Participación ciudadana en la política pública de deporte en Medellín / Citizen Participation in the Public Policy of Sport in Medellin

Resumen ¿Cuál es la incidencia de la participación ciudadana en la formulación de políticas públicas locales? Este artículo de reflexión responde, exploratoriamente, esta pregunta desde el caso de la política pública del deporte, la recreación y la actividad física en Medellín. Teniendo en cuenta el mismo método, instrumentos e información recolectada durante el proceso original de reformulación, se contrasta esta información con la incorporada en los documentos oficiales que recogen la actualización de la política pública. Aunque se invoca la metodología de co-creación, se mantienen los mismos canales y limitaciones a la participación ciudadana; entonces, se participa, pero no se co-crea.

Abstract What is the incidence of citizen participation in the formulation of local public policies? This reflective article answers, in an exploratory way, this question from the case of the public policy of sport, recreation, and physical activity in Medellin. By taking into account the same method, instruments, and information collected during the original reformulation process, this information is contrasted with that incorporated in the official documents that reflect the updating of the public policy. Although the methodology of co-creation is invoked, the same channels and limitations to citizen participation are maintained. Thus, there is participation, but there is no co-creation.

Association between complications and death within 30 days after noncardiac surgery.

BACKGROUND: Among adults undergoing contemporary noncardiac surgery, little is known about the frequency and timing of death and the associations between perioperative complications and mortality. We aimed to establish the frequency and timing of death and its association with perioperative complications. METHODS: We conducted a prospective cohort study of patients aged 45 years and older who underwent inpatient noncardiac surgery at 28 centres in 14 countries. We monitored patients for complications until 30 days after surgery and determined the relation between these complications and 30-day mortality using a Cox proportional hazards model. RESULTS: We included 40 004 patients. Of those, 715 patients (1.8%) died within 30 days of surgery. Five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery during the index admission to hospital and 210 deaths (29.4%) occurred after discharge from the hospital. Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2-3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9-2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6-6.8; AF 12.0%). INTERPRETATION: Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality. Study registration: ClinicalTrials.gov, no. NCT00512109.

Use of Hydrocolloid Dressings in Preventing Pressure Ulcers in High-risk Patients: a Retrospective Cohort.

OBJECTIVES: This work sought to evaluate the association between using preventive hydrocolloid dressings and the onset of pressure ulcers in hospitalized patients. METHODS: Retrospective cohort study that included adult patients with high risk of pressure ulcers (PU) evaluated according to the Braden scale and who had been admitted with preventive purposes to a skin care program. The preventive care prescribed by the nursing staff included using hydrocolloid dressing plus conventional care (HD+CC) or only conventional care (CC), in a tier IV hospital in Bogotá, Colombia. Information was obtained from the clinical records of the demographic variables, health, and complications during hospitalization. RESULTS: One-hundred seventy subjects were included in the study (23 in HD+CC and 147 in CC). In all, 30.4% of the patients in the HD+CC group and 17% in the CC group had PU during follow up (p=0.15). The ratio between the type of preventive treatment received and the development of PU obtained a raw Hazzard ratio (HR) of 1.35 (CI95%: 0.58-3.14; p=0.48) and HR adjusted for confounding variables of 1.06 (CI95%: 0.29-3.84 p=0.92). CONCLUSIONS: Our results showed no superiority of HD+CC against CC in preventing PU in adult patients with high risk according to the Braden scale. The cohort study did not reveal significant differences between both interventions. It is necessary to promote and develop clinical trials to evaluate the effectiveness of using dressings and other conventional care in high-risk patients for this type of event.

Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery.

IMPORTANCE: Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS). OBJECTIVE: To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality). DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013. EXPOSURES: Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement. MAIN OUTCOMES AND MEASURES: A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality. RESULTS: Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom. CONCLUSIONS AND RELEVANCE: Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.

