Laboratory intervention to improve the request of urinary albumin in primary care patients with arterial hypertension and financial implications.

INTRODUCTION: The request of Urinary albumin in primary care in Spain is insufficient to monitor patients with diabetes and hypertension (HTN). Our aim was to evaluate a strategy designed in consensus with general practitioners (GPs) to improve the request of urinary albumin in primary care patients with HTN according to guidelines, and to study its financial implications. MATERIALS AND METHODS: In a meeting with GPs, we decided that the Laboratory Information System (LIS) would automatically register the albumin-to-creatinine ratio (ACR) test in patients with HTN when the former had not been requested in the previous year. We counted the number of ACRs requested by the GPs, those that were automatically added through the intervention, and if they were measured through the strip assay or additionally through quantification. We calculated the economic cost of the additional registered ACR based on reagent cost. RESULTS: In the 6 months study period, the laboratory received 48,075 requests for primary care patients. For 3816 (7.9%), HTN was the indication that prompted the request. 386 ACR were automatically registered through the intervention. Use of strip analysis cost of 275.8 € but resulted in savings of 1450.3€ in albumin reagent. CONCLUSIONS: By making use of the laboratory technology, the strategy achieved a better adherence to the guidelines at no additional cost.

Indications for laboratory tests in primary care: assessment of the most frequent indications and requests with blank clinical information.

INTRODUCTION: The aim of this work is twofold. Firstly, to study the temporal evolution in the number of laboratory requests from primary care without clinical indication, and to analyse the number of such requests before and after the implementation of an automated requesting procedure. Secondly, to investigate what are the most frequent clinical indications that prompted laboratory testing. MATERIALS AND METHODS: This is a retrospective observational study conducted from January 2009 to December 2015. We counted the requests without clinical question, calculated the number of such requests per total number of requests and listed the most frequent indications. RESULTS: The number of tests requests with a blank clinical indication was significantly higher in 2009 when compared to 2015 (80% vs. 20%; P < 0.001). For every year in this 7-year period, dyslipidemia, essential hypertension and diabetes were the most prevalent diagnoses that prompted a laboratory test in primary care, accounting for more than 20% of all indications. CONCLUSIONS: The number of primary care requests without patient clinical question has decreased after the implementation of an automated requesting procedure. Disorders of lipid metabolism, essential hypertension and diabetes mellitus were the most prevalent diagnoses that prompted a laboratory test in primary care.

Uso de la escala CHADS 2 como predictor de riesgo de mortalidad en pacientes hipertensos. El estudio FAPRES / Use of the CHADS 2 score as a predictor of the risk of mortality in hypertensive patients. The FAPRES study

Fundamentos y objetivo: El objetivo del estudio es analizar la escala CHADS2 como marcador de riesgo de mortalidad en pacientes hipertensos, independientemente de la presencia o no de fibrilación auricular. Métodos: Se incluyó a 1.003 pacientes hipertensos ≥ 65 años, recogiendo factores de riesgo y puntuación CHADS2. Se realizó un seguimiento clínico de la mortalidad. Resultados: La media de edad de la población fue 72,8 ± 5,8 años; el 47,5% eran varones. Durante el seguimiento hubo 41 muertes, 20 de origen cardiovascular. Los pacientes con mayor CHADS2 tuvieron una mayor mortalidad: 1,5% en CHADS2 = 1; 4,7% en CHADS2 = 2; 9,1% en CHADS2 = 3, y 7,8% en CHADS2 ≥ 4. Conclusiones: La puntuación CHADS2 puede ser un instrumento clínico de sencilla aplicación para identificar pacientes hipertensos con alto riesgo de mortalidad (AU)

