Registro prospectivo de pacientes que presentan paro cardiorrespiratorio extrahospitalario en Santiago, Chile / A registry of out-of-hospital cardiac arrest in Chile

BACKGROUND: The rate of survival to hospital discharge is less than 10% for out-of-hospital cardiac arrest (OHCA). AIM: To develop and implement a Chilean prospective, standardized cardiac arrest registry following the Utstein criteria. MATERIAL AND METHODS: We conducted a prospective registry for patients presenting at an urban, academic, high complexity emergency department (ED) after having an OHCA. The facility serves approximately 10% of the national population. Data were registered and analyzed following the Utstein criteria for reporting OHCA. RESULTS: For three years, 289 patients aged 59 ± 19 years (63% men) were included. Fifty seven percent of patients were taken to a health care facility for the first medical assessment by relatives or witnesses and 34% was assisted and transferred by prehospital personnel. In the subgroup of non-traumatic OHCA, 28% (n = 54) received bystander cardiopulmonary resuscitation (CPR). The registered cardiac rhythms were asystole (61%), pulseless electrical activity (PEA) (25%) and ventricular tachycardia (VT) or ventricular fibrillation (VF) (11%). The overall survival rate to discharge from the hospital was 10%, while survival with mRankin score 0-1 was 5%. The median hospitalization length of stay was 18 days among those who survived, compared with five days for the group of patients that died during the hospital stay. CONCLUSIONS: OHCA is an important cause of death in Chile. The development of a national registry that follows the International Liaison Committee on Resuscitation guidelines is the first step to assess the profile of OHCA in the region. It will provide crucial information to identify prognostic factors and variables that can help develop standards of care and set up the basis to optimize cardiac arrest management within our country and region.

Detección del SARS-CoV-2 mediante RT-qPCR utilizando saliva en pacientes ambulatorios con estudio de COVID-19

Resumen Introducción: La pandemia de COVID-19 ha afectado a millones de personas en todo el mundo. La identificación de sujetos infectados ha sido importante para el control. Objetivo: Evaluar el rendimiento de una reacción de polimerasa en cadena (RPC) cuantitativa en tiempo real (en inglés: RT-qPCR) para SARS-CoV-2, utilizando saliva como matriz en comparación con un hisopado nasofaríngeo (HNF). Metodología: Se reclutaron adultos en atención ambulatoria, la mayoría sintomáticos. Fueron estudiadas 530 muestras pareadas de saliva e HNF con RT-qPCR. Resultados: Fueron positivas 59 muestras de HNF y 54 de saliva. La sensibilidad con saliva fue 91%, especificidad 100%, el valor predictor positivo (VPP) 100%, valor predictor negativo (VPN) 98%. El índice Kappa fue de 0,95 y LR-0,08. En promedio, el umbral de ciclo (en inglés cycle threshold-CT) de la saliva fue 3,99 puntos más alto que los de HNF (p < 0,0001) mostrando que la carga viral (CV) es menor en saliva. La carga viral en ambas disminuyó con el tiempo después del inicio de los síntomas. El muestreo de saliva fue preferido por los sujetos en lugar de HNF. Conclusión: Este estudio demuestra que la RPC para SARS-CoV-2 utilizando saliva, es adecuada para el diagnóstico de COVID-19 en adultos ambulatorios, especialmente en la etapa temprana de los síntomas.

Abstract Background: The COVID-19 pandemic has affected millions of people around the world. Part of control strategies is testing a large proportion of the population to identify and isolate the infected subjects. Aim: To evaluate the SARS-CoV-2 detection by the performance of a reverse transcription and quantitative polymerase chain reaction (RT-qPCR) against SARS-CoV-2, using saliva as a matrix compared to a nasopharyngeal swab (NPS) to simplify obtaining a diagnostic sample. Methods: Adults in outpatient care were recruited, 95% of them symptomatic. We studied 530 paired saliva and NPS samples by SARS-CoV-2 RT-qPCR. Results: Fifty-nine individuals tested positive in NPS and 54 in saliva samples. Sensitivity for saliva sample was 91%, specificity 100%, positive predictive value (PPV) 100%, negative predictive value (NPV) 98%. The Kappa index was 0.95 and LR-0.08. On average, the cycle threshold (CT) of saliva was 3.99 points higher than those of NPS (p < 0.0001) showing that viral load (VL) is lower in saliva than in NPS. Viral load in both decreased over the time after onset of symptoms. Saliva sampling was preferred by subjects instead of NPS. Conclusion: This study demonstrates that SARS-CoV-2 RT-qPCR using saliva, even with lower VL, is suitable for the diagnosis of COVID-19 in outpatient adults, especially at early stage of symptoms.

