Prognostic impact of chronic obstructive pulmonary disease and bronchial asthma in patients with heart failure.

PURPOSE: To analyze the impact of chronic obstructive pulmonary disease (COPD) and bronchial asthma on therapeutic management and prognosis of patients with heart failure (HF). METHODS: Analysis of the information collected in a clinical registry of patients referred to a specialized HF unit from January-2010 to June-2012. Clinical profile, treatment and prognosis of patients was evaluated, according to the presence of COPD or asthma. Survival analyses were conducted by means of Kaplan-Meier and Cox's methods. Median follow-up was 1493 days. RESULTS: We studied 2577 patients, of which 251 (9.7%) presented COPD and 96 (3.7%) bronchial asthma. Significant differences among study groups were observed regarding to the prescription of beta-blockers (COPD=89.6%; asthma=87.5%; no bronchopathy=94.1%; p=0.002) and SGLT2 inhibitors (COPD=35.1%; asthma=50%; no bronchopathy=38.3%; p=0.036). Also, patients with bronchial disease received less frequently a defibrillator (COPD=20.3%; asthma=20.8%; no broncopathy=29%; p=0.004). COPD was independently associated with increased risk of all-cause mortality (HR=1.64; 95% CI 1.33-2.02), all-cause death or HF admission (HR=1.47; 95% CI 1.22-1.76) and cardiovascular death or heart transplantation (HR=1.39; 95% CI 1.08-1.79) as compared with patients with no bronchopathy. Bronchial asthma was not significantly associated with increased risk of adverse outcomes. CONCLUSIONS: COPD, but not asthma, is an adverse independent prognostic factor in patients with HF.

Implementation of the use of SPECT-portable for evaluation of surgical margins in breast cancer with indication of ROLL: First results.

OBJECTIVES: Main objective: To compare the effectiveness for checking surgical margins between SPECT-portable and mammography of the piece (RxM). SECONDARY OBJECTIVE: To standardize a pre-operative protocol using SPECT-portable and to evaluate the time required in the use of this technique. MATERIAL AND METHODS: Prospective longitudinal study with 36 patients (39 lesions) diagnosed with breast cancer (CM) with criteria for SNOLL/ROLL. A pre-surgical study of the tumor lesion was performed, after the eco-guided administration of 99mTc-nanocolloids of albumin/99mTc-macroaggregates of albumin, in the tumor lesion. Hybrid images (optical + SPECT) and 3D navigation images with gamma probe are obtained using freehandSPECT. In the operating room, 4-5 images are obtained with freehandSPECT, (I) on skin for tumor location, (II) after exposure of surgical bed for resection guide, (III) of the surgical bed after exeresis, (IV and V) the anterior-posterior and lateral surface of the surgical specimen. The three criteria to decide to extend the margins are: (a) residual activity (cps) at the edges of the surgical bed resection; (b) visual analysis of the uptake in the specimen; (c) a minimum distance of 10 mm from the edges of the specimen to the center of greatest uptake, plus the radius of the lesion. We study the concordance of: the depth measurement between ultrasound and freehandSPECT; the surgical margins between freehandSPECT vs. mammography of the specimen (RxM), considering anatomical pathology (AP) as the gold standard technique as reference; surgical time used with freehandSPECT and RxM. RESULTS: Intraoperative localization was performed in all cases. False negative (FN: no detection margin affected) with freehandSPECT: 9 margins; with RxM: 8. True positive (TP: detection margin affected) with freehandSPECT: 5 margins, with RxM: 6. True negative (TN: consider free margin when healthy) with freehandSPECT: 213 margins; with RxM: 196. Negative predictive value (NPV: probability of negative margin on unaffected part) with freehandSPECT: 95.9%, with RxM: 96.07%. Specificity with freehandSPECT: 96.8%, with RxM: 97%. The concordance of surgical bed margins between freehandSPECT and RxM: 94.5%. Between freehandSPECT and AP: 93.1%. Between RxM and PA: 93.5%, being all statistically significant (p-value <0.000), so we can affirm that both techniques are related or dependent on the reference technique, the PA. Degree of correlation between SPECT-portable and low PA (Kappa index: 0.34, 95% CI [0.22-0.47], and between RxM and moderate PA (Kappa index: 0.42, 95% CI [0.29-0.56], p-value <0.001. Comparison of the successes and failures of both techniques (SPECT-portable and RxM) and PA: Distribution χ2: 0.023 with degree of freedom 1, with value <0.05, so we can affirm that both techniques are similar, since there are no significant statistical differences. Median total OR time: 60.25 min (30-145). Mean freehandSPECT OR time: 5 scans = 10 min. CONCLUSIONS: There are no statistically significant differences in the probability to rule out affective margins that require a second surgery between both techniques (SPECT-portable and RxM) so, the technique performed with SPECT-Portable is a useful and effective procedure, which requires specific training with an optimized and multidisciplinary protocol. The time spent with SPECT-portable is feasible for daily practice.