Foundations and aim: The aim of this study is to analyze the CHADS2 score as a marker of the risk of mortality in hypertensive patients, with and without the presence of atrial fibrillation. Methods: We included 1,003 hypertensive patients ≥ 65 years. Risk factors, and CHADS2 score were recorded among other factors, as well as clinical follow-up of number and type of deaths. Results: Mean age was 72.8 ± 5.8 years, and 47.5% were men. During follow-up there were 41 deaths, 20 were of cardiovascular origin. Patients with higher CHADS2 had a higher mortality: 1.5% CHADS2 = 1; 4.7% in CHADS2 = 2; 9.1% in CHADS2 = 3, and 7.8% in CHADS2 ≥ 4. Conclusions: The CHADS2 score can be a clinical instrument of easy application to identify hypertensive patients with a high risk of mortality (AU)

[Use of the CHADS2 score as a predictor of the risk of mortality in hypertensive patients. The FAPRES study]. / Uso de la escala CHADS2 como predictor de riesgo de mortalidad en pacientes hipertensos. El estudio FAPRES.

FOUNDATIONS AND AIM: The aim of this study is to analyze the CHADS2 score as a marker of the risk of mortality in hypertensive patients, with and without the presence of atrial fibrillation. METHODS: We included 1,003 hypertensive patients≥65 years. Risk factors, and CHADS2 score were recorded among other factors, as well as clinical follow-up of number and type of deaths. RESULTS: Mean age was 72.8±5.8 years, and 47.5% were men. During follow-up there were 41 deaths, 20 were of cardiovascular origin. Patients with higher CHADS2 had a higher mortality: 1.5% CHADS2=1; 4.7% in CHADS2=2; 9.1% in CHADS2=3, and 7.8% in CHADS2≥4. CONCLUSIONS: The CHADS2 score can be a clinical instrument of easy application to identify hypertensive patients with a high risk of mortality.

Automatic laboratory-based strategy to improve the diagnosis of type 2 diabetes in primary care.

INTRODUCTION: To study the pre-design and success of a strategy based on the addition of hemoglobin A1c (HbA1c) in the blood samples of certain primary care patients to detect new cases of type 2 diabetes. MATERIALS AND METHODS: In a first step, we retrospectively calculated the number of HbA1c that would have been measured in one year if HbA1c would have been processed, according to the guidelines of the American Diabetes Association (ADA). Based on those results we decided to prospectively measure HbA1c in every primary care patient above 45 years, with no HbA1c in the previous 3 years, and glucose concentration between 5.6-6.9 mmol/L, during an 18 months period. We calculated the number of HbA1c that were automatically added by the LIS based on our strategy, we evaluated the medical record of such subjects to confirm whether type 2 diabetes was finally confirmed, and we calculated the cost of our intervention. RESULTS: In a first stage, according to the guidelines, Hb1Ac should have been added to the blood samples of 13,085 patients, resulting in a cost of 14,973€. In the prospective study, the laboratory added Hb1Ac to 2092 patients, leading to an expense of 2393€. 314 patients had an HbA1c value ≥ 6.5% (48 mmol/mol). 82 were finally diagnosed as type 2 diabetes; 28 thanks to our strategy, with an individual cost of 85.4€; and 54 due to the request of HbA1c by the general practitioners (GPs), with a cost of 47.5€. CONCLUSION: The automatic laboratory-based strategy detected patients with type 2 diabetes in primary care, at a cost of 85.4€ per new case.

Education and communication is the key for the successful management of vitamin D test requesting.

INTRODUCTION: Pre-preanalytical and post-postanalytical phases are steps where the laboratory professional may play a crucial role. Measuring the serum circulating 25 hydroxyvitamin D level (25(OH)D) is recommended to evaluate vitamin D status in patients at risk for vitamin D deficiency while 1,25 hydroxyvitamin D (1,25(OH)2D) is only recommended to monitor several particular conditions (chronic kidney disease, hereditary phosphate-losing disorders, and some other) clearly defined by the current clinical guidelines of Endocrine Society. Our research hypothesis was that through education and communication through comments in the Laboratory Information System (LIS), we could improve appropriateness in the request vitamin D tests. MATERIALS AND METHODS: A retrospective observational cross-sectional study was conducted from January 2005 to December 2014. Each 1,25(OH)2D request was reviewed individually by a member of the laboratory staff. Starting in November 2011, each inappropriate 1,25(OH)2D request was registered in LIS and 25(OH)D was measured instead of 1,25(OH)2D. We counted the overall number of 1,25(OH)2D requests and the number of inappropriate requests which then were marked with a comment. RESULTS: The request of 25(OH)D increased along years. However, 1,25(OH)2D requests increased until 2012 when demand began to diminish. CONCLUSIONS: Education and communication through comments in the LIS, corrected the inappropriate request of 1,25(OH)2D and promoted the use of 25(OH)D to study vitamin D deficiency.