Implementación de guías de práctica clínica de la Asociación de Enfermeras de Ontario-RNAO: Una experiencia de enfermería en un hospital colombiano / Implementação de diretrizes de prática clínica do Ontário Nurses Association-RNAO: Uma experiência de enfermagem um hospital colombiano / Implementation of Clinical Practice Guidelines of the Registered Nurses Association of Ontario-RNAO: A Nursing Experience in a Colombian Hospital

Introducción: La implementación de guías de práctica clínica (GPC) es una estrategia que tiene como fin el aumento del uso de la evidencia en el contexto de toma de decisiones y construcción de políticas en salud. Profesionales de enfermería de la Fundación Cardioinfantil-Institución de Cardiología (FCI-IC) establecieron un convenio colaborativo con la Asociación de Enfermeras de Ontario (RNAO), Canadá, con el fin de implementar y evaluar tres de sus GPC en adultos hospitalizados. Objetivo: Describir el diseño, proceso y evaluación preliminar del plan de implementación entre julio 2012 y diciembre 2014. Metodología: La selección de GPC se realizó previo diagnóstico de necesidades y factibilidad: dos preventivas y una de cuidado. Las GPC de prevención fueron: Una de caídas y otra de úlceras por presión (UPP). La GPC de cuidado fue valoración y manejo de úlceras de pie diabético. Los indicadores seleccionados para las GPC prevención fueron frecuencia de evaluación y confirmación del riesgo y tasa de eventos (caídas y UPP). En la GPG cuidado se evaluó el porcentaje de pacientes valorados (miembros inferiores y pies) en admisiones; porcentaje de educación; y porcentaje de pacientes con reducción (curación) de herida en pie (del 50%). Resultados: La evaluación del riesgo con re-valoración a las 24-72 horas (caídas/UPP) fue realizada en todos los pacientes admitidos. Se observó una reducción en el uso de barandas, y una baja reducción en caídas. No se observó una reducción en UPP, pero hubo una limitación del tipo de UPP solo a grado II. Aumentó la valoración en miembros inferiores, la educación y el cuidado de úlceras en pie en pacientes diabéticos. Conclusiones: La implementación de las GPC y el trabajo en red con la RNAO han orientado nuestra práctica del cuidado en enfermería basado en la evaluación del riesgo y eventos. Limitaciones en el nivel de evidencia de algunas recomendaciones han promovido el desarrollo de una nueva investigación.

Introduction: The implementation or Clinical Practice Guidelines (CPG) is a strategy that whose goal is to increase the use of evidence in the context of decision making and building health policies. Nurses of The "Cardioinfantil-IC" Foundation (FCI-IC) established a collaborative agreement with the Registered Nurses Association of Ontario, Canada (RNAO), in order to implement and evaluate three of its GPC in adult inpatients. Objective: This paper describes the design, process and preliminary evaluation of an implementation plan between July 2012 and December 2014. Methodology: The selection of the CPG was made after an initial needs diagnosis and a feasibility analysis. Two CPGs were based on prevention: one about fall and another one about pressure ulcers (PU); and one more based on direct care related to assessment and management of diabetic foot ulcers. The indicators selected for CPG about prevention were frequency of evaluation and confirmation of risk and event rate (falls and UP). In the CPG about care was evaluated the percentage of assessed patients (lower limbs and feet) in admissions, the percentage of patient/family education, and the percentage of patients with foot injury reduction (50%). Results: The evaluation of the risk for falls and pressure ulcers with a reassessment ranging from 24 to 72 hours was performed in all patients that were admitted. There was a reduction in the use of guardrails, and a low reduction in falls. There was no change in the rate of pressure ulcers but the incidence of ulcers was limited to grade II. The assessment in lower limbs, the education, and care about foot ulcers in diabetic patients increased. Conclusions: The implementation process of GPC, as a result of the networking with the RNAO, has guided nursing care practice based on the assessment of risk and events. Some limitations in the level of evidence of some recommendations have promoted the development of a new research.

