Terapia secuencial: una opción en el paciente hemofílico que no responde al manejo con monoterapia con agentes puente, estudio observacional del GrHeCol (Grupo Hemofilia Colombia) / Sequential therapy: an option for hemophiliac patients not responding to monotherapy with bypassing agents. Observational study of the GrHeCol (Grupo Hemofilia Colombia)

RESUMEN Introducción: la hemofilia A y B severa son condiciones que predisponen al sangrado espontáneo. Una de las complicaciones de la terapia con concentrados de factores de coagulación es el desarrollo de anticuerpos o inhibidores contra los factores VIII o IX. El tratamiento en casos de inhibidores de título alto, para el control de la hemorragia, es la administración de agentes puente como el complejo protrombínico activado y Factor VII recombinante activado. La respuesta a cada uno de ellos no es predecible, en algunos casos puede ser necesario el uso de la terapia secuencial cuando esta estrategia falla. Objetivo: reportar cinco casos de hemofilia A severa e inhibidores de título alto con sangrado severo, sin respuesta clínica con monoterapia y que recibieron terapia secuencial. Métodos: estudio multicéntrico, descriptivo, observacional. Las variables cualitativas se presentan con frecuencias absolutas y relativas, y las cuantitativas se resumen con medidas de tendencia central. Resultados: cuatro pacientes evaluados que aportaron cinco eventos, la mediana de edad 20 años; mediana de días de monoterapia 10; 8,6 días de terapia secuencial, tiempo a resolver el sangrado cuatro días. Ausencia de complicaciones trombóticas. Conclusiones: la terapia secuencial es una opción para aquellos pacientes que no responden a la monoterapia y requieren control hemostático. En los cinco casos reportados, la terapia secuencial logró controlar el sangrado sin complicaciones.

SUMMARY Introduction and objectives: Patients diagnosed with severe hemophilia are at risk of developing inhibitors of low or high title, being the treatment of choice for this latter group of patients the immune tolerance therapy (ITI). In cases where the immune tolerance fails or presents bleeding events, we can use activated prothrombin complex (APCC) or Recombinant activated factor VII (rFVIIa); however, patients may fail to these agents as monotherapy. The aim of this paper is to report five cases of severe hemophilia and high titer inhibitors with mayor bleeding, which fail to respond to monotherapy and required sequential therapy. Methods: Case report study, qualitative variables are presented as absolute and relative frequencies and quantitative are summarized with measures of central tendency. Results: Five patients with median age 20 years; monotherapy treatment with median 10 days; 8.6 days of sequential therapy, time to control the bleeding: 4 days. There were no thrombotic complications. Conclusions: Sequential therapy is an option for patients who do not respond to monotherapy and requires hemostatic control. In all the cases of this report, the patients were responsive with bleeding control.

Optimization of door-to-electrocardiogram time within a critical pathway for the management of acute coronary syndromes at a teaching hospital in Colombia.

INTRODUCTION: Door-to-electrocardiogram (D2E) time is recognized as one of the quality parameters in the attention of acute coronary syndromes. Electrocardiogram realization within periods below 10 minutes increases the possibility to achieve quick and effective reperfusion, which has an impact on outcomes. OBJECTIVE: To describe the results of a strategy whose goal is to improve the fulfillment of the D2E deadline below 10 minutes in adults who attend the emergency service due to chest pain with clinical suspicion of acute coronary syndromes. METHODS: Before-and-after study that assesses D2E time upon the implementation of actions for the reorganization of the process of attention of the patients with chest pain within the context of the implementation of a critical pathway. RESULTS: A total of 373 patients were assessed, 204 in the before stage and 169 in the after stage. The median D2E time was 16 minutes in the before stage, in 41% of the cases it was below 10 minutes; upon the implementation of the change in the process of attention of chest pain the median was 5 minutes, with 63% of the cases below 10 minutes, exhibiting a statistically significant difference. CONCLUSIONS: The actions taken led to a lower median of D2E time and a higher percentage of patients with times below 10 minutes. However, further interventions are required to assure a higher number of patients with D2E times below 10 minutes.