Bariatric endocrinology: principles of medical practice.

Obesity, is a chronic, biological, preventable, and treatable disease. The accumulation of fat mass causes physical changes (adiposity), metabolic and hormonal changes due to adipose tissue dysfunction (adiposopathy), and psychological changes. Bariatric endocrinology was conceived from the need to address the neuro-endocrinological derangements that are associated with adiposopathy, and from the need to broaden the scope of the management of its complications. In addition to the well-established metabolic complications of overweight and obesity, adiposopathy leads to hyperinsulinemia, hyperleptinemia, hypoadiponectinemia, dysregulation of gut peptides including GLP-1 and ghrelin, the development of an inflammatory milieu, and the strong risk of vascular disease. Therapy for adiposopathy hinges on effectively lowering the ratio of orexigenic to anorexigenic signals reaching the the hypothalamus and other relevant brain regions, favoring a lower caloric intake. Adiposopathy, overweight and obesity should be treated indefinitely with the specific aims to reduce fat mass for the adiposity complications, and to normalize adipose tissue function for the adiposopathic complications. This paper defines the principles of medical practice in bariatric endocrinology-the treatment of overweight and obesity as means to treat adiposopathy and its accompanying metabolic and hormonal derangements.

Prevalencia de hipertensión arterial, sobrepeso y obesidad en poblaciones urbanas el estado de Sinaloa, México / Prevalence of arterial hypertension, overweight and obesity in urban populations of Sinaloa, Mexico

Determinar prevalencia de hipertensión arterial sistémica (HAS) y obesidad, en cuatro ciudades del estado de Sinaloa, México. El estudio incluyó 1,630 sujetos a quienes se les exploraron variables demográficas universales, de índole antropométrico constituidas por: peso, talla, índice de masa corporal (IMC) perímetro cintura (PC), así como presión arterial sistólica y diastólica por medio de esfigmómetro aneroide, y cálculo de la presión de pulso (PP). De las 1,630 personas estudiadas, 1,047 correspondieron al sexo femenino con edad promedio de 48.9 ± 14.19 años, y 583 fueron hombres con edad promedio de 53.8 ± 14.12 años. La prevalencia de HAS en las cuatro ciudades contempladas fue de 37.5%, siendo la Ciudad de Los Mochis donde se observó la mayor prevalencia (39%) en ambos sexos; la correspondiente de obesidad se observó en 27.3% mientras que en 45% se identificó sobrepeso. Conclusiones: La prevalencia de HAS encontrada es más alta que el promedio nacional; lo mismo se observó en las condiciones de sobrepeso y obesidad. Ambas circunstancias se distribuyeron mayoritariamente en sujetos del sexo masculino.

To determinate the high blood pressure prevalence (HBP) and obesity in four cities of Sinaloa, Mexico. This trial included 1,630 people who were explored on demographics and anthropometrics variables such as: weight, height , body mass index (BMI), waist perimeter (WP), as well as systolic and diastolic blood pressure by aneroid sphygmomanometer , and pulse pressure (PP) was calculated. Of 1,630 people on study, 1,047 corresponded to female gender with an age average of 48.9 ± 14.1 years and, 583 were male patients with an age average of 53.8 ± 14.1 years. The prevalence of HBP contemplated in the four cities was of 37.5%. Los Mochis city observed the highest HBP prevalence ( 39%) in both genders. The obesity was 27.3%, while the overweight was of 45%. Conclusions: The prevalence of HBP observed was higher than the national mean, these findings are observed in overweight and obesity. Both circumstances were primarily distributed in males.

