Clinical practice guidelines for diagnostic and treatment of the chronic heart failure.

Chronic heart failure continues to be one of the main causes of impairment in the functioning and quality of life of people who suffer from it, as well as one of the main causes of mortality in our country and around the world. Mexico has a high prevalence of risk factors for developing heart failure, such as high blood pressure, diabetes, and obesity, which makes it essential to have an evidence-based document that provides recommendations to health professionals involved in the diagnosis and treatment of these patients. This document establishes the clinical practice guide (CPG) prepared at the initiative of the Mexican Society of Cardiology (SMC) in collaboration with the Iberic American Agency for the Development and Evaluation of Health Technologies, with the purpose of establishing recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. This document complies with international quality standards, such as those described by the US Institute of Medicine (IOM), the National Institute of Clinical Excellence (NICE), the Intercollegiate Network for Scottish Guideline Development (SIGN) and the Guidelines International Network (G-I-N). The Guideline Development Group was integrated in a multi-collaborative and interdisciplinary manner with the support of methodologists with experience in systematic literature reviews and the development of CPG. A modified Delphi panel methodology was developed and conducted to achieve an adequate level of consensus in each of the recommendations contained in this CPG. We hope that this document contributes to better clinical decision making and becomes a reference point for clinicians who manage patients with chronic heart failure in all their clinical stages and in this way, we improve the quality of clinical care, improve their quality of life and reducing its complications.

La insuficiencia cardiaca crónica sigue siendo unas de las principales causas de afectación en el funcionamiento y en la calidad de vida de las personas que la presentan, así como una de las primeras causas de mortalidad en nuestro país y en todo el mundo. México tiene una alta prevalencia de factores de riesgo para desarrollar insuficiencia cardiaca, tales como hipertensión arterial, diabetes y obesidad, lo que hace imprescindible contar con un documento basado en la evidencia que brinde recomendaciones a los profesionales de la salud involucrados en el diagnóstico y el tratamiento de estos pacientes. Este documento establece la guía de práctica clínica (GPC) elaborada por iniciativa de la Sociedad Mexicana de Cardiología (SMC) en colaboración con la Agencia Iberoamericana de Desarrollo y Evaluación de Tecnologías en Salud, con la finalidad de establecer recomendaciones basadas en la mejor evidencia disponible y consensuadas por un grupo interdisciplinario y multicolaborativo de expertos. Cumple con estándares internacionales de calidad, como los descritos por el Institute of Medicine de los Estados Unidos de América (IOM), el National Institute of Clinical Excellence (NICE) del Reino Unido, la Intercollegiate Network for Scottish Guideline Development (SIGN) de Escocia y la Guidelines International Network (G-I-N). El grupo de desarrollo de la guía se integró de manera interdisciplinaria con el apoyo de metodólogos con experiencia en revisiones sistemáticas de la literatura y en el desarrollo de GPC. Se llevó a cabo y se condujo metodología de panel Delphi modificado para lograr un nivel de consenso adecuado en cada una de las recomendaciones contenidas en esta GPC. Esperamos que este documento contribuya para la mejor toma de decisiones clínicas y se convierta en un punto de referencia para los clínicos que manejan pacientes con insuficiencia cardiaca crónica en todas sus etapas clínicas, y de esta manera logremos mejorar la calidad en la atención clínica, aumentar la calidad de vida de los pacientes y disminuir las complicaciones de la enfermedad.

Reversión del síndrome metabólico por el consumo de ácidos grasos poliinsaturados / Metabolic syndrome reversion by polyunsaturated fatty acids ingestion

Fundamento y objetivo: La frecuencia del síndrome metabólico (SM) está creciendo y la dieta tiene una importante influencia en su evolución. Nuestro objetivo fue estudiar el efecto de 3 fuentes de ácidos grasos poliinsaturados sobre los parámetros del SM en humanos. Pacientes y método: Se diagnosticó SM según la Federación Internacional de Diabetes. Se asignaron cuasialeatoriamente 3 grupos de individuos (n = 15/grupo) a uno de los siguientes tratamientos durante 6 semanas: a) 1,8 g/d n-3 (1,08 g ácido eicosapentanoico + 0,72 g ácido docosahexanoico); b) 2,0 g/d conjugated linoleic acid (CLA, «ácido linoleico conjugado») (50:50, cis9:trans11, trans10:cis12), y c) 40 g/d nuez de Castilla. Los parámetros clínicos y bioquímicos se evaluaron antes y después del ensayo. Resultados: En el grupo con n-3 el nivel de triglicéridos disminuyó de 183,9 ± 35,2 mg/dl a 149,6 ± 29,0 mg/dl (p = 0,007). En el grupo con nuez de Castilla la concentración de HDL aumentó de 41,7 ± 5,2 mg/dl a 47,8 ± 5,4 mg/dl (p = 0,004) y el índice de Castelli (colesterol total/c-HDL) disminuyó de 4,86 ± 0,97 a 3,82 ± 0,81 (p = 0,004). No hubo cambios significativos en el grupo con CLA. Al final del ensayo, el 46,7% del grupo con nuez de castilla, el 46,7% del grupo con n-3 y el 20% del grupo con CLA se observaron sin SM. Conclusiones: Los grupos que consumieron ácidos grasos poliinsaturados n-3 y los contenidos en la nuez de castilla en dosis diarias moderadas durante 6 semanas mejoraron el componente dislipidemia del SM, hipertrigliceridemia y nivel bajo de HDL (AU)

