[The Emergency Medical System's response and its association with different outcomes in traffic accident victims in Mexican cities]. / La respuesta del Sistema Médico de Emergencias y su relación con distintos resultados en salud en personas lesionadas por el tránsito de dos ciudades mexicanas.

The aim of this article was to analyze the timeliness of emergency medical care (time transpired between the injury and the first contact with the Emergency Medical System) and its assocation with different negative health outcome in traffic accident victims treated at two Mexican hospitals, one in Guadalajara, Jalisco, and the other in León, Guanajuato, based on data from the Motor Vehicle Accident Epidemiological Surveillance System of the Bloomberg Philanthropies' Global Road Safety Program. Information was obtained on all patients treated for motor vehicle injuries in referral hospitals from May 2012 to November 2014. Multinomial logistic regression was used to model the health outcomes, categorized as short stay, prolonged hospitalization, disability, and death, compared to timeliness of care, adjusted by different target variables. A total of 2,575 patients were analyzed. Time from injury to care was 103.74 minutes (± 231.36) in León and 75.37 minutes (± 156.87) in Guadalajara; it was 38.02 and 36.23 minutes, respectively, in patients that received prehospital medical care. Timely care was associated with less prolonged hospital stay, but not with lower incidence of disability or death. Receiving prehospital medical care was associated statistically with negative health consequences. Timely care was associated with lower probability of prolonged hospitalization. Strategies are needed to evaluate and in turn improve the technical quality of prehospital medical care, including timeliness of care and adequate regulation.

El objetivo fue analizar la oportunidad de la atención médica de emergencias (tiempo transcurrido desde que ocurrió la lesión hasta el primer contacto con el Sistema Médico de Emergencias -SME) y su relación con distintas consecuencias negativas en salud, en pacientes con lesiones causadas por el tránsito, atendidos en dos hospitales de México, uno en Guadalajara, Jalisco y otro en León, Guanajuato. Se utilizó información del Sistema de Vigilancia Epidemiológica de las Lesiones Causadas por el Tránsito, establecido como parte del Programa Global de Seguridad Vial de la Filantropía de Bloomberg. Se recabó información de todos los pacientes atendidos por lesiones causadas por el tránsito en dos hospitales de referencia, de mayo 2012 a noviembre 2014. Se realizó una regresión logística multinomial para modelar los resultados en salud, categorizados en estancia corta, hospitalización prolongada, discapacidad y defunción, con la oportunidad de la atención, ajustando por distintas variables de interés. 2.575 lesionados fueron analizados. La oportunidad de la atención fue 103,74min (± 231,36) en León y 75,37min (± 156,87) en Guadalajara, siendo 38,02 y 36,23min en quienes recibieron atención médica prehospitalaria, respectivamente. La oportunidad de la atención se asoció con una menor estancia hospitalaria prolongada, pero no con una menor incidencia de discapacidad o muerte. Recibir atención médica prehospitalaria estuvo asociado con consecuencias negativas en salud. Una atención oportuna está asociada a una menor posibilidad de tener hospitalizaciones prolongadas. Es necesario impulsar estrategias para evaluar, y eventualmente mejorar la calidad técnica de la atención médica prehospitalaria, incluyendo la oportunidad de la atención y la adecuada regulación.

O objetivo deste estudo foi analisar a oportunidade da atenção médica de emergências (tempo transcorrido desde que ocorreu a lesão até o primeiro contato com o Sistema Médico de Emergências) e sua relação com distintas consequências negativas para a saúde, em pacientes com lesões causadas pelo trânsito, atendidos em dois hospitais do México, um em Guadalajara, Jalisco e outro em León, Guanajuato. Foi utilizada informação do Sistema de Vigilância Epidemiológica das Lesões Causadas pelo Trânsito, estabelecido como parte do Programa Global de Segurança Rodoviária da Filantropia de Bloomberg. Foram recolhidas informações de todos os pacientes atendidos por lesões causadas pelo trânsito nos hospitais de referência, de maio 2012 a novembro 2014. Foi realizada uma regressão logística multinomial para modelar os resultados na saúde, categorizados como: permanência curta hospitalar, hospitalização prolongada, portadores de deficiência e óbito com oportunidade de atenção, sendo ajustada por diferentes variáveis de interesse. Foram analisados 2.575 lesionados. A chance da atenção foi 103,74min (± 231,36) em León e 75,37min (± 156,87) em Guadalajara, sendo 38.02 e 36.23 min naqueles que receberam atenção médica pré-hospitalar, respectivamente. A chance da atenção foi associada com uma menor permanência hospitalar prolongada, mas não com uma menor incidência de deficiência ou morte. Receber atenção médica pré-hospitalar foi associado com consequências negativas na saúde. Uma atenção oportuna está associada à uma menor possibilidade de sofrer hospitalizações prolongadas. É necessário estimular estratégias para avaliar, e eventualmente melhorar a qualidade técnica da atenção médica pré-hospitalar, incluindo a chance da atenção e uma adequada regulação.