Conjuntivitis hiperplástica pigmentaria en pobladores de la altura / The pigmented hyperplasic conjunctivitis in people living at high-altitude

Introducción: La conjuntivitis hiperplásica pigmentaria en pobladores de la altura es una entidad caracterizada por hiperemia, pigmentación, hiperplasia y vasodilatación conjuntivales que se presenta en niños, adolescentes y adultos jóvenes en el área de exposición del limbo esclero-corneal palpebral de ambos ojos en habitantes permanentes de altitudes mayores a los 2,800 m.s.n.m. Objetivo: Difundir el conocimiento de esta afección que la padecen muchas personas en el Perú, ya que un gran porcentaje de la población vive en esos niveles. Material y métodos: Los autores presentan un estudio retrospectivo y descriptivo de esta entidad propia de las regiones andinas, seleccionando en forma aleatoria a 80 pobladores que viven permanentemente en lugares situados por encima de los 2,800 m.s.n.m. Resultados: La edad de las personas estudiadas con esta afección es entre los 8 a 22 años, predominando en los adolescentes de sexo masculino, con una relación hombre/mujer de 3/1. Las lesiones encontradas fueron de presentación bilateral, localizadas en el limbo corneo-escleral. La sintomatología difiere de la conjuntivitis vernal que está localizada en la conjuntiva bulbar y palpebral.

Introduction: The pigmented hyperplasic conjunctivitis in people living at high-altitude is a disease characterized by hyperemia, pigmentation, hyperplasia and dilatation of the vessels of the conjunctiva in both eyes. It affects children, teenagers and young adults living over 2,800 meters of the sea level. The lesions are developed on the sclerocorneal limbus. Objective: The purpose of this study is to spread the knowledge of the pigmented hyperplasic conjunctivitis in people living at high altitude because significant population in Perú lives at these levels. Material and methods: We present a retrospective and descriptive review of 80 people who presented this pathology living in areas over 2,800 meters of the sea level. Results: The range of age was 8-22 years, most people were teenagers. Rate man: woman was 3:1. Lesions were always bilateral and localized in sclerocorneal limbus. The symptoms are different of the vernal conjunctivitis localized in ocular and palpebral conjunctiva.

Preoperative statin therapy and troponin T predict early complications of coronary artery surgery.

BACKGROUND: Pretreatment with statins reduces early ischemic events after percutaneous coronary interventions, primarily in patients with a high level of inflammation markers. We sought to examine the association between preoperative statin therapy, systemic inflammation, and myocardial ischemia with the occurrence of early cardiac complications after coronary artery bypass grafting surgery. METHODS: One hundred forty-one consecutive patients who underwent coronary artery bypass grafting surgery from two university tertiary hospitals were stratified according to their preoperative status of statin therapy (87 treated and 54 nontreated). Preoperative blood samples were collected for measurement of lipid parameters, C-reactive protein, interleukin-6, and troponin T. The evaluated primary endpoint was a composite of death and myocardial infarction at 30 days. RESULTS: Patients undergoing preoperative statin therapy showed a reduced incidence of death (2.3% versus 13.0%, p = 0.012), myocardial infarction (5.7% versus 18.5%, p = 0.017), and primary combined endpoint (8.0% versus 22.2%, p = 0.017). In the multivariate model, preoperative troponin T greater than 0.01 ng/mL (odds ratio 6.85, p = 0.001) and nonstatin therapy (odds ratio 4.2, p = 0.01) predicted a higher risk of primary endpoint. Statins showed a significant interaction with troponin T status and benefited primarily those patients with positive troponin T. Among 19 patients with troponin T greater than 0.01 ng/mL, the primary endpoint occurred in all 6 nonstatin-treated patients, but it occurred in only 1 of 13 statin-treated patients (p < 0.001). Neither C-reactive protein nor interleukin-6 predicted early complications, nor did they interact with statin therapy (p = not significant). CONCLUSIONS: Preoperative statin therapy reduces early complications and offers additional protection in patients with positive troponin T status, regardless of inflammatory markers.

