Estudio de validación de cuatro diferentes criterios para el diagnóstico de síndrome metabólico en población infantil

  Introducción: El síndrome metabólico (SM) es un problema de salud pública, el cual no cuenta con estrategias adecuadas de prevención, diagnóstico y tratamiento para población infantil. Los criterios existentes son controversiales y no son aplicables en los niños. Asimismo, varían según autores y comités de expertos; lo que podría tener importantes consecuencias en el diagnóstico de SM, impactando el tratamiento oportuno y el pronóstico del individuo. Objetivo: Validar criterios (NCEP-ATPIII; Cook, Ford y Duncan, et al; Ferranti, et al; Cruz, et al; e IDF1) para el diagnóstico de SM en niños mexicanos. Metodología: Estudio transversal de 2599 niños entre 6 y 16 años, residentes de la Ciudad de México. Se consideró SM con tres o más de los cinco componentes en los distintos criterios; y dos o más componentes con la presencia de obesidad central para IDF. Se consideró como Gold Standard la combinación de los cinco criterios diagnósticos. Para identificar el mejor valor predictivo se calculó sensibilidad, especificidad, valor predictivo positivo (VPP), valor predictivo negativo (VPN) y razón de verosimilitud. Resultados: Se observó una mayor proporción de individuos diagnosticados con SM con el criterio de Ferranti, et al. en comparación con los demás criterios evaluados. Nuestra propuesta ad hoc presentó una alta sensibilidad (0,89) y especificidad (0,90) frente al Gold Standard aplicado. Conclusión: El criterio propuesto por nosotros contiene una elección de componentes sencillos y de bajo costo, que facilitará su aplicación, permitiendo la unificación en el diagnóstico, tratamiento y pronóstico poblacional, reduciendo los índices de morbimortalidad en mexicanos.Introduction Metabolic syndrome (MS) is a public health problem without appropriate strategies for prevention, diagnosis and treatment in children. Existing criteria are controversial and not applicable for pediatric population, with variations according to different authors and expert committees, which could have important consequences  in MS diagnosis, treatment and prognosis. Objective: To validate different definitions (NCEP-ATPIII; Cook, Ford and Duncan, et al; Ferranti, et al; Cruz, et al; and IDF1) for metabolic syndrome diagnosis in Mexican children. Methodology: Cross-sectional study of 2599 children aged between 6 and 16 years, residents of Mexico City. MS was defined as the presence of three or more of the five components in the different criteria; and two or more components with the presence of central obesity for IDF. The Gold Standard was considered as the combination of the five diagnostic criteria. To identify the best predictive value, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratio were calculated. Results: A greater proportion of individuals diagnosed with the Ferranti, et al criterion was observed in comparison with the other criteria evaluated. We proposed an ad hoc criteria which showed a high sensitivity (0,89) and specificity (0,90) compared to the Gold Standard applied. Conclusion: Our diagnostic criteria contains a choice of simple and low-cost components that will facilitate its application in health institutions and will unify- diagnostic criteria, treatment, and prognosis, reducing morbidity and mortality rates in Mexican population

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Evaluacion de la mucosa gástrica en caballos pura sangre de carrera medicadoscon antiinflamatorios no esteroideos

Se plantea como objetivo evaluar la mucosa gástrica de caballos Pura Sangre de Carrera medicados con los antinflamatorios no esteroideos. Se estudiaron un total de 30 equinos Pura Sangre de Carreras 15 de sexo macho y 15 hembras. El peso promedio fue de 450 kg, con una edad comprendida entre 2-4 años. Bajo similares condiciones de manejo, alimentación y en actividad atlética. Se les practico un examen clínico-gastroendoscopico previo al tratamiento, durante y después de la terapéutica. Los equinos fueron  agrupados en cuatro grupos: Grupo 1.- Diclofenac sódico, Grupo 2.- Fenilbutazona y Grupo 3.- Flunixin meglumine.Los resultados obtenidos sugieren que la medicación con AINES, por 48 horas a dosis terapéutica es capaz de inducir irritación de la mucosa gástrica. En relación a los fármacos  la medicación con diclofenac sódico induce un severo daño de la mucosa gástrica, específicamente inflamación aguda y erosión focal, en comparación con la terapia de fenilbutazona y flunixin meglumine respectivamente. En conclusión el uso prolongado de AINES a dosis terapéutica puede inducir cambios inflamatorios y degenerativos de la mucosa gástrica en caballos.The aim of this study was to evaluate the gastric mucosa of Thoroughbred Race medicated with nonsteroidal antiinflammatory drugs. We studied a total of 30 Thoroughbred horses’ sex 15 male and 15 females. The average weight was  450 kg, aged between 2-4 years. Under similar conditions of handling, feeding and athletic activity. Underwent clinical  examination gastroendoscopico before treatment, during and after therapy. The horses were divided into four groups: Group 1. - Diclofenac sodium, Group 2. - Phenylbutazone and Group 3. - Flunixin meglumine. The results suggest that NSAID medication for 48 hours at therapeutic doses can induce irritation of the gastric mucosa. In relation to drugs medication with diclofenac sodium induces a severe gastric mucosal damage, acute inflammation and specifically focal erosion, compared with phenylbutazone therapy and flunixin meglumine respectively. In conclusion, the prolonged use of NSAIDs at therapeutic doses can induce inflammatory and  degenerative changes of the gastric mucosa in horses

