Can we still consider treatment with colchicine effective in SARS-COV-2 infection? Systematic review, meta-analysis, and trial sequential analysis.

OBJECTIVE: To assess the effectiveness of colchicine, compared with standard of care, for reducing mortality, admission to intensive care, and use of mechanical ventilation. MATERIALS AND METHODS: We performed a systematic review, meta-analysis, and sequential trial analysis. The terms (SARS-CoV-2 OR COVID-19 OR coronavirus) AND (colchicine) were searched in MEDLINE, Scopus, Embase, Cochrane Central Register of Controlled Trials, and preprint repositories (February 2020 to April 2021, extended to June 2021). Risk of bias for randomised controlled trials and observational studies were assessed using the tools RoB 2.0 and ROBINS-I, respectively. We performed subgroup analyses based on study design and sensitivity analyses based on time of colchicine administration. RESULTS: We included six observational studies (1329 patients) and five clinical trials (16,048 patients). All studies but one were conducted in the hospital setting. Colchicine treatment was not associated with a significant decrease in mortality (RR 0.93, 95% CI 0.87 to 1; p=0.06, I2=72%) with a significant subgroup effect (p<0.001) depending on the design of the studies. The drug was effective in observational studies (RR 0.57, 95% CI 0.46 to 0.70, p<0.001, I2=50%) but not in clinical trials (RR 0.99, 95% CI 0.92 to 1.07, p=0.89, I2=21%). The effect of colchicine on intensive care admissions and the need for mechanical ventilation could not be confirmed. Trial sequential boundaries for cumulative meta-analyses of randomised controlled trials suggested no significant effect on mortality (p=0.182) beyond the optimal information size (13,107 patients). CONCLUSIONS: Our results suggest that colchicine treatment has no effect on mortality in hospitalised patients with SARS-CoV-2 infection, and that no further confirmatory clinical trials are needed owing to futility.

Hemoptisis masiva como complicación de cateterismo derecho con catéter de Swan-Ganz / Massive hemoptisis as complication of cathetering right with Swan-Ganz catheter

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Signos de «ojo de serpiente» y «trazo de lápiz» junto con parálisis diafragmática en paciente con isquemia medular anterior / «Snake eye» and «pencil-like» signs together with diaphragmatic paralysis in a patient with anterior spinal cord ischemia

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Respuesta de los autores: Accesibilidad al sistema sanitario de los pacientes diabéticos con síndrome coronario agudo con elevación del segmento ST / Author's reply: Accessibility to healthcare of diabetic patients with acute coronary syndrome with ST-segment elevation

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Respuesta de los autores: Educación y concienciación en el paciente diabético con síndrome coronario agudo con elevación del ST / Author's reply: Education and awareness in the diabetic patient with ST-segment elevation acute coronary syndrome

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Accesibilidad al sistema sanitario de los pacientes diabéticos con síndrome coronario agudo con elevación del segmento ST / Accessibility to health care of diabetic patients with acute coronary syndrome ST-segment elevation

OBJETIVOS: El objetivo de este estudio es medir la accesibilidad al sistema sanitario de los pacientes diabéticos y analizar si las posibles diferencias en la accesibilidad explican la mayor mortalidad conocida en aquellos. MÉTODOS: Estudio de cohortes retrospectivo, realizado en pacientes diabéticos con síndrome coronario agudo con elevación del segmento ST incluidos en los años 2010 al 2013 del registro ARIAM-SEMICYUC. Se realiza análisis crudo y ajustado mediante regresión logística no condicional. RESULTADOS: Se han analizado 4817 pacientes, de los cuales 1070 (22,2%) son diabéticos. Los pacientes diabéticos contactan con el sistema sanitario de la misma forma que los pacientes no diabéticos aunque con mayor retraso (retraso atribuible al paciente 90 min vs. 75 min con p = 0,004 y retraso prehospitalario 150 min vs. 130 min con p = 0,002). Una vez dentro del sistema sanitario, estos pacientes tienen menor tasa de reperfusión (50 vs. 57,7%; p < 0,001) pero sin objetivar mayor retraso en el tratamiento. Como ya es conocido, los pacientes diabéticos presentan una mayor mortalidad hospitalaria (12,5 vs. 6%; p < 0,001); sin embargo, no se identifican como variables predictoras independientes de la mortalidad ni el retraso atribuible al paciente ni el retraso prehospitalario. CONCLUSIONES: Los pacientes diabéticos tienen una mayor demora en el acceso al sistema sanitario, sin embargo no hemos podido objetivar que esta demora se relacione de forma independiente con la mayor mortalidad