Introdução: A implementação das diretrizes de prática clínica (CPG) é uma estratégia que visa aumentar o uso de provas no contexto da tomada de decisões e na construção de políticas no sistema de saúde. Os profissionais de enfermagem da Fundação Cardioinfantil-IC (FCI-IC) estabeleceram uma cordo de colaboraçãocom a Associação de Enfermeiras de Ontário (RNAO), Canadá, a fim de implementar e avaliartrês de seus GPC em adultos hospitalizados. Objetivo: Este artigo descreve o desenho, processo e avaliação preliminar do plano de implementação entre Julho de 2012 e Dezembro de 2014. Metodologia: A seleção de GPC foi realizada antes do diagnóstico das necessidades e da viabilidade: Duas preventivas e uma do cuidado. As GPC de prevenção foram: Uma das quedas e outra de úlceras por pressão (UPP). A GPC do cuidado foi a avaliação e gestão de úlceras do pé diabético. Os indicadores selecionados para as GPC de prevenção foram freqüentemente de avaliação e da confirmação do risco e a taxa de eventos (quedas e UPP). Na GPG, o cuidado foiavaliado a percentagem de pacientes avaliados (pernas e pés) nasadmissões; a percentagem de educação; e percentagem de pacientes comredução (cura) da ferida no pénum (50%). Resultados: A avaliação de risco comumare avaliação dentro de 24-72 horas (quedas/ UPP) foi realizada a todos os pacientes internados. Foi observada uma redução na utilização de trilhos, e uma baixoredução das quedas. Nenhuma redução foi observada em UPP, mas houveuma limitação do tipo de UPP sóao tipo II. Aumentou a avaliação nas pernas, a educação e o cuidado nas úlceras no péem pacientes diabéticos. Conclusões: A implementação da CPG e trabalhoem rede com o RNAO guiaramnoss aprática de cuidados de enfermagem com base na avaliação de risco e eventos. Limitaçõ esquantoao nível da evidência de algumas recomendações têm promovido o desenvolvimento de novas pesquisas.

Avances en el conocimiento de la prehabilitación y presentación del proyecto promoción de la ambulación precoz en pacientes de cirugía no cardíaca (PAMP) / Avanços no Conhecimento da Pré-reabilitação e Apresentação do Projeto Promoção da deambulação precoce em pacientes com cirurgia não cardíaca (PAMP) / Improvements in the knowledge of prehabilitation and presentation of the project: promotion of early ambulation in non-cardiac surgery patients (PAMP)

Introducción: La prehabilitación es un programa multidisciplinario que combina un conjunto de intervenciones (caminata, ejercicios aeróbicos, entrenamiento de los músculos inspiratorios, educación sobre nutrición y manejo psicológico) orientadas hacia el mejoramiento de la capacidad funcional de los pacientes antes de asumir cualquier tipo de cirugía. Su propósito es el de preparar físicamente a los pacientes que van a cirugía (especialmente población adulta y adulta mayor) y favorecer una rehabilitación rápida, la reducción de las complicaciones en el post operatorio, y una preparación adecuada para el egreso hospitalario. A pesar del conocimiento de la importancia de esta intervención poco se sabe sobre su beneficio en los resultados post operatorios de pacientes de cirugía no cardíaca. Objetivo: Describir la prehabilitación, los alcances de la evidencia científica en este tópico y presentar el proyecto promoción de la ambulación precoz en pacientes de cirugía no cardíaca (PAMP) como un modelo de investigación en cirugía no cardíaca y prehabilitacion. Metodología: Se realizó una revisión no sistemática de la literatura de los fundamentos de la prehabilitación, sus orígenes, tipos de intervenciones, importancia y su eficacia en la reducción de eventos en el post operatorio de pacientes de cirugía no cardíaca. Adicionalmente se llevó a cabo una revisión de la literatura que incluyó revisiones sistemáticas y metaanálisis de ensayos clínicos sobre intervenciones evaluadas sobre prehabilitación de cirugía no cardíaca. Finalmente, se describió el alcance del proyecto PAMP en todas sus fases y su progreso hacia la implementación de un ensayo clínico de prehabilitación en Colombia mediante el estudio PAMP fase II. Conclusiones: Se requiere implementar estrategias multidisciplinarias innovadoras que promuevan mejores resultados en el post operatorio de pacientes sometidos a cirugía no cardíaca...(AU)