La respuesta del Sistema Médico de Emergencias y su relación con distintos resultados en salud en personas lesionadas por el tránsito de dos ciudades mexicanas / The Emergency Medical System's response and its association with different outcomes in traffic accident victims in Mexican cities / A resposta do Sistema Médico de Emergências e sua relação com distintos resultados na saúde em pessoas lesionadas pelo trânsito de duas cidades mexicanas

Resumen: El objetivo fue analizar la oportunidad de la atención médica de emergencias (tiempo transcurrido desde que ocurrió la lesión hasta el primer contacto con el Sistema Médico de Emergencias -SME) y su relación con distintas consecuencias negativas en salud, en pacientes con lesiones causadas por el tránsito, atendidos en dos hospitales de México, uno en Guadalajara, Jalisco y otro en León, Guanajuato. Se utilizó información del Sistema de Vigilancia Epidemiológica de las Lesiones Causadas por el Tránsito, establecido como parte del Programa Global de Seguridad Vial de la Filantropía de Bloomberg. Se recabó información de todos los pacientes atendidos por lesiones causadas por el tránsito en dos hospitales de referencia, de mayo 2012 a noviembre 2014. Se realizó una regresión logística multinomial para modelar los resultados en salud, categorizados en estancia corta, hospitalización prolongada, discapacidad y defunción, con la oportunidad de la atención, ajustando por distintas variables de interés. 2.575 lesionados fueron analizados. La oportunidad de la atención fue 103,74min (± 231,36) en León y 75,37min (± 156,87) en Guadalajara, siendo 38,02 y 36,23min en quienes recibieron atención médica prehospitalaria, respectivamente. La oportunidad de la atención se asoció con una menor estancia hospitalaria prolongada, pero no con una menor incidencia de discapacidad o muerte. Recibir atención médica prehospitalaria estuvo asociado con consecuencias negativas en salud. Una atención oportuna está asociada a una menor posibilidad de tener hospitalizaciones prolongadas. Es necesario impulsar estrategias para evaluar, y eventualmente mejorar la calidad técnica de la atención médica prehospitalaria, incluyendo la oportunidad de la atención y la adecuada regulación.

Abstract: The aim of this article was to analyze the timeliness of emergency medical care (time transpired between the injury and the first contact with the Emergency Medical System) and its assocation with different negative health outcome in traffic accident victims treated at two Mexican hospitals, one in Guadalajara, Jalisco, and the other in León, Guanajuato, based on data from the Motor Vehicle Accident Epidemiological Surveillance System of the Bloomberg Philanthropies' Global Road Safety Program. Information was obtained on all patients treated for motor vehicle injuries in referral hospitals from May 2012 to November 2014. Multinomial logistic regression was used to model the health outcomes, categorized as short stay, prolonged hospitalization, disability, and death, compared to timeliness of care, adjusted by different target variables. A total of 2,575 patients were analyzed. Time from injury to care was 103.74 minutes (± 231.36) in León and 75.37 minutes (± 156.87) in Guadalajara; it was 38.02 and 36.23 minutes, respectively, in patients that received prehospital medical care. Timely care was associated with less prolonged hospital stay, but not with lower incidence of disability or death. Receiving prehospital medical care was associated statistically with negative health consequences. Timely care was associated with lower probability of prolonged hospitalization. Strategies are needed to evaluate and in turn improve the technical quality of prehospital medical care, including timeliness of care and adequate regulation.

