Los inhibidores SGLT2: una mirada al futuro del tratamiento de la insuficiencia cardiaca / Sodium-glucose cotransporter 2 inhibitors for the management of heart failure

Heart failure (HF) is a global health problem. There is a strong association h between HF and type 2 diabetes mellitus (DM2), with an increasing prevalence of patients having both conditions concomitantly. Sodium-glucose cotransporter 2 inhibitors (ISGLT2) significantly reduce cardiovascular events, including cardiovascular death. In this article we will focus on the current evidence about the effectiveness of these medications in adults with heart failure with reduced or preserved ejection fraction.

Efectos cardiovasculares de los inhibidores del cotransportador 2 de sodio-glucosa (ISGLT2): los mecanismos del beneficio en pacientes con insuficiencia cardíaca

La insuficiencia cardíaca (IC) es un problema de salud mundial. En la actualidad existe una clara asociación entre la IC y la diabetes mellitus tipo 2 (DM2), con una prevalencia cada vez mayor de pacientes que presentan concomitantemente ambas patologías. Los inhibidores del cotransportador 2 de sodio-glucosa (ISGLT2) han demostrado disminuir los eventos cardiovasculares, incluida la muerte de origen cardiovascular, por lo que se han instalado como uno de los pilares en su tratamiento. En el presente artículo se describen los principales mecanismos de acción de los ISGLT2 y sus efectos: mejora de condiciones de carga ventricular, metabolismo cardíaco, bioenergética, remodelado ventricular y sus efectos cardioprotectores directos y posiblemente antiarrítmicos.

Heart failure (HF) is a global health problem. Currently there is a clear association between HF and type 2 diabetes mellitus (DM2), with an increasing prevalence of patients presenting with both pathologies concomitantly. Sodium-glucose cotransporter 2 inhibitors (ISGLT2) have shown to significantly reduce cardiovascular events, including cardiovascular death. These results have placed ISGLT2 as one of the main pillars in the treatment of HF. This article will focus on the mechanisms of action, and their effects: improved ventricular loading conditions, cardiac metabolism, bioenergetics, ventricular remodeling, direct cardioprotective and possibly antiarrhythmic effects.

Determinación del nivel de dosis del ácido valproico e influencia de los fármacos inductores y no inductores enzimáticos en pacientes voluntarios de la ciudad de Mérida, Venezuela / Determination of valproic acid dose level and influence of enzyme-inducing and non-enzyme-inducing drugs in volunteer patients of the city of Mérida, Venezuela

Objetivo: Determinar los niveles/dosis (ND) del ácido valproico y la influencia de los fármacos inductores y no inductores enzimáticos en pacientes voluntarios de la ciudad de Mérida-Venezuela. Materiales y métodos: Se realizó un estudio experimental, observacional, prospectivo de corte transversal, en el Hospital de Mérida-Venezuela. Luego de pasar por los criterios de inclusión y exclusión, los pacientes firmaron el consentimiento informado en forma individual y voluntaria.El protocolo consistió en obtener la sangre de 88 pacientes (42 hombres y 46 mujeres) con edades entre 16 y 68 años, que sufrían de convulsiones parciales o generalizadas y que estaban recibiendo 3,97-38,04 mg/kg de ácido valproico (AVP) dos veces al día en monoterapia o en combinación con carbamacepina (CBZ), fenobarbital (PB), fenitoína (PHT), lamotrigina (LTG) y oxcarbacepina (OXC). Se tomó la muestra después de cuatro semanas de tratamiento, en condiciones de ayuno y antes de la administración del medicamento del presente día, para determinar posteriormente la concentración plasmática por medio del método de radioinmunoensayo. Con los datos de la concentración plasmática se determinó el ND. Resultados: En monoterapia con AVP se encontró que la concentración plasmática media era de 64,94 mg/l (DE 31,7) y el ND de 4,32 (DE 2,1). En combinación de AVP+CBZ+PB se obtuvo un ND de 2,31 (DE 0,06), con la combinación AVP+PB+PHT se obtuvo el ND de 2,46 (DE 0,43) y con la combinación AVP+PB+OXC se obtuvo un ND de 4,63 (DE 3,12). Conclusiones: Los fármacos administrados en forma concomitante influyen sobre la concentración plasmática y el ND del AVP en un grupo de pacientes de Mérida-Venezuela.

