Strengthening Essential Health Services Recovery Policy after the COVID-19 Pandemic. Evidence from the Mexican Institute of Social Security.

AIM: To evaluate the progress of the Mexican Institute of Social Security Recovery Policy (IMSS-RP) in addressing the decline in essential health services caused by the COVID-19 pandemic. METHODS: We analyzed eleven indicators of essential health services from 35 IMSS state delegations. The assessment included ambulatory and hospital care indicators such as breast and cervical cancer screening, family medicine, dental and specialty visits, diabetes and hypertension visits and health outcomes, deliveries, and elective surgeries. We analyzed the period before (January 2018-March 2021) and during (April 2021-June 2023) the implementation of the IMSS-RP. Statistical analysis to determine the association of the policy with service indicators and the change in their trends included an interrupted time series analysis and Poisson Generalized Estimating Equation models. RESULTS: The volume of services showed substantial declines during the first year of the COVID-19 pandemic, reaching between 11 and 81% of pre-pandemic levels. All services increased significantly during the first 27 months of the IMSS-RP implementation; specialty visits, cervical and breast cancer screening, and diabetes control exceeded pre-pandemic levels (103%,112%,103%, and 138%, respectively). However, only deliveries and the percentage of patients with controlled diabetes and hypertension showed a stable increase following the IMSS-RP implementation, whereas the remaining services showed an initial increase but began to decrease over time. CONCLUSIONS: After 27 months of implementation, IMSS-RP achieved progress in increasing the volume of essential health services and improving chronic disease control. However, declining trends in several services signal the need to focalize the policy.

[Lifestyle modification and risk factor control in the prevention and treatment of atrial fibrillation]. / Modificaciones en el estilo de vida y control de los factores de riesgo en la prevención y el tratamiento de la fibrilación auricular.

Atrial fibrillation (AF) is the most prevalent arrhythmia and is related with significant morbidity, mortality and costs. In spite of relevant advances in the prevention of embolic events and rhythm control, little has been done to reduce its prevalence, progression and impact, since it increases with ageing as well as with common risk factors such as alcohol intake, tobacco use and stress as well as with arterial hypertension, diabetes mellitus, heart failure, sleep apnea, kidney failure, chronic pulmonary obstructive disease, ischemic heart disease and stroke, among other important comorbidities. Fortunately, new evidence suggests that lifestyle modifications and adequate risk factors and comorbidities control could be effective in primary and secondary AF prevention, especially in its paroxysmal presentations. This is why a multidisciplinary approach integrating lifestyle modifications, risk factors and comorbidities control, is necessary in conjunction with rhythm or rate control and anticoagulation. Unfortunately, that holistic approach strategy is not considered, is scarcely studied or is subtilized in general clinical practice. The present statement's objectives are to: 1) review the relationship between habits, risk factors and illnesses with AF, 2) review the individual and common physiopathology mechanisms of each one of those conditions that may lead to AF, 3) review the effect of control of habits, risk factors and co-morbidities on the control and impact of AF, and 4) supply guidelines and recommendations to start multidisciplinary and integrative AF treatment.

La fibrilación auricular (FA) es la arritmia más frecuente y se asocia con importante morbilidad, mortalidad y costos. A pesar de los grandes avances en la prevención de eventos embólicos y en el control del ritmo, poco se ha realizado para reducir su prevalencia, progresión e impacto, debido a que incrementa con la edad y con la presencia de múltiples factores de riesgo muy comunes en la población, como obesidad, sedentarismo, alcoholismo, tabaquismo y estrés, así como con hipertensión arterial sistémica, diabetes mellitus, insuficiencia cardiaca, apnea del sueño, enfermedad renal crónica, enfermedad pulmonar obstructiva crónica, cardiopatía isquémica y enfermedad vascular cerebral, entre otra comorbilidad importante. Afortunadamente, nuevas evidencias demuestran que las modificaciones en el estilo de vida y el control adecuado de los factores de riesgo y de la comorbilidad pueden ser efectivos en la prevención primaria y secundaria de la FA, en especial en sus formas paroxísticas; para ello, es necesario un manejo multidisciplinario que integre las modificaciones en el estilo de vida, el manejo de los factores de riesgo y el control de la comorbilidad en el tratamiento de la FA en conjunto con el control del ritmo o de la frecuencia y la anticoagulación. Por desgracia, en la práctica clínica estas estrategias a menudo no se tienen en cuenta, son infrautilizadas y poco estudiadas. Los objetivos del presente posicionamiento son: 1) revisar la relación de los factores de riesgo y la comorbilidad con la FA, 2) revisar los mecanismos fisiopatológicos de cada una de estas condiciones, 3) revisar el impacto del control de los factores de riesgo y de la comorbilidad en el control y en el impacto de la FA, y 4) proporcionar guías y recomendaciones para la puesta en práctica de programas de tratamiento multidisciplinario e integral en pacientes con FA.

A Geospatial Model to Identify Areas Associated with Late- Stage Breast Cancer: A Spatial Epidemiology Approach.

OBJECTIVE: The aim of this study was to show how a geospatial model can be used to identify areas with a higher probability for late-stage breast cancer (BC) diagnoses. METHODS: Our study considered an ecological design. Clinical records at a tertiary care hospital were reviewed in order to obtain the place of residence and stage of the disease, which was classified as early (0-IIA) and late (IIB-IV) and whose diagnoses were made during the 2013-2017 period. Then, they were geolocated to identify the distribution and spatial trend. Subsequently, the pattern of location, i.e. scattered, random and concentrated, was statistically assessed and a geospatial model was elaborated to determine the probability of late diagnoses in the state of Jalisco, Mexico. RESULT: There were 1 954 (N) geolocated BC diagnoses: 58.3% were late. During the five-year period, a southwest-northeast trend was identified, nearly 9.5% of the surface of Jalisco, where 6 out of 10 (n= 751) late- stage diagnoses were concentrated. A concentrated and statistically significant pattern was identified in the southern, central and northern Pacific area of Jalisco, where the geospatial model delimited the places with the highest probability of late clinical stages (p <0.05). CONCLUSION: The geographical differences associated with the late diagnoses of BC suggest it is necessary to adapt and focus the strategies for early detection as an alternative to create a major impact on the population. Reproducible analysis tools were used in other contexts where geolocation data are available to complement public policies and strategies aimed to control BC.