Introduction: Prehabilitation is a multidisciplinary program that combines a set of interventions (walking, aerobic exercises, inspiratory muscle training, nutrition education and psychological management) aimed at improving the functional capacity of patients before assuming any type of surgery. Its purpose is to physically prepare patients before going to surgery (especially the adult and older adult population) and favor rapid rehabilitation, reduction of post-operative complications, and adequate preparation for hospital discharge. Despite the knowledge of the importance of this intervention it is not a practice implemented and little is known about its benefit in the postoperative results of non-cardiac surgery patients. Objective: To describe the prehabilitation and the scope of the scientific evidence in this topic. To present the PAMP project as a research model of prehabilitation in non-cardiac surgery. Methodology: We performed a non - systematic review of the literature on the fundamentals of prehabilitation, its origins, types of interventions, importance and its efficacy in the reduction of postoperative events in noncardiac surgery patients. Furthermore, we performed a literature review including systematic reviews and meta-analyzes of clinical trials on interventions of prehabilitation programs. Finally, this article presents the scope of the PAMP project in all its phases and its progress towards the implementation of a clinical trial of prehabilitation in Colombia through the PAMP phase II study was described. Conclusions: It is necessary to implement innovative multidisciplinary strategies that promote better results in the postoperative period of patients undergoing noncardiac surgery...(AU)

Introdução: Introdução: A pré-reabilitação é um programa multidisciplinar que combina um conjunto de intervenções (caminhada, aeróbica, treinamento muscular inspiratório, nutrição e psicologia) destinado a melhorar a capacidade funcional dos pacientes antes de fazer a cirurgia. O objetivo da pré-reabilitação é para reduzir as complicações que podem ocorrer durante o período pré-operatório (pré, trans e pós-operatório) em pessoas adultas e idosas. As complicações pré-reabilitação em todo o mundo é de 200 milhões e cerca de 1 milhão de doentes morrem durante os primeiros 30 dias depois de ter feito a cirurgia. A estimativa de risco antes da cirurgia identifica aos pacientes que necessitam de um acompanhamento mais intensivo e maior atenção depois da cirurgia. Embora a avaliação de risco antes da cirurgia pode melhorar a predição de mortalidade pós-operatória em cirurgia não cardíaca, pouco se sabe sobre a eficácia da pré-reabilitação como complemento na avaliação do risco para prevenir complicações e a norte pós-operatórias. Objetivo: Este documento é uma revisão da literatura sobre a prática de pré-reabilitação em pacientes cirúrgicos não cardíacos. Metodologia: Isso inclui uma revisão da sua definição e uma descrição geral do tipo de intervenções ou atividades implementadas. Resultados: Explica a evidência sobre o impacto desses programas sobre a evolução do paciente no pós-operatório; uma revisão de fato sobre a pré-reabilitação, a melhor prova da pré-reabilitação relatada em revisões sistemáticas e metaanálises. Conclusões: o avanço associado com a pesquisa nacional relacionada com a avaliação do estilo de vida sedentário e os fatores associados à inatividade, antes da cirurgia de pacientes não cardíacos e do estudo em progresso PAMP-Phase II (Promoção da deambulação pré-cirúrgica) um projeto piloto de pré-reabilitação liderado pela enfermagem em pacientes agendados para cirurgia não cardíaca na Colômbia...(AU)

¿Puede asociarse el sedentarismo con hallazgos clínicos de alarma de enfermedad crónica en adultos jóvenes?: un análisis en el proyecto CHICAMOCHA / Poderia associar-se o sedentarismo Ós conclusões clínicas de alarme de doenças crónicas em adultos jovens?: análise no projeto CHICAMOCHA / Can sedentarism be associated with alarm clinical findings of chronic diseases in young adults?: an analysis in CHICAMOCHA project