Statins and postoperative risk of atrial fibrillation following coronary artery bypass grafting.

Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting. Atrial remodeling has been observed in AF and has been associated with the development of this arrhythmia. Because 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) have been demonstrated to modify remodeling, we hypothesized a protective role of statins against postoperative AF. We also hypothesized that extracellular matrix turnover and brain natriuretic peptide (BNP) might be related to such atrial remodeling. We studied 234 consecutive patients who underwent coronary artery bypass grafting (173 men; 65 +/- 9 years of age) in whom the occurrence of postoperative AF was monitored. In a subgroup of 66 patients, we measured plasma levels of matrix metalloproteinase-1 (MMP-1), its inhibitor, tissue inhibitor matrix metalloproteinase-1 (TIMP-1; as indexes of extracellular matrix remodeling), and N-terminus pro-BNP (related to left ventricular function) at baseline and at 24 hours after surgery. Of 234 patients, 66 (28.2%) developed postoperative AF. In multivariate analysis, previous AF was related to an increase in the development of AF (odds ratio 11.92, 95% confidence interval 2.37 to 59.98, p = 0.026), whereas statin use was related to a decrease in arrhythmia (odds ratio 0.52, 95% confidence interval 0.28 to 0.96, p = 0.038). A higher TIMP-1/MMP-1 ratio at 24 hours after surgery was present in those who did not develop postoperative AF (p = 0.043). Statin use was associated with increased TIMP-1 levels and TIMP-1/MMP-1 ratio (p = 0.027 and 0.036, respectively). No significant relations to N-terminus pro-BNP were seen. In conclusion, previous AF and nonuse of statins are significantly associated with AF after coronary artery bypass grafting. Statin use may be protective against AF after coronary artery bypass grafting, possibly due to alterations in the extracellular matrix and remodeling after coronary artery bypass grafting.

[Reinfarction as a complication of acute myocardial infarction. PRIMVAC Registry data]. / El reinfarto como complicación del infarto agudo de miocardio. Datos del registro PRIMVAC.

INTRODUCTION AND OBJECTIVES: The clinical profile of patients with acute myocardial infarction (AMI) who have reinfarction (REAMI) during their stay in the intensive cardiologic care unit (ICCU) is not well known. The aim of this study was to identify factors predictive of REAMI, as well as its global incidence and mortality. PATIENTS AND METHOD: All patients with AMI admitted to the ICCU of 17 hospitals in the Comunidad de Valencia (Spain) in the period 1995-2000 (PRIMVAC Registry) were included. Differential characteristics between patients with or without REAMI were determined, and odds ratios (OR) for possible predictive factors were estimated with their 95% confidence intervals by logistic regression. RESULTS: A total of 12,071 patients were included. Mean age of the patients was of 65.5 years, the percentage of women was 23.8%, and the incidence of REAMI was 2.8%. The REAMI group was significantly older than the non-REAMI group. Female sex was significantly more common in the REAMI group. More diagnostic and therapeutic procedures were carried out, more drugs were used and there were more complications in the REAMI group. Mortality was significantly higher in the REAMI group (37.8% vs 12.6%). Only age, diabetes mellitus, previous myocardial infarction and the appearance of Q waves in the electrocardiogram were independently associated with the presence of REAMI. CONCLUSIONS: REAMI in the ICCU was associated with high mortality. Some clinical factors present during the first few hours after AMI were associated independently with the appearance of REAMI.