The road to recovery: an interrupted time series analysis of policy intervention to restore essential health services in Mexico during the COVID-19 pandemic.

Background: Recovery of health services disrupted by the COVID-19 pandemic represents a significant challenge in low- and middle-income countries. In April 2021, the Mexican Institute of Social Security (IMSS), which provides health care to 68.5 million people, launched the National Strategy for Health Services Recovery (Recovery policy). The study objective was to evaluate whether the Recovery policy addressed COVID-related declines in maternal, child health, and non-communicable diseases (NCDs) services. Methods: We analysed the data of 35 IMSS delegations from January 2019 to November 2021 on contraceptive visits, antenatal care consultations, deliveries, caesarean sections, sick children's consultations, child vaccination, breast and cervical cancer screening, diabetes and hypertension consultations, and control. We focused on the period before (April 2020 - March 2021) and during (April 2021 - November 2021) the Recovery policy and used an interrupted time series design and Poisson Generalized Estimating Equation models to estimate the association of this policy with service use and outcomes and change in their trends. Results: Despite the third wave of the pandemic in 2021, service utilization increased in the Recovery period, reaching (at minimum) 49% of pre-pandemic levels for sick children's consultations and (at maximum) 106% of pre-pandemic levels for breast cancer screenings. Evidence for the Recovery policy role was mixed: the policy was associated with increased facility deliveries (IRR = 1.15, 95%CI = 1.11-1.19) with a growing trend over time (IRR = 1.04, 95%CI = 1.03-1.05); antenatal care and child health services saw strong level effects but decrease over time. Additionally, the Recovery policy was associated with diabetes and hypertension control. Services recovery varied across delegations. Conclusions: Health service utilization and NCDs control demonstrated important gains in 2021, but evidence suggests the policy had inconsistent effects across services and decreasing impact over time. Further efforts to strengthen essential health services and ensure consistent recovery across delegations are warranted.

Análisis geográfico de nefropatía diabética e insuficiencia renal en el primer nivel de atención, IMSS 2019 / Geographic analysis of diabetic nephropathy and renal insufficiency in the primary care, IMSS 2019

Introducción: en un contexto donde la prevalencia de diabetes mellitus e hipertensión arterial ha aumentado significativamente en años recientes, las enfermedades renales adquieren importancia por la potencial demanda de atención especializada y de recursos en salud que requieren. Objetivo: analizar la distribución geográfica de la nefropatía diabética (ND) y la insuficiencia renal (IR) con base en las consultas otorgadas en unidades de primer nivel del Instituto Mexicano del Seguro Social (IMSS) durante 2019, para identificar las unidades médicas con mayor carga de atención. Material y métodos: estudio ecológico-exploratorio en el que se estimaron indicadores por cada mil derechohabientes en relación a las consultas otorgadas por ND e IR según la ocasión de servicio, la unidad médica familiar (UMF) de primer nivel y la representación. Se utilizó estadística espacial para analizar dichos indicadores. Resultados: el 45% de las consultas otorgadas fue por ND y el 52.4% por IR. La mayor carga por ND se registró en la UMF No. 50 de Cd. Juárez (Chihuahua) y en la No. 49 Gabino Barreda (Veracruz Sur), con 1.7 consultas de primera vez y 148.3 subsecuentes por mil derechohabientes, respectivamente. Mientras que en la UMF No. 40 Manlio Fabio Altamirano y No. 25 Cotaxtla, en Veracruz Norte, la mayor carga fue por IR, con 4.9 consultas de primera vez y 134.2 subsecuentes por mil derechohabientes, respectivamente. Conclusiones: los resultados podrían contribuir al fortalecimiento de las unidades médicas que así lo requieran y en la distribución eficiente de los recursos disponibles para atender la demanda de servicios de salud de ND e IR en el IMSS

Background: In a context where the prevalence of Diabetes Mellitus and Hypertension has increased significantly in recent years, kidney diseases become important for the potential demand for specialized health care and resources required. Objective: To analyze the geographical distribution of Diabetic Nephropathy (DN) and Renal Insufficiency (RI) based on the medical consultations given in first-level units of IMSS during 2019, to identify the medical units with the highest burden of care. Material and methods: Ecological-exploratory study in which indicators were estimated for every thousand persons in relation to medical consultations given by ND and RI according to service time, first-level medical unit (UMF) and representation to analyze the magnitude and geographic distribution at the national level. Results: 45% of medical consultations were by ND and 52.4% by RI. The highest burden per DN was registered in UMF No. 50 Cd. Juarez (Chihuahua) and No. 49 Gabino Barreda (Veracruz Sur), with 1.7 first-time medical consultations and 148.3 subsequent medical consultations per 1,000 persons, respectively. While in UMF No. 40 Manlio Fabio Altamirano and No. 25 Cotaxtla, in Veracruz Norte, the highest burden was for RI, with 4.9 first-time medical consultations and 134.2 subsequent medical consultations per 1000 persons, respectively. Conclusions: The results could contribute to strengthening of medical units where it is necessary and the efficient allocation of resources available to meet the demand for health services of ND and RI in IMSS.

Guía de práctica clínica mexicana para el diagnóstico y tratamiento de las dislipidemias y enfermedad cardiovascular aterosclerótica.