Massive deep vein thrombosis in pregnant women: The importance of individualizing the action plan.

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially lethal condition to be taken into account in pregnant women, where the situation is favored by the characteristic physiological changes of the pregnancy, childbirth and the puerperium. The management of this pathology in this type of patient is based on anticoagulation, with the benefits and drawbacks that this implies. We present the case of a pregnant woman with massive DVT and the issues are discussed, such as the method of delivery (vaginal vs. cesarean section) or the management of treatment (LMWH vs. UFH) in order to obtain the safest situation for the patient.

Telemedicine- versus outpatient-based initiation and management of ketogenic diet therapy in children with drug-resistant epilepsy during the COVID-19 pandemic.

INTRODUCTION: Initiation of ketogenic diet therapies (KDT) for pediatric epilepsy is usually done on an inpatient basis and the diet is managed during clinical appointments following a protocol of visits and routine tests. Because of the 2019 coronavirus disease (COVID-19) pandemic and the associated lock-down measures, we switched from outpatient to telemedicine-based KDT initiation. OBJECTIVE: To explore the feasibility, effectiveness, and safety of online KDT initiation and follow-up by comparing a group of children with drug-resistant epilepsy that was managed by telemedicine compared to a group that was treated on an outpatient basis. MATERIALS AND METHODS: An observational study was conducted in two groups of patients with drug-resistant epilepsy who initiated KDT and were followed up with an online versus an outpatient modality by the interdisciplinary KDT team of Hospital Pediatria JP Garrahan in Buenos Aires, Argentina. Dietary compliance, ketosis, retention rate, adverse effects, number of contacts, and clinical outcome were evaluated at 1, 3, and 6 months on the diet. RESULTS: Overall, 37 patients were included, of whom 18 started the KD by telemedicine and 19 on an outpatient basis. Minimum follow-up of the patients was 6 months. All patients received the classic ketogenic diet. No statistical differences between the two groups regarding efficacy and safety of the diet were found. CONCLUSIONS: Our results support the feasibility and safety of initiating and management of KDT by telemedicine. Patients and their families should be carefully selected in order to guarantee a good outcome.

Clinical profile and causes of death according to ejection fraction in patients with heart failure cared for in a specialized Cardiology unit.

BACKGROUND AND OBJECTIVE: Patients with heart failure are classified into three phenotypes based on left ventricular ejection fraction. This work aimed to compare the clinical profile, treatment, prognosis, and causes of death of patients with heart failure and reduced (<40%, HF-rEF), preserved (≥50%, HF-pEF), or mid-range (40-49%, HF-mrEF) left ventricular ejection fraction. METHODS: An analysis was conducted on the clinical data included in a prospective registry of patients with heart failure who were referred to a specific Cardiology unit from 2010 to 2019. RESULTS: A total of 1404 patients with HF-rEF, 239 patients with HF-mrEF, and 266 patients with HF-pEF were analyzed. Significant differences were observed among the groups in regard to several clinical characteristics and the frequency of prescription of neurohormonal blocking drugs. A multivariate Cox regression revealed an increased risk of all-cause mortality in patients with HF-pEF (hazard ratio 1.36; 95% confidence interval 1.03-1.80; p = 0.028) and patients with HF-mrEF (hazard ratio 1.36; 95% confidence interval 1.03-1.78; p = 0.029) as compared to patients with HF-rEF. Heart failure was the most frequent cause of death in the three subgroups. A higher relative weight of sudden death as a cause of death was observed among patients with HF-rEF while the relative weight of non-cardiovascular causes of death was higher among patients with HF-pEF and HF-mrEF. CONCLUSIONS: This study confirms the existence of significant differences among patients with HF-rEF, HF-mrEF, and HF-pEF with regard to their clinical profile, therapeutic management, prognosis, and causes of death.