El reinfarto como complicación del infarto agudo de miocardio. Datos del registro PRIMVAC / Reinfarction as a complication of acute myocardial infarction. PRIMVAC registry data

Introducción y objetivos. El perfil clínico de los pacientes con infarto agudo de miocardio (IAM) que presentan un reinfarto (REIAM) durante su estancia en la unidad de cuidados intensivos cardiológicos (UCIC) es poco conocido. El objetivo de este trabajo es determinar los factores predictores de REIAM, su incidencia global y su mortalidad. Pacientes y método. Se incluyó a todos los pacientes con IAM ingresados en las UCIC de 17 hospitales de la Comunidad Valenciana en el período 1995-2000. Se determinaron las características diferenciales de los pacientes con y sin REIAM, y se calcularon las odds ratio y sus intervalos de confianza del 95% mediante un análisis de regresión logística para los posibles factores predictores. Resultados. Se incluyó a 12.071 pacientes con IAM. La edad media fue de 65,5 años, la proporción de mujeres del 23,8% y la incidencia de REIAM del 2,8%. La edad fue significativamente mayor en el grupo con REIAM que en el grupo sin REIAM, al igual que el porcentaje de mujeres. Se realizaron más procedimientos, se utilizaron más fármacos y hubo más complicaciones en el grupo con REIAM. La mortalidad fue significativamente mayor en el grupo con REIAM (37,8 frente a 12,6%). La edad, la diabetes mellitus, el infarto de miocardio previo y el desarrollo de onda Q en el electrocardiograma se asociaron de forma independiente con la presencia de REIAM. Conclusiones. El REIAM en la UCIC conlleva una alta mortalidad. Algunos factores presentes en las primeras horas del IAM se asocian con la aparición de REIAM

Introduction and objectives. The clinical profile of patients with acute myocardial infarction (AMI) who have reinfarction (REAMI) during their stay in the intensive cardiologic care unit (ICCU) is not well known. The aim of this study was to identify factors predictive of REAMI, as well as its global incidence and mortality. Patients and method. All patients with AMI admitted to the ICCU of 17 hospitals in the Comunidad de Valencia (Spain) in the period 1995-2000 (PRIMVAC Registry) were included. Differential characteristics between patients with or without REAMI were determined, and odds ratios (OR) for possible predictive factors were estimated with their 95% confidence intervals by logistic regression. Results. A total of 12 071 patients were included. Mean age of the patients was of 65.5 years, the percentage of women was 23.8%, and the incidence of REAMI was 2.8%. The REAMI group was significantly older than the non-REAMI group. Female sex was significantly more common in the REAMI group. More diagnostic and therapeutic procedures were carried out, more drugs were used and there were more complications in the REAMI group. Mortality was significantly higher in the REAMI group (37.8% vs 12.6%). Only age, diabetes mellitus, previous myocardial infarction and the appearance of Q waves in the electrocardiogram were independently associated with the presence of REAMI. Conclusions. REAMI in the ICCU was associated with high mortality. Some clinical factors present during the first few hours after AMI were associated independently with the appearance of REAMI

[Prevalence and risk factors of varicose veins in adults]. / Prevalencia de varices en adultos y factores asociados.

BACKGROUND AND OBJECTIVE: We intended to estimate the prevalence of varicose veins in the mature population of the Valencia Community and to analyze its relationship with socio-demographic variables, self-reported health status, body mass index and the presence of hemorrhoids, tobacco smoking, alcohol consumption and physical activity. SUBJECTS AND METHOD: Information on self-reported varicose veins was collected from 1,778 adults older than 14 years (819 men and 959 women) who participated in the Health and Nutrition Survey of the Valencia Community (Spain). We estimated the prevalence of varicose veins by age groups and sex. To explore the association between varicose veins and variables, we estimated adjusted odds ratios (OR) with 95% confidence intervals (CI 95%) by multiple logistic regression. RESULTS: The overall prevalence of varicose veins was 16.4%, with a much higher prevalence in women that in men (26.7% versus 5.5%) and with older age. Gender and age were the 2 strongest predictors of varicose veins in multivariate analysis. Women had seven times more risk than men (OR = 7.01; CI 95%, 4.52-10.87) and those older than 35 years almost tripled the risk with respect to those aged 15-24 years. A body mass index of 30 kg/m2, a poor self-reported health status and hemorrhoids were significantly associated with the presence of varicose veins. Employers showed higher risk than workers. A moderate alcohol consumption (< or = 1 drink/day) was associated with a protective effect (OR = 0.50; CI 95%, 0.28-0.88). Tobacco smoking and physical activity were not associated with varicose veins. CONCLUSIONS: Although being a woman and having an advanced age were the strongest predictors of varicose veins, other factors such as a high BMI, poor health status, hemorrhoids and some professional categories may be also important factors in their presentation. A moderate alcohol consumption seems to have a protective effect.

