Satisfacción del usuario, sobre la calidad de atención recibida en medicina interna, de consulta externa, del Hospital Bautista de Managua Nicaragua, Junio 2019 / User satisfaction on the quality of care received in internal medicine, from outpatient clinic, from the Baptist Hospital of Managua Nicaragua, June 2019

Estudio descriptivo de corte transversal. Universo de 550 usuarios, muestra 227 usuarios, técnica través de encuesta, instrumento cuestionario de SERVQUAL, adaptado a servicios de salud, 22 preguntas de expectativas y 22 de percepciones, cinco dimensiones: bienes tangibles, confiabilidad, capacidad de respuesta, seguridad y empatía. Los datos recolectados se digitaron en una base de datos, procesándose en Microsoft Excel. El 54,6% fueron mujeres, grupo etario 50-59 años con 34,3%, el mayor porcentaje de satisfacción en expectativas, para Empatía 95,0% y en percepción fue Confiabilidad con 89,49%. Capacidad de respuesta, con menor porcentaje en expectativa 89,3% y percepción 74,24%. La brecha más alejada de 0 fue Capacidad de respuesta -0,75 puntos, con un índice de calidad de servicio de -0,46. El sexo de predominio fue mujeres, edad de más porcentaje 50-59 años, para expectativas, el mayor porcentaje fue Bienes tangibles, y menor, Capacidad de respuesta. Para percepción, el mayor porcentaje fue Empatía, y menor, Capacidad de respuesta. Índice de calidad menor a uno, considerando satisfactorio el servicio recibido.

Coronary vasospasm while treating supraventricular tachycardia: is adenosine really to blame?

Coronary artery spasm has been reported during adenosine stress testing. Herein, we describe a transient ST-segment elevation following adenosine therapy for supraventricular tachycardia. A 38-year-old male presented to the emergency department with palpitations. Electrocardiogram showed supraventricular tachycardia with short RP interval. Vagal maneuvers were unsuccessful. Adenosine was then administered in two successive injections of 6 and 12 mg dosages, respectively. A subsequent 12-lead electrocardiogram revealed ST-segment elevation in inferior leads with reciprocal changes. Coronary angiography disclosed nonobstructive coronary disease. A postprocedure electrocardiogram exhibited normal sinus rhythm with nonspecific T wave abnormalities. Cardiac biomarkers were elevated with a peak troponin I of 0.32. Echocardiogram depicted bicuspid aortic valve and normal systolic function. Electrophysiological study revealed a concealed left accessory pathway and successful radiofrequency ablation was performed. Given the dynamic changes in the electrocardiogram, we hypothesize that this event was most likely a coronary vasospasm. The mechanism of coronary spasm following adenosine injection remains uncertain. Potential mediators include KATP channels and adenosine-2 receptors.

Pseudo-pulmonic stenosis in non-hodgkin's large B-cell lymphoma.

There have only been a few cases reported of right ventricular outflow tract obstruction secondary to diffuse large B-cell lymphomas. Mediastinal masses rarely cause extrinsic compression of the heart resulting in hemodynamically significant obstruction. We report a rare case of right ventricular outflow tract obstruction secondary to diffuse large B-cell lymphomas. Echocardiography has been found to be a useful modality in the prompt identification of mediastinal masses and their effects on the otherwise healthy heart.

A multicenter, randomized, double-blind, placebo-controlled study of tolvaptan monotherapy compared to furosemide and the combination of tolvaptan and furosemide in patients with heart failure and systolic dysfunction.