The sum of kidney donor profile index and estimated post-transplant survival scale and their correlation with egfr decline in deceased donor kidney recipients

Background: The impact of donor quality on post-kidney transplant survival may vary by candidate condition. Objective: Analyzing the combined use of the Kidney Donor Profile Index (KDPI) and the estimated post-transplant survival (EPTS) scale and their correlation with the estimated glomerular filtration rate (eGFR) decline in deceased-donor kidney recipients (DDKR). Methods: This was a retrospective, observational cohort study. We included DDKRs between 2015 and 2017 at a national third-level hospital. Results: We analyzed 68 DDKR. The mean age at transplant was 41 ± 14 years, 47 (69%) had sensitization events, 18 (26%) had delayed graft function, and 16 (23%) acute rejection. The graft survival at 12 and 36 months was 98.1% (95% CI 94-100) and 83.7% (95% CI 65-100), respectively. The Pearson correlation coefficient between the percentage reduction in the annual eGFR and the sum of EPTS and KDPI scales was r = 0.61, p < 0.001. The correlation coefficient between the percentage reduction in the annual eGFR and the EPTS and KDPI scales separately was r = 0.55, p < 0.001, and r = 0.53, p < 0.001, respectively. Conclusions: The sum of EPTS and KDPI scales can provide a better donor-recipient relationship and has a moderately positive correlation with the decrease in eGFR in DDKR.

Paro cardiorrespiratorio extrahospitalario. Realidad de un hospital terciario chileno / Out of hospital cardiac arrest events at an urban Hospital in Chile

Background: The incidence of out of hospital cardiac arrest (OHCA) is approximately 20 to 140 per 100.000 inhabitants. International registries, based on Utstein criteria have allowed standardized reporting of OHCA profiles and outcomes in different countries. We proposed to create a local OHCA registry. Aim: To assess the quality of the information about OHCA currently recorded in medical records according to Utstein guidelines. Material and Methods: A retrospective analysis of medical records of patients arriving in the emergency room of a public hospital with OHCA during a 3-year period. Data regarding the patient characteristics, event and outcomes were analyzed. Results: During the revision period, 317 patients arrived with an OHCA. None of the medical records had complete data on items that are considered a minimum requirement by Utstein guidelines. Mean age of patients was 63 years old, 60% were men, the most common arrest rhythm was asystole (43%) and 8% of patients were discharged alive. Conclusions: Data recorded in medical records is insufficient to inform the profile of OHCA. A prospective registry is currently being implemented based on the information provided by this study. This registry should optimize reporting and data analysis.

Entrenamiento aeróbico de alta intensidad: Historia y fisiología clínica del ejercicio / High intensity aerobic interval training: history and clinical exercise physiology

La transición epidemiológica observada en las últimas décadas ha implicado un aumento creciente de enfermedades crónicas, fenómeno asociados con el estilo de vida de la población, al modelo alimentario y al sedentarismo, lo que predispone a la obesidad y a la resistencia a la insulina, condicionando patologías cardio metabólicas como la hipertensión arterial y la dislipidemia, favoreciendo el desarrollo del síndrome metabólico. El tratamiento consiste en el manejo farmacológico, mejoras en los hábitos alimentarios y la incorporación de la actividad física a la rutina diaria. Tradicionalmente los programas de ejercicio están orientados a un método aeróbico para mejorar los parámetros alterados. Sin embargo, actualmente han surgido nuevas estrategias de intervención como el entrenamiento interválico de alta intensidad, que ha evolucionado como un modelo de intervención eficaz, con real impacto en el estado de salud de la población. El objetivo de esta revisión es entregar una mirada histórica y actualizada del ejercicio interválico de alta intensidad, de su impacto en la población y de las adaptaciones fisiológicas que respaldan su uso como herramienta terapéutica.

The epidemiological transition observed in recent decades has led to a continuous increase in chronic non communicable diseases, phenomenon associated with the lifestyle of the population, the dietary pattern and physical inactivity, which predisposes to obesity and insulin resistance, conditioning cardiometabolic disease such as hypertension and dyslipidemia, allowing the development of metabolic syndrome. The treatment consists of pharmacological management, improving dietary habits and the incorporation of physical activity into the daily routine. Traditionally exercise programs are oriented to aerobic methods for improving altered parameters. New intervention strategies such as high-intensity interval training have been developed, which has evolved as a model of effective action, with a real positive impact on the health status of the population. The objective of this review is to provide a historical and updated look of high-intensity interval exercise, its impact on the population and physiological adaptations that support its use as a therapeutic tool.