ANTECEDENTES: Las enfermedades cardiovasculares son la principal causa mundial de mortalidad y México no es la excepción. Los datos epidemiológicos obtenidos en 1990 mostraron que los padecimientos cardiovasculares representaron el 19.8% de todas las causas de muerte en nuestro país; esta cifra se incrementó de manera significativa a un 25.5% para 2015. Diversas encuestas nacionales sugieren que más del 60% de la población adulta tiene al menos un factor de riesgo para padecer enfermedades cardiovasculares (obesidad o sobrepeso, hipertensión, tabaquismo, diabetes, dislipidemias). Por otro lado, datos de la Organización Panamericana de la Salud han relacionado el proceso de aterosclerosis como la primer causa de muerte prematura, reduciendo la expectativa de vida de manera sensible, lo que tiene una enorme repercusión social. OBJETIVO: Este documento constituye la guía de práctica clínica (GPC) elaborada por iniciativa de la Sociedad Mexicana de Cardiología en colaboración con la Sociedad Mexicana de Nutrición y Endocrinología, A.C., Asociación Nacional de Cardiólogos de México, A.C., Asociación Mexicana para la Prevención de la Aterosclerosis y sus Complicaciones, A.C., Comité Normativo Nacional de Medicina General, A.C., Colegio Nacional de Medicina Geriátrica, A.C., Colegio de Medicina Interna de México, A.C., Sociedad Mexicana de Angiología y Cirugía Vascular y Endovenosa, A.C., Instituto Mexicano de Investigaciones Nefrológicas, A.C. y la Academia Mexicana de Neurología, A.C.; con el apoyo metodológico de 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 de expertos. El objetivo de este documento es el de brindar recomendaciones basadas en evidencia para ayudar a los tomadores de decisión en el diagnóstico y tratamiento de las dislipidemias en nuestro país. MATERIAL Y MÉTODOS: Este documento cumple con estándares internacionales de calidad, como los descritos por el Instituto de Medicina de EE.UU., el Instituto de Excelencia Clínica de Gran Bretaña, la Red Colegiada para el Desarrollo de Guías de Escocia y la Red Internacional de Guías de Práctica Clínica. Se integró un grupo multidisciplinario de expertos clínicos y metodólogos con experiencia en revisiones sistemáticas de la literatura y el desarrollo de guías de práctica clínica. Se consensuó un documento de alcances, se establecieron las preguntas clínicas relevantes, se identificó de manera exhaustiva la mejor evidencia disponible evaluada críticamente en revisiones sistemáticas de la literatura y se desarrollaron las recomendaciones clínicas. Se utilizó la metodología de Panel Delphi modificado para lograr un nivel de consenso adecuado en cada una de las recomendaciones contenidas en esta GPC. RESULTADOS: Se consensuaron 23 preguntas clínicas que dieron origen a sus respectivas recomendaciones clínicas. CONCLUSIONES: Esperamos que este documento contribuya a la mejor toma de decisiones clínicas y se convierta en un punto de referencia para los clínicos y pacientes en el manejo de las dislipidemias y esto contribuya a disminuir la morbilidad y mortalidad derivada de los eventos cardiovasculares ateroscleróticos en nuestro país. BACKGROUND: Cardiovascular diseases are the leading cause of mortality worldwide and Mexico is no exception. The epidemiological data obtained in 1990 showed that cardiovascular diseases represented 19.8% of all causes of death in our country. This figure increased significantly to 25.5% for 2015. Some national surveys suggest that more than 60% of the adult population has at least one risk factor for cardiovascular disease (obesity or overweight, hypertension, smoking, diabetes, dyslipidemias). On the other hand, data from the Pan American Health Organization have linked the process of atherosclerosis as the first cause of premature death, significantly reducing life expectancy, which has enormous social repercussions. OBJECTIVE: This document constitutes the Clinical Practice Guide (CPG) prepared at the initiative of the Mexican Society of Cardiology in collaboration with the Mexican Society of Nutrition and Endocrinology, AC, National Association of Cardiologists of Mexico, AC, Mexican Association for the Prevention of Atherosclerosis and its Complications, AC, National Normative Committee of General Medicine, AC, National College of Geriatric Medicine, AC, College of Internal Medicine of Mexico, AC, Mexican Society of Angiology and Vascular and Endovenous Surgery, AC, Mexican Institute of Research Nephrological, AC and the Mexican Academy of Neurology, A.C.; with the methodological support of the Ibero-American Agency for the Development and Evaluation of Health Technologies, in order to establish recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. The objective of this document is to provide evidence-based recommendations to help decision makers in the diagnosis and treatment of dyslipidemias in our country. MATERIAL AND METHODS: This document complies with international quality standards, such as those described by the Institute of Medicine of the USA, the Institute of Clinical Excellence of Great Britain, the Scottish Intercollegiate Guideline Network and the Guidelines International Network. A multidisciplinary group of clinical experts and methodologists with experience in systematic reviews of the literature and the development of clinical practice guidelines was formed. A scope document was agreed upon, relevant clinical questions were established, the best available evidence critically evaluated in systematic literature reviews was exhaustively identified, and clinical recommendations were developed. The modified Delphi Panel methodology was used to achieve an adequate level of consensus in each of the recommendations contained in this CPG. RESULTS: 23 clinical questions were agreed upon which gave rise to their respective clinical recommendations. CONCLUSIONS: We consider that this document contributes to better clinical decision-making and becomes a point of reference for clinicians and patients in the management of dyslipidemias and this contributes to reducing the morbidity and mortality derived from atherosclerotic cardiovascular events in our country.

[Medical Care of people living with HIV in the Instituto Mexicano del Seguro Social]. / Atención a personas que viven con el VIH en el IMSS.