La asociación entre sedentarismo y enfermedades crónicas no transmisibles (ECNT) requiere décadas de exposición. Es posible que esta se manifieste mas tempranamente, por algunos hallazgos clinicos en adultos jóvenes. Objetivo: Probar la hipótesis de que en adultos jóvenes el sedentarismo se asocia con algunos signos o síntomas de alarma para el desarrollo posterior de ECNT. Metodología: Usando la evaluación inicial (años 2000-2003) del proyecto CHICAMOCHA, en 1539 donantes de sangre clinicamente saludables con pruebas de tamización negativas (edad media 36, DE 8,3 años, 66% hombres) se estudió la asociación entre sedentarismo y una serie de hallazgos clinicos. Se definió sedentarismo como reportar actividad física moderada-intensa ≤150 minutos/semana (incluyendo el trabajo). El desenlace primario fue el compuesto de 11 hallazgos (5 síntomas y 6 signos) de alarma encontrados en la valoración médica. La asociación fue estimada usando un modelo regresión logística ajustado por covariables. Resultados: Se encontra que 56.9% (IC95% 54.3 û 59.3) de los participantes eran sedentarios. En el análisis multivariado, el sedentarismo se asoció positivamente con el estado civil soltero y negativamente con estar empleado. No se encontraron asociaciones significativas en el compuesto agregado de 5 sintomas (OR ajustado 1.07, IC95% 0.90 û 1.26), 6 signos (OR ajustado 1.01, IC95% 0.79 û 1.28). Sin embargo, se observó un gradiente positivo no significativo por el número de hallazgos presentes (1 hallazgo OR=0.91, IC95% 0.61 û 1.35), 2 hallazgos (OR=1.20, IC95% 0.84 û 1.73), 3 o más hallazgos (OR=1.31, IC95% 0.91 û 1.89). Conclusiones: Más de la mitad de la población estudiada se encontró sedentaria. Aunque este factor no se encontró asociado con signos o síntomas individualmente, se identificó un gradiente no significativo con el número de estos hallazgos, posiblemente relacionado con el tiempo de exposición relativamente breve.

The association between Sedentary Lifestyle (SL) and Chronic Non-Communicable Diseases (NCD) takes decades of exposure. It is possible to be seen at an early stage in young adults due to some clinical findings. Objective: Test the hypothesis that a sedentary lifestyle in young adults is associated with some signs or symptoms of alarm for the further development of NCD. Methodology: Using the initial evaluation (years 2000-2003) of CHICAMOCHA project, it was found that 1539 blood donors were healthy with negative screening test results (mean age 36, SD 8.3 years, 66% male). The association between sedentary lifestyle and a series of clinical findings was studied. Sedentary Lifestyle was defined as moderate-intense physical activity of ≤150 minutes/week (including work). The primary outcome was the composite of 11 findings (5 symptoms and 6 signs) found in the medical assessment. We computed multivariate logistic regression models for both individual and pooled outcomes. Results: SL was found in 56.9% (IC95% 54.3û59.3) participants. In multivariate analysis SL was positively associated with single marital status and negatively associated with being employed. There were no significant associations between SL and the composite of 5 symptoms (Covariate-adjusted pooled OR 1.07, 95%CI 0.90û1.26), or 6 signs (Covariate-adjusted pooled OR 1.01, 95%CI 0.79û1.28). However, a positive non-significant gradient in association with the number of findings (Covariate-adjusted OR for any one clinical finding OR=0.91, 95%CI 0.61û1.35; any two findings OR=1.20, 95%CI 0.84 û 1.73, or 3 or more findings OR=1.31, 95%CI 0.91û1.89) was observed. Conclusions: It was found that more than half of the studied population presented a sedentary lifestyle. Even though this factor was not associated with individual signs and symptoms, a non-significant gradient was found, possibly related to a short exposure that may explain these results.

A associação entre sedentarismo e doenþas crónicas não transmissíveis (DCNT) requer décadas de exposição o. É possivel que esta se manifeste mais cedo, pelo que se tem observado clinicamente em alguns adultos jovens. Objetivo: Testar a hipótese de que um estilo de vida sedentário em adultos jovens está associada com alguns sinais ou sinais de alerta para o desenvolvimento de doenças não transmissíveis. Metodologia: Usando a avaliação inicial (2000-2003) do projeto CHICAMOCHA, em 1539 doadores de sangue clinicamente saudáveis com testes de rastreio negativos (idade média de 36 anos, 8.3 anos, 66% do sexo masculino), estudou-se a associação entre sedentarismo e uma sÚrie de achados clínicos. O sedentarismo foi definido como atividade física moderada-intensa ≤150 minutos / semana (incluindo trabalho). O desfecho primário foi o composto de 11 resultados (cinco sintomas e 6 sinais) de alarme encontrados na avaliação médica. A associação foi estimada utilizando um modelo de regressão logistica ajustado para co-variáveis. Resultados: Verificou-se que 56.9% (IC 95% 54.3-59.3) dos participantes eram sedentários. Na análise multivariada, o sedentarismo foi positivamente associado com o estado civil de solteiro e negativamente ao fato de estar empregado. Não foram encontradas associações significativas no agregado composto por 5 sintomas (OR ajustado 1,07, IC95% 0,90-1,26), 6 sinais (OR ajustado 1.01, IC95% 0.79 û 1.28). No entanto, é observado, um gradiente positivo, nada significativo pela descoberta presente (1 resultado OR = 0.91, IC 95% 0.61-1.35), 2 resultados (OR = 1.20, IC95% 0.84-1.73), 3 ou mais resultados (OR = 1.31, IC 95% 0.91 é 1.89). Conclusões: Mais da metade da população do estudo foi encontrada sedentária. Embora este fator não foi encontrado associado com sinais ou sintomas individualmente, foi identificado um gradiente não significativo com o número destes achados, possivelmente relacionada com o tempo de exposição relativamente curto.