Resumo: O objetivo deste estudo foi analisar a oportunidade da atenção médica de emergências (tempo transcorrido desde que ocorreu a lesão até o primeiro contato com o Sistema Médico de Emergências) e sua relação com distintas consequências negativas para a saúde, em pacientes com lesões causadas pelo trânsito, atendidos em dois hospitais do México, um em Guadalajara, Jalisco e outro em León, Guanajuato. Foi utilizada informação do Sistema de Vigilância Epidemiológica das Lesões Causadas pelo Trânsito, estabelecido como parte do Programa Global de Segurança Rodoviária da Filantropia de Bloomberg. Foram recolhidas informações de todos os pacientes atendidos por lesões causadas pelo trânsito nos hospitais de referência, de maio 2012 a novembro 2014. Foi realizada uma regressão logística multinomial para modelar os resultados na saúde, categorizados como: permanência curta hospitalar, hospitalização prolongada, portadores de deficiência e óbito com oportunidade de atenção, sendo ajustada por diferentes variáveis de interesse. Foram analisados 2.575 lesionados. A chance da atenção foi 103,74min (± 231,36) em León e 75,37min (± 156,87) em Guadalajara, sendo 38.02 e 36.23 min naqueles que receberam atenção médica pré-hospitalar, respectivamente. A chance da atenção foi associada com uma menor permanência hospitalar prolongada, mas não com uma menor incidência de deficiência ou morte. Receber atenção médica pré-hospitalar foi associado com consequências negativas na saúde. Uma atenção oportuna está associada à uma menor possibilidade de sofrer hospitalizações prolongadas. É necessário estimular estratégias para avaliar, e eventualmente melhorar a qualidade técnica da atenção médica pré-hospitalar, incluindo a chance da atenção e uma adequada regulação.

Uso de biofeedback de variabilidad de la frecuencia cardiaca durante la radioterapia como método de distracción cognitiva y autorregulación en un paciente pediátrico: Informe de caso / Biofeedback use of heart rate variability during radiotherapy as a method of cognitive distraction and self-regulation in a pediatric patient: A case report

Objetivo: Evaluar la efectividad del uso de biofeedback de variabilidad de frecuencia cardiaca (VFC) durante la radioterapia como método de distracción cognitiva y autoregulación emocional en un paciente pediátrico. Método: La paciente es una niña de 11 años con diagnóstico de sarcoma de Ewing en la pierna izquierda. Recibió 28 sesiones de radioterapia. Antes de iniciar tratamiento, se evaluó psicológicamente a la paciente con la entrevista Mini Kid, identificando que no tenía psicopatología. Dos semanas previas a iniciar, se evaluó la frecuencia cardiaca (FC) y variabilidad (VFC) de la misma (indicadores que han sido utilizados previamente como correlatos fisiológicos de estrés y relajación) con un software especializado llamado EmWave, identificando que sí presentaba activación fisiológica asociada a estrés. Se hizo entrenamiento en respiración diafragmática apoyado con el equipo de retroalimentación dos semanas previas a la radioterapia. El día que inició tratamiento, se volvió a evaluar la frecuencia y variabilidad antes de comenzar. Durante la radioterapia se instrumentó a la paciente al software y se permitió que ella escogiera el juego (que registra las variables de FC y VFC e interactúa conforme ella logra autoregulación fisiológica) y éste era proyectado en el techo de la sala mientras recibía la radiación. Resultados: Se identificaron cambios en la variabilidad de la frecuencia cardiaca, logrando una autoregulación, mostrando así que la paciente aprendió a relajarse y que lo puso en práctica durante la radioterapia. Conclusión: El uso del biofeedback es innovador en el tratamiento con radioterapia; permite al paciente integrar los dos métodos más utilizados como preparación para la misma: distraer el foco atencional y lograr una autoregulación. Se sugiere ampliar la muestra para conocer los efectos y generalizar los resultados (AU)