Iatrogenic tracheal rupture in a patient with acute respiratory distress syndrome due to SARS-CoV-2 pneumonia.

Iatrogenic tracheal rupture (ITR) is a serious complication secondary to procedures such as emergent orotracheal intubation or tracheostomy, among others. The management of ITR depends on the size, extension and location of the injury, along with the patient's respiratory status and comorbidities. The priority of treatment is to keep the airway permeable to ensure adequate ventilation. We present the case of a tracheal rupture after performing a percutaneous tracheostomy, in a patient diagnosed with severe acute respiratory distress syndrome secondary to bilateral interstitial pneumonia due to SARS-Cov-2. The issues are discussed, such as the management (conservative vs. surgical) depending on the features of the injury and the patient, in the extraordinary context that the COVID-19 pandemic has entailed.

Structurally Uncommon Secondary Metabolites Derived from Endophytic Fungi.

Among microorganisms, endophytic fungi are the least studied, but they have attracted attention due to their high biological diversity and ability to produce novel and bioactive secondary metabolites to protect their host plant against biotic and abiotic stress. These compounds belong to different structural classes, such as alkaloids, peptides, terpenoids, polyketides, and steroids, which could present significant biological activities that are useful for pharmacological or medical applications. Recent reviews on endophytic fungi have mainly focused on the production of novel bioactive compounds. Here, we focus on compounds produced by endophytic fungi, reported with uncommon bioactive structures, establishing the neighbor net and diversity of endophytic fungi. The review includes compounds published from January 2015 to December 2020 that were catalogued as unprecedented, rare, uncommon, or possessing novel structural skeletons from more than 39 different genera, with Aspergillus and Penicillium being the most mentioned. They were reported as displaying cytotoxic, antitumor, antimicrobial, antiviral, or anti-inflammatory activity. The solid culture, using rice as a carbon source, was the most common medium utilized in the fermentation process when this type of compound was isolated.

Epidemiological Aspects of Maternal and Congenital Toxoplasmosis in Panama.

In Panama, epidemiological data on congenital toxoplasmosis are limited, making it difficult to understand the scope of clinical manifestations in the population and factors that may increase the risk of infection. This study provides insight into the epidemiological situation of maternal and congenital toxoplasmosis in Panama and contributing information on the burden of this disease in Central America. Blood samples were collected from 2326 pregnant women and used for the detection of anti-T. gondii antibodies. A high seroprevalence (44.41%) was observed for T. gondii infection in pregnant women from different regions of Panama, with an estimated incidence rate of congenital toxoplasmosis of 3.8 cases per 1000 live births. The main risk factors associated with T. gondii infection using bivariate statistical analysis were an elementary level education and maternal age range of 34-45 years. Multivariate statistical analyses revealed that in some regions (San Miguelito, North and West regions), the number of positive cases correlated with the presence of pets, stray dogs and the consumption of poultry. In other regions (East and Metropolitan regions), the absence of pets was considered a protective factor associated with negative cases, while the presence of stray cats and the age range of 25-34 years did not represent any risk in these regions.