Objective: To determine valproic acid level/dose ratio (ND) and the influence of enzyme-inducing and non-enzymeinducing drugs in volunteer patients of the city of Mérida, Venezuela. Materials and methods: An experimental, observational, prospective, cross-sectional study was conducted at the Hospital de Mérida, Venezuela. After undergoing the inclusion and exclusion criteria process, patients signed an informed consent individually and voluntarily. The protocol consisted in collecting blood from 88 patients (42 males y 46 females) from 16 to 68 years old, who had partial or generalized seizures, and were receiving 3.97-38.04 mg/kg of valproic acid (AVP) twice a day as monotherapy or combination therapy with carbamazepine (CBZ), phenobarbital (PB), phenytoin (PHT), lamotrigine (LTG) and oxcarbazepine (OXC). A sample was taken after four weeks of treatment, in the fasting state and before the administration of the medication of the day. Afterwards, plasma concentration was determined through a radioimmunoassay method. The ND was established using the plasma concentration data. Results: AVP monotherapy showed a mean plasma concentration of 64.94 mg/l (SD 31.7) and ND of 4.32 (SD 2.1). Combination therapy with AVP+CBZ+PB showed an ND of 2.31 (SD 0.06), combination therapy with AVP+PB+PHT showed an ND of 2.46 (SD 0.43) and combination therapy with AVP+PB+OXC showed an ND of 4.63 (SD 3.12). Conclusions: The administration of concomitant drugs affected plasma concentration and AVP ND in a group of patients of the Hospital de Mérida, Venezuela.

Galectina-3: experiencia en pacientes chilenos con diagnóstico de insuficiencia cardíaca descompensada / Galectin-3 levels in patients hospitalized for decompensated heart failure

Background: Galectin-3 (Gal-3) is a mediator of myocardial fibrosis involved in cardiac remodeling and a potential new prognosis marker in heart failure (HF). Aim: To measure Gal-3 at the moment of discharge in patients hospitalized for HF and its association with different variables. Material and Methods: Patients hospitalized for decompensated HF from four hospitals between August 2014 and March 2015, were included. Demographic, clinical and laboratory variables were recorded at the time of admission. At discharge, a blood sample was withdrawn to measure Gal-3 and brain natriuretic propeptide (Pro-BNP). Patients were separated in two groups, according to the level of Gal-3 (using a cutoff value of 17.8 ng/mL), comparing clinical and laboratory values between groups. Results: We included 52 patients with HF aged 70 ± 17 years (42% females). Functional capacity was III-IV in 46% of patients and the ejection fraction was 34.9 ± 13.4%. Pro-BNP values at discharge were 5,323 ± 8,665 pg/mL. Gal-3 values were 23.8 ± 16.6 ng/mL. Sixty percent of patients had values over 17.8 ng/mL. Those with elevated Gal-3 levels were older (75 ±16 and 62 ± 15 years, respectively, p = 0.025) and were hypertensive in a higher proportion (90.5% and 57.1% respectively, p = 0.021). Conclusions: In patients hospitalized for HF, Gal-3 levels are higher in older and hypertensive subjects.

Factores asociados a fragilidad en pacientes hospitalizados con insuficiencia cardiaca descompensada / Frailty in patients admitted to hospital with acute decompensated heart failure

Background: Frailty is a geriatric syndrome characterized by a progressive impairment in the subjects’ ability to respond to environmental stress. Frailty is more commonly found in heart failure (HF) patients than in general population and it is an independent predictor of rehospitalization, emergency room visits and death. Aim: To estimate the prevalence of frailty in patients with decompensated HF admitted to four hospitals in Santiago, Chile. Material and Methods: Cross-sectional study. Subjects aged 60 or older consecutively admitted for decompensated HF to the study centers between August 2014 and March 2015 were included. Frailty was defined as the presence of three or more of the following criteria: unintended weight loss, muscular weakness, depression symptoms (exhaustion), reduced gait speed and low physical activity. Independent variables were tested for association using simple logistic regression. Variables associated with frailty (p < 0.05) were included in a multiple logistic regression model. Results: Seventy-nine subjects were included. The prevalence of frailty was 50.6%. Frail patients were mostly female (52.6%) and older than non-frail subjects (73.7± 7.9 vs 68.2 ± 7.1; p < 0.003). Independent predictors of frailty were age (Odds raio (OR) 1.10; 95% confidence intervals (CI): 1.03-1.17), quality of life measured with the Minnesota Living with Heart Failure Questionnaire (OR 1.07; IC95%: 1.03-1.11), previous hospitalizations (OR 2.56; 95%CI: 1.02-6.43) and number of medications (OR 4.46; 95%CI: 1.11-17.32). Conclusions: The prevalence of frailty in patients admitted to the hospital for decompensated heart failure is high. Age, quality of life, hospitalizations and polypharmacy were factors associated with frailty in this group of participants.

