Eficacia en la reducción de eventos adversos de la insulinoterapia en pauta bolo-basal frente a la pauta deslizante en pacientes con diabetes durante la hospitalización convencional: revisión sistemática de la literatura y metaanálisis / Effective adverse event reduction with bolus-basal versus sliding scale insulin therapy in patients with diabetes during conventional hospitalization: Systematic review and meta-analysis

Introducción: El objetivo de esta revisión es evaluar la efectividad para disminuir los eventos adversos clínicos y la seguridad de la insulinoterapia en régimen bolo-basal-corrector o basal-corrector frente a la insulinoterapia en «pauta deslizante», en pacientes con diabetes o con hiperglucemia de reciente diagnóstico ingresados en una planta de hospitalización convencional, no críticos, tanto médica como quirúrgica. Método: Se realizó búsqueda en Medline. La odds ratio fue la medida resumen principal. Se empleó un modelo de efectos aleatorios con la técnica de Mante-Haenszel. Resultados: Novecientas cincuenta y siete citas de las cuales 9 fueron finalmente incluidas en la revisión sistemática. Los pacientes en el grupo BB tuvieron un mejor control glucémico que aquellos con PD. Globalmente, se objetiva una tendencia no significativa hacia un menor riesgo de eventos adversos en el grupo BB frente a PD (OR 0,67 —IC 95%: 0,22-2,04— [I2 = 71%]). Existe una tendencia no significativa hacia un mayor riesgo de hipoglucemia en el grupo BB (OR: 2,29; IC 95% 0,50-10,49 [I2 = 70%]). Conclusión: A pesar de su beneficio para el control glucémico durante la hospitalización, esta revisión no ha objetivado que el uso de la pauta BB disminuya eventos clínicos en pacientes hospitalizados en planta convencional. Debido a la heterogeneidad en los resultados, consideramos que se requieren ensayos clínicos que contemplen su efecto en subgrupos de pacientes en los que la pauta BB se pueda usar de forma segura y con períodos de seguimiento más prolongados (AU)

Introduction: The aim of this review was to assess the effectiveness to reduce clinical adverse events and safety of insulin administered in basal-bolus-corrector or basal-corrector regimens (BB) versus a sliding scale scheme (SS) in patients with diabetes or newly diagnosed hyperglycemia admitted to a conventional (not critical) medical or surgical hospital ward. Method: A Medline search was conducted. The Odds ratio was the main summary measure. A random effects model with the Mantel-Haenszel procedure was used. Results: A total of 957 citations were collected, of which nine were finally included in the systematic review. Patients in the BB group had better blood glucose control than those with SS. Overall, there was a nonsignificant trend to a lower risk of adverse events in the BB as compared to the SS group (OR 0.67 [95% CI 0.22 to 2.04], [I2 = 71%]). There was a nonsignificant trend to an increased risk of hypoglycemia in the BB group (OR 2.29 [95% CI 0.50 to 10.49] [I2 = 70%]). Conclusion: Despite its benefit for glycemic control during hospitalization, this review did not show that use of the BB scheme decreases clinical events in patients hospitalized in a conventional ward. Because of heterogeneity of the results, we think that clinical trials are needed addressing its effect in patient subgroups in which the BB scheme may be used safely and with longer follow-up periods (AU)

Effective adverse event reduction with bolus-basal versus sliding scale insulin therapy in patients with diabetes during conventional hospitalization: Systematic review and meta-analysis.

INTRODUCTION: The aim of this review was to assess the effectiveness to reduce clinical adverse events and safety of insulin administered in basal-bolus-corrector or basal-corrector regimens (BB) versus a sliding scale scheme (SS) in patients with diabetes or newly diagnosed hyperglycemia admitted to a conventional (not critical) medical or surgical hospital ward. METHOD: A Medline search was conducted. The Odds ratio was the main summary measure. A random effects model with the Mantel-Haenszel procedure was used. RESULTS: A total of 957 citations were collected, of which nine were finally included in the systematic review. Patients in the BB group had better blood glucose control than those with SS. Overall, there was a nonsignificant trend to a lower risk of adverse events in the BB as compared to the SS group (OR 0.67 [95% CI 0.22 to 2.04], [I(2)=71%]). There was a nonsignificant trend to an increased risk of hypoglycemia in the BB group (OR 2.29 [95% CI 0.50 to 10.49] [I(2)=70%]). CONCLUSION: Despite its benefit for glycemic control during hospitalization, this review did not show that use of the BB scheme decreases clinical events in patients hospitalized in a conventional ward. Because of heterogeneity of the results, we think that clinical trials are needed addressing its effect in patient subgroups in which the BB scheme may be used safely and with longer follow-up periods.

Streptococcus bovis bacteraemia revisited: clinical and microbiological correlates in a contemporary series of 59 patients.