OBJECTIVES: To measure accessibility to health care among diabetic patients and analyze whether differences in delay explain differences in hospital mortality. METHODS: A retrospective cohort study was conducted in diabetic patients with acute coronary syndrome with ST-segment elevation included in the ARIAM-SEMICYUC registry (2010-2013). Crude and adjusted analyses were performed using unconditional logistic regression. RESULTS: A total of 4817 patients were analyzed, of whom 1070 (22.2%) were diabetics. No differences were found in access to health care between diabetic and non-diabetic patients. Diabetic patients presented with longer patient delay (90 min vs. 75 min; p = .004) and prehospital delay (150min vs. 130 min; p = .002). Once the health system was contacted, diabetic patients had a lower reperfusion rate (50% vs. 57.7%; p < .001), but no longer delay in treatment was observed compared with the non-diabetic individuals. Diabetic patients have greater in-hospital mortality (12.5 vs. 6%; p < .001), though neither patient delay nor prehospital delay were identified as independent predictors of in-hospital mortality. CONCLUSIONS: Diabetic patients had a longer delay in access to health care, though such delay was not independently related to increased mortality

[Accessibility to health care of diabetic patients with acute coronary syndrome ST-segment elevation]. / Accesibilidad al sistema sanitario de los pacientes diabéticos con síndrome coronario agudo con elevación del segmento ST.

OBJECTIVES: To measure accessibility to health care among diabetic patients and analyze whether differences in delay explain differences in hospital mortality. METHODS: A retrospective cohort study was conducted in diabetic patients with acute coronary syndrome with ST-segment elevation included in the ARIAM-SEMICYUC registry (2010-2013). Crude and adjusted analyses were performed using unconditional logistic regression. RESULTS: A total of 4817 patients were analyzed, of whom 1070 (22.2%) were diabetics. No differences were found in access to health care between diabetic and non-diabetic patients. Diabetic patients presented with longer patient delay (90 min vs. 75 min; p=.004) and prehospital delay (150 min vs. 130 min; p=.002). Once the health system was contacted, diabetic patients had a lower reperfusion rate (50% vs. 57.7%; p<.001), but no longer delay in treatment was observed compared with the non-diabetic individuals. Diabetic patients have greater in-hospital mortality (12.5 vs. 6%; p <.001), though neither patient delay nor prehospital delay were identified as independent predictors of in-hospital mortality. CONCLUSIONS: Diabetic patients had a longer delay in access to health care, though such delay was not independently related to increased mortality.

Respuesta de los autores: Predictores del uso de la estrategia invasiva precoz en mujeres con síndrome coronario agudo sin elevación de ST / Author's reply: Predictors of the use of the early invasive strategy in women with non-ST-elevation acute coronary syndrome

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Predictores del uso de la estrategia invasiva precoz en mujeres con síndrome coronario agudo sin elevación de ST / Predictors of the use of the early invasive strategy in women with non-ST-elevation acute coronary syndrome

OBJETIVO: Identificar los determinantes asociados a la estrategia invasiva precoz (EIP) en mujeres con síndrome coronario agudo sin elevación de ST (SCASEST). DISEÑO: Estudio de cohortes retrospectivo. Análisis crudo y ajustado de la realización de EIP mediante regresión logística no condicional. Ámbito: Unidades coronarias participantes en 2010-2011 en el registro ARIAM-SEMICYUC. PACIENTES: Cuatrocientas cuarenta mujeres con SCASEST. Se excluyeron 16 por datos insuficientes y 58 con coronariografía electiva (> 72 h). Variables analizadas: Demográficas, factores de riesgo coronario, medicación previa, comorbilidad. Características clínicas, analíticas, hemodinámicas y electrocardiográficas del episodio. RESULTADOS: Las mujeres tratadas conservadoramente presentaban mayor edad, mayor prevalencia de anticoagulación oral, diabetes, lesiones coronarias previas e insuficiencia cardiaca (p < 0,005), mayor riesgo hemorrágico e isquémico basal (p = 0,05) y mayor frecuencia cardiaca al ingreso (p < 0,05). Tras el ajuste solo la edad mayor de 80 años (OR: 0,48; IC 95%: 0,27-0,82; p = 0,009), las lesiones coronarias conocidas (OR: 0,47; IC 95%: 0,26-0,84, p = 0,011) y la frecuencia cardiaca (OR: 0,98; IC 95%: 0,97-0,99, p = 0,003) se asociaron de forma independiente al tratamiento conservador. El tabaquismo (OR: 2,50; IC 95%: 1,20-5,19; p = 0,013) y el electrocardiograma de alto riesgo (OR: 2,96; IC 95%: 1, 72-4,97; p < 0,001) se asociaron a la EIP. La exclusión de muertes precoces (< 24 h) no alteró estos resultados. CONCLUSIONES: En mujeres con SCASEST el tabaquismo y el electrocardiograma de alto riesgo al ingreso son factores independientes asociados a la EIP. Las lesiones coronarias previas conocidas, la edad > 80 años y el aumento de la frecuencia cardiaca son factores independientes asociados al tratamiento conservador