Infection by the human immunodeficiency virus (HIV) is apublic health problem worldwide, however, the incidence has remained relatively stable. In Mexico, around 10,000 new cases are reported each year. The Instituto Mexicano del Seguro Social (IMSS) has been a pioneer in the care of people living with HIV (PLWHA), gradually incorporating the different antiretroviral drugs (ARV). The first ARV used at the institutional level was zidovudine, in the 1990s, and later other agents were incorporated, such as protease inhibitors, drugs from the group of non-nucleoside analogs, and integrase inhibitors. In 2020, the migration to ARV schemes coformulated in a single tablet based on integrase inhibitors, which constitute a highly effective option and timely supply of drugs has been achieved in 99% of the population. In the aspect of prevention, the IMSS has also been a pioneer by being the first institution to implement HIV pre-exposure prophylaxis in 2021 at the national level and since 2022 universal post-exposure prophylaxis is available. The IMSS continues to be at the forefront incorporating the use of different management tools and instruments for the benefit of the population living with HIV. This document summarizes the history of HIV in the IMSS from the beginning of the epidemic to the present time.

La infección por el virus de la inmunodeficiencia humana (VIH) es un problema de salud pública a nivel mundial, sin embargo, la incidencia ha permanecido relativamente estable. En México se informa de alrededor de 10,000 casos nuevos al año. El Instituto Mexicano del Seguro Social (IMSS) ha sido pionero en la atención a las personas que viven con el VIH (PVV), incorporando paulatinamente los diferentes medicamentos antirretrovirales (ARV). El primer ARV utilizado a nivel institucional fue la zidovudina, en la década de los noventa, y posteriormente fueron incorporados otros agentes como los inhibidores de la proteasa, los medicamentos del grupo de los análogos no nucleósidos y los inhibidores de la integrasa. En el año 2020 ocurrió la migración a esquemas de ARV coformulados en una sola tableta a base de inhibidores de la integrasa, que constituyen una opción de alta eficacia y se ha logrado el surtimiento oportuno de los fármacos en el 99% de la población. En el aspecto de la prevención, el IMSS también ha sido pionero al ser la primera institución en implementar la profilaxis preexposición de VIH en el año 2021 a nivel nacional y desde el año 2022 se dispone de la profilaxis postexposición universal. El IMSS continúa a la vanguardia incorporando el uso de diferentes herramientas e instrumentos de gestión para beneficio de la población que vive con el VIH. En el presente documento se sintetiza la historia del VIH en el IMSS desde los inicios de la epidemia hasta el momento actual.

Guía de práctica clínica mexicana para el diagnóstico y tratamiento de las dislipidemias y enfermedad cardiovascular aterosclerótica / Mexican clinical practice guideline for the diagnosis and treatment of dyslipidemias and atherosclerotic cardiovascular disease

resumen está disponible en el texto completo

Abstract Background: Cardiovascular diseases are the leading cause of mortality worldwide and Mexico is no exception. The epidemiological data obtained in 1990 showed that cardiovascular diseases represented 19.8% of all causes of death in our country. This figure increased significantly to 25.5% for 2015. Some national surveys suggest that more than 60% of the adult population has at least one risk factor for cardiovascular disease (obesity or overweight, hypertension, smoking, diabetes, dyslipidemias). On the other hand, data from the Pan American Health Organization have linked the process of atherosclerosis as the first cause of premature death, significantly reducing life expectancy, which has enormous social repercussions. Objective: This document constitutes the Clinical Practice Guide (CPG) prepared at the initiative of the Mexican Society of Cardiology in collaboration with the Mexican Society of Nutrition and Endocrinology, AC, National Association of Cardiologists of Mexico, AC, Mexican Association for the Prevention of Atherosclerosis and its Complications, AC, National Normative Committee of General Medicine, AC, National College of Geriatric Medicine, AC, College of Internal Medicine of Mexico, AC, Mexican Society of Angiology and Vascular and Endovenous Surgery, AC, Mexican Institute of Research Nephrological, AC and the Mexican Academy of Neurology, A.C.; with the methodological support of the Ibero-American Agency for the Development and Evaluation of Health Technologies, in order to establish recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. The objective of this document is to provide evidence-based recommendations to help decision makers in the diagnosis and treatment of dyslipidemias in our country. Material and methods: This document complies with international quality standards, such as those described by the Institute of Medicine of the USA, the Institute of Clinical Excellence of Great Britain, the Scottish Intercollegiate Guideline Network and the Guidelines International Network. A multidisciplinary group of clinical experts and methodologists with experience in systematic reviews of the literature and the development of clinical practice guidelines was formed. A scope document was agreed upon, relevant clinical questions were established, the best available evidence critically evaluated in systematic literature reviews was exhaustively identified, and clinical recommendations were developed. The modified Delphi Panel methodology was used to achieve an adequate level of consensus in each of the recommendations contained in this CPG. Results: 23 clinical questions were agreed upon which gave rise to their respective clinical recommendations. Conclusions: We consider that this document contributes to better clinical decision-making and becomes a point of reference for clinicians and patients in the management of dyslipidemias and this contributes to reducing the morbidity and mortality derived from atherosclerotic cardiovascular events in our country.

Guía práctica interinstitucional para el tratamiento del infarto agudo de miocardio / Interinstitutional clinical practice guidelines for the treatment of acute myocardial infarction

Resumen Introducción: México tiene la mortalidad más alta a 30 días por infarto agudo de miocardio (IAM), el cual constituye una de las principales causas de mortalidad en el país: 28 % versus 7.5 % del promedio de los países de la Organización para la Cooperación y el Desarrollo Económicos. Objetivo: Establecer las rutas críticas y las estrategias farmacológicas esenciales interinstitucionales para la atención de los pacientes con IAM en México, independientemente de su condición socioeconómica. Método: Se reunió a un grupo de expertos en diagnóstico y tratamiento de IAM, representantes de las principales instituciones públicas de salud de México, así como las sociedades cardiológicas mexicanas, Cruz Roja Mexicana y representantes de la Sociedad Española de Cardiología, con la finalidad de optimizar las estrategias con base en la mejor evidencia existente. Resultados: Se diseñó una guía de práctica clínica interinstitucional para el diagnóstico temprano y tratamiento oportuno del IAM con elevación del segmento ST, siguiendo el horizonte clínico de la enfermedad, con la propuesta de algoritmos que mejoren el pronóstico de los pacientes que acuden por IAM a los servicios de urgencias. Conclusión: Con la presente guía práctica, el grupo de expertos propone universalizar el diagnóstico y tratamiento en el IAM, independientemente de la condición socioeconómica del paciente.