Attention deficit hyperactivity disorder is an independent risk factor for lower resilience in adolescents: a pilot study / Transtorno de déficit de atenção com hiperatividade é fator de risco independente para menor resiliência em adolescentes: estudo piloto

Objective: Attention deficit hyperactivity disorder (ADHD) is associated with impaired daily functioning in a wide range of domains. Resilience, the ability to overcome and recover from challenges, has been scarcely investigated in ADHD and could potentially provide novel strategies for treatment. However, since ADHD is often comorbid with other clinical conditions, it is necessary to better understand if it impairs resilience levels when controlled for other variables. This pilot study is the first to investigate the correlation between quantitative measures of resilience and ADHD using strict diagnostic criteria by controlling this correlation for comorbid conditions.Methods:Twelve adolescents diagnosed with ADHD via semi-structured interview using Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) were compared to 12 adolescents exhibiting typical development, regarding resilience, in an analysis controlled for anxiety and depression levels, socioeconomic status, and intelligence quotient (IQ).Results: The ADHD group was less resilient than the control group (p < 0.01). Importantly, resilience in the ADHD group was not correlated with depression or anxiety, age, intelligence level, and socioeconomic status.Conclusions:ADHD seems to be associated with lower resilience, which cannot be explained by depression, anxiety, intelligence level, age, or socioeconomic status.

Objetivo: O transtorno de déficit de atenção com hiperatividade (TDAH) se associa a comprometimento funcional em diferentes domínios. Resiliência, o modo como indivíduos enfrentam e superam dificuldades, não foi investigada de modo suficiente no TDAH e poderia sugerir potenciais novas estratégias terapêuticas. Entretanto, sendo o TDAH frequentemente comórbido com outras condições clinicas, é necessário entender se ele compromete a resiliência de modo independente de outras variáveis. Este estudo piloto é o primeiro a investigar a correlação entre medidas quantitativas de resiliência e TDAH diagnosticado de modo estrito controlando-a por variáveis clínicas.Método: Os níveis de resiliência de 12 adolescentes diagnosticados com TDAH de acordo com os critérios do sistema Manual Diagnóstico e Estatístico de Transtornos Mentais, 4ª edição (DSM-IV) através de entrevista semiestruturada foram comparados aos de 12 adolescentes com desenvolvimento típico, em uma análise controlada por níveis de ansiedade e depressão, status socioeconômico e inteligência.Resultados: O grupo TDAH apresentou menor resiliência do que o grupo controle (p < 0,01). Não houve correlação entre resiliência e depressão ou ansiedade, idade, inteligência ou nível socioeconômico.Conclusões: TDAH parece estar associado a baixos níveis de resiliência que não podem ser justificados por depressão, ansiedade, inteligência, idade ou condição socioeconômica.

Análisis de variabilidad del ritmo cardiaco y su relación con la sensibilidad insulínica en pacientes obesos y con sobrepeso / Heart rate variability and insulin resistance among obese males

Background: Heart rate variability analysis provides quantitative information about vagal and sympathetic modulation of cardiac function. Aim: To analyze the relationship between heart rate variability and insulin resistance in obese patients. Material and Methods: Male participants were studied, divided in 10 obese subjects aged 27 ± 2 years with a body mass index (BMI) of 31.2 ± 1.3 kg/m², 15 overweight subjects aged 24 ± 3 years with a BMI of 26.7 ± 1.5 kg/m² and 14 normal weight subjects aged 21 ± 2 years with a BMI of 22.5 ± 1.3 kg/m². Resting heart rate variability was measured in a period of 5 minutes. A spectral analysis was done measuring the low frequency/high frequency ratio (LF/HF). A non- linear analysis was carried out measuring the standard deviation of the instantaneous variation of RR intervals (SD1) and α-1 or a fractal analysis of RR interval complexity. A fasting blood sample was obtained to measure blood glucose and insulin and calculate the homeostasis model assessment for insulin resistance (HOMA-IR). Results: Among obese subjects HOMA-IR, LF/HF, α-1 and SD1 values were 2.6 ± 2.1, 2.4 ± 1.8, 1.2 ± 0.06 and 22.5 ± 10 respectively. The figures for normal weight subjects were 0.5 ± 0.1, 1.3 ± 0.2, 0.9 ± 0.3 and 26 ± 7.8 respectively. Conclusions: There is an association between spectral and fractal values of heart rate variability and HOMA-IR. These results may indicate a predominance of sympathetic control of heart rate among obese subjects.

Seguimiento alejado de pacientes evaluados en una Unidad de Dolor Torácico / Long term follow up of patients consulting in a Chest Pain Unit