EXIT: Estado del arte y cómo lo hacemos

Resumen El protocolo EXIT (tratamiento ex-útero intraparto) es una técnica que permite establecer una vía aérea segura y estable, en un feto con obstrucción de esta o riesgo al momento del parto. Se basa en mantener la circulación uteroplacentaria con anestesia neonatal, logrando una hipotonía uterina controlada. Todo otorrinolaringólogo que se desempeñe en un hospital que cuente con un servicio de obstetricia de alta complejidad puede ser requerido en este tipo de casos y debe tener un protocolo establecido de cómo proceder. En nuestro medio se trata de un procedimiento poco frecuente que obliga a la revisión de la técnica. No existe un protocolo único en la literatura internacional, pero sí principios fundamentales. Se presenta caso clínico de un embarazo, en que se identifica una masa cervical fetal, realizándose el protocolo EXIT. Se realiza una revisión de la literatura, se describen los principios de esta técnica, así como también nuestro enfrentamiento y lecciones aprendidas.

Abstract The EXIT protocol (ex-utero intrapartum treatment) is a technique that allows establishing a safe and stable airway in a fetus with airway obstruction, or at risk of it, at the time of delivery. It is based on maintaining uteroplacental circulation with neonatal anesthesia, achieving controlled uterine hypotonia. Any otolaryngologist working in a hospital that has a highly complex gynecology and obstetric service may be required in this type of case and must have an established protocol of how to proceed. In our setting, it is an infrequent procedure, so it requires a revision of the surgical technique. There is no established protocol in the literature, but there are fundamental principles. We describe a clinical case of a pregnancy where a fetal cervical mass was identified, and an EXIT protocol was performed. A review of the literature is presented, the principles of this technique are described, as well as our procedure and lessons learned.

Frequency of Toxoplasma gondii and Risk Factors Associated with the Infection in Stray Dogs and Cats of Panama.

Stray animals such as dogs and cats have an important role in maintaining the transmission cycles and dissemination of Toxoplasma gondii. Therefore, the objective of this study was to evaluate the frequency of T. gondii in stray dogs and cats in six different regions of Panama and determine risk factors associated with the dynamics of infection in each of the studied regions. Data were obtained using serological tests for the detection of anti-T. gondii IgG and IgM antibodies. The results of this study revealed an overall infection frequency of 23.73%. The infection frequencies found in dog and cat populations were 25.70% and 21.93% respectively, showing no statistically significant difference. Risk factor correlations suggested different infection dynamics depending on the region analyzed. The San Miguelito, North and West regions were more associated with positive cases in dogs with an age range greater than 13 months. Conversely, the Metro, Central and East regions were more associated with negative cases in cats with age ranging between 0 and 5 months. Infection of the parasite in stray animals can be influenced by intrinsic characteristics of each region, which can potentiate different risk factors associated with the different routes of transmission.

Iatrogenic tracheal rupture in a patient with acute respiratory distress syndrome due to SARS-CoV-2 pneumonia. / Rotura traqueal iatrogénica en paciente con síndrome de distrés respiratorio agudo por neumonía SARS-CoV-2.

Iatrogenic tracheal rupture is a serious complication secondary to procedures such as emergent orotracheal intubation or tracheostomy, among others. The management of iatrogenic tracheal rupture depends on the size, extension and location of the injury, along with the patient's respiratory status and comorbidities. The priority of treatment is to keep the airway permeable to ensure adequate ventilation. We present the case of a tracheal rupture after performing a percutaneous tracheostomy, in a patient diagnosed with severe acute respiratory distress syndrome secondary to bilateral interstitial pneumonia due to SARS-CoV-2. The issues are discussed, such as the management (conservative vs. surgical) depending on the features of the injury and the patient, in the extraordinary context that the COVID-19 pandemic has entailed.

The Epidemiological and Clinical Characteristics of the Epidemic of Syphilis in Barcelona. / Las características epidemiológicas y clínicas de la epidemia de sífilis en Barcelona.