Background and objective: Metabolic syndrome (MS) frequency is growing and diet has an important influence on its evolution. Our objective was to study the effect of 3 sources of polyunsaturated fatty acids on MS parameters in humans. Patients and method: The MS was diagnosed according to the International Diabetes Federation. Three groups of individuals (n = 15/group) were quasi-randomly assigned to one of the following treatments during 6 weeks: a) 1.8 g/d n-3 (1.08 g eicosapentoaenoic acid + 0.72 g docosahexaenoic acid); b) 2.0 g/d conjugated linoleic acid (CLA, 50:50, cis9:trans11, trans10:cis12), and c) 40 g/d walnut. The clinical and biochemical parameters were evaluated at the beginning and the end of the essay. Results: In the group with n-3 the triglycerides level decreased from 183.9 ± 35.2 mg/dl to 149.6 ± 29.0 mg/dl (P = .007). In the group with walnut the HDL level rose from 41.7 ± 5.2 mg/dl to 47.8 ± 5.4 mg/dl (P = .004) and the Castelli index (total cholesterol/HDL) decreased from 4.86 ± 0.97 to 3.82 ± 0.81 (P = .004). There were not significant changes in the CLA group. At the end of the essay, 46.7% of walnut group patients, 46.7% of n-3 group and 20% of CLA group, had no MS. Conclusions: The groups that consumed polyunsaturated fatty acids n-3 and those in walnut in moderate daily doses during 6 weeks had an improvement of the dyslipidemia component of MS, hypertriglyceridemia and low HDL level (AU)

[Metabolic syndrome reversion by polyunsaturated fatty acids ingestion]. / Reversión del síndrome metabólico por el consumo de ácidos grasos poliinsaturados.

BACKGROUND AND OBJECTIVE: Metabolic syndrome (MS) frequency is growing and diet has an important influence on its evolution. Our objective was to study the effect of 3 sources of polyunsaturated fatty acids on MS parameters in humans. PATIENTS AND METHOD: The MS was diagnosed according to the International Diabetes Federation. Three groups of individuals (n=15/group) were quasi-randomly assigned to one of the following treatments during 6 weeks: a) 1.8 g/d n-3 (1.08g eicosapentoaenoic acid+0.72 g docosahexaenoic acid); b) 2.0 g/d conjugated linoleic acid (CLA, 50:50, cis9:trans11, trans10:cis12), and c) 40 g/d walnut. The clinical and biochemical parameters were evaluated at the beginning and the end of the essay. RESULTS: In the group with n-3 the triglycerides level decreased from 183.9 ± 35.2mg/dl to 149.6 ± 29.0mg/dl (P=.007). In the group with walnut the HDL level rose from 41.7 ± 5.2mg/dl to 47.8 ± 5.4 mg/dl (P=.004) and the Castelli index (total cholesterol/HDL) decreased from 4.86 ± 0.97 to 3.82 ± 0.81 (P=.004). There were not significant changes in the CLA group. At the end of the essay, 46.7% of walnut group patients, 46.7% of n-3 group and 20% of CLA group, had no MS. CONCLUSIONS: The groups that consumed polyunsaturated fatty acids n-3 and those in walnut in moderate daily doses during 6 weeks had an improvement of the dyslipidemia component of MS, hypertriglyceridemia and low HDL level.

Abdominal wall hernias in end-stage renal disease patients on peritoneal dialysis.