Evaluación de eficacia y seguridad de Dabigatran y Rivaroxaban, comparados con Warfarina y otros anticoagulantes orales, en pacientes con fibrilación auricular / Efficacy and safety assessment of Dabigatran and Rivaroxaban compared to warfarin and other oral anticoagulants in patients with atrial fibrillation

Introducción: el uso de los nuevos anticoagulantes orales como Dabigatran, Ribaroxaban y Apixaban en pacientes con FA no valvular ha sido evaluado en los estudios RELY, ROCKET-AF y ARISTOTELE, respectivamente. En ellos se demuestra su eficacia en la prevención de embolia, con un perfil de seguridad similar o incluso mejor que la terapia estándar con Warfarina. En los últimos tres años es significativo el número de estudios (revisiones sistemáticas, más que ECA) que se han publicado con estos nuevos anticoagulantes orales. Dada su relativa recién aparición e indicación por las Guías de Práctica Clínica, se hace necesario adelantar una revisión de literatura que permita sintetizar todos estos nuevos conocimientos y poder generar una o varias recomendaciones aplicables a la población colombiana. Objetivos: sintetizar y evaluar la eficacia y seguridad de Rivaroxaban y Dabigatran en adultos con fibrilación auricular no valvular. Métodos: revisión sistemática de literatura. Se incluyeron estudios de pacientes con fibrilación auricular no valvular en quienes se interviniera con Warfarina o alguno de los nuevos anticoagulantes aprobados en Colombia (Dabigatran, Rivaroxaban, Apixaban). El Apixaban solo se tuvo en cuenta como medicamento comparador. Serealizó una búsqueda en los principales recursos bibliográficos (Cochrane, Medline, Embase, LILACS) para revisiones sistemáticas con meta-análisis y meta-análisis en red. Adicionalmente se realizó una búsqueda de ECA y estudios observacionales para meta-analizar y reportar las medidas de efecto que no fueran descritas por las revisiones sistemáticas elegidas, según los desenlaces propuestos por el grupo desarrollador. Resultados: se seleccionaron 15 estudios de un total de 1840. Se encontraron comparaciones directas entre Rivaroxaban y Dabigatran con Warfarina, así como comparaciones indirectas entre los nuevos anticoagulantes orales para la mayoría de desenlaces propuestos. Para el desenlace primario (ACV isquémico) se encontró beneficio con Dabigatran 150mg en comparación con Warfarina y con Dabigatran 110mg (OR=0,76 (0,58-0,98) y 0,67 (0,53-0,86) respectivamente). Ninguna comparación indirecta fue estadísticamente significativa para eficacia. Tanto Dabigatran (150mg y 110mg) como Rivaroxaban son más seguros que Warfarina para la prevención de hemorragias intracraneales (OR=0,42 (0,28-0,61); 0,30 (0,19-0,46) y 0,64 (0,46-0,88) respectivamente). Conclusiones: Dabigatran (150 mg) es más eficaz que Warfarina para la prevención de ACV isquémico. Rivaroxaban es más eficaz que Warfarina para la prevención de embolismos sistémicos. El uso de Dabigatran (150 o 110 mg) o de Rivaroxaban es más seguro que Warfarina para la prevención de hemorragias intracraneanas. Debido a la falta de comparaciones directas, no es posible afirmar que la eficacia de uno de los NACOS aprobados para su uso en Colombia sea más eficaz que otro. Sin embargo, Dabigatran parece brindar un mayor beneficio clínico neto que Rivaroxaban para esta indicación terapéutica.(AU)

Trypanocidal drugs for chronic asymptomatic Trypanosoma cruzi infection.