Abstract Introduction: Mexico has the highest 30-day acute myocardial infarction (AMI) mortality rate: 28% versus 7.5% on average for the OECD countries, and it constitutes one of the main causes of mortality in the country. Objective: To establish critical pathways and essential interinstitutional pharmacological strategies for the care of patients with AMI in Mexico, regardless of their socioeconomic status. Method: A group of experts in AMI diagnosis and treatment, representatives of the main public health institutions in Mexico, as well as the Mexican cardiology societies, the Mexican Red Cross and representatives of the Spanish Society of Cardiology, were brought together in order to optimize strategies based on the best existing evidence. Results: An interinstitutional clinical practice guideline was designed for early diagnosis and timely treatment of AMI with ST elevation, following the clinical horizon of the disease, with the proposal of algorithms that improve the prognosis of patients who attend the emergency services due to an AMI. Conclusion: With these clinical practice guidelines, the group of experts proposes to universalize AMI diagnosis and treatment, regardless of patient socioeconomic status.

Hacia una medicina de excelencia en México: el protocolo Código Infarto, una visión desde la bioética traslacional / Towards medicine of excellence in Mexico: the "Código Infarto" protocol, a view from the perspective of translational bioethics

Resumen Introducción: México es el país con mayor mortalidad por infarto agudo de miocardio con elevación del segmento ST (IAM CEST), por lo que el Instituto Mexicano del Seguro Social desarrolló el protocolo de atención para los servicios de urgencias denominado Código Infarto. En este artículo se discuten aspectos de la medicina traslacional con una perspectiva bioética e integral. Objetivo: Analizar el protocolo Código Infarto desde la perspectiva de la bioética traslacional. Método: Se realizó una aproximación centrada en el problema a través del equilibrio reflexivo, así como la aplicación del método integral para el discernimiento ético. Resultados: El protocolo de atención para los servicios de urgencias Código Infarto se rige por la medicina basada en la evidencia y la medicina basada en valores; se orienta por el principio de integridad que considera las seis dimensiones de la calidad para la atención de pacientes con IAM CEST. Conclusión: El protocolo supera algunos determinantes sociales adversos que afectan la atención médica del IAM CEST, disminuye la mortalidad, la carga económica global de la enfermedad y desarrolla una medicina de excelencia de alto alcance social.

Abstract Introduction: Mexico is the country with the highest mortality due to ST-elevation acute myocardial infarction (STEMI), and the IMSS has therefore developed the protocol of care for emergency departments called Código Infarto (Infarction Code). In this article, aspects of translational medicine are discussed with a bioethical and comprehensive perspective. Objective: To analyze the Código Infarto protocol from the perspective of translational bioethics. Method: A problem-centered approach was carried out through reflective equilibrium (or Rawls' method), as well as by applying the integral method for ethical discernment. Results: The protocol of care for emergency services Código Infarto is governed by evidence-based medicine and value-based medicine; it is guided by a principle of integrity that considers six dimensions of quality for the care of patients with STEMI. Conclusion: The protocol overcomes some adverse social determinants that affect STEMI medical care, reduces mortality and global economic disease burden, and develops medicine of excellence with high social reach.

Excerpts from the documents of Mexican positions and recommendations in cardiovascular diseases and COVID-19.

The recommendations in which the Mexican Society of Cardiology (SMC) in conjunction with the National Association of Cardiologists of Mexico (ANCAM) as well as different Mexican medical associations linked to cardiology are presented, after a comprehensive and consensual review and analysis of the topics related to cardiovascular diseases in the COVID-19 pandemic. Scientific positions are analyzed and responsible recommendations on general measures are given to patients, with personal care, healthy eating, regular physical activity, actions in case of cardio-respiratory arrest, protection of the patient and health personnel as well as precise indications in the use of non-invasive cardiovascular imaging, prescription of medications, care in specific topics such as systemic arterial hypertension, heart failure, arrhythmias and acute coronary syndromes, in addition to emphasizing electrophysiology, interventionism, cardiac surgery and in cardiac rehabilitation. The main interest is to provide the medical community with a general orientation on what to do in daily practice and patients with cardiovascular diseases in the setting of this unprecedented epidemiological crisis of COVID-19.

Se presentan las recomendaciones en las cuales la Sociedad Mexicana de Cardiología (SMC) en conjunto con la Asociación Nacional de Cardiólogos de México (ANCAM), así como diferentes asociaciones médicas mexicanas vinculadas con la cardiología, después de una revisión y análisis exhaustivo y consensuado sobre los tópicos relacionados con las enfermedades cardiovasculares en la pandemia de COVID-19, se analizan posturas científicas y se dan recomendaciones responsables sobre medidas generales a los pacientes, con cuidados personales, alimentación saludable, actividad física regular, acciones en caso de paro cardiorrespiratorio, la protección del paciente y del personal de salud así como las indicaciones precisas en el uso de la imagen cardiovascular no invasiva, la prescripción de medicamentos, cuidados en tópicos específicos como en la hipertensión arterial sistémica, insuficiencia cardiaca, arritmias y síndromes coronarios agudos, además de hacer énfasis en los procedimientos de electrofisiología, intervencionismo, cirugía cardiaca y en la rehabilitación cardiaca. El interés principal es brindar a la comunidad médica una orientación general sobre el quehacer en la práctica cotidiana y pacientes con enfermedades cardiovasculares en el escenario esta crisis epidemiológica sin precedentes de COVID-19.