OBJECTIVE: To characterise the clinical features, associations and outcome in a contemporary series of patients with Streptococcus bovis bacteraemia (SBB). METHODS: Retrospective analysis of all episodes of SBB at the University Hospital 12 de Octubre (Madrid, Spain) between January 1997 and November 2008 was performed. Patient data were reviewed, focusing on clinical and microbiological associations with the different biotypes of S. bovis. RESULTS: Fifty-nine episodes of SBB were documented in 59 adult patients (30 males; mean age: 70.9 ± 15.0 years). Chronic liver disease was identified in 20 patients (33.9%). Sixteen patients (27.1%) presented infective endocarditis (IE) and 14 (23.7%) had a biliary source of bacteraemia. Thirty-three patients (55.9%) underwent colonic evaluation, adenomatous polyps being the most common finding (21 patients). Malignancy was diagnosed following SBB in 9 cases, including 6 patients with colorectal carcinoma (18.2% of those who underwent colonic evaluation). Of 22 isolates biotyped, 12 were S. bovis biotype I and 10 were S. bovis biotype II. IE was more frequent among patients with S. bovis biotype I (P =0.010), whereas bacteraemia due to biotype II species was more likely to be of biliary origin (P=0.078). CONCLUSIONS: S. bovis biotyping identifies some clinically relevant associations.

Predicción pronóstica en pacientes con carcinoma hepatocelular no subsidiario de tratamiento locorregional / Prognostic prediction in patients with hepatocellular carcinoma not amenable to locoregional treatment

Fundamento y objetivo: Los pacientes con carcinoma hepatocelular (CHC) no subsidiarios de tratamiento locorregional presentan una serie de características (cirrosis descompensada o extensión extrahepática) que obligan a evaluar de forma específica la utilidad de los distintos sistemas de estadificación propuestos para esta entidad. Pacientes y método: Analizamos 100 pacientes (69 varones) con una edad media (DE) de 70,2 años (10,7), y establecimos su estadificación al diagnóstico del CHC según los modelos de Okuda, Cancer of the Liver Italian Program, Barcelona Clinic Liver Cancer (BCLC) y Japan Integrated Staging score. Empleando la mortalidad a los 6 y a los 12 meses como objetivo, calculamos el área bajo la curva (ABC) de características operativas del receptor. Resultados: El modelo BCLC mostró la mejor capacidad de predicción, tanto a los 6 (ABC: 0,871) como a los 12 meses (ABC: 0,924), y mantuvo la significación estadística en el análisis multivariante de Cox (hazard ratio: 9,14 para el estadio BCLC C frente a A [p<0,001] y 9,53 para el estadio BCLC D frente a A [p=0,004]) (AU)

Background and objective: Patients with hepatocellular carcinoma (HCC) not amenable to locoregional therapy have some specific clinical characteristics (advanced cirrhosis or extrahepatic spread) that lead us to ascertain the prognostic efficacy of the different staging systems proposed for this entity. Patients and method: We analyze 100 patients (69 males) with a mean age of 70.2 (10.7) years. Tumor staging was performed at baseline according to the following systems: Okuda, Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), and Japan Integrated Staging (JIS) score. We determine the area under the receiver operating characteristic curve (AUC) using the 6 and 12-month mortality as endpoint. Results: The BCLC system had the best predictive power for mortality both at 6 (AUC, 0.871) and 12 months (AUC, 0.924) from diagnosis. In the Cox multivariate analysis, this model showed an independent prognostic effect [hazard ratio: 9.14 for BCLC stage C versus A (p<0.001), and 9.53 for stage D versus A (p=0.004)]. Conclusions: The BCLC system provided the best prognostic stratification for patients with HCC not amenable to locoregional therapy (AU)

[Prognostic prediction in patients with hepatocellular carcinoma not amenable to locoregional treatment]. / Predicción pronóstica en pacientes con carcinoma hepatocelular no subsidiario de tratamiento locorregional.

BACKGROUND AND OBJECTIVE: Patients with hepatocellular carcinoma (HCC) not amenable to locoregional therapy have some specific clinical characteristics (advanced cirrhosis or extrahepatic spread) that lead us to ascertain the prognostic efficacy of the different staging systems proposed for this entity. PATIENTS AND METHOD: We analyze 100 patients (69 males) with a mean age of 70.2 (10.7) years. Tumor staging was performed at baseline according to the following systems: Okuda, Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), and Japan Integrated Staging (JIS) score. We determine the area under the receiver operating characteristic curve (AUC) using the 6 and 12-month mortality as endpoint. RESULTS: The BCLC system had the best predictive power for mortality both at 6 (AUC, 0.871) and 12 months (AUC, 0.924) from diagnosis. In the Cox multivariate analysis, this model showed an independent prognostic effect [hazard ratio: 9.14 for BCLC stage C versus A (p<0.001), and 9.53 for stage D versus A (p=0.004)]. CONCLUSIONS: The BCLC system provided the best prognostic stratification for patients with HCC not amenable to locoregional therapy.

Splenic abscess: a review of 22 cases in a single institution.

PURPOSE: To describe the demographics, clinical features, etiology, imaging findings, bacteriologic profile, treatment and outcome in patients presenting splenic abscess in a European tertiary hospital. METHODS: Review of the medical charts of patients in whom splenic abscess was diagnosed at a tertiary hospital in Madrid (Spain) within a nine-year period. RESULTS: Twenty-two cases (13 males, 9 females) were found. Mycobacterium tuberculosis was the most frequent causative microorganism, accounting for 8 cases, and immunosuppression the main predisposing factor (in 63.6% of the patients). Symptoms were quite unspecific, leading to a long, median time until diagnosis (17 days). The overall mortality rate was 18.2% and it was 25% in patients with tuberculosis and 14.28% in patients with other causes of splenic abscesses (p=0.6). CONCLUSIONS: Immunosuppressed states are the predisposing condition for splenic abscess in almost two thirds of the patients. We found a higher percentage of M. tuberculosis than that previously reported in the English literature.