BACKGROUND: Prevention of chronic chagasic cardiomyopathy (CCC) by treating infected populations with trypanocidal therapy (TT) remains a challenge. Despite a renewed enthusiasm for TT, uncertainty regarding its efficacy, concerns about its safety and limited availability remain barriers for a wider use of conventional drugs. We have updated a previous version of this review. OBJECTIVES: To systematically search, appraise, identify and extract data from eligible studies comparing the outcome of cohorts of seropositive individuals to Trypanosoma cruzi exposed to TT versus placebo or no treatment. SEARCH METHODS: We sought eligible studies in electronic databases (Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2014); MEDLINE (Ovid, 1946 to January week 5 2014); EMBASE (Ovid, 1980 to 2014 week 6) and LILACS (up to 6 May 2010)) by combining terms related with the disease and the treatment. The search also included a Google search, handsearch for references in review or selected articles, and search of expert files. We applied no language restrictions. SELECTION CRITERIA: Review authors screened the retrieved references for eligibility (those dealing with human participants treated with TT) and then assessed the pre-selected studies in full for inclusion. We included randomised controlled trials (RCTs) and observational studies that provided data on either mortality or clinical progression of CCC after at least four years of follow-up. DATA COLLECTION AND ANALYSIS: Teams of two review authors independently carried out the study selection, data extraction and risk of bias assessment, with a referee resolving disagreement within the pairs. Data collection included study design, characteristics of the population and interventions or exposures and outcome measures. We defined categories of outcome data as parasite-related (positive serology, xenodiagnosis or polymerase chain reaction (PCR) after TT) and participant-related (including efficacy outcomes such as progression towards CCC, all-cause mortality and side effects of TT). We reported pooled outcome data as Mantel-Haenszel odds ratios (OR) or standardised mean differences (SMD) along with 95% confidence intervals (CI), using a random-effects model. I(2) statistics provided an estimate of heterogeneity across studies. We conducted an exploratory meta-regression analysis of the relationship between positive-serology and progression of CCC or mortality. MAIN RESULTS: We included 13 studies involving 4229 participants (six RCTs, n = 1096, five RCTs of intermediate risk of bias, one RCT of high risk of bias; four non-randomised experiments, n = 1639 and three observational studies, n = 1494). Ten studies tested nitroderivative drugs nifurtimox or benznidazole (three exposed participants to allopurinol, one to itraconazole). Five studies were conducted in Brazil, five in Argentina, one in Bolivia, one in Chile and one in Venezuela.TT was associated with substantial, but heterogeneous reductions on parasite-related outcomes such as positive serology (9 studies, OR 0.21, 95% CI 0.10 to 0.44, I(2) = 76%), positive PCR (2 studies, OR 0.50, 95% CI 0.27 to 0.92, I(2) = 0%), positive xenodiagnosis after treatment (6 studies, OR 0.35, 95% CI 0.14 to 0.86, I(2) = 79%), or reduction on antibody titres (3 studies, SMD -0.56, 95% CI -0.89 to -0.23, I(2) = 28%). Efficacy data on patient-related outcomes was largely from non-RCTs. TT with nitroderivatives was associated with potentially important, but imprecise and inconsistent reductions in progression of CCC (4 studies, 106 events, OR 0.74, 95% CI 0.32 to 1.73, I(2) = 66%) and mortality after TT (6 studies, 99 events, OR 0.55, 95% CI 0.26 to 1.14, I(2) = 48%). The overall median incidence of any severe side effects among 1475 individuals from five studies exposed to TT was 2.7%, and the overall discontinuation of this two-month therapy in RCTs (5 studies, 134 events) was 20.5% (versus 4.3% among controls) and 10.4% in other five studies (125 events). AUTHORS' CONCLUSIONS: Despite the evidence that TT reduced parasite-related outcomes, the low quality and inconsistency of the data for patient-important outcomes must be treated with caution. More geographically diverse RCTs testing newer forms of TT are warranted in order to 1. estimate efficacy more precisely, 2. explore factors potentially responsible for the heterogeneity of results and 3. increase knowledge on the efficacy/tolerance balance of conventional TT.