BACKGROUND: Since 2000, substantial increases in syphilis have been reported in metropolitan areas of Western countries, with increases noted among men who have sex with men (MSM). Clinical manifestations of syphilis might be influenced by concomitant VIH infection and previous episodes of syphilis. The objectives of this study were to describe the epidemiological and clinical characteristics of the cases of syphilis diagnosed in Barcelona. METHODS: Retrospective study of cases with early syphilis diagnosed in the referral STI Unit of Barcelona from January 2003 to December 2013. Revision of medical records with structured collection of epidemiological and clinical data. Univariate and multivariate statistical analyses comparing the characteristics of MSM cases with and without VIH infection and with and without previous syphilis. RESULTS: A total of 1702 cases of syphilis (37% primary, 48% secondary and 14% early latent) were diagnosed, 93% of them in MSM. Among MSM 40% were coinfected with VIH, VIH-positive cases were associated with a previous syphilis (aOR, 5.2 [95% CI, 3.32-8.24]) and with unprotected anal intercourse (aOR, 1.75 [95%CI, 1.17-2.63]). Cases with a history of syphilis presented less often with primary syphilis compared to those without it (27.5% vs. 40%) (aOR, 0.58 [95% CI, 0.44-0.77]). One year after treatment, the clinical and serological evolution were similar between VIH-positive and VIH-negative cases. CONCLUSION: The epidemic of syphilis in Barcelona disproportionately affects MSM and is closelly linked to VIH infection. The presentation of syphilis is influenced by VIH infection and by previous history of syphilis, without significant differences in their evolution after one year of treatment.

High sensitivity and reproducibility of in-house ELISAs using different genotypes of Trypanosoma cruzi.

The adequate choice of Trypanosoma cruzi strains as antigen source for the diagnosis of Chagas disease is still controversial due to differences in terms of accuracy reported between different diagnostic tests. In this study was determined if the genetic variability between different genotypes of T. cruzi (TcI, TcII and TcIV) affect the final diagnosis of Chagas disease. The sensitivity and specificity index of in-house ELISA tests prepared with different T. cruzi strains were evaluated with chagasic and non-chagasic control sera and using the TESA-blot as a reference test. The results of this study revealed that the sensitivity index did not vary, with percentages of 100% for all strains in both tests. However, the specificity index for ELISA tests showed differences between 92% and 98%, but were reduced to 78%-89% when Leishmania-positive sera were included. All ELISAs and TESA-blot prepared with different antigens and the recombinant Wiener test were challenged in an endemic community for Chagas disease in Panama. Both ELISAs and TESA-blot recognized the same positive sera, corroborating the sensitivity indexes (100%) found with the control sera. The TESA-blot maintained the specificity index of 100% and did not display false positives. However, the recombinant Wiener test decreased its sensitivity to 81.25%.

Radioiodine treatment of differentiated thyroid cancer related to guidelines and scientific literature. / Tratamiento del cáncer diferenciado de tiroides con radioyodo a la luz de las guías y de la literatura científica.

In differentiated thyroid cancer (DTC), radioiodine is administered to eliminate residual normal thyroid tissue after thyroidectomy (ablative treatment), to treat residual microscopic disease (adjuvant treatment), and to treat macroscopic or metastatic disease. Currently, treatment of DTC with 131I is still a matter of controversy due to the absence of prospective clinical trials assessing its benefit in terms of overall survival and recurrence-free interval. The current recommendations of the experts are based on observational retrospective data and on their interpretation of the literature. Pending the results of the prospective trials that are currently underway, the use of 131I seems to be justified not only in high-risk patients, but also in intermediate-risk and low-risk patients. The guidelines of The American and British Thyroid Association, European and American Societies of Nuclear Medicine, The European Consensus Group and the latest edition of National Comprehensive Cancer Network (NCCN) were considered in drawing up this continuing education document, we also undertook a review of the related scientific literature.

Clinical experience with integrase inhibitors in HIV-2-infected individuals in Spain.

BACKGROUND: HIV-2 is a neglected virus despite estimates of 1-2 million people being infected worldwide. The virus is naturally resistant to some antiretrovirals used to treat HIV-1 and therapeutic options are limited for patients with HIV-2. METHODS: In this retrospective observational study, we analysed all HIV-2-infected individuals treated with integrase strand transfer inhibitors (INSTIs) recorded in the Spanish HIV-2 cohort. Demographics, treatment modalities, laboratory values, quantitative HIV-2 RNA and CD4 counts as well as drug resistance were analysed. RESULTS: From a total of 354 HIV-2-infected patients recruited by the Spanish HIV-2 cohort as of December 2017, INSTIs had been given to 44, in 18 as first-line therapy and in 26 after failing other antiretroviral regimens. After a median follow-up of 13 months of INSTI-based therapy, undetectable viraemia for HIV-2 was achieved in 89% of treatment-naive and in 65.4% of treatment-experienced patients. In parallel, CD4 gains were 82 and 126 cells/mm3, respectively. Treatment failure occurred in 15 patients, 2 being treatment-naive and 13 treatment-experienced. INSTI resistance changes were recognized in 12 patients: N155H (5), Q148H/R (3), Y143C/G (3) and R263K (1). CONCLUSIONS: Combinations based on INSTIs are effective and safe treatment options for HIV-2-infected individuals. However, resistance mutations to INSTIs are selected frequently in failing patients, reducing the already limited treatment options.

The effect of light and outdoor activity in natural lighting on the progression of myopia in children.

PURPOSE: To investigate potential risk factors for the progression of myopia. METHODS: Prospective study. Myopic progression was evaluated by cycloplegic autorefraction and axial length (AL) every 6 months in children 6 to 15 years old. Univariate analysis and multiple logistic regression were applied. RESULTS: Around 82 children with median age of 10.3±2.3 years. Myopia progressed by -0.816±0.6 D over 18 months. Increased myopic spherical equivalent refraction (SER) was correlated with increase in AL (P<0.001). Univariate analysis found SER to be significantly associated with: age, especially between 6 and 9.4 years old (P=0.001), parental myopia (P=0.028), and less time spent outdoors (P=0.009). There was a significantly greater increase in SER during months with the least daylight hours (P<0.001). CONCLUSION: Outdoor activities and daylight have a protective effect against increased AL and progression of myopia. Younger children with significant myopia should be monitored closely, especially those around 6 years old with myopic parents.

Conocimiento, prácticas de prevención y bioseguridad sobre Brucelosis en trabajadores de hatos lecheros de Caaguazú-Paraguay / Knowledge, prevention and biosecurity practices about Brucellosis of workers exposed to risk of dairy data of Caaguazú-Paraguay

Introducción: La Brucelosis es una zoonosis común y en muchos países es un problema sanitario prevalente. En Paraguay no se ha encontrado evidencia de los conocimientos que tienen los trabajadores de hatos lecheros y las prácticas preventivas que utilizan. Objetivo: Evaluar el conocimiento, las prácticas de prevención y de bioseguridad sobre Brucelosis de los trabajadores expuestos a riesgo en hatos lecheros del departamento de Caaguazú, Paraguay. Materiales y métodos: Se realizó un estudio transversal, en una muestra representativa de establecimientos ganaderos del Departamento de Caaguazú. De mayo a junio de 2017 se entrevistó a 720 trabajadores de 360 hatos lecheros, utilizando un cuestionario estructurado, con preguntas cerradas. Se obtuvo información de los conocimientos, prácticas de prevención y bioseguridad sobre Brucelosis. Resultados: La mediana de edad de los trabajadores fue 34 años, 70% eran hombres. El 11,7% era analfabeto y 62,1% solo culminó la primaria. El 90% se desempeñaba como tambero/ordeñador. El 64% manifestó que no conocía la enfermedad, 73,6% ignoraba la forma en que se adquiere la enfermedad, 71,5% nunca recibió información acerca de la Brucelosis. El 73,3% no tenía conocimientos de las prácticas preventivas. Todos consumían subproductos lácteos sin pasteurizar, principalmente queso paraguay Conclusión: Existe desconocimiento de la enfermedad y la forma de transmisión. Las prácticas de riesgo son frecuentes. Es necesario implementar programas de educación y concienciación sobre la Brucelosis. Palabras clave: Brucelosis; conocimientos; prácticas de prevención; medidas de bioseguridad; humanos.