Extractos de los documentos de posicionamientos y recomendaciones mexicanas en enfermedades cardiovasculares y COVID-19 / Excerpts from the documents of Mexican positions and recommendations in cardiovascular diseases and COVID-19

Resumen Se presentan las recomendaciones en las cuales la Sociedad Mexicana de Cardiología (SMC) en conjunto con la Asociación Nacional de Cardiólogos de México (ANCAM), así como diferentes asociaciones médicas mexicanas vinculadas con la cardiología, después de una revisión y análisis exhaustivo y consensuado sobre los tópicos relacionados con las enfermedades cardiovasculares en la pandemia de COVID-19, se analizan posturas científicas y se dan recomendaciones responsables sobre medidas generales a los pacientes, con cuidados personales, alimentación saludable, actividad física regular, acciones en caso de paro cardiorrespiratorio, la protección del paciente y del personal de salud así como las indicaciones precisas en el uso de la imagen cardiovascular no invasiva, la prescripción de medicamentos, cuidados en tópicos específicos como en la hipertensión arterial sistémica, insuficiencia cardiaca, arritmias y síndromes coronarios agudos, además de hacer énfasis en los procedimientos de electrofisiología, intervencionismo, cirugía cardiaca y en la rehabilitación cardiaca. El interés principal es brindar a la comunidad médica una orientación general sobre el quehacer en la práctica cotidiana y pacientes con enfermedades cardiovasculares en el escenario esta crisis epidemiológica sin precedentes de COVID-19.

Abstract The recommendations in which the Mexican Society of Cardiology (SMC) in conjunction with the National Association of Cardiologists of Mexico (ANCAM) as well as different Mexican medical associations linked to cardiology are presented, after a comprehensive and consensual review and analysis of the topics related to cardiovascular diseases in the COVID-19 pandemic. Scientific positions are analyzed and responsible recommendations on general measures are given to patients, with personal care, healthy eating, regular physical activity, actions in case of cardio-respiratory arrest, protection of the patient and health personnel as well as precise indications in the use of non-invasive cardiovascular imaging, prescription of medications, care in specific topics such as systemic arterial hypertension, heart failure, arrhythmias and acute coronary syndromes, in addition to emphasizing electrophysiology, interventionism, cardiac surgery and in cardiac rehabilitation. The main interest is to provide the medical community with a general orientation on what to do in daily practice and patients with cardiovascular diseases in the setting of this unprecedented epidemiological crisis of COVID-19.

[Efecto de la rehabilitación cardiaca temprana en pacientes incluidos en Código Infarto].

Introduction: Early cardiac rehabilitation (ECR) implemented in the Infarction Code (IC) protocol is a strategy in the care of acute myocardial infarction. The purpose of this study was to identify the effect of ECR in IC-included patients. Method: Case-control study. Consecutive patients diagnosed with acute myocardial infarction and admitted to a cardiology hospital between February 2015 and June 2017 were included. Two groups were created: I and II, before and after IC and ECR. Results: We included 1141 patients, 220 in group I and 921 in group II, with an age of 62.64 ± 10.53 years; 80.9 % were males and 19.1 % females. The main risk factors for groups I and II were sedentariness, 92.7 % versus 77.8 %; dyslipidemia, 80.9 % versus 55.8 %; hypertension, 63.2 % versus 62 %; smoking, 66.8 % versus 59.2 %; and diabetes, 54.5 % versus 59.1 %. Rehabilitation was started earlier (1.8 ± 1.6 versus 4.2 ± 3.2) and the days spent in intensive therapy and hospitalization were fewer in group II (2.4 ± 2.2 versus 4.8 ± 4.1 and 8.6 ± 5.2 versus 12.3 ± 7.7, p < 0.0001, respectively), as well as the days of disability (58.6 versus 67.7). Conclusions: IC and ECR are complementary strategies that allow an early discharge from intensive therapy and hospitalization, as well as better quality of life and fewer days of disability leave.

Introducción: La rehabilitación cardiaca temprana (RCT) implementada en el protocolo Código Infarto (CI) es una estrategia en la atención del infarto agudo de miocardio. El objetivo fue identificar el efecto de la RCT en pacientes incluidos en CI. Método: Estudio de casos y controles. Se incluyeron pacientes consecutivos con diagnóstico de infarto agudo de miocardio ingresados a un hospital de cardiología entre febrero de 2015 y junio de 2017. Se crearon dos grupos: I y II, antes y después de CI y RCT. Resultados: Se incluyeron 1141 pacientes: 220 del grupo I y 921 del grupo II, edad 62.64 ± 10.53 años; 80.9 % hombres y 19.1 % mujeres. Los principales factores de riesgo para los grupos I y II fueron sedentarismo, 92.7 y 77.8 %; dislipidemia, 80.9 y 55.8 %; hipertensión, 63.2 y 62 %; tabaquismo, 66.8 y 59.2 %; y diabetes, 54.5 y 59.1 %. En el grupo II se inició antes la rehabilitación (1.8 ± 1.6 y 4.2 ± 3.2) y los días en terapia intensiva y hospitalización fueron menores (2.4 ± 2.2 y 4.8 ± 4.1; 8.6 ± 5.2 y 12.3 ± 7.7), así como los días de incapacidad (58.6 y 67.7). Conclusiones: CI y RCT son estrategias complementarias que permiten alta temprana de terapia intensiva y hospitalización, mejor calidad de vida y menos días de incapacidad laboral.