The role of transrectal ultrasound in the diagnosis of prostate cancer: new contributions / O papel da ecografia transretal no diagnóstico do câncer da próstata: novas contribuições

Objective: The present study was aimed at evaluating the contribution of transrectal prostate ultrasound in the screening for prostate neoplasias and in the guidance of prostate biopsies. Materials and Methods: Prospective study developed over a one-year period. All the patients with indication for prostate biopsy were evaluated. Regardless of PSA values, the patients underwent ultrasound in order to identify suspicious nodules (confirmed by two observers). Sextant biopsy was subsequently performed. In cases of finding suspicious nodules, an additional puncture directed to such nodules was done. Results: In a total of 155 cases the prevalence of malignancy was of 53%. Suspicious nodules were detected in 34 patients, and 25 where malignant (positive predictive value of 74%). The specificity and sensitivity for suspicious nodules were 88% and 31% respectively. Comparatively with the randomly obtained sextant specimens, the rate of findings of neoplasia was higher in the specimens obtained with puncture directed to the nodule (p = 0.032). No statistically significant difference was observed in the Gleason score for both types of specimens (p = 0.172). Conclusion: The high positive predictive value and the high rate of findings of neoplasia in specimens of suspicious nodules should be taken into consideration in the future. The authors suggest a biopsy technique similar to the one described in the present study (sextant biopsy plus puncture directed to the suspicious nodule). .

Objetivo: O objetivo deste estudo é avaliar o papel da ecografia prostática transretal no rastreamento da neoplasia prostática e na orientação da biópsia prostática. Materiais e Métodos: Estudo prospectivo com a duração de um ano. Foram avaliados todos os doentes com indicação para biópsia. Ignorando o valor de PSA, realizamos ecografia para identificar nódulos suspeitos (confirmados por dois observadores). Efetuamos, depois, biópsia dirigida a todos os sextantes. Nos casos com nódulo suspeito, efetuamos ainda punção adicional dirigida ao nódulo. Resultados: Num total de 155 casos, a prevalência de malignidade foi 53%. Detectamos nódulos suspeitos em 34 pacientes, 25 dos quais malignos (valor preditivo positivo de 74%). A especificidade e a sensibilidade dos nódulos suspeitos foram 88% e 31%, respectivamente. A porcentagem de tumor foi superior nas biópsias dirigidas ao nódulo, comparativamente à amostra com maior representação tumoral obtida aleatoriamente (p = 0,032). Não houve diferença estatisticamente significativa entre o escore de Gleason de ambas as amostras (p = 0,172). Conclusão: O elevado valor preditivo positivo e a elevada representação tumoral nos nódulos considerados suspeitos deverão ser levados em consideração no futuro. Sugerimos uma técnica de biópsia igual à utilizada neste estudo (biópsia sextante mais punção dirigida a nódulo suspeito). .

Estimación indirecta de la función renal y mortalidad por insuficiencia cardíaca: buscando el mejor predictor / Estimation of renal function and mortality in congestive heart failure: a search for the best indicator