OBJECTIVE: To describe our experience with hernioplasty in peritoneal dialysis patients and to identify possible risk factors for surgical complications. DESIGN: A 4-year retrospective chart review of data. SETTING: Peritoneal dialysis unit of a university hospital. PATIENTS AND METHODS: 58 hernias in 50 patients were included. Detailed surgical technique and complications were recorded. Possible risk factors included age, gender, weight, height, body mass index, previous surgery, diabetes, time on dialysis, emergency surgery, hospital stay, type of hernia, mesh use, blood hemoglobin, and serum urea, creatinine, and potassium. RESULTS: Complications occurred in 12 hernioplasties (4 wound infections, 2 peritonitis, 4 catheter dysfunction, and 5 re-operations). Recurrence rate was 12% without mesh use and 0% with mesh hernioplasty. Dialysis was re-instituted in 96% of cases within 3 days postoperatively. Identified risk factors for complications were diabetes, low weight, low height, small body mass index, and low serum creatinine. CONCLUSIONS: Mesh hernioplasty in peritoneal dialysis patients is advisable. Postoperative dialysis with low volume is feasible after surgery. Prospective studies will corroborate our risk factors for morbidity.

[Dengue fever during pregnancy. Cases report]. / Dengue durante el embarazo. Comunicación de casos.

Dengue is known as an endemic disease of tropical and subtropical regions. It was considered a disease very frequent on kids, but recently an increase was reported on adult people. Some of these cases were related to pregnant women, for that reason, we decided to check eight cases, including just the mothers who presented dengue virus infection through ELISA IgM. IgG and ELISA IgM studies. Five products were determined between 3 and 9-born-babies. Eight cases of dengue were analyzed during pregnancy, three cases of fever dengue and five cases of hemorrhagic dengue; main complications detected were threat of abortion, and premature labour, postsurgical bleeding with desiccant haematoma of uterine artery, oligohydramnios, as well as pleural effusion, two of the neonates were classified as septic for presenting fever. In no case, IgG or IgM for fever dengue was detected in neonates.

Living related kidney transplantation without calcineurin inhibitors: initial experience in a Mexican center.

We performed a prospective randomized trial comparing sirolimus/mycophenolate mofetil (MMF)/prednisone to cyclosporine/MMF/prednisone and selected induction therapy with basiliximab. Twenty patients received sirolimus (10 mg loading dose followed by 3 mg/m body surface area/day, keeping 24-hr trough levels at 10-15 ng/mL for six months and 5-10 ng/mL thereafter. Twenty-one patients began cyclosporine (4 to 8 mg/kg/day, keeping 12-hour trough levels at 150-300 ng/mL for 6 months and 100-200 ng/mL afterwards). Mean follow up was 15.8 months. One-year patient and graft survival was similar in both groups (>90%). Acute rejection rate was 16.6% in the sirolimus group and 5.2% in the cyclosporine group (P=NS). There were no differences in mean serum creatinine between groups. No patients who received basiliximab and had sirolimus target levels suffered acute rejection at one year. The sirolimus group had significantly higher cholesterol and triglycerides. A calcineurin inhibitor-free regimen using sirolimus produces comparable one-year transplant outcomes in living related kidney transplants compared to a calcineurin inhibitor regimen.

[Ectopia cordis: multidisciplinary approach with successful result]. / Ectopia cordis: manejo multidisciplinario con resultado exitoso.

Ectopia cordis is a pathology in which the heart is complete or partially outside of the thoracic cavity. It represents a challenge for the diagnosis and handling because of its high perinatal mortality. We present the first case of thoracic ectopia cordis with prenatal diagnostic (27th week), its multidisciplinary handling at Hospital de Ginecopediatria núm. 71 of the Centro Medico Nacional Adolfo Ruiz Cortines, IMSS, in Veracruz, Mexico. We communicate the case of a 24 year-old woman referred by her correspondent medical unit with the diagnosis of 23.6 weeks pregnancy with suspicion of heart malformation by ultrasound. The pregnancy was followed-up until the 38th week, when it was programmed a caesarean section. The newborn had ectopia cordis, which was treated at the moment of birth. In this article, we present pictures of the heart defect as well as its evolution. The up-to-date bibliography is revised about the medical profile and treatment. The handling of the ectopia cordis includes an appropriate prenatal diagnosis through echocardiograph, a multidisciplinary perinatal team, to program the caesarean operation, aseptic handling of the newborn, immediate correction of the wall defect with skin torn piece without trying to correct the costal grill, specific hemodynamic cares, to reprogramme a correction of associated defects.

Conversion from calcineurin inhibitor to sirolimus for renal function deterioration in kidney allograft recipients.