Aim: To assess the effectiveness of heart rate variability (HRV) biofeedback during radiotherapy as an intervention to promote cognitive distraction and emotional regulation un a paediatric patient. Method: Patient is an 11 years old female with Ewing Sarcoma on left leg. She recieved 28 radiotherapy sessions. Before initiating treatment, the patient was assessed with Mini International Neuropsychiatric Interview KID (MINI KID). She did not have a psychiatirc diagnostic, nor significative anxiety as rated by these instruments. Two weeks prior initiating radiotherapy, Heart rate (HR) and heart rate variability (HRV) (measures that have been used previously as physiologic corralates of stress and relaxation) were measured with a specialized software called EmWave. Results identified that there was a psysiologic activation related to stress. At the same session, the patient was trained in diaphragmatic breathing assisted with HRV biofeedback. The day the radiotherapy treatment started, HR and HRV were assessed an hour before. During radiotherapy, patient was instrumented to the software and the display was projected on the ceiling so that she could interact with the program at the same time she recieved radiotherapy. Patient was asked to choose the display she prefered (presented as interactive games by EmWave) and HR as well as HRV were measured during treatment. Results: Changes in HRV during radiotherapy were presented, these changes have been reported as indicative of self regulation, reflecting that the patient learned this behavior and was able to implement it during her treatment. Conclussion: The use of biofeedback is innovative in treatment with radiotherapy; it allows the patient to integrate the two most used methods for psychological preparation: attentional distraction and self regulation methods. It’s suggested to amplify the sample in order to learn more about the use of biofeedback in radiotherapy and generalize results (AU)

Informe de 3 casos de reanimación extrahospitalaria en la ciudad de Querétaro: Importancia de un sistema integral de atención de emergencias médicas / Prehospital cardiac resuscitation in Queretaro, Mexico: Report of 3 cases. Importance of an integral emergency medical care system

En México, el paro cardiaco que ocurre fuera de las instalaciones hospitalarias representa un problema de salud pública debido a que se estima que es responsable de 33,000 a 150,000 muertes al año. La mortalidad que se informa, en las escasas publicaciones que existen en México, son tan elevadas que incluso llegan al 100% de los eventos, cifras mucho más altas que las informadas en otros países. En la ciudad de Querétaro no se tenían documentados casos de reanimación exitosa en los últimos 5 años, sin embargo, en el 2012 se informaron varios casos en los que la reanimación logró obtener el retorno de la circulación espontánea. Se presentan3 casos con retorno de la circulación espontánea en la escena y pulso a la llegada al hospital. De ellos, 2 egresaron con vida del hospital; pero uno de estos con pobre actividad cerebral. Factores como reanimación cardiopulmonar comunitaria, desfibrilación en los primeros minutos y mejores tiempos de respuesta del sistema de urgencia se relacionan con la supervivencia de las víctimas. Podrían mejorarse los resultados de este poco explorado problema de salud en el contexto mexicano con la mejora de la calidad del servicio de manera continua, con la difusión de estrategias de educación pública en reanimación cardiopulmonar asistida por la persona que está en ese momento, la participación de la policía en la reanimación cardiopulmonar y la desfibrilación, con los programas de acceso público a la desfibrilación y la determinación de indicadores de retroalimentación.

In Mexico, out-of-hospital cardiac arrest is a health problem that represents 33,000 to 150,000 or more deaths per year. The few existent reports show mortality as high as 100% in contrast to some international reports that show higher survival rates. In Queretaro, during the last 5 years there were no successful resuscitation cases. However, in 2012 some patients were reported to have return of spontaneous circulation. We report in this article 3 cases with return of spontaneous circulation and pulse at arrival to the hospital. Two of the patients were discharged alive, one of them with poor cerebral performance category. Community cardiopulmonary resuscitation, early defibrillation and better emergency medical system response times, are related with survival. This poorly explored health problem in Queretaro could be increased with quality and good public education, bystander assisted cardiopulmonary resuscitation, police involvement in cardiopulmonary resuscitation and defibrillation, public access defibrillation programs and measurement of indicators and feedback for better results.

[Prehospital cardiac resuscitation in Queretaro, Mexico. Report of 3 cases. Importance of an integral emergency medical care system]. / Informe de 3 casos de reanimación extrahospitalaria en la ciudad de Querétaro. Importancia de un sistema integral de atención de emergencias médicas.

In Mexico, out-of-hospital cardiac arrest is a health problem that represents 33,000 to 150,000 or more deaths per year. The few existent reports show mortality as high as 100% in contrast to some international reports that show higher survival rates. In Queretaro, during the last 5 years there were no successful resuscitation cases. However, in 2012 some patients were reported to have return of spontaneous circulation. We report in this article 3 cases with return of spontaneous circulation and pulse at arrival to the hospital. Two of the patients were discharged alive, one of them with poor cerebral performance category. Community cardiopulmonary resuscitation, early defibrillation and better emergency medical system response times, are related with survival. This poorly explored health problem in Queretaro could be increased with quality and good public education, bystander assisted cardiopulmonary resuscitation, police involvement in cardiopulmonary resuscitation and defibrillation, public access defibrillation programs and measurement of indicators and feedback for better results.