Antecedentes: Uno de los principales predictores de eventos adversos en pacientes con insuficiencia cardíaca (IC) es el deterioro de función renal luego de una hospitalización. Estudios recientes han cuestionado la utilidad de la fórmula de Cockroft-Gault (CG) para estimar la función renal en estos pacientes. Objetivo: Evaluar la utilidad de distintos modelos para determinación indirecta de función renal como pre-dictores de mortalidad alejada en sujetos con IC. Método: Estudio descriptivo analítico. Se incorporaron en forma consecutiva pacientes admitidos de 14 hospitales chilenos con el diagnóstico de IC descompensada entre enero 2002 y julio 2012. Las características de los pacientes se compararon mediante t de Student o chi cuadrado según correspondía. En base a la creatininemia al alta se estimó la tasa de filtración glomerular mediante las formulas CG, MDRD-4 y CKD-Epi. El acuerdo entre los resultados de cada fórmula se analizó mediante kappa de acuerdo para clasificación en estadios de función renal y según el método de Bland-Alt-man. Los pacientes se clasificaron por cuartiles según la estimación de cada fórmula; la sobrevida se analizó con el método de Kaplan-Meier y la capacidad de cada fórmula para predecir eventos mediante un modelo de riesgo proporcional de Cox. La mortalidad al fin del seguimiento se determinó por la base de datos del Servicio Nacional de Registro Civil e Identificación. Resultados: Se incluyeron 1584 pacientes, 45,3 por ciento de sexo femenino. La edad promedio fue de 70,5+/-20 años. La creatinina al ingreso fue 1,63+/-1,48 mg/dL y al egreso de 1,59+/-1,41 mg/dL (p=NS). Todos los modelos estimaron un porcentaje similar de población con falla renal al momento del alta (Cl Crea < 60 ml/min/1.73m2): CG 57,3 por ciento, MDRD-4 54,9 por ciento y CKD-Epi 54,9 por ciento. El clearance de creatinina estimado por CG (59,4+/-30,4 mL/min/1,74) fue mayor al estimado por CKD-Epi o MDRD-4 (54,2+/-25,1 y 57,8+/-27 mL/min/1,73m2)...

Background. One of the best predictors of adverse events in patients with congestive heart failure (CHF) is the deterioration of renal function following hospitalization. Recent studies have questioned the usefulness of the Cockroft-Gault (CG) formula to estimate renal function in these patients. Aim: To evaluate the usefulness of different indirect methods for estimation of renal function in the prediction of late mortality in patients with CHF. Method: Consecutive patients admitted for CHF in 14 different hospitals from January 2002 and July 2012 were analyzed. Student’s t or Chi square were used as appropriate for statistical comparisons. The serum creatinine level at the time of discharge was used to estimate glomerular filtration rate (GFR) from 3 different formulae: CG, MDRD-4 and CKD-Epi. Agreement among methods for different assignment to different stages of renal failure was evaluated by the "kappa" statistics and the Bland- Altmann method. Survival according to the estimation from each formula was compared by the log-rank statistics on Kaplan-Meier’s survival curves. The ability of each formula to predict adverse events was evaluated by a Cox proportional hazards method. Mortality was obtained from de National Identification Registry. Results: 1548 patients were included, 45.3 percent of them females. Mean age was 70.5 years (SD 20). Creatinine level was 1,63+/-1,48 mg/dL at admission and 1,59+/-1,41 mg/dL at discharge (p=NS). The proportion of patients with renal failure ( creatinine clearance < 60ml/min/1.73 m2) was similar for all methods (CG: 57.3 percent, MDRD-4 54.9 percent and CKD-Epi 54.9 percent). Creatinine clearance by CG (59,4+/-30,4 mL/min/1,73m2) was higher than that estimated by CKD-EPI (54,2+/-25,1/1.73 m2) or MDRD-4 (57,8+/-27 mL/min/1,73m2). Both CKD-Epi and MDMD-4 correctly identified a subgroup of patients with lower late mortality (CKD-Epi quartiles 3 and 4, OR 0,5 IC95 percent 0,35-0,72; MDRD-4 quartiles 3 and 4...

Vigilancia de la equinococosis quística en perros y niños en la provincia de Río Negro, Argentina / Cystic echinococcosis in dogs and children in the province of Río Negro, Argentina