[Mortality of myocardial infarction in the PRIMVAC registry. Prognostic factors]. / Mortalidad del infarto de miocardio en el registro PRIMVAC. Factores pronósticos.

BACKGROUND AND OBJECTIVE: The aim of this study was to determine the mortality due to acute myocardial infarction in the coronary units from Comunidad Valenciana (Spain) and the prognostic factors associated with a higher mortality. PATIENTS AND METHOD: Demographic characteristics, coronary risk factors, electrocardiographic ischemic signs, complications and mortality of patients with acute myocardial infarction admitted in the coronary units were collected. The study period comprised January 1995-December 1999. Death incidence was measured during coronary unit's stay. Factors associated with poor prognosis were analyzed. RESULTS: 10.213 patients entered into the study. Mean age at admission was 65 12 years. 23.8% were females (76.2% males). Global mortality in coronary units was 13.3%. Independent variables associated with higher mortality were (p < 0.05): advanced age (OR=1.06 [1.05-1.06]), female sex (OR=1.45 [1.26-1.66]), diabetes mellitus (OR=1.53 [1.35-1.74]), previous myocardial infarction (OR=1.46 [1.23-1.70]), previous angor pectoris (OR=1.29 [1.13-1.49]) and Q-wave infarction (OR=1.23 [1.03-1.43]). Factors associated with lower mortality were: hypercholesterolemia (OR=0.76 [0.66-0.78]), smoking (OR=0.65 [0.57-0.74]) and thrombolysis (OR=0.85 [0.78-0.92]). CONCLUSIONS: At present, in the reperfusion therapy era, acute myocardial infarction has a high mortality after coronary unit admission. Several clinical factors are associated with a worse prognosis.

Insulin subcutaneous application vs. continuous infusion for postoperative blood glucose control in patients with non-insulin-dependent diabetes mellitus.

BACKGROUND: Frequently, the use of insulin is considered for metabolic control in postoperative patients with non-insulin-dependent diabetes mellitus (NIDDM). We sought to determine the best method for control of glucose in NIDDM non-insulin patients during postoperative care. METHODS: Two algorithms were developed: subcutaneous administration of insulin (SC), and continuous intravenous infusion (IV). A randomized, controlled clinical trial was designed. In addition, both experimental groups were compared with a non-concurrent routinely managed group (RM) with insulin administration under no predetermined algorithm. Eligible patients were those subjected to major surgery under general anesthesia or spinal blockade. They were followed for 48 h after surgery. Target variables were capillary and central blood glucose, insulin dose administered, urine glucose and ketone strip determination, and development of hyper- or hypoglycemia. RESULTS: A total of 62 patients were studied (RM = 25, SC = 19, IV = 18). Results for both experimental algorithms were similar except for the IV group that required less insulin per hour compared to SC (0.64 vs. 0.34 U/h; p = 0.0003). The RM control group showed poor control in all capillary glucose measurements (194.9 +/- 26.8 mg/dL) compared with the two experimental algorithms (SC = 129.9 +/- 21; IV = 131.6 +/- 20.4) (p <0.05). More hyperglycemia events appeared in the RM group (p = 0.016). Only one hypoglycemia event occurred in the IV group. CONCLUSIONS: Postoperative control of NIDDM is similar with both tested methods. The use of any of the algorithms studied improves metabolic control substantially because it standardizes postoperative management of the diabetic patient with timely determination of capillary blood glucose and insulin administration. However, IV administration has the advantage of accomplishing adequate control with a smaller insulin dose.