Background: Brucellosis is a common zoonosis and in many countries it is a prevalent health problem. In Paraguay, no evidence has been found of the knowledge that dairy herd workers have and the preventive practices they use. Objective: To evaluate the knowledge, prevention and biosecurity practices on Brucellosis of workers exposed to risk in dairy herds of Caaguazú. Materials and methods: A cross-sectional study was carried out in a representative sample of livestock establishments in the Department of Caaguazú. From May to June 2017, 720 workers from 360 dairy farms were interviewed, using a structured questionnaire with closed questions. Information on the knowledge, prevention and biosecurity practices on brucellosis was obtained. Result: The median age of the workers was 34 years, 70% were men. 11.7% were illiterate and 62.1% only completed the primary. 90% worked as a tambero/milker. Sixty-four percent said they did not know about the disease, 73.6% did not know how the disease was acquired, 71.5% never received information about brucellosis. 73.3% had no knowledge of preventive practices. All consumed unpasteurized dairy byproducts, mainly Paraguayan cheese. Conclusion: There is a lack of knowledge of the disease and the way of transmission. Risk practices are frequent. It is necessary to implement education and awareness programs on brucellosis. Keywords: Brucellosis; knowledge; prevention practices; biosecurity;survey; human.

Políticas y Programas que reducen los gastos catastróficos de salud en países de bajos y medianos ingresos / Policies and programs that reduce catastrophic health expenditures in low and middle income countries

RESUMEN Objetivo: Identificar las políticas y programas que han logrado reducir el gasto catastrófico de salud, en los países de bajos y medianos ingresos. Métodos: Revisión sistemática de publicaciones entre enero de 2013 y diciembre de 2017 mediante una estrategia de búsqueda secuencial con palabras claves y selección mediante criterios de inclusión PICO. Incluimos estudios experimentales, casi experimentales y otros diseños de comparación controlados. Resultados: Identificamos 5.668 publicaciones que evalúan gastos catastróficos, de los cuales 4.678 se relacionaban con distintas intervenciones sanitarias frecuentes que actúan sobre el modelo de financiamiento, 860 utilizaron metodologías rigurosas y 443 correspondían a países de bajos y medianos ingresos. Revisamos títulos y resúmenes y preseleccionamos 44 publicaciones que fueron revisadas exhaustivamente. Incluimos 8 publicaciones para el análisis: 3 realizadas en China, 2 en India, 1 en Lao, 1 en Indonesia y 1 en México. En la evaluación de impacto, 4 no demostraron variaciones estadísticamente significativas. Otros 4 demostraron reducción del gasto catastrófico, mediante distintos modelos de seguros de gestión pública. Conclusiones: Es posible ampliar la protección financiera de la población y evitar gastos catastróficos ante enfermedades, bajo ciertas condiciones y mediante intervenciones específicas como esquemas de aseguramiento público. El acervo de evidencias rigurosas en escaso y se necesitan más estudios sobre otros modelos de intervenciones. Palabras claves: protección financiera en salud, financiamiento de salud, gasto de bolsillo de salud, gasto catastrófico de salud, cobertura universal de salud.

ABSTRACT Objective: Identify the policies and programs that have managed to reduce catastrophic health spending in low and middle-income countries. Methods: A systematic review of publications between January 2013 and December 2017 through a strategy of sequential search with keywords and selection using PICO inclusion criteria. We included experimental, quasi-experimental and other controlled comparison designs. Results: We identified 5,668 publications that assess catastrophic expenditures, of which 4,678 were related to different frequent health interventions that act on the financing model, 860 used rigorous methodologies and 443 corresponded to low and middle-income countries. We reviewed titles and abstracts, and 44 publications were pre-selected and extensively revised. We included 8 publications for the analysis: 3 carried out in China, 2 in India, 1 in Lao, 1 in Indonesia and 1 in Mexico. In the impact evaluation, 4 did not show statistically significant variations. Another 4 showed a reduction in catastrophic spending, through different models of public management insurance. Conclusions: It is possible to expand the financial protection of the population and avoid catastrophic expenses in the face of diseases, under certain conditions and through specific interventions such as public insurance schemes. The collection of rigorous evidence in scarce and more studies are needed on other models of interventions. Key words: financial protection in health, health financing, out of pocket payments, catastrophic health expenditure, universal health coverage.