Análisis de la inclusión de la policía en la respuesta de emergencias al paro cardiorrespiratorio extrahospitalario / Analysis of the inclussion of police personnel on the out of hospital cardiac arrest emergency response

OBJETIVO: El presente estudio busca analizar una alternativa al pronóstico de paro cardiorrespiratorio extrahospitalario (PCE) como problema de salud pública al involucrar a los cuerpos policiacos en la respuesta de emergencias. MATERIAL Y MÉTODOS: Se analizó retrospectivamente un registro de PCE iniciado en junio de 2009. Se contrastó un modelo basado en un número limitado de ambulancias con primera respuesta por la policía. RESULTADOS: La mortalidad fue de 100 por ciento, tiempos de respuesta elevados y 10.8 por ciento recibió reanimación cardiopulmonar (RCP) por testigos presenciales. En 63.7 por ciento de los eventos la policía llegaba antes que la ambulancia y en 1.5 por ciento el policía dio RCP. El costo por vida salvada fue 5.8-60 millones de pesos en un modelo sólo con ambulancias vs. 0.5-5.5 millones de pesos en un modelo con primera respuesta policiaca. CONCLUSIONES: La intervención de la policía en la ciudad de Querétaro facilitaría la disminución de la mortalidad por PCE a un menor costo.

OBJETIVE: Out-of-hospital cardiac arrest (OCHA) is a public health problem in which survival depends on community initial response among others. This study tries to analyze what's the proportional cost of enhancing such response by involving the police corps in it. MATERIALS AND METHODS: We analyzed retrospectively an OCHA registry started on June 2009. We contrasted a model with limited number of ambulances and police based first response. RESULTS: Mortality was 100 percent, response times high and 10.8 percent of the victims were receiving cardiopulmonary resuscitation (CPR) by bystanders. In 63.7 percent of the events the police arrived before the ambulance, in 1.5 percent of these cases the police provided CPR. The cost for each saved life was of 5.8-60 million Mexican pesos per life with only ambulance model vs 0.5-5.5 million Mexican pesos on a police first response model with 12 ambulances. CONCLUSIONS: In Queretaro interventions can be performed taking advantage of the response capacity of the existing police focused on diminishing mortality from OCHA at a lesser cost than delegating this function only to ambulances.

[Analysis of the inclusion of police personnel on the out of hospital cardiac arrest emergency response]. / Análisis de la inclusión de la policía en la respuesta de emergencias al paro cardiorrespiratorio extrahospitalario.

OBJECTIVE: Out-of-hospital cardiac arrest (OCHA) is a public health problem in which survival depends on community initial response among others. This study tries to analyze what's the proportional cost of enhancing such response by involving the police corps in it. MATERIALS AND METHODS: We analyzed retrospectively an OCHA registry started on June 2009. We contrasted a model with limited number of ambulances and police based first response. RESULTS: Mortality was 100%, response times high and 10.8% of the victims were receiving cardiopulmonary resuscitation (CPR) by bystanders. In 63.7% of the events the police arrived before the ambulance, in 1.5% of these cases the police provided CPR. The cost for each saved life was of 5.8-60 million Mexican pesos per life with only ambulance model vs 0.5-5.5 million Mexican pesos on a police first response model with 12 ambulances. CONCLUSIONS: In Queretaro interventions can be performed taking advantage of the response capacity of the existing police focused on diminishing mortality from OCHA at a lesser cost than delegating this function only to ambulances.

[Syncope in the elderly: findings of diagnostic complementary tests in a University Hospital]. / Séncope en el anciano: Hallazgos de pruebas complementarias en un Centro Hospitalario Universitario.