BACKGROUND: Increased vasopressin levels may be present in patient with chronic heart failure (HF) and contribute to pathophysiology through effects on the vasopressin V2 receptor. The presence of background diuretic therapy may confound evaluations of vasopressin receptor antagonists (VRA). METHODS AND RESULTS: Eligible patients had HF (New York Heart Association Class II-III), systolic dysfunction (left ventricular ejection fraction ≤0.40) and signs of congestion (eg, edema, rales). At screening, patients were removed from baseline diuretic therapy and placed on a low-sodium diet (2 g/day). After a 2-day run-in period, 83 patients were randomized to placebo (n = 21), monotherapy with the vasopressin V2 receptor antagonist tolvaptan (TLV) 30 mg (n = 20), monotherapy with furosemide 80 mg (FURO, n = 22) or both TLV 30 mg and FURO 80 mg (n = 20) once daily for 7 days. Patients were on standard background therapy and not fluid-restricted throughout the study. A decrease in body weight of -1.37 ± 1.61, -0.54 ± 1.59, and -1.13 ± 1.49 kg was observed versus baseline for TLV, FURO, and TLV+FURO, respectively, at day 8. At the same point, the placebo group showed a body weight increase of +0.72 ± 2.42 kg versus baseline (P = .0006 for TLV versus placebo). Increases in urine volume from baseline were greater with TLV alone (2646 ± 1503 mL/24 hours) than with FURO (894 ± 853 mL/24 hours, P < .001), or PLC (423 ± 786 mL/24 hours, P < .001), and similar to TLV+FURO (2585 ± 2119 mL/24 hours). An increase in serum sodium within the normal range was also observed in TLV-treated patients (P < .02 versus placebo; P < .01 versus FURO). No changes in serum potassium, other laboratory values, or blood pressure were observed. TLV therapy was well tolerated. CONCLUSIONS: In patients with HF and signs of volume overload, TLV monotherapy without concomitant loop diuretic therapy reduced body weight when compared to placebo without adverse changes in serum electrolytes, during a sodium restricted diet while on background medications including angiotensin-converting enzyme inhibitors and ß-blockers.

Prediction of medical morbidity and mortality after acute myocardial infarction in patients at increased psychosocial risk in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study.

BACKGROUND: Patients with myocardial infarction (MI) are at further increased risk for untoward events when patients also exhibit low social support and/or depression. The ENRICHD study was the largest controlled trial in post-MI patients attempting to treat these psychological comorbidities and provides an opportunity to examine the medical and psychological characteristics that may affect risk in this population. METHODS: We analyzed the baseline characteristics and their relationship to the primary end point of long-term mortality and recurrent infarction and to the secondary end points of overall mortality and cardiovascular mortality in 2481 post-MI patients. Cox proportional hazards models were used to predict the risk of these outcomes over a mean of 2.5 years of follow-up. RESULTS: Death or nonfatal MI occurred in 24.1%, all-cause mortality in 13.7%, and cardiovascular mortality in 8.4% of the sample (62% of the total). Age, heart failure, pulmonary disease, Killip class, ejection fraction, an elevated creatinine, the use of non-angiotensin-coverting enzyme asodilators, prior MI, diabetes, depression, and bypass surgery after acute MI were all significant multivariable predictors. CONCLUSIONS: The medical predictors of adverse events in post-MI patients with low social support and/or depression were similar to those of patients with MI in other clinical trials.

Vasopeptidase inhibition with omapatrilat in chronic heart failure: acute and long-term hemodynamic and neurohumoral effects.

OBJECTIVES: We investigated the acute and long-term hemodynamic and neurohumoral effects of the vasopeptidase inhibitor omapatrilat in human heart failure. BACKGROUND: Angiotensin-converting enzyme (ACE) inhibition constitutes a major advance in the treatment of chronic heart failure (CHF). Simultaneous inhibition of both neutral endopeptidase and ACE with omapatrilat may represent a new treatment strategy in CHF. METHODS: Three hundred and sixty-nine patients with symptomatic heart failure were randomized to double-blind treatment with omapatrilat (first 190 patients: 2.5 mg, 5 mg or 10 mg; last 179 patients: 2.5 mg, 20 mg or 40 mg once daily) for 12 weeks. RESULTS: Acutely, the 10 mg, 20 mg and 40 mg doses of omapatrilat produced greater reductions in pulmonary capillary wedge pressure (PCWP), systolic blood pressure (SBP) and systemic vascular resistance compared with 2.5 mg. Higher doses were associated with greater increases in vasodilator and natriuretic peptides, in addition to ACE inhibition. After 12 weeks, omapatrilat 20 mg and 40 mg showed greater falls from baseline in PCWP (40 mg: 0 h to 12 h average change -7.3 +/- 0.8 mm Hg) and SBP (40 mg: -11.7 +/- 1.7 mm Hg) than 2.5 mg (both p < 0.01 vs. 2.5 mg). The incidence of adverse experiences and patient withdrawal were similar in all groups. CONCLUSIONS: In CHF, the acute hemodynamic benefit seen with higher doses of omapatrilat was associated with increases in plasma vasodilator and natriuretic peptide levels in addition to ACE inhibition. After 12 weeks, the hemodynamic benefit was maintained. Omapatrilat may be a promising new agent in CHF.

Naked plasmid DNA encoding fibroblast growth factor type 1 for the treatment of end-stage unreconstructible lower extremity ischemia: preliminary results of a phase I trial.