La equinococosis quística (EQ) es una enfermedad endémica en la provincia de Río Negro, Argentina. El programa de control de esta afección desarrolla sistemas de vigilancia epidemiológica basados en las técnicas de coproELISA/Western blot (WB) en muestras de heces de perros recolectadas del suelo, a fin de determinar establecimientos ganaderos (unidades epidemiológicas o UE) con transmisión presente. El objetivo de esta investigación fue evaluar la prevalencia de EQ en establecimientos ganaderos y su relación con la presencia de casos de EQ en niños de 0 a 14 años. Se seleccionaron aleatoriamente UE donde se obtuvieron muestras de materia fecal canina, las que fueron procesadas mediante coproELISA/WB. Asimismo, se identificaron casos nuevos ocurridos en niños del rango etario señalado. Se obtuvieron 571 muestras de 278 UE; 37 (6,5 %) fueron positivas a coproELISA/WB de 37 (13,3 %) UE con transmisión presente. Las diferencias con el relevamiento efectuado en el período 2003-2004 resultaron no significativas (p = 0,9), mientras que las diferencias con el relevamiento efectuado en UE de poblaciones originarias en 2009-2010 resultaron significativas (p = 0,02). Con relación a la densidad animal en el área de trabajo, las UE que dieron un resultado negativo tuvieron un promedio de 2 (DE: 2,1) perros por UE, en las UE con infección presente el promedio fue de 3 (DE 4,2), esta diferencia fue estadísticamente significativa (p = 0,02). Se diagnosticaron 12 casos en niños menores de 15 años. Se estableció que los casos de hidatidosis, en promedio, se situaron a menor distancia de los campos positivos a coproELISA/WB que de los campos negativos (p= 0,00307). La prueba de coproELISA/WB permitió identificar la dispersión de EQ en establecimientos ganaderos y analizar su relación con la ocurrencia de casos en niños.

Cystic echinococcosis (CE) is an endemic disease in the province of Río Negro, Argentina. The control program against CE has developed monitoring surveillance systems. Currently, the coproELISA/Western blot (WB) test is used to determine transmission in livestock farms (epidemiological units or EU) from collected dry field-dispersed dog feces. The objective was to evaluate the prevalence of CE on livestock farms and its relationship with CE cases in children aged 0-14 years. Canine fecal samples were obtained from randomly selected livestock farms and processed by the coproELISA/WB test. Furthermore, new cases in children in the same age group mentioned above were identified. In 278 EU, 571 samples of canine feces were obtained. There were 37 positive samples for coproELISA/WB (6.5%) and the presence of transmission was demonstrated in 37 EU (13.3%). There were no significant differences (p=0.9) with the survey conducted in the period 2003-2004 while there were significant differences (p=0.02) with the EU survey of native populations conducted in 2009-2010. With respect to animal density in the work area, the EU yielding negative results had an average of 2 dogs (SD 2.1) per EU while in the EU having positive results the average was 3 dogs (SD 4.2), showing statistically significant differences (p=0.02). In children under 15 years of age, 12 cases were diagnosed. This study has identified, on average, that the cases of hydatid disease are closer in the positive fields than in the negative fields (p=0.00307).The coproELISA/WB test allowed to identify the dispersion of CE on livestock farms and its relationship with the occurrence of cases in children in 2009-2010.

Incidencia e importancia pronóstica del deterioro de la función renal en pacientes hospitalizados con insuficiencia cardiaca / Deterioration of kidney function as a risk factor for mortality among patients hospitalized for heart failure

Background: Acute deterioration of kidney function among patients admitted to the hospital for cardiac failure is associated with an increased mortality. Aim: To investigate the association between deterioration of kidney function and mortality among patients hospitalized for cardiac failure. Material and Methods: Patients admitted for decompensated cardiac failure to 14 Chilean hospitals between 2002 and 2009 were incorporated to the study. Clinical and laboratory features were registered. Serum creatinine values on admission and discharge were determined. Hospital and long term mortality was determined requesting death certificates to the National Identification Service at the end of follow up, lasting 635 ± 581 days. Results: One thousand sixty four patients were incorporated and 1100, aged 68 ± 13 years (45% females) had information about renal function. Seventy seven percent were hypertensive and 36% were diabetic. Mean ejection fraction was 41 ± 18% and 34% had an ejection fraction over 50%. Mean admission creatinine was 1.7 ± 1.6 mg/dl and 19% had a creatinine over 2 mg/dl. Serum creatinine increased more than 0.5 mg/dl during hospitalization in 9% of general patients and in 11% of diabetics. The increase in creatinine was associated with a higher risk of hospital mortality (odds ratio (OR) 12.9, 95% confidence intervals (CI) 6.7-27.6) and long term mortality (OR 2.1, 95% CI 1.6-3). Conclusions: The deterioration of renal function during hospitalization of patients with heart failure is a risk factor for hospital and long term mortality.