Efecto de la rehabilitación cardiaca temprana en pacientes incluidos en Código Infarto / Effect of early cardiac rehabilitation in patients included in Codigo Infarto

Resumen Introducción: La rehabilitación cardiaca temprana (RCT) implementada en el protocolo Código Infarto (CI) es una estrategia en la atención del infarto agudo de miocardio. El objetivo fue identificar el efecto de la RCT en pacientes incluidos en CI. Método: Estudio de casos y controles. Se incluyeron pacientes consecutivos con diagnóstico de infarto agudo de miocardio ingresados a un hospital de cardiología entre febrero de 2015 y junio de 2017. Se crearon dos grupos: I y II, antes y después de CI y RCT. Resultados: Se incluyeron 1141 pacientes: 220 del grupo I y 921 del grupo II, edad 62.64 ± 10.53 años; 80.9 % hombres y 19.1 % mujeres. Los principales factores de riesgo para los grupos I y II fueron sedentarismo, 92.7 y 77.8 %; dislipidemia, 80.9 y 55.8 %; hipertensión, 63.2 y 62 %; tabaquismo, 66.8 y 59.2 %; y diabetes, 54.5 y 59.1 %. En el grupo II se inició antes la rehabilitación (1.8 ± 1.6 y 4.2 ± 3.2) y los días en terapia intensiva y hospitalización fueron menores (2.4 ± 2.2 y 4.8 ± 4.1; 8.6 ± 5.2 y 12.3 ± 7.7), así como los días de incapacidad (58.6 y 67.7). Conclusiones: CI y RCT son estrategias complementarias que permiten alta temprana de terapia intensiva y hospitalización, mejor calidad de vida y menos días de incapacidad laboral.

Abstract Introduction: Early cardiac rehabilitation (ECR) implemented in the Infarction Code (IC) protocol is a strategy in the care of acute myocardial infarction. The purpose of this study was to identify the effect of ECR in IC-included patients. Method: Case-control study. Consecutive patients diagnosed with acute myocardial infarction and admitted to a cardiology hospital between February 2015 and June 2017 were included. Two groups were created: I and II, before and after IC and ECR. Results: We included 1141 patients, 220 in group I and 921 in group II, with an age of 62.64 ± 10.53 years; 80.9 % were males and 19.1 % females. The main risk factors for groups I and II were sedentariness, 92.7 % versus 77.8 %; dyslipidemia, 80.9 % versus 55.8 %; hypertension, 63.2 % versus 62 %; smoking, 66.8 % versus 59.2 %; and diabetes, 54.5 % versus 59.1 %. Rehabilitation was started earlier (1.8 ± 1.6 versus 4.2 ± 3.2) and the days spent in intensive therapy and hospitalization were fewer in group II (2.4 ± 2.2 versus 4.8 ± 4.1 and 8.6 ± 5.2 versus 12.3 ± 7.7, p < 0.0001, respectively), as well as the days of disability (58.6 versus 67.7). Conclusions: IC and ECR are complementary strategies that allow an early discharge from intensive therapy and hospitalization, as well as better quality of life and fewer days of disability leave.

Formas de medición de la presión arterial sistémica: el debate continúa / Forms of measurement of systemic blood pressure: the debate continues

Resumen La medición de la presión arterial en el brazo continúa siendo la técnica patrón de referencia para el diagnóstico de hipertensión arterial sistémica. Sin embargo, las formas de medir la presión arterial han dado mucho de qué hablar en años recientes. Si bien los aparatos de medición con mercurio han sido desplazados por los digitales, ahora el cuestionamiento es dónde debe medirse la presión. A saber está la forma de medición en consultorio y los métodos fuera de él: medición intermitente domiciliaria o, bien, monitoreo ambulatorio de la presión arterial. Estos dos últimos han dado la oportunidad de identificar mejor el patrón de comportamiento y su variabilidad biológica, lo que acerca aún más al médico al conocimiento del comportamiento de las variaciones de presión en los sujetos con hipertensión arterial y prehipertensión. En esta revisión se discuten los alcances y limitaciones de cada forma de medición de la presión arterial.

Abstract The measurement of blood pressure in the arm continues to be the standard technique for the diagnosis of systemic arterial hypertension. However, the way to measure blood pressure has given much to talk about in recent years. While mercury-containing measuring have been displaced by digital devices, now questioning is where the pressure must be measured. To know this form of measurement in practice and methods outside the office: Home intermittent measurement or ambulatory blood pressure monitoring. These last two have given the opportunity to better identify the pattern of behavior and biological variability, what further approaches the medical knowledge of the behavior of the pressure variations in arterial hypertension and prehypertension subject carriers. In this review, we will discuss the scope and limitations of each form of measurement of blood pressure.

Implementation of a Nationwide Strategy for the Prevention, Treatment, and Rehabilitation of Cardiovascular Disease "A Todo Corazón".

The cardiovascular diseases (CVDs) have a growing impact over the world mortality, affecting mostly low and middle-income countries. This is due to changes in the population pyramid and the increase in unhealthy lifestyles that predispose the global population to cardiovascular risk factors such as overweight, obesity, smoking, hypertension, diabetes, dyslipidemias and metabolic syndrome. Ischemic heart disease and the cerebral vascular event remain the first causes of death reported by the World Health Organization (WHO) for more than a decade. Mexico has high prevalence in obesity, overweight, hypertension and diabetes in the population over 20 years old; Within the OECD countries (Organization for Economic Cooperation and Development) are the country with the highest mortality due to acute myocardial infarction over 45 years in the first 30 days. In order to face the growing pandemic of CVDs, the IMSS, it has developed and implemented a comprehensive care program called "A Todo Corazon", it is the first program of integral care which seeks to strengthen the actions to improving the impact of CVDs from health. This review is focused on describing the 7 axes that make up the program; each axe is described in detail. Axes one to three are dedicated to promotion and primary prevention of CVDs. Axes 4 and 5 are dedicated to infarction code, as a national strategy to confront the principal cause of death in Mexico. Finally axes 6 and 7 are dedicated to intensive care, secondary prevention and rehabilitation of CVDs.

STEMI and NSTEMI: Real-world Study in Mexico (RENASCA).

