of parents with children affected by cystic fibrosis. MATERIALS AND METHODS: Observed and expected isonimy as well as endogamy components (Fr, Fn, Ft, and the values α and B) were calculated for 35 parents of children diagnosed with cystic fibrosis. These parameters were calculated for both the total population of Antioquia Province and for an eastern subpopulation of Antioquia. RESULTS: The values obtained for Fr, Fn, Ft, α and B were 0.01, 0.007, 0.019, 268 and 0.44, respectively for the total population of Antioquia. For the eastern subpopulation, the values were 0.026, 0.0017, 0.027, 135 and 0.62. The most frequent last-names in the total sample (n=70) were Gómez (6%), Alzate (4%), and González (3.7 %), whilst for the eastern subpopulation (n=32) were Gómez (8%) and Marín (6%). CONCLUSIONS: A high percentage of last-names was shared, as is reflected in the isonimy values. Similarly, the presence of a reduced number of last-names in an important percentage of the population is reflected in the Fr values obtained for both analyses, which suggest homogeneity. Thus, it is expected a low number of CFTR mutations in the children from Antioquia with cystic fibrosis.

Sepsis por Leuconostoc spp. en un lactante sano / Sepsis by Leuconostoc spp. in a healthy infant

El género Leuconostoc, del grupo de bacterias ácido-lácticas, son cocos grampositivos resistentes a vancomicina, distribuidos en la naturaleza y empleados en la industria alimentaria. Clásicamente considerado inocuo para la especie humana, se lo ha implicado en diversas patologías en sujetos susceptibles; se lo aisló cada vez con más frecuencia y con un amplio perfil de patogenicidad, por lo que en la actualidad se clasifica como patógeno oportunista emergente. Los niños son especialmente vulnerables, sobre todo prematuros y afectos de patología digestiva grave. La puerta de entrada no ha sido estudiada en profundidad; las más probables son la digestiva, en intestinos alterados, y la cutánea, a través de la pérdida de su integridad.Otras formas descritas son contaminaciones de la nutrición parenteral y enteral, esta última asociada sobre todo al uso de sondas gástricas. Los aislados casos descritos en pacientes inmunocompetentes sin factores de riesgo involucran, sobre todo, a lactantes sanos, como el caso que presentamos.

Haplotipos del gen de la globina beta en portadores de hemoglobina S en Colombia / Beta globin haplotypes in hemoglobin S carriers in Colombia

Introducción. La mutación de la hemoglobina S (HbS) va acompañada por otras mutaciones en la región del cromosoma 11, conocida como conjunto de la globina beta(beta globin cluster). El patrón de combinación de estos polimorfismos da lugar a los haplotipos que se heredan junto con la mutación de la hemoglobina S, se denominan haplotipos de la mutación bs y revisten gran importancia epidemiológica y clínica. Objetivo. Determinar la frecuencia de los principales haplotipos asociados al gen HBB en pacientes colombianos heterocigotos para hemoglobina S. Materiales y métodos. En la Clínica Colsanitas se han estudiado a la fecha 1.200 muestras de sangre periférica de niños en busca de hemoglobinopatías, y se ha encontrado el rasgo falciforme como la hemoglobinopatía más frecuente. Se determinaron los haplotipos del gen HBB que presentaron la mutación beta-S en 33 niños con patrón electroforético de hemoglobina AS, mediante reacción en cadena de la polimerasa (PCR) y enzimas de restricción. Se determinaron el patrón electroforético de la hemoglobina, el nivel de hemoglobina fetal y los parámetros hematológicos de cada individuo. Resultados. Los haplotipos de la hemoglobina S encontrados con mayor frecuencia en la muestra analizada son de origen africano y su orden de aparición fue mayor para el haplotipo Bantú (36,4 %), seguido por Senegal (30,3 %), Benín (21,2 %) y Camerún (12,1 %). La electroforesis de hemoglobina confirmó el fenotipo AS; la dosificación de hemoglobina fetal mostró niveles por debajo de 1 % y los parámetros hematológicos analizados mostraron valores normales en el 100 % de los individuos. Conclusión. Los haplotipos de la HbS encontrados con mayor frecuencia en la muestra estudiada eran de origen africano y su distribución variaba de acuerdo con el lugar de prodedencia del individuo. La mayor frecuencia correspodió al haplotipo Bantú.

Introduction. The hemoglobin S (HbS) mutation is accompanied by other mutations in the region of chromosome 11 known as "beta globin cluster". The pattern of combination of these polymorphisms giving rise to the haplotypes that co-inherit the HbS mutation, are called haplotypes bs, and are of great epidemiological and clinical significance. Objective. The frequencies of major haplotypes associated with S beta-globin gene was determined in Colombian patients heterozygous for hemoglobin S. Materials and methods. As part of the national neonatal screening program at Clínica Colsanitas, located in major cities of Colombia, nearly 1,200 children from different areas of the country were examined for hemoglobinopathies. The sickle cell trait was identified as the most common. S beta-globin gene haplotypes were determined by PCR and restriction enzymes in 33 children with AS hemoglobin electrophoretic patterns (carrier state). In addition, electrophoretic patterns of hemoglobin, fetal hemoglobin levels and hematologic parameters of each individual were identified. Results. The most frequent haplotypes in Colombia were the Bantú haplotype (36.4 %), followed by Senegal (30.3 %), Benin (21.2 %) and Cameroon (12.1 %) haplotypes. Hemoglobin electrophoresis confirmed the AS phenotype in all patients, and fetal hemoglobin levels below 1%. Other hematological parameters were normal in all cases. Conclusion. The HbS haplotypes found more frequently in the sample were of African origin, and their distribution varied according to the place of origin of the individual. The most frequent corresponded to the Bantu haplotype.