Polimorfismos genéticos y su influencia en la efectividad del tratamiento quimioterapéutico de pacientes leucémicos / Genetic polymorphisms and its influence in chemotherapeutic treatment of leukemic patients

En Chile la incidencia de leucemia es de 4.2/100.000 adultos al año. Dentro de ellas, 2,8/100.000 son leucemias agudas y 1,4/100.000 son leucemias crónicas. La quimioterapia para el cáncer ha progresado desde su introducción a la práctica clínica y constituye una modalidad terapéutica muy útil en las leucemias. Sin embargo, su uso se ve limitado por la imposibilidad de predecir la respuesta individual, por lo que la elección de la terapia suele ser en base a criterios médicos y de las guías clínicas establecidas. Esta variación inter-individual en la respuesta a un fármaco antineoplásico puede deberse a factores farmacocinéticos y/o farmacodinámicos, relacionados con otros factores genético-metabólicos, que se traducen en variantes polimórficas de las enzimas encargadas de la biotransformación de estos fármacos o receptores. Al respecto, se estima que la genética da cuenta entre un 20 a un 95 por ciento de la variabilidad en la respuesta terapéutica y toxicológica. De todas las drogas conocidas involucradas en reacciones adversas un 80 por ciento son metabolizadas por estas enzimas. Este artículo pretende dar una visión general acerca de la respuesta potencial de los pacientes sometidos a los protocolos quimioterapéuticos establecidos en Chile para las leucemias de acuerdo a sus perfiles genéticos en las enzimas de biotransformación involucradas.

In Chile, the incidence of leukemia is 4.2/100.000 adults a year. Among them, 2.8/100.000 is acute leukemia and 1.4/100.000 chronic leukemia. The chemotherapy for cancer has been improved through the years in clinical practice and it constitutes a very useful therapeutic option in leukemia. However, its use is limited due to uncertain response; therefore, the pharmacotherapy choice is mainly empiric. In this sense the inter-individual differences in response to antineoplastic drugs could be due to pharmacokinetic factors (affecting absorption, distribution, metabolism and excretion) or pharmacodinamics (affecting receptors or another pharmacological target). It is estimated that genetics accounts for 20 to 95 percent of variability in therapeutics and toxicological response to drugs, which are mainly metabolized through polymorphic biotransformation enzymes (80 percent). Therefore, the present review gives a comprehensive study of the probable response of patients to established leukemia chemotherapy treatment in Chile according their genetic profiles on involved metabolizing enzymes.

Metabolismo energético del corazón y sus proyecciones en el tratamiento de la insuficiencia cardíaca / Heart energy metabolism and its role in the treatment of heart failure

It is unknown why heart failure progresses even when patients are treated with the best therapy available. Evidences suggest that heart failure progression is due to loss of neurohumoral blockade in advanced stages of the disease and to alterations in myocardial metabolism induced, in part, by this neurohumoral activation. Alterations in cardiac energy metabolism, especially those related to substrate utilization and insulin resistance, reduce the efficiency of energy production, causing a heart energy reserve deficit. These events play a basic role in heart failure progression. Therefore, modulation of cardiac metabolism has arisen as a promissory therapy in the treatment of heart failure. This review describes myocardial energy metabolism, evaluates the role of impaired energy metabolism in heart failure progression and describes new therapies for heart failure involving metabolic intervention.

Polución por material particulado fino (PM 2.5) incrementa las hospitalizaciones por insuficiencia cardiaca / Small particle air pollution (PM2.5) leads to an in crease in hospitalization rate for congestive heart failure