INTRODUCTION: Mexico is the country with the highest mortality due to acute myocardial infarction in adults older than 45 years old according to the OECD (28 vs. 7.5% of the average). The first real-world study, RENASCA IMSS, showed a high-risk population at 65%, but 50% without reperfusion strategies. The aim was to describe the clinical presentation, treatment, and outcomes of acute coronary syndromes at the IMSS. METHODS: RENASCA IMSS is a nation-wide, prospective, longitudinal-cohort study. We include consecutive patients with an Acute Coronary Syndrome diagnosis (ACC/AHA/ESC) admitted in 177 representative hospitals of the IMSS (166 of second level and 11 of third level of attention). In an electronic database clinical, paraclinical, times, reperfusion treatment, complications, and other variables were assessed. Confidentiality was maintained in data and informed consent was obtained. Registrer calibration was performed with more than 80% of the variables and 80% of the cases. RESULTS: From March 1, 2014 to December 25, 2017; 21,827 patients were enrolled presenting an average age 63.2 ± 11.7, 75% men (16,259) and 25% women (5,568). The most frequent risk factors were: hypertension (60.5%), smoking (46.8%), diabetes (45.5%), dyslipidemia (35.3%) and metabolic syndrome (39.1%). STEMI diagnosis was established in 73.2% of the patients and NSTEMI in 26.8%. The STEMI group within the Code Infarction showed an improvement in the reperfusion therapy (34.9% before vs. 71.4% after, p ≤0.0001) and reduction of mortality (21.1 vs. 9.4%, p ≤0.0001); while the NSTEMI group showed high risk set by a GRACE score of 131.5 ± 43.7 vs. 135.9 + 41.7, p ≤0.0001. Mortality was more frequent within the STEMI group (14.9 vs. 7.6%, p ≤0.0001). CONCLUSIONS: RENASCA IMSS study represents the largest Acute Coronary Syndromes real-world study in Mexico, demonstrating that the Mexican population has a high risk. Patients with a STEMI diagnosis were more frequently enrolled and were associated with higher mortality and complications; however, there is improvement in the reperfusion therapy and in mortality with the Code Infarction strategy.

Dysfunctional immunometabolic effects of vitamin D deficiency, increased cardiometabolic risk. Potential epidemiological alert in America? / Efectos inmunometabólicos disfuncionales de la deficiencia de vitamina D y aumento de riesgo cardiometabólico. ¿Potencial alerta epidemiológica en América?

Vitamin D deficiency is a serious public health problem worldwide that affects not only skeletal health, but also a wide range of acute and chronic diseases. However, there is still skepticism because of the lack of randomized, controlled trials to support association studies on the benefits of vitamin D for non-skeletal health. This review was based on articles published during the 1980-2015 obtained from the Cochrane Central Register of controlled trials, MEDLINE and PubMed, and focuses on recent challenges with regard to the definition of vitamin D deficiency and how to achieve optimal serum 25-hydroxyvitamin D levels from dietary sources, supplements, and sun exposure. The effect of vitamin D on epigenetic fetal programming and regulation of genes that may potentially explain why vitamin D could have such lifelong comprehensive health benefits is reviewed. Optimization of vitamin D levels in children and adults around the world has potential benefits to improve skeletal health and to reduce the risk of chronic diseases, including some types of cancer, autoimmune diseases, infectious diseases, type 2 diabetes mellitus, and severe cardiovascular disorders such as atherothrombosis, neurocognitive disorders, and mortality.

[Quality dimensions focused on the healthcare protocol Infarction Code (Código Infarto)]. / Dimensiones de calidad enfocadas en el protocolo de atención Código Infarto

The Código Infarto (Infarction Code) strategy is part of the comprehensive care program "A Todo Corazón" (To All Heart), whose aim is to reinforce the prevention and health care of cardiovascular diseases. Mexico faces a big challenge, since it is the country with greater mortality secondary to acute myocardial infarction (AMI) in the first 30 days in patients of 45 years or older (28% compared with 7.9% of the average). In addition, Mexico's population has a high prevalence of risk factors (hypertension, diabetes, tobacco use, dyslipidemias, overweight, and obesity). It is for these reasons that 18 months ago the Instituto Mexicano del Seguro Social (IMSS) implemented the first care protocol for patients with AMI, called Código Infarto, whose main aim is to guarantee the diagnosis and treatment of patients with AMI, so that they can receive, once they are admitted at IMSS emergency rooms, primary angioplasty in less than 90 minutes, or fibrinolytic therapy in less than 30 minutes. The quality focus in the Código Infarto strategy has six main dimensions: security, effectiveness, its focus on the patient, opportune, efficient, and [it offers] equitable [treatment]. The implementation of Código Infarto in IMSS is the first institutional strategy to face the leading cause of death in our country and it has produced up until now very encouraging results.

La estrategia Código Infarto es parte del programa de atención integral "A Todo Corazón", el cual pretende fortalecer las acciones para la prevención y atención de las enfermedades cardiovasculares. México tiene un gran reto al ser el país con mayor mortalidad por infarto agudo de miocardio en los primeros 30 días en pacientes mayores de 45 años (28%, comparado con 7.9% del promedio), además de que tiene una población con alta prevalencia de factores de riesgo, como hipertensión, diabetes, tabaquismo, dislipidemias, sobrepeso y obesidad. Es por ello que desde hace 18 meses implementamos en el Instituto Mexicano del Seguro Social (IMSS) el primer protocolo de atención para los pacientes con infarto agudo de miocardio, llamado Código Infarto, cuya finalidad es garantizar el diagnóstico y el tratamiento de los pacientes con infarto agudo de miocardio, de manera que reciban angioplastía primaria en menos de 90 minutos o terapia fibrinolítica en menos de 30 minutos una vez que ingresen a los servicios de urgencias del IMSS. El enfoque de la calidad en la estrategia Código Infarto tiene seis dimensiones y pilares fundamentales: seguridad, efectividad, se centra en el paciente, es oportuna, eficiente y equitativa. La implementación de Código Infarto en el IMSS es la primera estrategia institucional para abordar la primera causa de muerte en nuestro país con resultados muy alentadores hasta este momento.