Primera caminada durante la hospitalización de pacientes con Infarto Agudo del Miocardio / First walk during hospitalization among patients with Myocardial Infarction

A pesar de los beneficios documentados acerca de la rehabilitación cardiovascular (RC) después de un infarto agudo de miocardio (IAM), existe aún incertidumbre sobre la implementación de la ambulación precoz como el elemento inicial de la RC durante el periodo de hospitalización. El siguiente artículo presenta una revisión de la literatura acerca de la práctica del inicio de la caminada o ambulación de pacientes hospitalizados con un diagnóstico de IAM. En este se incluye una descripción de los patrones (día, hora, tipo de actividad) de movilización observados en algunas instituciones de salud, desde que el paciente se sienta en su cama, se levanta e inicia su primera caminada. Además se explora la evidencia existente sobre el efecto de la ambulación precoz y se hace una actualización crítica sobre las guías de manejo que orientan esta práctica en hospitalización. Finalmente, se describe la importancia de la implementación de la ambulación precoz, teniendo en cuenta los avances científicos del tratamiento del infarto y sus posibles determinantes, basados en la experiencia obtenida en el Programa de Ambulación Precoz (PAMP), desarrollado por la Escuela de Enfermería y el Observatorio Epidemiológico de Enfermedades Cardiovasculares de la de la Universidad Industrial de Santander

Despite the documented efficacy of cardiac rehabilitation (CR) after acute myocardial infarction, there is uncertainty about early ambulation, as the initial stage of CR while in hospital. The aims of the following article are to conduct a literature review about the practice of the firs walk or early ambulation after acute myocardial infarction in-hospital, and the clinical patterns (day, time, frequency) of this practice from bed rest to walk. We explored research advances on the topic, the factors that may predict early ambulation in hospital, and the current guidelines as the foundation for its practice and patient care. Furthermore, this review intends to analyze the existing evidence about the benefits for the patient, and the importance of its implementation. Finally, this article describes the progress achieved in the Research Program of Early Ambulation developed by the Observatory of Cardiovascular Disease Epidemiology and the Nursing School at Universidad Industrial de Santander

Carencia de Revisiones Sistemáticas en la Literatura Biomédica Latinoamericana: El caso del Tratamiento Tripanocida en la Enfermedad de Chagas / Lack of systematic reviews in biomedical Latin-American literature: the case of the tripanocide treatment in Chagas disease

La síntesis de información en revisiones sistemáticas (RS) es la base para la elaboración de guías y recomendaciones en el cuidado de salud basado en la evidencia. En la enfermedad de Chagas (ECHA), las recomendaciones sobre el uso del tratamiento tripanocida (TT), no han tenido modificaciones sustanciales durante décadas. OBJETIVO: Determinar las características estructurales y metodológicas de los artículos de revisión (AR) sobre la eficacia del TT en la infección crónica por Trypanosoma cruzi (ICTC). MÉTODOS: Se realizó una revisión sistemática cualitativa, tomando como universo las publicacoines registradas en MEDLINE y LILACS a partir de 1990. Dos revisores independientemente tamizaron los resúmenes, seleccionaron artículos relevantes y luego extrajeron datos acerca de la estructura y metodología de los AR de interés. El acuerdo entre los revisores a través de los tres pasos fue evaluado. RESULTADOS: Entre 200 resúmenes tamizados, se encontraron 22 artículos potencialmente relevantes, de los cuales 6 (27.3 por ciento) fueron identificados como AR en el tópico de interés. Todos los AR fueron publicados por autores latinoamericanos en revistas latinoamericanas. Ninguno de estos artículos contenía una sección de métodos y sólo uno de ellos presentaba una síntesis numérica de información. No se identificó ningún AR como RS. El acuerdo entre evaluadores fue bueno (K=0.5). CONCLUSIÓN: La no existencia de RS puede dilatar la generación de recomendaciones basadas en la síntesis de la nueva evidencia disponible e impedir la definición de los vacíos de conocimiento en este tópico. La responsbilidad de generarlos recae prinicpalmente en la comunidad académica latinoamericana