BACKGROUND: Calcineurin inhibitors play an important role in chronic allograft dysfunction. Sirolimus is an interesting alternative in renal transplant patients because it is less nephrotoxic than calcineurin inhibitors. METHODS: A chart review of the clinical outcome of kidney transplant patients converted to sirolimus with progressive allograft dysfunction is reported herein. Fifteen patients (average age: 32.3 years, 44 months mean time of conversion) were included. Indication for conversion was a >20% increase in serum creatinine over the last 6 months or progression to the range of 2-4.5 mg/dL. Patients underwent abrupt cessation of cyclosporine and sirolimus addition at 2-5 mg/day. RESULTS: Concomitant immunosuppression remained unchanged during conversion. Targeted sirolimus level was 8-12 ng/mL. Serum creatinine dropped from pre-conversion level of 2.75 +/- 0.83 to 2.14 +/- 0.67 and 1.97 +/- 0.66 mg/dL at 3 and 6 months (p <0.05). There was a significant decrease in blood urea nitrogen, hemoglobin and serum calcium at 3 months post-conversion as well as serum calcium and potassium at 6 months post-conversion (p <0.05). There were no rejection episodes. Patient and graft survival was 100% with three infectious complications. CONCLUSIONS: Monitored sirolimus conversion with sharp withdrawal of calcineurin inhibitor is an alternative for patients with deteriorating renal function and chronic allograft nephropathy.

[Perinatal hospital mortality: its relationship with prenatal care quality]. / Mortalidad perinatal hospitalaria y su relación con la calidad de la atención prenatal.

OBJECTIVE: Our aim was to analyze infant mortality at the Mexican Institute of Social Security (IMSS) North Veracruz, Mexico, Delegation from the perspective of prenatal care quality. MATERIALS AND METHODS: We performed a retrospective case-control study and included all cases of perinatal mortality at the IMSS at North Veracruz from July 1 to December 31, 2003. There were two controls per case matched by gender and date of birth. Prenatal care quality was evaluated by a specifically developed questionnaire. RESULTS: A total of 53 cases were used for the final analysis. Maternal age was similar between cases and controls (p = 0.814). There were fewer prenatal appointments (p = 0.0001), fewer test performed [blood test (p = 0.0001) and urine test (p = 0.004)], higher obstetric risk (p = 0.004), and fewer obstetric ultrasound imaging studies developed (p = 0.022) in cases of perinatal mortality vs. controls. Main variables related with perinatal mortality were the following: absent of blood test (odds ratio [OR] 4.7, 95% confidence interval [Cl 95%] 2.2-9.9, p = 0.0001); urine test (OR 4.4, CI 95% 1.5-12.6, p = 0.004), and obstetric ultrasound studies (OR 2.3, Cl 95%, 1.1-4.8, p = 0.022), and having fewer than five prenatal appointments (OR 2.2, Cl 95% 1.1-4.4, p = 0.018). CONCLUSIONS: There is evidence of inadequate prenatal care quality in cases of hospital perinatal mortality in Veracruz. Absence of obstetric ultrasound imaging studies and blood tests during prenatal care increases the risk of perinatal mortality 2-4 times.

Informe del primer trasplante de bloque cardiopulmonar realizado en México / Report of the first cardiopulmonar block transplantation performed in Mexico

Objetivo: Informar sobre el primer trasplante cardiopulmonar que se realiza en México. Diseño: Informe de caso clínico. Se trató de paciente femenino de 47 años de edad, con hipertensión pulmonar severa y defecto septal auricular en clase funcional III. El día 4 de junio de 1995, en el Hospital de Cardiología del Centro Médico Nacional Siglo XXI se obtuvo bloque cardiopulmonar a partir de donación múltiple y se traspantó a la paciente. Resultados: El tiempo de hipotermia isquémica fue de 3 horas. La actividad cardíaca reinició a los 14 segundos de reperfusión. El destete de la derivación cardiopulmonar se efectuó sin problemas. A las 36 horas presentó abdomen agudo por hemoperitoneo, se requirió laparotomía por hemostasia, además de detectarse pancreatitis. El bloque cardiopulmonar funcionó adecuadamente por 5 días al cabo de los cuales presentó aumento de cortocorcuitos, hipoxemia, bajo gasto cardíaco y falleció al sexto día. El informe de la autopsia fue: pancreatitis edematosa, rechazo de corazón y pulmón, cambios isquémicos del miocardio y edema pulmonar. Conclusión: Es factible realizar trasplante cardiopulmonar en nuestro país. Las complicaciones coinciden con las descritas en la literatura mundial