OBJECTIVE: To identify determinants associated to an early invasive strategy in women with acute coronary syndromes without ST elevation (NSTE-ACS). DESIGN: A retrospective cohort study was made. Crude and adjusted analysis of the performance of the early invasive strategy using logistic regression. SETTING: Coronary Units enrolled in 2010 - 2011 in the ARIAM-SEMICYUC registry. PATIENTS: A total of 440 women with NSTE-ACS were studied. Sixteen patients were excluded due to insufficient data, together with 58 patients subjected to elective coronary angiography (> 72h). Variables analyzed: Demographic parameters, coronary risk factors, previous medication, comorbidity. Clinical, laboratory, hemodynamic and electrocardiographic data of the episode. RESULTS: Women treated conservatively were of older age, had oral anticoagulation, diabetes, previous coronary lesions, and heart failure (p < 0,005), increased baseline bleeding and ischemic risk (p = 0,05) and a higher heart rate upon admission (p < 0,05). After adjustment, only age > 80 years (OR 0,48, 95% CI 0,27 to 0,82, p = 0,009), known coronary lesions (OR 0,47, 95% CI 0,26-0,84, p = 0,011), and heart rate (OR 0,98, 95% CI 0,97-0,99, p = 0,003) were independently associated to conservative treatment. Smoking (OR 2.50, 95% CI 1.20 to 5.19, p = 0,013) and high-risk electrocardiogram (OR 2.96, 95% CI 1.72 to 4.97, p < 0,001) were associated to the early invasive strategy. The exclusion of early deaths (<24h) did not alter these results. CONCLUSIONS: In women with NSTE ACS, smoking and a high-risk electrocardiogram upon admission were independent factors associated to the early invasive strategy. Previous coronary lesions, age > 80 years and increased heart rate were independent factors associated to conservative treatment

[Predictors of the use of the early invasive strategy in women with non-ST-elevation acute coronary syndrome]. / Predictores del uso de la estrategia invasiva precoz en mujeres con síndrome coronario agudo sin elevación de ST.

OBJECTIVE: To identify determinants associated to an early invasive strategy in women with acute coronary syndromes without ST elevation (NSTE-ACS). DESIGN: A retrospective cohort study was made. Crude and adjusted analysis of the performance of the early invasive strategy using logistic regression. SETTING: Coronary Units enrolled in 2010 - 2011 in the ARIAM-SEMICYUC registry. PATIENTS: A total of 440 women with NSTE-ACS were studied. Sixteen patients were excluded due to insufficient data, together with 58 patients subjected to elective coronary angiography (> 72 h). VARIABLES ANALYZED: Demographic parameters, coronary risk factors, previous medication, comorbidity. Clinical, laboratory, hemodynamic and electrocardiographic data of the episode. RESULTS: Women treated conservatively were of older age, had oral anticoagulation, diabetes, previous coronary lesions, and heart failure (p<0.005), increased baseline bleeding and ischemic risk (p=0.05) and a higher heart rate upon admission (p<0.05). After adjustment, only age > 80 years (OR 0.48, 95% CI 0.27 to 0.82, p=0.009), known coronary lesions (OR 0.47, 95% CI 0.26-0.84, p=0.011), and heart rate (OR 0.98, 95% CI 0.97-0.99, p=0.003) were independently associated to conservative treatment. Smoking (OR 2.50, 95% CI 1.20 to 5.19, p=0.013) and high-risk electrocardiogram (OR 2.96, 95% CI 1.72 to 4.97, p<0.001) were associated to the early invasive strategy. The exclusion of early deaths (<24 h) did not alter these results. CONCLUSIONS: In women with NSTE ACS, smoking and a high-risk electrocardiogram upon admission were independent factors associated to the early invasive strategy. Previous coronary lesions, age > 80 years and increased heart rate were independent factors associated to conservative treatment.

Intensity of continuous renal replacement therapies in patients with severe sepsis and septic shock: a systematic review and meta-analysis.

The purpose of this study was to assess the efficacy of continuous renal replacement therapies in patients with severe sepsis or septic shock, with or without acute kidney injury. We performed a systematic search in Medline, Embase, Web of Knowledge, Cochrane Library and Clinicaltrials.gov and a hand search of the retrieved studies. We included both randomised controlled clinical trials and subgroups of randomised trials that assessed the effect of continuous renal replacement therapies (at traditional or high doses) and reported clinical outcomes in adult patients with severe sepsis or septic shock. The study selection and data extraction were performed by duplicate. Analysis of heterogeneity and meta-analysis was performed according to the Cochrane Collaboration guidelines for conducting systematic reviews of interventions. Twelve studies (1895 patients) met the inclusion criteria. Pooling of all studies resulted in a mortality risk ratio of 0.96 (95% confidence interval 0.83 to 1.12). The studies showed moderate statistical heterogeneity (I2 statistic 52%, P = 0.02). The effect on mortality was not modified (interaction P values non significant) by the dose of continuous renal replacement therapies, the severity of illness or the risk of bias. The available evidence suggests that these therapies in patients with severe sepsis or septic shock are not associated with an improvement in other outcomes such as haemodynamics, pulmonary gas exchange, multiple organ dysfunction syndrome or length of stay. The best available evidence does not support the routine use of continuous renal replacement therapies (at traditional or high doses) in patients with severe sepsis or septic shock.

Hemofiltración en sepsis: ¿cuál es la evidencia? / Hemofiltration in sepsis: What is the evidence?

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