Effect of SGLT2 Inhibitors on Stroke and Atrial Fibrillation in Diabetic Kidney Disease: Results From the CREDENCE Trial and Meta-Analysis

BACKGROUND AND PURPOSE: Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus.METHODS: CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-analysis.RESULTS: In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55-1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61-1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19-1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20-1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53-1.10]; n=115). The overall effects in the 4 CVOTs combined were: total stroke (HRpooled, 0.96 [95% CI, 0.82-1.12]), ischemic stroke (HRpooled, 1.01 [95% CI, 0.89-1.14]), hemorrhagic stroke (HRpooled, 0.50 [95% CI, 0.30-0.83]), undetermined stroke (HRpooled, 0.86 [95% CI, 0.49-1.51]), and AF/AFL (HRpooled, 0.81 [95% CI, 0.71-0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (<45 mL/min/1.73 m2]) subgroup (HRpooled, 0.50 [95% CI, 0.31-0.79]).CONCLUSIONS: Although we found no clear effect of SGLT2i on total stroke in CREDENCE or across trials combined, there was some evidence of benefit in preventing hemorrhagic stroke and AF/AFL, as well as total stroke for those with lowest estimated glomerular filtration rate. Future research should focus on confirming these data and exploring potential mechanisms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02065791

Kidney and Cardiovascular Effects of Canagliflozin According to Age and Sex: A Post Hoc Analysis of the CREDENCE Randomized Clinical Trial

Rationale & Objective: It is unclear whether the effect of canagliflozin on adverse kidney and cardiovascular events in those with diabetic kid-ney disease varies by age and sex. We assessed the effects of canagliflozin among age group categories and between sexes in the Canagli-flozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) study.Study Design: Secondary analysis of a random-ized controlled trial. Setting & Participants: Participants in the CREDENCE trial. Intervention: Participants were randomly assigned to receive canagliflozin 100 mg/d or placebo.Outcomes: Primary composite outcome of kid-ney failure, doubling of serum creatinine con-centration, or death due to kidney or cardiovascular disease. Prespecified secondary and safety outcomes were also analyzed. Out-comes were evaluated by age at baseline (<60, 60-69, and >_70 years) and sex in the intention-to-treat population using Cox regression models.Results: The mean age of the cohort was 63.0 & PLUSMN; 9.2 years, and 34% were female. Older age and female sex were independently associ-ated with a lower risk of the composite of adverse kidney outcomes. There was no evidence that the effect of canagliflozin on the primary outcome (acomposite of kidney failure, a doubling of serum creatinine concentration, or death from kidney or cardiovascular causes) differed between age groups (HRs, 0.67 [95% CI, 0.52-0.87], 0.63 [0.4 8-0.82], and 0.89 [0.61-1.29] for ages <60, 60-69, and >_70 years, respectively; P = 0.3 for interaction) or sexes (HRs, 0.71 [95% CI, 0.5 4-0.95] and 0.69 [0.56-0.8 4] in women and men, respectively; P = 0.8 for interaction). No differences in safety outcomes by age group or sex were observed.Limitations: This was a post hoc analysis with multiple comparisons.Conclusions: Canagliflozin consistently reduced the relative risk of kidney events in people with diabetic kidney disease in both sexes and across age subgroups. As a result of greater background risk, the absolute reduction in adverse kidney outcomes was greater in younger participants.Funding: This post hoc analysis of the CREDENCE trial was not funded. The CREDENCE study was sponsored by Janssen Research and Development and was conducted collaboratively by the sponsor, an academic-led steering committee, and an academic research organization, George Clinical.Trial Registration: The original CREDENCE trial was registered at ClinicalTrials.gov with study number NCT02065791

International Nosocomial Infection Control Consortiu (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care–associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line–associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline