Carga de enfermedad de los adolescentes en Uruguay y su comparación con la de América Latina y el Caribe / Global burden of disease among teenagers in Uruguay and its comparison with Latin America and the Caribbean

Resumen Introducción. La adolescencia es considerada una etapa de buena salud y por tanto poco estudiada. El objetivo de este estudio es describir la evolución de la mortalidad en adolescentes en Uruguay y analizar la carga de enfermedad en esta etapa de la vida, a través de la medida de los Años de Vida Perdidos por Muerte Prematura en Uruguay y su comparación con los de América Latina y el Caribe según sexo, causa y subregión. Metodología. Se utilizaron fuentes de datos secundarias: el registro nacional de defunciones del Uruguay, el primer estudio de Carga Global de Enfermedad en Uruguay y la información presentada por la página de visualización de datos del Instituto de Métricas y Evaluación en Salud. Resultados. La mortalidad en los adolescentes se ha mantenidos aproximadamente estable entre 1997 y 2015. Loa años perdidos por muerte prematura para el Uruguay son más en los hombres y sus principales causas son los accidentes de tránsito, heridas auto infringidas y violencia. El mismo comportamiento se presenta en la región. Conclusiones. Los determinantes sociales de la salud vinculados a la pobreza e inequidad tienen un rol en el desarrollo de depresión, conductas riesgosas y violentas que posiblemente expliquen la perdida de años por muerte prematura en esta etapa de la vida.

Abstract Introduction. Adolescence is considered a healthy stage of life and therefore little studied. This study described mortality over time in teenagers in Uruguay and analysed the burden of disease at this stage of life by the measure of Years of Life Lost by Premature Death in Uruguay and by comparison with rates in Latin America and the Caribbean by sex, cause and sub-region. Methodology. Secondary data sources used were the national registry of deaths in Uruguay, the first Global Burden of Disease study in Uruguay and the information on the data visualisation page of the Institute of Metrics and Health Evaluation. Data were extracted by the authors and displayed in tables and graphs. Results. Teenager mortality held roughly stable between 1997 and 2015. More years were lost to premature death among Uruguayan men, the main causes being traffic accidents, self-inflicted injuries and violence. The same behaviour occurs throughout the region. Conclusions. The social determinants of health connected with poverty and inequality play a role in the development of depression, risky and violent behaviour, which possibly explain the loss of years due to premature death in adolescence.

Mordeduras por animales en niños. ¿Cuál es la situación actual en el Departamento de Emergencia Pediátrica del Centro Hospitalario Pereira Rossell? / Animal bites in children. What is the current situation in the Pediatric Emergency Department at Pereira Rossell Hospital?

Resumen: Las mordeduras de animales ocupan el 1% de las consultas en urgencias. En la mayoría el animal agresor es el perro, pudiendo generar lesiones de diversa gravedad, complicaciones infecciosas y secuelas. Objetivos: conocer la incidencia de mordeduras de animales en DEP-CHPR, características de la población, lesiones infligidas y conducta inicial. Material y método: estudio descriptivo, retrospectivo de pacientes que consultaron en DEP-CHPR por mordedura de animal, entre el 1/1/2013 y el 31/12/2015. Fuente: historias clínicas informatizadas. Se utilizó Epi-Info versión 3.5.4. Resultados: 872 niños mordidos (0,5% del total de consultas). Varones 544 (62%). Edad media 6 años (1 mes-14 años). Verano y primavera: 505 consultas (58%). En 442 pacientes (50%) animal conocido. Animal agresor: perro 837 (96%). Localización: Cara y cuero cabelludo: 478 (55%); media de edad 4,2 años. En miembros 327 (37,5%), múltiples 73 (8,4%). Severidad: leves 790 (90%), severa 7 (0,8%). Destino: domicilio 802 (92%), cuidados moderados 63 (7,2%), cuidados intensivos 7 (0,9%). No fallecimientos. En 428 (49%) suturas. Antibiótico profiláctico: 770 (88%). Secuelas estéticas: 26 (3%). Vacuna antitetánica vigente: 852 (98%). Notificación al Ministerio de Salud: 148 (17%). Conclusiones: este tipo de lesiones persisten con resultados similares a estudios anteriores. Los niños más pequeños sufren heridas más graves que afectan predominantemente cara y cuero cabelludo. Los pacientes mordidos requieren un abordaje integral: manejo de las lesiones, evaluación de riesgo de zoonosis y prevención de complicaciones. La adherencia al tratamiento antibiótico profiláctico fue elevada. Es necesario difundir protocolos de actuación y tratamiento que incluyan la notificación obligatoria y fortalecer las medidas de prevención primaria.