OBJECTIVE: The objective of this study was to evaluate the safety and tolerance of increasing single and repeated (n = 2) doses of intramuscular naked plasmid DNA encoding for fibroblast growth factor (FGF) type 1 (NV1FGF) administered to patients with unreconstructible end-stage peripheral arterial occlusive disease (PAD). The secondary objectives were to determine the biologic activity of NV1FGF on hemodynamic and clinical parameters associated with improved perfusion. METHODS: Fifty-one patients with unreconstructible peripheral arterial occlusive disease with rest pain or tissue necrosis underwent treatment with intramuscular NV1FGF. Increasing single (500, 1000, 2000, 4000, 8000, and 16,000 microg) and repeated (2 x 500, 2 x 1000, 2 x 2000, 2 x 4000, and 2 x 8000 microg) doses of NV1FGF were injected into the ischemic thigh and calf. Arteriography was performed before treatment and was repeated 12 weeks after treatment. Side effects and serious adverse events were monitored. Measurements of plasma and urine levels were performed to evaluate NV1FGF plasmid distribution. Serum FGF-1 was measured as an analysis of gene expression at the protein level. Transcutaneous oxygen pressure, ankle brachial index, toe brachial index, pain assessment with visual analog scale, and ulcer healing also were assessed. The safety results are presented for 51 patients, and the clinical outcomes are presented for the first 15 patients (500 to 4000 microg) who completed the 6-month follow-up study. RESULTS: NV1FGF was well tolerated. Sixty-six serious adverse events were reported; however, none were considered to be related to NV1FGF. Four patients had adverse events that were possibly or probably related to the study treatment: injection site pain, pain, peripheral edema, myasthenia, and paresthesia. No laboratory adverse events were related to the study treatment. Two deaths remote from the treatment were considered not related. Biodistribution of plasmid was limited and transient in plasma and absent in urine. No increase in the FGF-1 serum level was detected. A significant reduction in pain (P <.001) and aggregate ulcer size (P <.01) was associated with an increased transcutaneous oxygen pressure (P <.01) as compared with baseline pretreatment values. A significant increase in ankle brachial index (P <.01) was seen. CONCLUSION: NV1FGF is well tolerated and potentially could be effective for the treatment of patients with end-stage limb ischemia. Biologic parameters indicate improved perfusion after NV1FGF administration. Dose response is not yet evident. The safety of NV1FGF and the magnitude of improvement observed in this study encourage further investigation with a placebo-controlled, double-blind clinical trial.

Digitized electrocardiograms recorded with bipolar right-infraclavicular leads compared to electrocardiograms recorded with unipolar chest V leads and bipolar lead II.

This article presents a method for the evaluation of cardiac depolarizations in a relatively short time with a minimum number of electrodes. With the negative electrode attached to the right infraclavicular region, voltage variations on the chest surface exhibit larger excursions than do the usual unipolar leads. Peak voltages of the PQRST waveforms measured on 12 normal patients by both methods were similar in polarity but were statistically significantly higher in the right infraclavicular leads. Data are presented on 21 normal patients, which show that digitized signals allow for an expanded time-scale leading to higher resolution of rate of change and onset and offset times. The digitized signals also more clearly define notches that distort the QRS complex. In 55 cardiac patients, the 12-lead unipolar electrocardiograms were visually compared to digitized electrocardiograms recorded by using the bipolar right infraclavicular leads. The authors suggest that RIC leads would be most useful in the design of a pocket-sized digitizing bipolar-lead electrocardiograph.

Manejo del infarto agudo del miocardio: estudio comparativo de experiencias en el Hospital Jackson Memorial de Miami y Hospital Luis Vernaza de Guayaquil / Handling of the acute infarct of the myocardium: comparative study of experiences in Memorial the Jackson Hospital of Miami and Hospital Luis Vernaza de Guayaquil

El infarto agudo del miocardio (IAM) es una de las enfermedades más comunes y su mortalidad es mayor después de las primeras horas de inicio. Es por ende importante hacer un rápido diagnóstico para acelerar la admisión del paciente y proveer terapia adecuada. El objetivo principal se basó en establecer diferencias de manejo entre el Jackson Memorial Hospital (JMH) de Miami y el Hospital Luis Vernaza (HLV) de Guayaquil. El siguiente es un estudio prospectivo. Se incluyeron 30 pacientes en Miami y 15 en Guayaquil que cumplieron con criterios diagnósticos para IAM. En el HLV se diagnosticó prácticamente por manifestaciones de isquemia y un electrocardiograma, no se utilizaron trombolíticos, ni inhidores de la gicloproteina...