Antecedentes: Estudios recientes han reportado una asociación entre la contaminación ambiental por material particulado (PM) y el riesgo de hospitalizaciones de pacientes con insuficiencia cardiaca (IC). La región metropolitana de nuestro país constituye un área geográfica en la cual la contaminación es especialmente relevante, asociándose a incrementos periódicos en la morbimortalidad por causa respiratoria. Sin embargo el efecto de la polución por PM en la morbilidad de pacientes con IC no ha sido evaluado en forma sistemática. Objetivo: Evaluar la asociación entre el PM fino y las hospitalizaciones por IC descompensada en hospitales pertenecientes al registro ICARO del área metropolitana. Métodos: Estudio prospectivo. Entre enero 2002 a diciembre de 2008 se recolectaron las fichas médicas de 529 pacientes residentes de Santiago hospitalizados por IC descompensada. Las variables meteorológicas y de contaminación fueron obtenidas de la red MACAM. Para estudiar la asociación entre las hospitalizaciones y los niveles de contaminación (PM10 y PM2,5), se aplicó un diseño de Casos cruzados estratificado por tiempo (Time-stratified Case-crossover), controlando por temperatura y punto de rocío. El impacto de los niveles de contaminación en el número de hospitalizaciones se evaluó asumiendo una latencia en el efecto de la polución de 0 a 10 días. Resultados: La edad media de la población en estudio fue de 73.8 años. La etiología más frecuente fue isquémica (27 por ciento) e hipertensiva (27 por ciento). Un 73.2 por ciento de los pacientes eran hipertensos y 32.6 por ciento tenían antecedentes de diabetes mellitus. Se observó un aumento en la admisión por IC descompensada en pacientes de ambos sexos, menores de 74 años, con desde un 22.7 por ciento (p=0.03) por cada incremento en 10 ug/m3 de PM2.5 calculado con media móvil, cuatro días después de la exposición hasta un 44.8 por ciento (p=0.006) a 10 días de la exposición. Los pacientes con antecedentes de ...

Background: Recent studies have reported an increase risk of hospitalization in patients with congestive heart failure (CHF) in association with air pollution by small particles. The Metropolitan region in Chile is characterized by high pollution indexes which are related to increased mortality from respiratory diseases. No systematic evaluation of the effect of particle pollution upon morbidity in patients with CHF is available. Aim. To evaluate the association between fine particle pollution and hospitalization rate for decompensated CHF in hospitals participating in the ICARO registry of CHF in the Metropolitan area of Santiago. Methods. In a prospective design the clinical records of 529 patients who were hospitalized for decompensated CHF from Jan 2002 to Dec 2008 were analyzed Meteorological and pollution indexes were obtained from de MACAM monitoring network. A time stratified case cross-over design was used to study the association between hospitalization rate and pollution indexes (PM10 and PM25. Data was controlled for temperature and "punto de rocío" . A 0 to 10 day latency period was estimated to evaluate the influence of pollution on hospitalization rate. Results. The mean age of patients was 73.8 years. Etiologies for CHF included ischemic heart disease (27 percent) and hypertensive heart disease (27 percent). 73.2 percent of patients were hypertensives and 32.6 percent had evidence of DM. Hospitalization rate for CHF in men or women > 74 years of age increased from 22.7 percent 4 days after exposure to 44.8 percent 10 days after exposure (p=0.006). Diabetic patients were more susceptible to hospitalization with an 18 percent increased rate for each 10ug/m3 PM2.5 concentration at 8 days after exposure. Male and female hypertensive patients <74 years of age were also susceptible with a 28 percent (2.1 to 43/5 percent, CI) increase in hospitalization rate at 5 days after exposure. Conclusion: Patients with CHF who are diabetics or hy...

Influencia de factores socioculturales en la evolución alejada de pacientes con insuficiencia cardíaca / Influence of social and cultural factors in the late course of patients with congestive heart failure

Objetivo: Evaluar el impacto de los factores socioculturales (SC) en Las características del cuidado de la insuficiencia cardiaca (IC) y la evolución post alta en pacientes admitidos con diagnostico de IC descompensada a hospitales del registro ICARO en el periodo 2006-2008.Método: Registro prospectivo de 14 hospitales. Se incorporaron en forma consecutiva pacientes admitidos con el diagnostico de IC descompensada entre enero 2006 y mayo 2008. La mortalidad al fin del seguimiento se determino por la base de datos del Servicio Nacional del Registro Civil e Identificación. Se definió como terapia optima la combinación de en betabloqueador con cualquiera de los siguientes: inhibidores de la enzima convertidora de angiotensina (IECA), antagonistas del receptor de angiotensina Il (ARAlI), hidralazina/isosorbide o espironolactona. Las características de los pacientes se compararon mediante t de Student o chi cuadrado según correspondía. La sobrevida se evaluó mediante Kaplan-Meier.Resultados: Los pacientes de bajo nivel SC son do mayor edad (71 +/- 11 v/s 66 +/-15 años respectivamente, p<0.01). predomina el género femenino (52.2 por ciento v/s 26.1 por ciento, p<0,01), y su previsión fue mayoritariamente FONASA (90 por ciento). La etiología isquémica fue más frecuente en el estrato SC alto (34,5 vs. 16,6 por ciento) y la hipertensiva en el nivel SC bajo (30,3 v/s 16,6 por ciento). La utilización de ARA II fue más frecuente en el nivel SC alto con una tendencia a menor utilización de IECA, el uso de betabloqueadores espironolactona hidralazina e isosorbide amiodarona y anticoagulante fue menor en el estrato SC bajo.