Background: Chest pain (CT) constitutes an important cause of consultation and diagnostic dilemma in the emergency room, especially due to the possible presence of coronary disease. Its presentation, diagnosis and prognosis are different between men and women. Aim: To report a follow-up of patients attended at a Chest Pain Unit (CPU), evaluating gender differences. Material and Methods: Prospective evaluation of patients that consulted for chest pain in a period of 4 years. Baseline characteristics and the final diagnosis from CPU or hospitalization were registered. Telephonic follow-up was performed for at least one year. Mortality was determined using the national mortality registry. Results: A total of 1,168 patients aged 62 ± 23 years, 69 percent men, were followed for a mean of 28 ± 20 months. A definitive diagnosis of coronary disease (CD) was done in 32 percent. Mortality among women and men with CD was 28 and 14 percent respectively (p = 0,02). Predictor variables for mortality were the presence of a complete left branch block in the initial electrocardiogram, with an odds ratio (OR) of 12,5 (95 percent confi dence intervals (CI): 1,98-25,8), the presence of coronary disease with an OR of 3,98 (95 percent CI: 1,45-13,8) and elevated troponin I with an OR 2,12 (95 percent CI: 1,05-7,89). Female gender lost significance in the adjusted model. Conclusions: Complete left branch block, elevated troponin I and coronary etiology of CP are indicators of bad prognosis among patients that consult for CP. Women have twice the mortality of men after 28 months of follow-up.

Estudio descriptivo en relación a los tiempos de demora en pacientes que consultan por dolor torácico en servicio de urgencia de un hospital universitario / Descriptive study related to the waiting time of the patients consulting for thoracic pain in the urgency service of a university hospital

Introducción: En nuestro país las enfermedades cardiovasculares son la primera causa de muerte, en particular el infarto agudo al miocardio. Recomendaciones nacionales basadas en las normativas de garantías explícitas en salud (GES) vigentes, establecen que el tiempo para el electrocardiograma (ECG) y la primera evaluación de un paciente con sintomatología sugerente de síndrome coronario agudo (SCA) sea menor a 30 minutos desde el ingreso al servicio de urgencia. Objetivos: Estudiar los tiempos desde el ingreso al servicio de urgencia hasta el registro del ECG en pacientes que consultan por dolor torácico (DT). Métodos: Se revisó una cohorte consecutiva de pacientes que consultaron por DT no traumático en el servicio de urgencia durante 30 días. Se incluyeron todos los pacientes a quienes se les solicitó ECG dentro de su evaluación. Se obtuvieron los tiempos en relación a la hora de consulta y hora de registro del ECG, características demográficas, diagnósticos de egreso del servicio de urgencia y diferencias en los tiempos según la hora del día de consulta. Los resultados fueron analizados con ANOVA, t de student, Chi cuadrado, y tests no paramétricos de acuerdo a las características y distribución de las variables. Los tiempos puerta-ECG se expresan en medianas y rangos interquantiles. Resultados: Se estudiaron 164 pacientes con DT, la edad promedio fue 50,7 +/- 17,6 años, 60% sexo masculino. En cuanto a los diagnósticos de egreso del servicio de urgencia, un 20% correspondió a DT coronario (síndrome coronario agudo) y un 80% a DT no coronario (cualquier otra etiología). Se analizaron ambos grupos por separado para todas las variables. La media de la edad fue de 63,7+/9,9 años y de 47,4+/17,6 años respectivamente (p< 0,01). Los tiempos puerta-ECG fueron de 15 min. (RIQ 9-39) y de 31 min. (RIQ 15-34) respectivamente (p< 0,01). En cuanto a los tiempos y a los segmentos horarios de turnos, hubo diferencia significativa siendo menor.

In Chile, cardiovascular diseases are the first cause of death, in particular acute myocardial infarction. National recommendations based on current policies established a maximum door to electrocardiogram (ECG) and first evaluation times in patients with chest pain (CP), to be less than 30 minutes. Objectives: Establish the time elapsed from the door of the emergency department (ED) to the recording of the ECG in patients with CP. Method: We reviewed a consecutive cohort of patients presenting with non-traumatic CP to an academic ED during a 30-day period. All patients with CP that had an ECG performed on the ED evaluation where included. We gathered the information on time from the ED admission to ECG, demographic characteristics, ED’s disposition diagnosis and differences in times according to hours of day. The results were analyzed with ANOVA, T test, Chi-square and non-parametric test according to the type and distribution of the data. Results: A total of 164 patients with CP were included. The mean age was 50,7 +/-17,6 years, 60% were men. The ED disposition diagnosis was: 20% coronary chest pain (ACS) and 80% non-coronary CP (other causes of chest pain). Comparing the patients with coronary CP with non coronary CP, the mean age was 63,7 +/-9,9 years and 47,4 +/-17,6 years respectively (p<0,01). When analyzed according to time of day, the frequency of coronary chest pain was higher during the morning period (7:00 to 15:00 hrs) than the evening (15:00 to 23:00 hrs) or night (23:00 to 7:00 hrs), with 27% of patients diagnosed with ACS in the morning versus 16% in the evening and 17% at night. The median door to ECG time was 15 minutes (IQR 9 to 39) for the ACS group and 31 minutes (IQR 18 to 63) for the non-coronary CP group (p<0,0001). There was a significant difference in door to ECG time during the morning versus evening and night, with a median time of 24 minutes (IQR 15 to 34) for morning, 37 minutes...