Summary: Animal bites represent 1% of emergency visits. In most cases attacking animals are dogs, causing lesions of variable entity, infectious complications and sequelae. Objectives: to learn about the incidence of animal bites in the Pediatric Emergency Department at Pereira Rossell Hospital, the characteristics of this population, the kind of lesions and their initial management. Method: descriptive, retrospective study including patients in the Pediatric Emergency Department at Pereira Rossell Hospital who consulted for animal bites between 1/1/13 - 12/31/15. Source: computerized clinical registries. Epi-Info version 3.5.4. was used. Results: 872 bitten children were included in the study (0.5% of total visits). Male 544 (62%). Median age was 6 years old (1 month -14 years), consultations in summer and spring 505 (58%). In 442 patients (50%) the animal was known. Attacker animal: dog 837 (96%). As to the site, face and scalp added up to 478 (55%); median age being 4.2 years old, and bites in the limbs added up to 327 (37.5%), multiple lesions were seen in 73 children (8.4%). Regarding severity: mild 790 (90%) and severe 7 (0.8%). Outcome: 802 children we discharged (92%), 63 were admitted (7.2%), admitted in the intensive care unit 7 (0.9%). No deaths we recorded. In 428 (49%) of cases suture was needed. Prophilactic antibiotic: 770 (88%). Aesthetic sequelae in 26 children (3%). Tetanus vaccine: 852 (98%). Notification to the Ministry of Health: 148 (17%). Conclusions: this kind of lesions persist, similar to previous local studies. Younger children suffer more severe lesions affecting mostly their face and scalp. Bitten patients require a comprehensive approach: injury management, evaluation of zoonosis risk and prevention of complications. Adherence to antibiotic treatment was high. It is necessary to spread management protocols that include compulsory notification to authorities and to strengthen the prevention measures.

Impacto de la implementación de oxigenoterapia de alto flujo en el manejo de la insuficiencia respiratoria por infecciones respiratorias agudas bajas en un departamento de emergencia pediátrica / Impact of high flow nasal cannula oxygen in the management of acute respiratory failure in a Pediatric Emergency Department

Introducción: la oxigenoterapia de alto flujo (OAF) administrada por cánulas nasales, se ha instaurado como una técnica sencilla, fácil de administrar, de bajo costo, sin complicaciones graves, efectiva para el tratamiento de la insuficiencia respiratoria (IR) en infecciones respiratorias agudas bajas (IRAB). Su aplicación temprana podría mejorar la evolución de estos niños. Objetivos: comunicar la primera experiencia con OAF en niños con IRAB en un Departamento de Emergencia Pediátrica (DEP). Compararla con una cohorte histórica de niños que no la recibió. Métodos: estudio descriptivo, prospectivo (1 de junio de 2013-20 de setiembre de 2013). Todos los niños tratados con OAF en DEP del Centro Hospitalario Pereira Rossell. Criterios de inclusión: <2 años con IRAB viral con IR y escore de Tal >8 o ³7 mantenido, apneas reiteradas, saturación de oxígeno <90% con O2 por máscara de flujo libre. Criterios de exclusión: pCO2 >70 mmHg, pH <7,2, depresión de conciencia, falla hemodinámica. Resultados: OAF 36 niños; mediana 4 meses; bronquiolitis 83%; VRS+ 58%. Destino pacientes en OAF: cuidados moderados 78%, UCI 22%, AVM 22%. No complicaciones ni fallecimientos. Cohorte histórica: 91 niños con IRAB no tratados con OAF. Cohorte histórica: UCI: 40 (44%) versus OAF (p=0,0005). AVM: cohorte histórica 30 (33%) versus OAF (p=0,026). Menores 6 meses: con OAF AVM 5 (19%), cohorte histórica: 25(45%) (p=0,026). Conclusiones: en un porcentaje elevado de pacientes fue posible evitar el ingreso a UCI. La necesidad de AVM en menores de 6 meses con OAF fue significativamente menor. La incorporación temprana de OAF en las IRAB graves modificó la forma de tratamiento de estos pacientes en la emergencia.

Introduction: high flow nasal cannula oxygen (HFNC) has become a simple, easy to implement, non-expensive technique, without serious complications, to treat respiratory failure in lower respiratory tract infections (LRTI). Its early implementation could improve outcome in these children. Objectives: to communicate the first experience with HFNC in children with LRTI in a Pediatric Emergency Department. To compare it with a historical cohort of children who did not receive HFNC. Methods: descriptive, prospective study (01/06/13-20/09/2013). Every child treated with HFNC in the Emergency Department -Pereira Rossell Hospital. Inclusion criteria: <2 years old with viral LRTI, respiratory failure and Tal score >8 or persistent ³7, persistent apnea, oxygen saturation <90% with O2 mask. Exclusion criteria: pCO2>70 mmHg, pH<7.2, depression of consciousness, hemodynamic failure. Results: HFNC 36 children; median age 4 months; bronchiolitis 83%; VRS+ 58%. Destination HFNC patients: admission 78%, PICU 22%, MV 22%. No complications, no deaths.. Historic cohort: 91 children with LRTI not treated with HFNC; PICU: 40(44%) vs HFNC (p=0.0005). MV: historic cohort 30(33%) vs HFNC (p=0.026). Younger than 6 months: HFNCO MV 5(19%), historic cohort: 25(45%) (p=0.026). Conclusions: admission to PICU was prevented in a high number of patients. Need for MV in patients younger than 6 months with HFNC was significantly lower. The early application of HFNC in severe LRTI modified the treatment of these patients in the emergency department.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition.

BACKGROUND: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. METHODS: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. FINDINGS: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. INTERPRETATION: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions. FUNDING: Bill & Melinda Gates Foundation.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. METHODS: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. FINDINGS: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. INTERPRETATION: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. FUNDING: Bill & Melinda Gates Foundation.