Aim: to evaluate de impact of social and cultural (S-C) factors in the care and course of patients with congestive heart failure (CHF) enrolled in the ICARO study (national registry for patients with head failure). Methods: Patients were enrolled from 2006 through 2008. They were discharged from 14 hospitals participating in the prospectively designed ICARO study. Late mortality was obtained from the national Identification registry. Optimal medical therapy was defined as the use of a betablocker in addition to any of the following ACE inhibitors, ARA II. combination of hydralazine and nitrates, or spironolactone. Statistical analysis included Students t tesl. chi square and Kaplan Meir and Log-rank testing, as appropriate. Results: Patients with a low S-C level were older (71 +/- 11 vs 66 +/- IS years. p<0.01). more frequently females (52.2 percent vs 26.1 percent, p<0.01) and most of them belonged in the FONASA health insurance system (90 percent). Ischemic heart disease was more prevalent in the high S-C level (34.5 vs 16.6 percent) and hypertension in the low S-C level (30.3 vs 16.6 percent). ARA II rather than ACE inhibitors were more commonly used in the high S-C level: A CE inhibitors, betablockers, spironolactone, hydralazine-nitrates, amiodarone and anticoagulatioo were less frequently used in the low S-C level. After discharge a more intensive treatment of heart failure was observed; however, this was less seen in the low S-C level. Patients with decreased left ventricular ejection fraction were similarly treated in both groups. An optimal therapy for CHF was used in 43.7 percent, 43.3 percent and 51.1 percent in S-C levels low, intermediate and high, respectively (NS). Independent predictors for late mortality were age>70 years (HR 2.71 (CI 1.55-3.03), low S-C level (HR 1.57, CII. 17- 2.09), EF<50 percent (HR 1.49, CI 1.04-2.14) and absence of optimal medical therapy at discharge (HR 0.52, CI 0.41-0.66).

Caracterización del cáncer superficial de vejiga en el Hospital Barros Luco Trudeau en el período 2002-2006 / Superficial bladder cancer in Barros Luco Trudeau Hospital between 2002 and 2006

Introducción: En EE.UU. el cáncer de vejiga representa la quinta causa más frecuente de cáncer. El carcinoma urotelial es el tipo histológico más frecuente. RTU asociado a inmunoterapia es el tratamiento de elección. El objetivo de este trabajo es caracterizar una muestra de pacientes con cáncer superficial de vejiga. Materiales y método: Se realizó un estudio descriptivo retrospectivo de 48 fichas clínicas seleccionadas del período 2002-2006. Resultados: De la muestra 77 por ciento correspondió a hombres. Un 90 por ciento presentó cáncer de urotelio. La ubicación más frecuente fue multifocal. La RTU fue el tratamiento más utilizado. Conclusiones: La mayoría de nuestros datos fueron similares a lo descrito en otras publicaciones. La muestra pequeña o un factor económico podría explicar el bajo uso de RTU asociado a inmunoterapia.

Introduction: Bladder cancer is the fifth most frequent type of cancer in the United States of America. Urothelial carcinoma being the most common histological type. TUR in association with immunotherapy is the treatment of choice. The objective of this study is to characterize a group of patients with superficial bladder cancer. Materials and Method: 48 clinical records were used to perform a descriptive retrospective study during a period between 2002-2006.Results: 77percent of cases were men. 90percent presented urothelial carcinoma. The most frequent location was multifocal. TUR was the clinical intervention that was most utilized. Conclusions: The majority of our results are similar to those seen in other publications. he small size of the group or an economical factor might explain the limited use of combined TUR - immunotherapy.