UNLABELLED: Syncope is a common symptom among older adults. Its aetiologic diagnosis is mainly clinical, but when it has an unknown origin, complementary studies are necessary. We present the experience of a single center in diagnosing Unknown Origin Syncope (UOS). METHODS: We performed a transversal retrolective study to assess the different tests done to patients studied because of USO. RESULTS: The mean age of the older group was 77.6 +/- 6.9 years. The 24-hour Hotter were abnormal in 77.9% of patients, but diagnostic in only 16.3%. Age older than 65 years was associated with a 1.9 increase (CI 95% 0.9-4) in the possibilities of having a diagnosis, while age lesser than 65 was associated with a 0.5 risk CI 95% 0.2-1.08 of having a diagnosis. The 48-hour holter showed similar results. Older age was associated with a 1.69 OR, CI 95% 0.6-4.4 to have a positive Tilt test (91% of older patients). They had mainly the vasodepressor variety of neurally-mediated syncope. (57.1% Vs 40.1%, p = 0.01). Of the 6 electrophysiologic studies performed in people older than 65 years, 3 where diagnostic (50% Vs 33.3%, p = 0.6). CONCLUSIONS: Complimentary tests in people elder than 65 years are diagnostic in a higher proportion than in their younger counterparts. Nevertheless there is a higher risk of false-positive results, so tests such as head-up tilt test should be more carefully interpreted.

Séncope en el anciano: hallazgos de pruebas complementarias en un Centro Hospitalario Universitario / Syncope in the elderly: findings of diagnostic complementary tests in a University Hospital

Syncope is a common symptom among older adults. Its aetiologic diagnosis is mainly clinical, but when it has an unknown origin, complementary studies are necessary. We present the experience of a single center in diagnosing Unknown Origin Syncope (UOS). METHODS: We performed a transversal retrolective study to assess the different tests done to patients studied because of USO. RESULTS: The mean age of the older group was 77.6 +/- 6.9 years. The 24-hour Hotter were abnormal in 77.9% of patients, but diagnostic in only 16.3%. Age older than 65 years was associated with a 1.9 increase (CI 95% 0.9-4) in the possibilities of having a diagnosis, while age lesser than 65 was associated with a 0.5 risk CI 95% 0.2-1.08 of having a diagnosis. The 48-hour holter showed similar results. Older age was associated with a 1.69 OR, CI 95% 0.6-4.4 to have a positive Tilt test (91% of older patients). They had mainly the vasodepressor variety of neurally-mediated syncope. (57.1% Vs 40.1%, p = 0.01). Of the 6 electrophysiologic studies performed in people older than 65 years, 3 where diagnostic (50% Vs 33.3%, p = 0.6). CONCLUSIONS: Complimentary tests in people elder than 65 years are diagnostic in a higher proportion than in their younger counterparts. Nevertheless there is a higher risk of false-positive results, so tests such as head-up tilt test should be more carefully interpreted.

Out-of-hospital cardiac arrest: first documented experience in a Mexican urban setting.

OBJECTIVE: Out-of-hospital cardiac arrest is one of the leading causes of death in Mexico, but many survival and prognostic factors are unknown. The aim of this study was to assess out-of-hospital cardiac arrest in a Mexican city. METHODS: This was a prospective, cohort study that evaluated the records of the major ambulance services in the city of Queretaro, Mexico. Means, standard deviation, and percentages for the categorical variables were obtained. Logistic regression was performed to determine the effects between interventions, times, and return of spontaneous circulation (ROSC). RESULTS: For an 11-month period, 148 out-of-hospital cardiac arrest cases were recorded. The mean age of the victims was 54 +/- 22.6 years and 90 (65.3%) were males. Forty-nine cases were related to cardiac disease, 46 to other disease, 27 to trauma, 18 to terminal illnesses, and three to drowning. Twelve (8.6%) patients had a pulse upon hospital arrival, but none survived to discharge. No victims were defibrillated prior to ambulance arrival. The collapse-assessment interval was 22.5 +/- 19:1 minutes, the mean value for the ambulance response times was 13:6 +/-10:4 minutes. Basic emergency medical technicians applied chest compressions to 40 victims (27.2%), controlled the airway in 32 (21.8%), and defibrillated seven (4.8%). Chest compressions and airway control showed an OR of 8 and 12 respectively for ROSC. CONCLUSIONS: The poor survival rate in this study emphasizes the need to improve efforts in provider training and public education. Authorities must promote actions to enhance prehospital emergency services capabilities, shorten response times, and provide community education to increase the chances of survival for out-of-hospital cardiac arrest victims in Mexico.